Transurethral resection of the prostate: the new old standard

Reasons to believe in vaporization: a review of the benefits of photo-selective and transurethral vaporization

PURPOSE

In the current review, we will discuss the state of the literature of vaporization of the prostate for the treatment of benign prostatic enlargement (BPE). We discuss two methods of vaporization of the prostate: Transurethral Vaporization of the Prostate (TUVP) and Greenlight Photo-selective Vaporization of the Prostate (PVP).

METHODS

A comprehensive review of the literature was performed on TUVP and PVP. The literature on transurethral resection of the prostate (TURP) was also extensively reviewed as a comparative surgical method.

RESULTS

The evidence shows that TUVP appears to be the safer choice, as compared to TURP due to less intra- and peri-operative complications. PVP was associated with less bleeding complications than TURP with outpatient discharge. Importantly, PVP was not associated with serious bleeding events requiring blood transfusions or medical treatment in patients under anticoagulation or antiplatelet therapies. PVP was also shown to be a cost-effective option compared to TURP.

CONCLUSION

Prostate vaporization for the treatment of BPE appears to be an efficient and safer alternative to TURP. Vaporization techniques, particularly Greenlight PVP, should be offered to most men, especially those under anticoagulation therapy, as well as patients at risk of bleeding complications.

A randomized trial of transvesical prostatectomy versus transurethral resection of the prostate for prostate greater than 80 mL

OBJECTIVES

We compared the safety and efficacy of transvesical prostatectomy (TVP) and transurethral resection of the prostate (TURP) for prostate greater than 80 mL in a prospective randomized trial.

METHODS

Eighty patients with urodynamic obstruction and prostate volume >80 mL were prospectively randomized and assigned to TVP or TURP. Patients were assessed preoperatively and followed up at 3 and 12 months postoperatively. International prostate symptom score (IPSS), quality of life score (QoLS), maximum flow rate (Q(max)(.)), and postvoid residual volume (PVR) were obtained at each follow-up. Perioperative data and postoperative outcomes were compared. All complications were recorded.

RESULTS

Of 80 patients eligible to participate, 69 patients completed 12 months of follow-up. TURP procedure was not faster than TVP procedure (P = .41); 53.2% and 84.4% of prostatic tissue were resected after TURP and TVP, respectively (P < .001). In the TVP group, IPSS, Q(max)(.), QoLS, and PVR volume were significantly better than those in TURP group at 3 and 12 months of follow-up. At 12 months postoperatively, IPSS improved 87.6% and 62.3%, mean Q(max)(.) increased by 11.49 mL/s (230.2%) and 6.33 mL/s (102%), and mean PVR volume decreased by 71.2 mL (88.6%) and 65.4 mL (70.5%) in TVP and TURP group, respectively. Two TURP patients developed urethral stricture requiring reoperation.

CONCLUSIONS

TVP may be more effective and safer than TURP for the benign prostatic hyperplasia patient whose prostate volume is >80 mL.

[The low hydraulic pressure transurethral resection of the prostate results in 340 patients with great adenomas]

INTRODUCTION

the transurethral resection of prostate TURP is the elective treatment for the small and medium adenomas. In this study they analyse the effectiveness, the results and the postoperative morbidity in the resection of the great adenomas.

PATIENTS AND METHOD

We study 340 patients with great adenomas and symptomatic infravesical obstruction that were operated with the low hydraulic pressure RTUP between August of 1999 and June of 2006.

