Completeness and efficiency of prostate tissue removal: loop resection compared with a new operative technique of transurethral electrovaporization

Benign prostatic hyperplasia and lower urinary tract symptoms in African Americans and Latinos: treatment in the context of common comorbidities

Benign prostatic hyperplasia (BPH), with accompanying lower urinary tract symptoms (LUTS), is a common age-related condition associated with a variety of cardiovascular, metabolic, and sexual comorbidities. While there is debate, in the United States race and ethnicity, particularly among Latinos and African American men, may confer an elevated risk for BPH and LUTS. Hypertension and deficits in sexual health are more common among African American men, while both Latino and African American men experience more metabolic-related disorders, including diabetes mellitus, insulin resistance, and end-stage renal disease. Although socioeconomic factors may play a significant role in these disparities, pathological and genetic variations between patients of different races and ethnicities are additional factors in the development of BPH. The proliferation of available treatments for BPH demands greater discernment in treatment selection, and comorbidities represent a central criterion upon which choice of appropriate BPH therapy should be based. This article reviews common comorbidities in minority populations, describes challenges to BPH management, and discusses medical, surgical, and phytotherapeutic treatment options.

Transurethral electrovaporization vs transurethral resection for symptomatic prostatic obstruction: a meta-analysis

OBJECTIVE

To compare the effectiveness and safety of transurethral electrovaporization (TUEVP) and transurethral resection of the prostate (TURP) for symptomatic bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH).

METHODS

Publications comparing TUEVP and TURP were identified systematically using Medline, the Cochrane Controlled Trial Register and other database search engines. From a total of 25 randomized controlled trials, 20 studies met the predefined inclusion criteria and were subjected to a formal meta-analysis. Primary endpoints were symptom scores and peak urinary flow rates. Secondary endpoints included transfusion requirements, operative time, duration of catheterization, incidence of adverse events, hospital stay, re-operation rates and sexual dysfunction.

RESULTS

After 1 year of follow-up there was no significant difference between TUEVP and TURP in urinary symptom scores and peak urinary flow rates. There was heterogeneity at baseline for both primary outcome measures. TUEVP was associated with significantly lower transfusion requirements, a shorter catheterization time, and a shorter length of stay. TURP was associated with a lower risk of urinary retention afterward and re-operation than was TUEVP.

CONCLUSION

This formal meta-analysis suggests that both TUEVP and TURP in patients with symptomatic bladder outlet obstruction provide comparable improvements in maximum urinary flow rates and symptom scores. While comparative analysis is limited by the methodological shortcomings of the underlying studies and the short follow-up, both TURP and TUEVP may offer distinct advantages in terms of secondary outcomes. A future, well-designed, multicentre randomized clinical trial with extended follow-up may be needed to better define the role of vaporization techniques in treating patients with symptomatic BPH.

Rotoresect for bloodless transurethral resection of the prostate: a 4-year follow-up

OBJECTIVE

To report the results and long-term follow-up of transurethral resection of the prostate (TURP) with a new resection device, the Rotoresect (Karl Storz, Tuttlingen, Germany).

PATIENTS AND METHODS

Most endoscopic resection techniques for benign prostatic tissue aim for high ablation rates and minimal bleeding. Available resection electrodes are effective, but cause high blood loss (loop electrode), or less bleeding but poorer ablation rates (electrovaporization). To resolve these conflicts the Rotoresect was developed in 1995; it consists of a specially designed rotating resection electrode, driven by a micromotor, and a high-frequency current to enable simultaneous coagulation, vaporization and mechanical tissue removal during resection. To date, 84 patients with benign prostatic hyperplasia have had their prostate resected with this device (mean prostate size 46.0, sd 18.4 mL) and have been assessed for up to 4 years.

RESULTS

During resection there was very little bleeding, with no significant changes in haemoglobin or sodium levels. The mean (sd) duration of catheterization was 1.4 (1.1) days; the urinary peak flow rate was improved from 9.7 (3.2) to 24.2 (8.23) mL/s and the residual urine volume reduced from 187.3 (109.6) to 22.7 (19.5) mL. The International Prostate Symptom Score and quality-of-life index were both improved, from 24.0 (7.5) to 4.1 (2.7), and 4.2 (3.2) to 0.8 (0.9), respectively. Overall the results were stable during the 4 years of follow-up.

CONCLUSION

The Rotoresect combines the advantages of standard resection (high ablation rate) by actively rotating the resection electrode, and the haemostatic effect of electrovaporization (minimal blood loss) by simultaneous tissue coagulation and vaporization.

Electrovaporization of prostate at power settings below 100 W

BACKGROUND AND PURPOSE

Prostate electrovaporization has usually been performed at high power settings in the pure cut mode, using traditional electrosurgical generators. However, this practice is empirically based on the fact that a vaporization electrode is larger than a cutting wire loop. The role of the electrosurgical unit (ESU) in prostate electrovaporization has not been studied in detail.

METHODS

In this Phase II cohort comparison study, we evaluated two different ESUs, coupled to the most clinically efficient vaporization roller electrode available in our opinion, to determine the lowest panel power settings that permit consistent tissue removal despite the desiccation normally produced during electrovaporization.

RESULTS

One of these ESUs, the Excalibur Plus, permitted prostate electrovaporization at panel settings below 100 W for the first time, without compromising satisfactory early clinical outcomes. In a small number of cases, the spiked VaporTrode-Force 2 combination permitted effective electrovaporization at a lower power setting (180 W) than has previously been described when this ESU was coupled with the grooved VaporTrode, regardless of prostate size. During bench tests, a comparison of the actual power output curves in the clinically effective panel power setting range for each ESU revealed that the Force 2 overestimated the actual power output as impedance increased, while the Excalibur Plus underestimated it. This difference may explain why tissue could be vaporized at such low panel settings without the use of computer-controlled technology.

CONCLUSION

These findings indicate a potential for improving the safety and efficiency of tissue clearance during prostate electrovaporization through future modifications in monopolar electrode design coupled with use of a generator that can either maintain or slowly increase actual power output as impedance increases at low panel settings. A Phase III clinical study would be justified on the basis of our preliminary results.