TRANSURETHRAL PROSTATECTOMY

Comparison of effectiveness of monopolar and bipolar transurethral resection of the prostate and open prostatectomy in large benign prostatic hyperplasia

PURPOSE

Transurethral resection of the prostate (TURP) is still considered the gold standard in the treatment of benign prostatic hyperplasia (BPH). However, open prostatectomy is indicated for prostate glands over 75 ml. There have been few reports concerning the use of TURP for large prostate glands over 100 ml. Herein we compared the effectiveness of monopolar TURP, bipolar TURP, and open prostatectomy in prostate glands larger than 100 ml.

MATERIALS AND METHODS

We reviewed the data of 48 patients with prostate glands larger than 100 ml. A total of 19, 17, and 12 patients underwent monopolar TURP (group A), bipolar TURP (group B), or open prostatectomy (group C), respectively. Preoperative International Prostate Symptom Score (IPSS), maximal flow rate (Qmax), prostate volume, resected tissue volume, resection velocity, and operative time were documented. Postoperative hemoglobin, serum sodium change, hospital stay, and postoperative 6-month IPSS and Qmax were evaluated.

RESULTS

The prostate volumes did not differ significantly among the three groups. Operative time was similar in the two TURP groups, but open prostatectomy required a longer operative time. There was no significant difference in the resected prostate tissue or resection velocity between the two TURP groups. There was a marked decrease in postoperative serum sodium in the monopolar group compared with the other two groups. Among the groups, bipolar TURP required a shorter hospitalization. Postoperative IPSS, quality of life (QoL), and Qmax improved significantly in all groups.

CONCLUSIONS

Even for large prostate glands, the results of this study suggest that bipolar TURP is an effective and safe operation owing to the significant improvements in voiding symptoms, shorter hospitalization, and fewer complications such as transurethral resection syndrome.

Changing aspects in the evaluation and treatment of patients with benign prostatic hyperplasia

Lower urinary tract symptoms are a common clinical symptom among men and a frequent reason for referring to a urologist. The most important information comes from the patient history because evaluation of symptoms is fundamental in the diagnosis and treatment planning for LUTS. Other aspects of the initial evaluation, such as the physical examination and initial laboratory values, can provide valuable additional information about the severity of the disease and the need for treatment. If treatment is warranted based on this information, additional diagnostic tests may be appropriate to set a pretreatment baseline, rule out other conditions, and plan treatment approach. Fortunately, a variety of effective medical and surgical treatments are available to treat this common disease.

A 3-year follow-up of a prospective randomized trial comparing transurethral electrovaporization of the prostate with standard transurethral prostatectomy

OBJECTIVE

To compare the safety, efficacy and durability of transurethral electrovaporization of the prostate (TUVP) with standard transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

In all, 104 patients admitted from the waiting list for surgery for BPH were randomized to either TUVP (52 patients, mean age 67.5 years) or TURP (52 patients, mean age 70.2 years); 51, 47 and 40 patients in each arm completed 1, 2 and 3 years of follow-up, respectively. Patients were assessed at baseline and during the follow-up using the International Prostate Symptom Score (IPSS), the associated quality-of-life score (QoL), postvoid residual volume (PVR) and maximum urinary flow rate (Qmax).

RESULTS

Both groups had comparable mean IPSS, QoL, Qmax and PVR at baseline. The mean (SD) values for TUVP and TURP, respectively, at 3 years showed a significant and maintained improvement in IPSS, at 4.1 (3.3) and 7.1 (6.2) (P = 0.01), in QoL, at 1.0 (0.9) and 1.6 (1.4) (P = 0.04), and in Qmax, at 22.2 (8.5) and 18 (7.1) mL/s (P = 0.02), with decreases in PVR of 30 (38) and 21.9 (26.2) mL (P = 0.27). The re-operation rate in each group was 4% during the first year, 4% during the second year and 5% during the third year. After surgery and at 1, 2 and 3 years of follow-up, impotence was reported in 17% of the TUVP group and 11% of the TURP group (P = 0.49), and retrograde ejaculation in 72% of the TUVP group and 89% of the TURP group (P = 0.47).

CONCLUSION

The 3-year follow-up results confirm that TUVP is as effective as standard TURP in the treatment of moderate-sized BPH. The long-term side-effects and complications were comparable and the initial improvement was maintained over 3 years in most patients in both groups.

[Incidental prostatic cancer]

OBJECTIVE

To evaluate the incidence of incidental prostate cancer and PSA ability to predict its presence.