RESULTS

Average Age of the patients 69 years (range 51-89). Prostate volume by TRUS, 107 ml (70-204). PSA 7,94 ng/ml (0,71-26,4). Weight of the resected fragments: 74,5gr. (50-160), time of the intervention 65 min. (35-155), postoperative urethral catheterisation 1.7 days (1-8), suprapubic derivation 6.5 days (5-15), the duration of hospital stay after surgery were 8 days (7-16), peak flow pre-op. 11.2 ml/sec. (5-15,7), post-operative 19.7 ml/sec. (7-41,3). There were no cases of TURP syndrome in this group. Operative complications: Urinary infection without fever (bacteria >100.000) 95 patients (27.9%), bladder derivation by preoperative urinary retention 53 patients (15,6%). 18 patients (5,3%) with postoperative urinary retention. 11 patients (3,2%), with infection and fever >38 degrees C. 7 patients (2%) with postoperative bladder bleeding, 2 patients (0,6%) with urethral lesion. 1 patient (0.3%), with massive scrotal hematoma (after vasectomy). Control of the pre and post operative hemoglobin: Hemoglobin pre-op 15 g/dl (12-19,3), hemoglobin post-op 11,5 g/dl (7,6-16,4), difference of (- 3,5g/dl) 23,3%. In only 29 patients (8.5%) it was necessary to carry out a sanguineous transfusions (heterolog) of 2 to 4 EC (500 ml), the TRUS was 125 ml, weight of the fragments 90 gr. (52-140), the hemoglobin pre-op was 14,72g/dl and post-op of 8,8g/dl with a difference of (- 5,92g/dl) 40.2%.

CONCLUSIONS

The video assisted low hydraulic pressure TURP, is an effective method in the surgical treatment of great prostate adenomas. The severe postoperative complications are little, and in 311 patients (91.5%) it was not necessary sanguineous transfusion. The stationary treatment and the urethral catheterisation is smaller in comparison with the open adenomectomy.

Photoselektive Vaporisation der Prostata

BACKGROUND

We report about our experiences with photoselective vaporization of the prostate (PVP) in patients with symptomatic benign prostatic hyperplasia (BPH) and total prostate volume larger than 80 cm(3).

PATIENTS AND METHODS

The study included 201 patients with BPH: 51 (25.4%) patients had a prostate volume larger than 80 cm(3) and 150 (74.6%) patients had a volume smaller than 80 cm(3) in the preoperative transrectal ultrasound.

RESULTS

The mean operation time for patients with large prostates was 79 min. Neither TUR syndrome nor severe bleeding was observed. In patients with large adenomas peak urinary flow increased by 135, 136, and 132% after 6, 12, and 24 months, respectively. The overall complication rate was comparable in both groups.

CONCLUSION

PVP is characterized by excellent perioperative safety and significant improvement of voiding parameters. PVP is feasible in patients with large prostates.

Holmium laser enucleation of the prostate for prostates of >125 mL

OBJECTIVE

To examine a group of patients treated with holmium laser enucleation of the prostate (HoLEP) and with the bladder outlet obstructed by an exceptionally large (>125 mL) prostate, as such men are often not considered candidates for endoscopic treatments and historically have required open surgery.

PATIENTS AND METHODS

We analysed retrospectively all patients with prostates of > 125 mL on transrectal ultrasonography (TRUS) who underwent HoLEP between January 2000 and January 2005.

RESULTS

Eighty-six patients were identified; their mean (range) age was 72.6 (48-90) years and prostate volume 170.2 (125-309) mL. Their mean preoperative prostate-specific antigen (PSA) level was 9.82 ng/mL and preoperative American Urologic Association symptom score (AUA-SS) was 19.6. The mean operative duration and hospital stay were 128.1 min and 26.1 h, respectively. The mean weight of tissue enucleated was 140.2 g. At the 1-month follow-up the mean AUA-SS (63 men) was 8.4 and at 6 months (35 men) it was 6.4. The mean serum PSA level in 48 patients was 0.96 ng/mL, a reduction of 90%. TRUS measurements in 20 patients gave a mean prostate volume of 30.8 mL, a reduction of 82%. At the 1-year follow-up the mean AUA-SS of 22 patients was 5.1.

CONCLUSIONS

The present report details the largest series of patients, with the largest mean prostate size, treated by any endoscopic surgical method. HoLEP may be the ideal treatment for men with prostates of > 125 mL with symptoms of bladder outlet obstruction.

Tratamiento combinado del adenoma prostático con el KPT-láser de 80 Watt y la resección transuretral de baja presión

INTRODUCTION

The purpose of this prospective study is to determine the effectiveness of method for vaporisation and elimination of the prostate adenoma. The results are analysed that obtain when combining this Laser-method with the resection at low pressure.

