Bipolar vaporization of the prostate: is it ready for the primetime?

Network meta-analysis of the treatment safety and efficacy of different energy systems in prostate vaporization

Many clinical trials and meta-analyses have examined vaporization with different energy instruments has been recognized by the American Urological Association (AUA) and the European Association of Urology (EAU) as a promising treatment for benign prostate hyperplasia. However, there is still a lack of evidence for a network comparison between different vaporization devices. The PubMed, Embase, Cochrane and Web of Science databases were searched to identify randomized controlled trials (RCTs) of different energy systems for prostate vaporization. Pairwise and network meta-analyses (NMA) were performed to analyze the outcome regarding surgery time, complications, short-term maximum urine flow rate (Qmax), and long-term Qmax. The Stata software was used for paired meta-analysis. A Bayesian NMA model with ADDIS software was applied to achieve the indirect comparison of different energy systems. Node-splitting analysis and inconsistency factors were used to test inconsistency for closed-loop indirect comparison. Fifteen studies were included in this study, involving three types of energy systems used in prostate vaporization: diode laser (wavelength: 980 nm, power: 200-300 W, mode: continuous), green-light laser (wavelength: 532 nm, power: 80-180 W, mode: continuous), and bipolar plasma vaporization (bipolar electrode, power: 270-280 W, mode: pulsed). In the conventional paired meta-analysis, significantly better short-term efficacy was found in green light laser vaporization, while no significant difference was detected in other parameters. According to the results of the NMA, a greenlight laser is recommended for prostate vaporization rather than the other two systems. When considering operation time, overall complications, short-term Qmax, and long-term Qmax, there were no significant differences among green-light laser vaporization, diode laser vaporization, and bipolar vaporization in BPH treatment. However, according to the probability ranking and benefit-risk analysis results, the green-light laser might be the best energy system for prostate vaporization in BPH treatment.

Recurrent vesicourethral anastomotic stenosis following treatment for prostate cancer: an effective endoscopic treatment using bipolar plasma button and triamcinolone

PURPOSE

To evaluate the efficacy of deep bladder neck incision plus adjuvant Triamcinolone in the treatment of recurrent vesicourethral anastomotic stenosis following surgical treatment for prostate cancer.

MATERIALS AND METHODS

A retrospective review of patients undergoing bladder neck incision from 2013 to 2019 was conducted. Patients who had previously undergone surgical treatment for prostate cancer and had failed treatment for bladder neck contracture were included.

RESULTS

Twenty patients underwent deep bladder neck incision (BNI) with plasma button and adjuvant injection with a patency rate of 85%. Complete obliteration portended worst prognosis with 100% recurrence.

CONCLUSIONS

Deep BNI with triamcinolone is a minimally morbid alternative for treatment of refractory vesicourethral anastomotic contractures.

Bipolar vaporization of the prostate may cause higher complication rates compared to bipolar loop resection: a randomized prospective trial

INTRODUCTION

Transurethral resection of the prostate (TURP) by resection loop or vaporization button is becoming a standard of care due to its better safety profile (less bleeding and less incidence of TUR syndrome). However, there are published data showing bipolar vaporization may be associated with increased late complications. In this study, we compared results of bipolar TURP using the resection loop versus vaporization button for treatment of benign prostatic hyperplasia (BPH) to determine the relative safety profile.

PATIENTS AND METHODS

Between January 2013 and March 2014, 89 patients with BPH were randomized to surgical intervention either by Olympus (Gyrus) Bipolar loop TURP or Olympus (Gyrus) Bipolar button vaporization. Inclusion criteria were; BPH with Q-max < 10 ml/s, IPSS  > 18 and prostate volume > 40 g. All patients were evaluated preoperatively and at 1, 3 and 9 months. Evaluation included IPSS, uroflowmetry, prostate volume by ultrasound. Clavien complications and operative time were recorded. Statistical analysis was done using Statistical Package of Social Science (SPSS) version 17 software.

