Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc

Shedding light on polypragmasy of pain after transurethral prostate surgery procedures: a systematic review and meta-analysis

PURPOSE AND OBJECTIVE

To evaluate and compare the incidences of post-operative pelvic pain (PPP) in patients undergoing ablation, enucleation and conventional transurethral resection of the prostate (TURP).

METHODS

A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Using MEDLINE via PubMed and Cochrane CENTRAL, randomised control trials (RCTs) and observational studies reporting PPP rates post-ablation, enucleation or TURP were identified. The risk of biases (RoB) in RCTs and observation studies were assessed using the Cochrane RoB1.0 tool and the Newcastle-Ottawa Scale, respectively.

RESULTS

62 studies were included for qualitative analysis, while 51 of them reported number of patients with PPP post-intervention. Three observational studies and 13 RCTs compared the rates of PPP in patients undergoing ablation, enucleation or TURP. The most reported types of PPP are dysuria, abdominal pain and irritative symptoms. The pooled incidence of PPP at 1-month follow-up in patients undergoing ablation, enucleation and TURP were 0.15 (95% CI 0.10-0.22), 0.09 (95% CI 0.04-0.19 and 0.10 (95% CI 0.06-0.15), respectively. PPP is no longer prevalent at 3-months and onwards post-operatively. Ablation is associated with a higher risk of PPP than enucleation (RR 2.19, 95% CI 1.04-4.62) and TURP (RR 2.40, 95% CI 1.03-5.62) in observational studies but not RCTs; and there were no significant differences in the rates of PPP upon comparison of other modalities.

CONCLUSION

PPP is common after transurethral benign prostatic hyperplasia surgery. Patients undergoing ablation had a higher rate of post-intervention PPP than those undergoing enucleation and TURP in observational studies.

Lasers are superfluous for the surgical management of benign prostatic hyperplasia in the developing world

Lasers have been given much hype as regards their use in surgical management of benign prostatic hyperplasia (BPH). Transurethral resection of prostate (TURP), especially with its modifications still remains the gold standard treatment for BPH, owing to its efficacy and proven advantages over laser prostatectomy. Cost, unproven long-term durability, steep learning curve, and no advantages of laser prostatectomy over TURP and its modifications, make lasers superfluous in the surgical management of BPH in developing countries.

Transurethral vapor resection of prostate is a good alternative for prostates >70 g

BACKGROUND AND PURPOSE

The morbidity associated with transurethral resection of the prostate (TURP) for large-volume prostates has prompted attempts to modify the standard equipment and techniques. Patients with large prostates (>70 g) need longer operative time, and have greater blood loss and higher irrigant fluid requirements; therefore, the traditional surgical recommendation for the management of benign prostatic hyperplasia (BPH) >70 g is open surgery. We assessed the effectiveness and safety of transurethral vapor resection of the prostate (TUVRP) for the management of prostate glands with a volume >70 g.

MATERIALS AND METHODS

Eighty-nine patients with a diagnosis of BPH who had a prostate volume >70 grams determined by abdominal ultrasonography underwent TUVRP between July 2002 and March 2006. Preoperative evaluation included assessment of International Prostate Symptom Score (IPSS), prostate volume, postvoid residual (PVR), and maximum flow rate (Q(max)). Intraoperative and postoperative parameters, including operative time, total irrigant requirement, blood loss, duration of postoperative catheterization, hospital stay, and complications were also analyzed.

RESULTS

The mean prostate volume for the 89 patients was 83.3 g (range 70-169 g). The mean age was 67.25 years (range 55-87 yr). Symptom duration varied from 2 months to 7 years. Twenty-two patients used a catheter preoperatively. The mean IPSS score, Q(max), and PVR were 23, 7.1 mL/sec, and 116 mL, respectively. The mean operative time was 64 minutes, and mean irrigant used was 21.4 L. The mean weight of resected tissue was 31.3 g. The average postoperative catheter duration was 2.25 days. Complications included transient dysuria in 11 patients, hyponatremia in two patients, and urethral stricture in two patients. No patient required a blood transfusion postoperatively. The effectiveness as assessed at 6 months was IPSS 5.1, Q(max) 22.5 mL/sec, and PVR not significant.