MATERIAL AND METHOD

151 patients with BPH symptomatic were treated between August 2004 and january 2006 with the KTP-Laser or combined with low pressure TURP. The additional Resection was carried out in those patients with large adenomas or to have accentuated middle lobule. The ablative effect was controlled at the end of the operation with TRUS (transrectal ultrasound).

RESULTS

151 patients were divided in 2 groups, group 1 (n:43) those with single laser treatment and group 2 (n: 108) with combined treatment. The control of the post-miccional peak-flow demonstrates an increase of 65,6% in group 1, and of 122,4 % in group 2.

CONCLUSION

Our study reveals the advantages of combining both operative procedures to mainly obtain a better result in the ablation of the prostate adenoma in prostates of great size.

Photoselective vaporization (PVP) versus transurethral resection of the prostate (TURP): a prospective bi-centre study of perioperative morbidity and early functional outcome

OBJECTIVES

To compare the early follow-up and perioperative morbidity of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) in patients (pts.) suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIAL AND METHOD

101 pts. underwent PVP (n = 64) and TURP (n = 37) in a prospective, non-randomized bi-centre trial. Inclusion criteria were identical at both centres. Primary outcome parameters were maximum urinary flow rate (Q(max)), post-void residual volume (V(res)), International Prostate Symptom Score (IPSS). Secondary outcomes included intraoperative surgical parameters and perioperative and post-discharge morbidity.

RESULTS

Baseline characteristics of both groups were similar. Operating time was slightly shorter in the TURP group (p = 0.047). During TURP significant more irrigation solution was used (p < 0.001). Decrease of serum haemoglobin (p = 0.027) and serum sodium (p = 0.013) was larger after TURP. Catheter drainage was removed significant earlier after PVP than after TURP (p < 0.001). Outcome of Q(max), and IPSS were similar in both groups within 6 months. The sort of perioperative complications was different in both groups, however overall cumulative perioperative morbidity was comparable (PVP 39.1% versus TURP 43.2.1%; ns).

CONCLUSION

PVP provides excellent intraoperative safety, instant tissue removal, and immediate relief from obstructive voiding symptoms, similar to TURP. Early outcomes 6-months after PVP and TURP are comparable.

Photoselective Vaporization of the Prostate: The Basel Experience after 108 Procedures

OBJECTIVES

This study aims to investigate safety and efficacy of 80 watt high-power potassium titanyl phosphate (KTP) laser vaporization of the prostate in men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

METHODS

108 patients underwent 80W KTP laser vaporization. Functional follow-up included measurement of maximum urinary flow rate (Qmax), postvoid residual volume (Vres) and International Prostate Symptom Score (IPSS) within a 12 months period.

RESULTS

The average prostate volume was 52.2+/-24.3 ml and the preoperative PSA value was 3.6+/-3.6 ng/dl. Mean operation time was 54.5+/-25.0 min. Qmax increased highly significantly (p<0.001) by 111% (+7.9 ml/s) at discharge, 212% (+15.1 ml/s) after three months, 201% (+14.3 ml/s) after six months and 252% (+17.9 ml/s) after 12 months. Correspondingly, Vres, IPSS and Bother Score improved to an extent that was statistically highly significant (p<0.001) immediately after surgery. The observed complication rate within one year was low.

CONCLUSIONS

80 W KTP laser vaporization is a virtually bloodless, safe and effective procedure for surgical treatment of LUTS secondary to BPH. A significant improvement of objective and subjective voiding parameters was observed just after surgery. KTP laser vaporization is associated with a low rate of complications.

Dilutional hyponatremia of TURP syndrome: a historical event in the 21st century

OBJECTIVES

To evaluate the risk of hyponatremia and transurethral resection of the prostate (TURP) syndrome after bipolar saline TURP in patients with large-volume, benign prostatic hyperplasia and statistically significant comorbidities.

METHODS

Five patients with large symptomatic benign prostatic hyperplasia and significant comorbidities underwent saline TURP. Data were collected regarding patient profile, prostate weight, operative time, and perioperative events. In particular, we studied and compared the preoperative and postoperative serum sodium concentrations and hematocrit.