RESULTS

44 patients were included in bipolar TURP and 45 patients in vaporization arm. Preoperative mean prostate volume (59 g versus 58 g, p = 0.52) and mean IPSS (19 versus 20, p = 0.38) were equivalent in both groups. Vaporization was associated with a significant increase in operative time (mean of 81 ± 15 min range 40-110 versus 55 ± 10 min range 30-70 min, p < 0.001), less blood loss (0.8% versus 2.0% drop in hemoglobin, p < 0.001) but increased postoperative urinary frequency (80% versus 50%, p < 0.001), hematuria with clots up to 4 weeks post surgery (20% versus 2%, p < 0.001) and postoperative urethral stricture (11% versus 0%, p < 0.001). Both techniques improved urine flow with Q-max (17 ml/s versus 18 ml/s p = 0.22). Prostate volume (32 g versus 31 g, p = 0.31) and IPSS (6 versus 5, p = 0.22), were comparable in both treatment arms.

CONCLUSIONS

Bipolar vaporization of the prostate, despite being a technically robust, speedy and with less intraoperative bleeding, appears to be associated with increased postoperative irritative symptoms, increased late-onset postoperative bleeding and high urethral stricture rates.

Comparison of Short-Term Outcomes between Button-Type Bipolar Plasma Vaporization and Transurethral Resection for the Prostate: A Systematic Review and Meta-Analysis

Background: Previous meta-analysis evaluated a limited number of parameters regarding the comparison of BTPV and TURP for BPH. Method: PubMed, Embase and Cochrane Library were searched for literature comparing BTPV with TURP. Data of efficacy (IPSS, Qmax, PVR and QoL) and safety were extracted and evaluated using either SMD or OR with 95% CI. All analyses were performed by RevMan 5.3. Results: Eleven trials with 1690 patients were selected. Compare to BTPV, TURP had better 6-month IPSS (SMD=0.36, 95% CI 0.08 to 0.63), better 1- (SMD=-0.38, 95% CI -0.63 to -0.12), 6- (SMD=-0.73, 95% CI -0.99 to -0.46) and 12-month Qmax (SMD=-0.47, 95% CI -0.85 to -0.10), better 6-month PVR (SMD=1.18, 95% CI 0.87 to 1.48), as well as better 3- (SMD=-0.24, 95% CI -0.48 to -0.01) and 6-month QoL (SMD=-0.62, 95% CI -0.91 to -0.33). However, BTPV had shorter catheterization time (SMD=-0.96, 95% CI -1.12 to -0.79) and hospital stay (SMD=-0.71, 95% CI -0.89 to -0.53), less hemoglobin decrease (SMD=-1.09, 95% CI -1.27 to -0.91) and virtually shorter operation time (SMD=-0.15, 95% CI -0.31 to 0.01). Moreover, BTPV had fewer occurrence of overall complications (OR=0.52, 95% CI 0.40 to 0.69), Clavien III-IV complications (OR=0.61, 95% CI 0.37 to 1.02), blood transfusion (OR=0.25, 95% CI 0.09 to 0.69), hematuria (OR=0.27, 95% CI 0.13 to 0.56) and capsular perforation (OR=0.19, 95% CI 0.08 to 0.48). Subgroup analysis indicated BTPV and bipolar TURP had similar total complications (OR 1.08, 95% CI 0.40-2.88, P=0.88) and Clavien III-IV complications (OR 1.42, 95% CI 0.36-5.57, P=0.61) and blood transfusion rate (OR 0.28, 95% CI 0.04-1.73, P=0.17). Conclusion: Both TURP and BTPV could significantly improve IPPS, Qmax, PVR and QoL. TURP had slightly better short-term efficacy, while BTPV had better safety. However, subgroup analysis found bipolar TURP and BTPV had similar safety.

Plasmakinetic resection technology for the treatment of benign prostatic hyperplasia: evidence from a systematic review and meta-analysis

The aim of this study was to compare plasmakinetic resection of the prostate (PKRP) with transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) in terms of efficacy and safety. Published RCTs were searched from PubMed, Embase, Science Citation Index, and Cochrane Library up to April 10, 2014. After methodological quality assessment and data extraction, meta-analysis was performed using the STATA 12.0 software. 18 reports of 16 RCTs were included in this analysis. Meta-analyses showed that PKRP significantly improved Qmax at 12 months, but no significant difference was found for other efficacy outcomes. In terms of safety, treatment of PKRP was associated with reduced drop in serum sodium, lower TUR syndrome, reduced need of blood transfusion, clot retention, and shorter catheterization time and hospital stay; in contrast, there were no significant differences in the analysis of operative time, postoperative fever, and long-term postoperative complications. In summary, current evidence suggests that, although PKRP and TURP are both effective for BPH, PKRP is associated with additional potential benefits in efficacy and more favorable safety profile. It may be possible that PKRP may replace the TURP in the future and become a new standard surgical procedure.

