Comparison of transurethral prostate resection and plasmakinetic prostate resection according to cautery artefacts in tissue specimens

Necrosis zone depth after bipolar plasma vaporization and resection in the human prostate

Objectives

To compare the depth of thermal necrosis after use of bipolar resection and vaporization technique comparing intra-individually bipolar loop and bipolar button electrodes.

Methods

Transurethral resection and vaporization of the prostate was performed in 55 male patients (260 specimens in total). In a standardized procedure, a bipolar resection loop was used for resection, and a bipolar button electrode was used for vaporization. Both electrodes were applied in each patient, either in the left or in the right lateral lobe. The depth of necrotic zones in the resected or vaporized tissue of each patient was measured in a standardized way by light microscopy.

Results

The mean depth with standard deviation of thermal injury caused by the loop electrode was 0.0495±0.0274 mm. The vaporization electrode caused a mean thermal depth with standard deviation of 0.0477±0.0276 mm. The mean difference of necrosis zone depths between the two types of electrodes (PlasmaButton-resection loop) was -0.0018 mm (p=0.691).

Conclusion

For the first time, we present directly measured values of the absolute necrosis zone depth after application of plasma in the transurethral treatment of benign prostatic hyperplasia. The measured values were lower than in all other transurethral procedures. Standardized procedures of measurement and evaluation allow a statistically significant statement that the low necrosis depth in bipolar procedures is independent of the applied electrodes.

Predictors of Unfavorable Pathology in Patients with Incidental (pT1a-T1b) Prostate Cancer

BACKGROUND

Incidental prostate cancer (IPCa) is encountered in 10% of surgical procedures for benign prostatic obstruction (BPO). Identification of patients with underlying detrimental prostate cancer is paramount for tailored treatment decision-making, but guideline recommendations for this setting are lacking.

OBJECTIVE

To highlight clinical and histological characteristics related to BPO surgery that may predict IPCa with unfavorable pathology.

DESIGN, SETTING, AND PARTICIPANTS

We included men with IPCa who underwent radical prostatectomy (RP) in the short term after IPCa diagnosis. Two cohorts were built according to final pathology for the RP specimen: unfavorable pathology (International Society of Urological Pathology [ISUP] grade group [GG] ≥3 and/or ≥pT3a and/or pN1) versus favorable pathology.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We performed multivariate regression analysis for the endpoint, which was unfavorable pathology for the RP specimen. Using the model estimates for prostate-specific antigen (PSA), ISUP GG, age, and prostate volume, we established a model for estimating the risk of unfavorable histopathology.

RESULTS AND LIMITATIONS

Overall, 112 patients were included in the final assessment. On multivariate analysis, PSA (odds ratio [OR] 1.083, 95% confidence interval [CI] 1.003-1.170; p = 0.042), ISUP GG for the specimen from BPO surgery (OR 3.090; 95% CI 1.129-8.457; p = 0.028), and age (OR 1.121, 95% CI 1.026-1.225; p = 0.012) were independent predictors for unfavorable histopathology. On receiver operating characteristic analysis, the area under the curve was 0.751. A novel calculator was developed to predict adverse pathology for men with IPCa. The study is limited by its retrospective design.

CONCLUSIONS

For men with IPCa, PSA before surgery for BPO, ISUP GG, and age are independent predictors of unfavorable disease. Our results might improve preoperative risk assessment for patient counseling.

PATIENT SUMMARY

We developed a novel calculator to estimate the risk of underlying detrimental disease in men diagnosed with prostate cancer at surgery for benign prostatic obstruction.

Bipolar Transurethral Resection of Bladder Tumor Provides Better Tissue for Histopathology But Has No Superior Efficacy and Safety: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Bipolar transurethral resection of bladder tumors (TURBTs) has been claimed to have lesser complications and better specimen quality, but recent studies have contradictory results, and hence, we conducted this study to compare the clinical efficacy and safety of monopolar and bipolar electrosurgical modalities in TURBTs.