RESULTS

The mean age was 68 years (range 57 to 76). The mean resection weight of the prostatic chips was 49.6 g (range 37 to 62). Senior urology residents under the supervision of the university faculty performed all procedures. The average operative time was 2 hours, 22 minutes (range 98 to 175 minutes). The mean serum sodium concentration decreased by 1.6 mg/dL (from 138.4 mg/dL preoperatively to 136.8 mg/dL postoperatively). The mean hematocrit decreased by 5.60% (from 40.24% preoperatively to 34.64% postoperatively). Postoperative recovery was uneventful in all 5 patients.

CONCLUSIONS

Bipolar saline TURP is safe and eliminates the risk of TURP syndrome in high-risk patients with large prostates that require lengthy resection. In addition, the system permits the faculty to spend the time needed for teaching and training urology residents without compromising patient safety.

Die 80-Watt-Kalium-Titanyl-Phosphat- (KTP-)Laservaporisation der Prostata

BACKGROUND

Despite good efficacy, even in our days, TURP remains a potentially difficult procedure to perform and is associated with significant risks for the patient. Several alternatives have been tried to reduce the known perioperative morbidity. We report our first experiences with 80 W potassium titanyl phosphate (KTP) laser vaporization of the prostate in patients with symptomatic BPH.

PATIENTS AND METHODS

In 70 patients 80 W KTP laser vaporization was performed successfully. Mean age was 70.5 years (46-93 years) and mean transrectal prostate volume was 48.1 ml (10-250 ml).

RESULTS

Mean operating time was 41 min ( n=22), 64 min ( n=33), and 80 min ( n=15) for a 26 ml, 46 ml, and a 91 ml prostate, respectively. At time of discharge, after 1 month, and 6 months the urinary peak flow increased by 75.4%, 166.8%, and 168.6%, respectively.

CONCLUSION

The 80 W KTP laser vaporization of the prostate combines the tissue-debulking properties of transurethral resection of the prostate with the known good hemostatic properties of other laser procedures. It is a safe procedure for the patient and provides a virtually bloodless operation and immediate improvement of voiding.

Transurethral Resection in the Management of Urethral and Prostatic Neoplasia in 6 Dogs

OBJECTIVE

To assess cystoscopic transurethral resection (TUR) for the palliative management of dogs with neoplastic infiltration of the urethra.

STUDY DESIGN

Prospective clinical trial.

ANIMALS

Six client-owned dogs.

METHODS

Cystoscopic examination and electrosurgical TUR were performed in dogs with urination difficulties caused by prostatic or urethral neoplasia. TUR was performed in a retrograde manner in female dogs and antegrade in male dogs via exploratory celiotomy and ventral cystotomy. Cystoscopic examination was used to determine the extent of neoplastic involvement of the urethra. TUR involved piecemeal removal of neoplastic tissue from the urethral lumen using an electrocautery cutting loop. Hemorrhage was controlled with a cystoscopic cauterized roller-ball. In 2 male dogs, intraoperative radiation therapy (IORT) was used to treat both prostatic neoplasia and the sublumbar lymph node bed. Surgical technique, complications, adjuvant treatment, and outcome were recorded.

RESULTS

TUR was performed in 3 male dogs with prostatic carcinoma and 2 female dogs with urethral transitional cell carcinoma (TCC). In 1 female dog, TUR was attempted but not successful because of cystoscope diameter. Iatrogenic urethral perforation occurred during TUR in 3 dogs. In 2 dogs, prolonged exposure to lavage fluid resulted in clinical and biochemical abnormalities consistent with TUR syndrome. Dysuria resolved in 5 dogs within 10 days of TUR. Treatment-related complications included urinary tract infection and tumor seeding. Local tumor progression and metastasis occurred in all dogs.

CONCLUSIONS

TUR (in combination with chemotherapy+/-IORT) resulted in rapid palliation of urination difficulties in male dogs with prostatic carcinoma. In female dogs with urethral TCC, however, electrosurgical TUR cannot be recommended because of a high intra- and postoperative complication rate with no improvement in postoperative management compared with historical reports of tube cystostomy.

CLINICAL RELEVANCE

TUR is a novel alternative for the palliation of male dogs with prostatic carcinoma. In female dogs with urethral TCC, electrosurgical TUR does not provide any advantages compared with tube cystostomy.