Monopolar versus Plasmakinetic™ Energy Effect on Prostatic Tissue Damage in Terms of PSA Levels: A Prospective Randomized Trial

INTRODUCTION

We investigated the monopolar and bipolar energy effects on prostate and correlated the results with the type of pathology, thus determining the relationship between tissue damage and the PSA level.

MATERIAL AND METHODS

One hundred and twenty four patients underwent TURP and according to the energy source, 2 groups were designed as monopolar (Group 1) and bipolar energy (Group 2). Hemoglobin and free and total PSA were measured preoperatively and 6 hours postoperatively, and differences were calculated. The weight of resected tissue and operation time were also recorded. Two groups were also formed later according to the pathology as chronic prostatitis (CP) and BPH. The findings were analyzed.

RESULTS

There were no statistical differences between the groups in terms of age; prostate volumes; resected tissue; operation times; pre- and postoperative Hb, total-free PSA, IPSS, PVR, and quality of life scores; or postoperative maximum flow rates. Changes in total-free PSA (25.7 and 10.8 ng/dl for PSA; 13.2 and 5.76 ng/dl for free PSA for Groups 1 and 2, respectively) were significantly different between Groups 1 and 2. There was a statistical difference in total PSA between the groups among CP patients (28.18 and 11.73 ng/dl for Groups 1 and 2, respectively). But no statistical difference existed among BPH patients. The change in Hb differed based on pathological results.

CONCLUSION

Bipolar TURP is less invasive than monopolar TURP on the basis of postoperative PSA levels. In addition, bleeding during TURP is affected not by the kind of energy, but by the pathology.

Bipolar transurethral vaporization: a superior procedure in benign prostatic hyperplasia: a prospective randomized comparison with bipolar TURP

OBJECTIVE

To compare the outcomes of bipolar transurethral vaporization of the prostate (TUVP) with bipolar transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

In a prospective randomized trial, 88 patients with moderate to severe lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) underwent bipolar TUVP (N = 39) or bipolar TURP (N = 49) from October 2010 to November 2011. The inclusion criteria were age > 50 years, prostate volume of 30-80 mL, serum PSA < 4 ng/mL, IPSS ≥ 20, Qmax ≤ 10 mL/s and failed medical therapy. The perioperative and postoperative outcomes were evaluated and the IPSS and Qmax were assessed preoperatively and 3 months after procedure in all cases.

RESULTS

Both groups were similar in patient age, prostate volume, preoperative IPSS and Qmax. The TUVP group had significantly lower mean values of operative time, hospital stay, catheterization period, irrigation fluid volume and serum hemoglobin, creatinine, sodium and potassium changes compared with TURP group. No significant differences were seen between two groups regarding complications (TUVP = 10.3%; TURP = 12.2%) and modified Clavien classification of complications. No TUR syndrome, obturator reflex or epididymitis occurred in both groups. Re-hospitalization and transfusion due to clot retention (N = 2) and urethral stricture (N = 1) were reported only in the TURP group. Three patients experienced urinary retention after catheter removal in the TUVP group. Two patients were re-catheterized temporarily and one patient required repeat bipolar TUVP. Three months after surgery, two groups had significant improvement in IPSS and Qmax. But the TUVP group had significantly lower IPSS and higher Qmax than TURP group.

CONCLUSIONS

Bipolar TUVP is a safe, effective and low cost procedure among minimally invasive surgeries of BPH. Compared with bipolar TURP, the bipolar TUVP had similar complications, better perioperative and postoperative outcomes, superior hemostasis and higher efficacy.