CONCLUSIONS

TUVRP is safe and effective in patients with large prostates (>70 g) with minimal complications and faster postoperative recovery. This technique helps to avoid the morbidity associated with open surgery.

Benignes Prostatasyndrom (BPS)

Today, the surgical treatment of the benign prostatic syndrome (BPS) often follows a course of drug treatment. Besides conventional transurethral resection of the prostate (TURP), which has represented the standard therapeutic option for decades, and its in part significant modifications ("vaporizing resection"; bipolar resection), much of the interest has shifted to alternative instrumental procedures like transurethral microwave therapy (TUMT), transurethral needle ablation of the prostate (TUNA) or several laser techniques. By reviewing the current literature, preferably from randomized controlled trials, these different procedures are critically assessed. Moreover, the present role of open prostatectomy is discussed.

Transurethral Electrovapor Resection versus Standard Transurethral Resection Treatment for a Large Prostate: A 2-Year Follow-Up Study Conducted in Taiwan

INTRODUCTION

Those patients featuring a large prostate and undergoing transurethral resection typically face a longer duration of surgery, they have a higher degree of hemorrhage and a higher irrigant volume required for the procedure, and they tend to reflect a higher incidence of morbidity than is the case for a small prostate. We report on the relative safety and efficacy of transurethral electrovapor resection of the prostate (TUVRP) as compared with standard transurethral resection of the prostate (TURP) for Taiwanese patients having a prostate size >50 ml.

PATIENTS AND METHODS

Seventy-six symptomatic benign prostatic hyperplasia patients featuring a prostate size >50 ml were randomized and underwent either TUVRP using wedge loop or standard TURP. Perioperative parameters, treatment outcome, and adverse events associated with the surgical procedure are assessed herein.

RESULTS

Mean operation time, changes in hemoglobin levels, resected prostate weight, perioperative irrigant volume needed, and incidences of recatheterizations and readmissions, all differed significantly when the two surgical procedures were compared. The average expense differences for the two procedures were impressive (p < 0.0001). No postoperative intergroup sexual dysfunction differences were noted. Clinical improvements following either TUVRP or TURP were significant and sustained for at least a period of 2 years. Intergroup comparison of International Prostate Symptom Score, quality of life, peak flow rate, and postvoid residual volume revealed no significant differences at 2 years (p = 0.45, 0.48, 0.12, and 0.29, respectively). The need for postoperative medical retreatment and/or reoperation did not differ significantly between the two groups (p = 0.62 and p = 0.56, respectively, at 6 months and p = 0.47 and p = 0.48, respectively, at 2 years).

CONCLUSIONS

The TUVRP procedure offers advantages as regards a number of perioperative parameters when compared with the TURP procedure, and it seems that TUVRP might provide at least an equivalent treatment outcome as is the case for TURP.

Techniques and long-term results of surgical procedures for BPH

OBJECTIVE

To provide an overview on the current status of the long-term outcomes of instrumental treatment options for patients with lower urinary tract symptoms that are suggestive of bladder outlet obstruction.

METHODS

Based on MEDLINE database searches, we performed a systematic review of the literature with a focus on peer-reviewed articles about surgical benign prostatic hyperplasia (BPH) therapy published between 2000 and 2005. Special emphasis was given to randomized controlled trials on long-term outcome with a minimum follow-up of five years.

RESULTS

Data on clinical outcome with a follow-up of more than 10 years are available for open prostatectomy (OP), transurethral resection of the prostate (TURP), and transurethral microwave therapy. Studies with a follow-up of at least five years are obtainable for transurethral incision of the prostate, transurethral vaporisation of the prostate, transurethral needle ablation of the prostate, Holmium:YAG laser enucleation of the prostate, potassium-titanyl-phosphate laser vaporization of the prostate, and interstitial laser coagulation of the prostate. Among these long-term reports, OP and TURP provide the most durable results.