MATERIAL AND METHOD

Retrospective study of 862 patients undergoing prostate surgery between 1994 and 1997, both inclusive. Digital rectal examination provided no suspicion of neoformation. Mean age was 68 +/- 7.5 years. Mean PSA, 8.3 +/- 10 ng/ml (Hybritech). 15% patients had previously undergone at least one ultrasound-guided biopsy in the peripheral area. 55% patients underwent retropubic surgery and the remaining 45% prostate transurethral resection. Ultrasound prostate volume for both patient groups was 107 +/- 63 cc and 45 +/- 25 cc, respectively.

RESULTS

Incidental cancer was found in 6% patients; 65% were T1a and 35% T1b. Mean PSA concentration in cancer patients was almost significantly (p = 0.05) higher than in patients with BPH. Patients with PSA > 10 ng/ml presented a significantly higher incidence of cancer (p = 0.02). Patients with previous prostate biopsy showed a cancer incidence rate of 12% versus 5% patients with no previous biopsy (p = 0.001).

CONCLUSIONS

Incidence of incidental prostate cancer was 6%. PSA was not a good predictor of incidental cancer. Patients with PSA > 10 ng/ml, showed higher incidence of cancer. Younger patients with PSA > 10 ng/ml, and at least one negative biopsy of the peripheral area should undergo biopsy of the transitional area prior to surgery.

Atherosclerosis-induced chronic ischemia causes bladder fibrosis and non-compliance in the rabbit

PURPOSE

The overall goal was to determine whether chronic ischemia and hypercholesterolemia interfere with bladder function and structure. The roles of atherosclerosis-induced chronic ischemia and hypercholesterolemia in bladder fibrosis and non-compliance were studied in the rabbit. The relationship between ischemia-induced changes in the expression of transforming growth factor-beta1 (TGF-beta1) and basic fibroblast growth factor (bFGF) and the severity of bladder fibrosis was also investigated.

MATERIALS AND METHODS

Male New Zealand White rabbits were divided into chronic bladder ischemia (CBI, n = 11), hypercholesterolemia (Hch, n = 8) and control (n = 8) groups. The CBI group underwent balloon endothelial injury of the iliac arteries and received a 0.5% cholesterol diet. The Hch group received a 0.5% cholesterol diet alone. The control group was placed on a regular diet. After 16 weeks, iliac artery and bladder wall blood flow measurements, cystometrograms (CMG) and aorto-iliac arteriograms were obtained in all animals. Iliac arteries and bladder tissues were processed for histological staining and computer-assisted histomorphometric image analysis. The expressions of TGF-beta1 and bFGF in bladder tissue were determined by immunohistochemical staining utilizing monoclonal antibodies.

RESULTS

At 16 weeks, arteriography and histology showed significant diffuse atherosclerotic occlusive disease of the aorto-iliac arteries in the CBI group. Iliac artery and bladder wall blood flows were significantly decreased in the CBI group compared with the Hch and control groups. Atherosclerosis-induced CBI shifted the volume-pressure curve to the left and caused severe bladder fibrosis. Hypercholesterolemia also caused fibrosis and non-compliance but to a much lesser extent compared with those caused by CBI. In histomorphometry, the percentage of detrusor smooth muscle was moderately decreased in the Hch group and severely decreased in the CBI group compared with the control group. In immunohistochemical stains of bladder tissues, bFGF expression was similar in the three groups of animals. TGF-beta1 expression was significantly greater in bladder tissues from the CBI group compared with the Hch and control groups.

CONCLUSIONS

Our studies show that atherosclerosis-induced chronic ischemia increases TGF-beta1 expression in the bladder leading to fibrosis, smooth muscle atrophy and non-compliance. Hypercholesterolemia also interferes with bladder structure and compliance but to a significantly lesser extent compared with CBI. Our studies suggest that arterial insufficiency and hypercholesterolemia, common aging-associated disorders, may play important roles in the pathophysiology of voiding dysfunction in the elderly.

Combination of pneumatic lithotripsy and transurethral prostatectomy in bladder stones with benign prostatic hyperplasia

We present our experience with combined pneumatic lithotripsy and transurethral resection of the prostate (TURP) in 52 patients with bladder stone(s) and benign prostatic hyperplasia (BPH). All stones were fragmented with the pneumatic Swiss Lithoclast. Pneumatic lithotripsy and evacuation caused a mean increase of 16 minutes in operating time. No complications, other than mild hematuria, were observed intraoperatively because of pneumatic lithotripsy. We observed early and long-term complications related to the procedure in 13% of patients. The average hospital stay was 3.2 days. The combination of pneumatic lithotripsy and TURP appears to be an effective, safe, and economical treatment method for patients with bladder stone(s) and BPH.