Continuous vs conventional bipolar plasma vaporisation of the prostate and standard monopolar resection: a prospective, randomised comparison of a new technological advance

OBJECTIVES

To evaluate in a prospective, randomised trial the surgical efficiency and safety of a new energy source enabling a continuous bipolar plasma vaporisation of the prostate (C-BPVP) by comparing with standard vaporisation (S-BPVP) and monopolar transurethral resection of the prostate (TURP) in men with benign prostatic hyperplasia (BPH). To comparatively assess the short-term functional outcome of the three methods.

PATIENTS AND METHODS

In all, 180 men with BPH with prostate volumes of 30-80 mL, maximum urinary flow rates (Q(max)) of <10 mL/s and International Prostate Symptom Score (IPSS) of >19 were equally randomised for C-BPVP, S-BPVP and monopolar TURP. All men were evaluated preoperatively and at 1, 3 and 6 months after surgery by IPSS, Q(max), health-related quality of life (HRQL) score and post-void residual urine volume (PVR). The prostate volume and PSA level were postoperatively assessed at 6 months.

RESULTS

The mean operation time was significantly reduced in C-BPVP vs S-BPVP and TURP, with a substantial 22.4% and 39.1% decrease in duration for C-BPVP when compared with S-BPVP and TURP, respectively. The mean haemoglobin level decrease (0.4 and 0.6 vs 1.4 g/dL), capsular perforation rate (1.7% and 3.3% vs 10%), postoperative haematuria rate (1.7% and 1.7% vs 13.3%), catheterisation period (24.1 and 23.9 vs 73.6 h) and hospital stay (2.1 and 2.2 vs 4.5 days) were significantly lower for C-BPVP and S-BPVP vs TURP. At 1, 3 and 6 months follow-up, there were statistically ameliorated IPSS and Q(max) measurements in the C-BPVP and S-BPVP series, while similar HRQL scores, PVRs, PSA levels and postoperative prostate volumes were found in all three study arms.

CONCLUSIONS

The operation time for C-BPVP was on average 20% and 40% quicker than S-BPVP and TURP, respectively. Both C-BPVP and S-BPVP had better perioperative safety and improved follow-up voiding and symptom scores than TURP.

Pure bipolar plasma vaporization of the prostate: the Zürich experience

INTRODUCTION AND OBJECTIVES

Bipolar plasma vaporization (BPV) has been introduced as an alternative to transurethral resection of the prostate (TURP). Promising short-term results, but inferior mid-term results compared to TURP have been reported following first-generation bipolar electrovaporization. Outcome data following second-generation BPV are still scarce. The aim of this investigation was to evaluate the intra- and postoperative outcomes of contemporary BPV in a center with long-standing expertise on laser vaporization of the prostate.

METHODS

A consecutive series of 83 patients undergoing BPV in a tertiary referral center was prospectively evaluated. The investigated outcome parameters included the maximum flow rate (Qmax), postvoid residual volume, International Prostate Symptom Score (IPSS)/quality of life (Qol), and prostate-specific antigen (PSA) tests. Follow-up investigations took place after 6 weeks, 6 months, and 12 months. The Wilcoxon signed-rank test was used to compare pre- and post-treatment parameters.

RESULTS

The median (range) preoperative prostate volume was 41 mL (17-111 mL). The preoperative IPSS, Qol, Qmax, and residual volume were 16 (2-35), 4 (0-6), 10.1 mL/s (3-29.3 mL/s), and 87 mL (0-1000 mL), respectively. One third of the patients were undergoing platelet aggregation inhibition (PAI). No intraoperative complications occurred. Postoperatively, 13 patients (15.7%) had to be recatheterized. Three patients (3.6%) had clot retention and 28 patients (34%) reported any grade of dysuria. After 6 weeks, all outcome parameters improved significantly and remained improved over the 12-month observation period [IPSS: 3 (0-2); Qol: 1 (0-4); Qmax: 17.2 mL/s (3.2-56 mL/s); residual volume 11 mL (0-190 mL)]. The PSA reduction was 60% at study conclusion. Three patients (3.6%) developed a urethral stricture and four patients (4.8%) bladder neck sclerosis. Re-resections were not necessary.

CONCLUSIONS

Contemporary BPV is a safe and efficacious treatment option even for patients undergoing PAI. Early urinary retention and temporary dysuria seem to be specific side effects of the treatment. Bleeding complications are rare. Long-term follow-up is needed to confirm these promising short-term results.