MATERIALS AND METHODS

A total of 287 patients were enrolled in the study and underwent TURBTs between July 2015 and September 2016. Patients undergoing surgery under general anesthesia and restage procedure were excluded from the study. Patient demographic profile, tumor characteristics, and complications of the procedures such as obturator jerk, bladder perforation, blood loss, need for resurgery, and transurethral resection syndrome were recorded. Tumor specimens were analyzed for stage, grade, deep muscle invasion, and quantity and quality of thermal artifacts.

RESULTS

A total of 160 patients were block randomized and analyzed with 80 patients in either group. Patient demographics and tumor characteristics were comparable between the groups. Change in hemoglobin levels and incidence of bladder perforation were comparable between the groups. A higher proportion of patients in bipolar group had obturator jerk compared with those in monopolar group, however, it was not statistically significant (24% vs 14%; p = 0.23). A higher proportion of patients in bipolar group did not have thermal artifacts when compared with monopolar group (27.5% vs 5%; p < 0.0001).

CONCLUSIONS

The operative risks of bipolar TURBT such as obturator jerk, bladder perforation, and blood loss are comparable with monopolar resection. However, less thermal artifacts in tissue samples obtained with bipolar resection may be helpful to the pathologist in interpretation of histopathologic findings.

34BetaE12 and Alfa-Methylacyl Coenzyme A Racemase (AMACR) Antibodies Better Than p63 Antibody Distinguish Normal and Neoplastic Glands in Prostatic Tissue With Thermal Artifacts

The occurrence of inked margins with crush artifact derived from the electrocauterization in radical prostatectomy and/or the presence of crushed areas with distorted glands in prostatic samples after transurethral resection of prostate (TURP) can induce a significant interobserver variability during histopathologic evaluation of specimens. The specific immunostaining for basal cell markers 34BetaE12 and p63 and for alfa-methylacyl coenzyme A racemase (AMACR) in neoplastic cells is commonly used as an ancillary tool to establish benign and malignant glands. In this study we carried out the immunohistochemical reactions for p63, 34BetaE12, and AMACR on 3 different and successive paraffin sections to discriminate malignant and benign prostatic glands, distorted and crushed by the thermal artifacts in 60 radical prostatectomies and 50 TURP samples. All prostatic acinar adenocarcinoma showed the loss of basal cell markers and expression of AMACR, whereas p63 failed to stain the basal cell layer in benign crushed prostatic glands. The same cauterized glands were steadily positive for 34BetaE12. The high percentage of p63 false negative cases in benign distorted and crushed glands could be explained by the thermal artifacts which might cause lack of p63 antigenicity. In contrast, the antigenicity of 34BetaE12 and AMACR seem not to be affected by cautery artifacts. Thus, in cauterized suspicious prostatic glands an immunohistochemistry panel including, p63, 34BetaE12, and AMACR or only 34BetaE12 is recommended. In addition, after the first evaluation with only p63, we suggest that a separate and confirmatory staining for 34BetaE12 is strongly recommended.

Bipolar plasma kinetic enucleation of non-muscle-invasive bladder cancer: Initial experience with a novel technique

Objective

To assess the effectiveness and safety of bipolar plasma kinetic energy for en bloc enucleation of non-muscle-invasive bladder cancer (NMIBC).

Patients and methods

In all, 46 patients diagnosed with suspected NMIBC were included. All patients were diagnosed using ultrasonography, computed tomography, and diagnostic cystoscopy, and then underwent bipolar plasma kinetic enucleation of bladder tumour (PKEBT). At the end of the procedure, all patients had a single-dose (40 mg in 40 mL saline) intravesical installation of mitomycin C (<6 h after bipolar PKEBT). Follow-up diagnostic cystoscopy was performed at 3, 6, and 12 months.