Transurethral resection of the prostate versus transurethral electrovaporization of the prostate: a blinded, prospective comparative study with 1-year followup

PURPOSE

Transurethral electrovaporization of the prostate has been increasingly used as a surgical adjunct in the management of men with lower urinary tract symptoms. In this prospective study we compare the safety and efficacy of transurethral resection of the prostate and electrovaporization.

MATERIALS AND METHODS

We compared 32 consecutive men (mean age 68.9 years) with lower urinary tract symptoms treated by transurethral electrovaporization of the prostate to a cohort of 32 men (mean age 72.8 years) treated by transurethral resection of the prostate. Parameters of evaluation included American Urological Association symptom score, peak urinary flow rate, adverse events, including serial changes in serum hematocrit and sodium, operative time, postoperative catheterization time, hospitalization time and days lost from work. The data were analyzed by an investigator who was blinded to which procedure was performed.

RESULTS

A total of 61 patients were evaluable for followup at 1 year. None required retreatment. At 1 year symptom score decreased 12.8 (66% of patients) and 12.2 (67%) and peak urinary flow increased 9.7 ml. per second (135%) and 11.3 ml. per second (136%) for electrovaporization and resection, respectively, (p <0.001). Operative time was significantly longer with electrovaporization than with resection (47.6 +/- 17.6 versus 34.6 +/- 11.2 minutes, p <0.003). Catheterization time (67.4 +/- 13.6 versus 12.9 +/- 4.6 hours), hospitalization time (2.6 +/- 0.9 versus 1.3 +/- 0.5 days) and days lost from work (18.4 +/- 7.6 versus 6.7 +/- 2.1) were significantly greater for resection than electrovaporization, respectively. There were no major complications in the electrovaporization group while in the resection group 1 patient required transfusion (5 units) and in 1 a clinical transurethral resection syndrome developed. Potency and retrograde ejaculation were normal in 18 of 18 patients (100%) and 13 of 17 (76%) after resection and 19 of 20 (95%) and 17 of 20 (85%) after electrovaporization.

CONCLUSIONS

The results indicate that transurethral resection and transurethral electrovaporization of the prostate are effective in reducing lower urinary tract symptoms with similar preservation of sexual function. Both significantly improve peak urinary flow, although resection to a greater degree. Postoperative morbidity, catheterization time, hospitalization time and days lost from work were significantly less, and operative time was significantly longer with electrovaporization. Further studies are underway to determine the long-term durability of response of transurethral electrovaporization of the prostate relative to transurethral resection.

Transurethral electrovaporization of the prostate: one-year experience

OBJECTIVES

To determine the safety and efficacy of transurethral electrovaporization of the prostate (TVP) in men with lower urinary tract symptoms.

METHODS

A prospective trial of 114 consecutive patients who underwent TVP since August 1994 was conducted. The mean follow-up period was 12.3 months. Parameters evaluated included American Urological Association symptom score (Sx), peak urinary flow rate (Qmax), operative time, postoperative catheterization time, length of hospital stay, and loss of days from work.

RESULTS

Of the 109 men available for follow-up, Sx decreased from 16.7 to 7.3, 6.5, 6.3, and 5.4 at 3, 6, 12, and 18 months, respectively (P < 0.001), whereas Qmax increased from 7.9 to 14.8, 15.6, 16.7, and 16.5 mL/s at 3, 6, 12, and 18 months, respectively (P < 0.001). Mean catheterization time was 10.4 hours; mean hospital period was 0.9 days, and average loss of days from work was 5.6. Complications included intermittent postoperative hematuria in 65 patients (57%). Clot retention in 6 (5%), and bulbar urethral stricture in 2 (2%). Of 74 men who were potent preoperatively, none had postoperative erectile dysfunction; retrograde ejaculation was noted in 62 (84%). Significant postoperative irritative symptoms were reported in 10 men (9%).

CONCLUSIONS

On the basis of 1-year follow-up data, this study demonstrates that TVP is a safe and effective modality for treating lower urinary tract symptoms. However, longer, prospective, blinded studies are needed to determine efficacy relative to transurethral resection of the prostate.