CONCLUSIONS

The most substantial long-term data on surgical procedures for BPH are available for conventional therapy, namely TURP. Concerning the techniques that have emerged within the last decade, there is clear evidence that the outcomes are more sustainable for truly ablative and thus deobstructing procedures.

Comparison of standard transurethral resection, transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g

OBJECTIVES

To compare the safety and efficacy of two alternatives for surgically treating symptomatic benign prostatic hyperplasia (BPH), i.e. transurethral vapour resection of the prostate (TUVRP) and holmium laser enucleation of the prostate (HOLEP), with transurethral resection of the prostate (TURP), the standard surgical therapy, as treating large prostates is associated with greater morbidity, and to date there is no simultaneous comparison of these three methods.

PATIENTS AND METHODS

We prospectively randomized 150 patients (50 in each group) with BPH and glands of >40 g to undergo either TURP, TUVRP or HOLEP. The evaluation before treatment included urine culture, serum prostate specific antigen (PSA) level estimation, the International Prostate Symptom Score (IPSS), peak urinary flow rate (Q(max)), and transabdominal ultrasonography to estimate prostate size and postvoid urine residue (PVR). The operative duration, blood loss, resected tissue weight, change in levels of haemoglobin and serum sodium, nursing contact time, duration of catheterization, and complications were noted. After surgery patients were reassessed for the IPSS, Q(max) and PVR at 6 months and 1 year.

RESULTS

The patients in all three groups had comparable characteristics before surgery. The mean operating duration and intraoperative irrigant used for TUVRP was less than for HOLEP or TURP, and blood loss with HOLEP and TUVRP was less than with TURP (all P < 0.001). Postoperative irrigation, nursing contact time, and catheter duration were significantly less for HOLEP than TURP or TUVRP, and for TUVRP than TURP. At follow-up, patients in all groups had a significant improvement from baseline in IPSS, Q(max,) and PVR, but the differences between the groups were not significant at 6 months or 1 year.

CONCLUSIONS

HOLEP and TUVRP are both acceptable alternatives to TURP for treating large prostate glands, with less perioperative morbidity and comparable efficacy at 6 months and 1 year.

Vaporization of the prostate

PURPOSE OF REVIEW

Transurethral resection of the prostate remains the treatment of choice for men with symptomatic benign prostatic enlargement. Concerns regarding the morbidity of this operation have led to the development of alternative surgical procedures. Vaporization of the prostate can be achieved using either laser energy or electrosurgery. The advantage of these approaches is that they allow tissue removal with reduced blood loss. Vaporization techniques have been around for almost a decade and more powerful lasers have recently become available. This has led to a minor resurgence in interest in laser vaporization. We reviewed articles on all forms of vaporization of the prostate published in the 12 months from August 2002.

RECENT FINDINGS

Electrovaporization of the prostate is an effective treatment for men who require surgery for benign prostatic enlargement. The results are well maintained at 5 years follow-up with low reoperation rates. Scanty data are available for the Gyrus (Gyrus Medical Ltd, Cardiff, Wales) bipolar electrovaporization system but preliminary results suggest there is no significant advantage over transurethral resection of the prostate. Early forms of laser vaporization of the prostate are not as effective as either transurethral resection of the prostate or transurethral electrovaporization of the prostate and have a higher retreatment rate. Newer, more powerful lasers have been recently introduced with encouraging initial results in small numbers of patients.

SUMMARY

Electrovaporization of the prostate is a safe, effective and durable alternative to transurethral resection. Early laser vaporization techniques have high retreatment rates, which limit their cost-effectiveness. Few data are yet available on high-powered lasers for bladder outflow obstruction. Whether any vaporization technique will stand the test of time is unclear.