Results

The mean (SD) enucleation time was 17 (5.4) min, operative time was 27.9 (11.4) min, haemoglobin drop was 1.3 (0.9) g/dL, postoperative irrigation time was 1.7 (2.3) h, and hospital stay was 35.4 (13) h. There was intraoperative bleeding in three patients, with one requiring blood transfusion. There were no other perioperative complications. At the 1-month follow-up, six (13%) patients were diagnosed with residual tumour and underwent repeat bipolar PKEBT. The overall recurrence rate at 12 months’ follow-up was 15.2%.

Conclusion

Bipolar PKEBT is an effective procedure for managing NMIBC, as it preserves the entire lamina propria and detrusor muscle in well-intact specimens, with negligible perioperative complications.

Histomorphological features of resected bladder tumors: Do energy source makes any difference

Context:

The recent advent of bipolar energy in bladder tumor resection has raised many questions regarding density of current and its effect on histopathology of the resected transurethral resection of bladder tumor (TURBT) chips.

Aims:

The aim of this study is to evaluate the histomorphological features in resected bladder tumors comparing bipolar versus conventional (monopolar) energy.

Settings and Design:

Inclusion criteria were patients with primary presentation of carcinoma urinary bladder undergoing TURBT. The patients with prior resections were excluded as these could jeopardize the results of cautery artifacts.

Materials and Methods:

From February 2010 to December 2011, 61 patients with primary carcinoma bladder and meeting our inclusion criteria were compared. Group 1 (n = 31) underwent bipolar-TURBT (B-TURBT) and Group 2 (n = 30) monopolar-TURBT (M-TURBT). Two pathologists, who were blinded to the form of electrocautery used, examined the resected tissue. The degree of cautery artifact in each specimen was recorded. The severity of the cautery artifact was graded as absent, mild, moderate, or severe. The mean age, tumor size, and resection time were recorded in both groups.

Statistical Analysis Used:

Data were analyzed using SPSS 16. Data were compared in between groups using paired t-test and Pearson's Chi-square test. The significance level was set at 0.05.

Results:

The mean age, tumor size, and resection time were similar in between the two groups. The pathologists had no obscurity in reaching a correct diagnosis in all cases. The cautery artifacts were graded as absent in 10 (32.2%) and 8 (26.67%), mild in 12 (38.7%) and 11 (36.67%), moderate in 5 (16.1%) and 7 (23.33%) and severe in 4 (12.9%) and 5 (16.66%) cases, respectively in Group 1 and 2. There was no statistically significant histomorphogical dissimilarity between specimens according to the type of cautery used.

Conclusions:

Bladder tissue obtained from B-TURBT is of equivalent histomorphological feature as that of standard M-TURBT.

Comparison of deep biopsy tissue damage from transurethral resection of bladder tumors between bipolar and monopolar devices

Purpose

Bipolar energy has recently been used for transurethral resection of bladder tumor (TURBT). Although this modality is thought to be safe, there are some controversies concerning the pathologic accuracy of the biopsy specimens. We compared clinical efficacy, safety, and pathologic characteristics of deep biopsy specimens between bipolar and monopolar devices.

Materials and Methods

From January 2002 to June 2007, a total of 115 patients underwent TURBT with deep biopsy with the use of bipolar (bipolar group, n=64) or monopolar (monopolar group, n=51) devices. We retrospectively analyzed tumor size, tumor number, urine cytology, perioperative blood loss (postoperative changes in hemoglobin levels), complications, duration of catheterization, duration of hospitalization, pathologic stage, WHO grade, deep biopsy specimen thickness, and grade of thermal damage.

Results

There were no statistical differences in tumor size, tumor number, urine cytology, complications, duration of hospitalization, pathologic stage, or WHO grade between the two groups. Postoperative changes in hemoglobin levels were significantly lower in the bipolar group (p=0.038), and the duration of catheterization was shorter in the bipolar group (p=0.026). The deep biopsy specimen thickness was significantly thinner in the bipolar group (2.25±0.94 mm vs. 3.02±1.39 mm, p<0.05). The grade of thermal damage was not statistically different between the two groups (p=0.862).

Conclusions

In terms of clinical efficacy and safety, bipolar TURBT is comparable to monopolar TURBT, having advantages in perioperative blood loss and duration of catheterization. In addition, pathologic changes in deep biopsy after bipolar and monopolar TURBT are similar. Bipolar TURBT can be properly used for bladder tumors without pathologic error.

Bipolar technology for transurethral prostatectomy

Bipolar electrosurgical technology has gained worldwide attention with various companies introducing devices, such as the Gyrus PlasmaKinetic™ Tissue Management System (Gyrus ACMI, MN, USA) and the Olympus(®) UES-40 Surgmaster generator (Olympus, Tokyo, Japan), which is aimed at minimizing the morbidity of standard monopolar transurethral resection of the prostate (TURP), whilst also maintaining efficacy and durability. The Gyrus PlasmaKinetic System effectively controls bleeding, resulting in a clear operative field; it greatly reduces risk of transurethral resection syndrome, thus providing a new option among minimally-invasive surgical treatments for benign prostatic hyperplasia. In a meta-analysis of head-to-head comparisons between the monopolar and bipolar TURP, the operation times, transfusion rates, retention rates after catheter removal and urethral complications did not differ significantly. Irrigation and catheterization duration was significantly longer with monopolar TURP.

Comparison of transrectal ultrasound-guided biopsy of the prostate and transurethral resection of the prostate for detection of prostate cancer in patients with moderate lower urinary tract symptoms

BACKGROUND

To compare transrectal ultrasound (TRUS)-guided biopsy of the prostate and transurethral resection of the prostate (TURP) for detection of prostate cancer (PCa) in patients with moderate lower urinary tract symptoms (LUTS) by retrospective chart review.

METHODS

Between January 2004 and December 2008, a total of 520 patients, aged 50.3-81.5 years, with moderate LUTS (International Prostate Symptom Score, 8-19), and elevation of prostate-specific antigen (≥ 4 ng/mL), or abnormal findings by digital rectal examination, were enrolled for evaluation. All the patients were recommended to receive TRUS-guided biopsy of the prostate (TRUS biopsy group) or TURP (TURP group) due to the possibility of PCa, according to their choice after full explanation by the doctors.

RESULTS

There were 379 patients in the TRUS biopsy group and 141 in the TURP group. PCa was detected in 80 patients (21.1%) in the TRUS group and in 27 (19.1%) in the TURP group. Clinically localized PCa (T1-2N0M0) was found in 46 patients (57.5%) in the TRUS biopsy group and in 16 (59.3%) in the TURP group. Bone metastasis was noticed in 22 (27.5%) patients in the TRUS biopsy group and in 7 (25.9%) in the TURP group. The percentage of low-grade tumor was significantly higher in the TURP group than in the TRUS biopsy group (11.1% vs. 5%).

CONCLUSION

TURP was not superior to TRUS-guided biopsy of the prostate for detection of PCa in patients with moderate LUTS and prostate-specific antigen ≥ 4 ng/mL.

Technological advances in transurethral resection of the prostate: bipolar versus monopolar TURP

One of the most significant recent advancements in transurethral resection of the prostate (TURP) is the incorporation of bipolar technology. Bipolar circuitry allows TURP to be performed in a normal saline environment, which addresses a fundamental concern of conventional monopolar TURP (i.e., the use of hypo-osmolar irrigation). As a result, the risks of dilutional hyponatremia and transurethral resection (TUR) syndrome are eliminated, allowing for longer and safer resection. This review discusses the principles and applications of electrosurgery in conventional monopolar as well as new bipolar saline-based TURP systems. This review also addresses the positive impact on patient safety and resident training.