NBI - plasma vaporization hybrid approach in bladder cancer endoscopic management

OBJECTIVES

A prospective study was performed aiming to evaluate the surgical efficacy, perioperative safety profile, diagnostic accuracy and medium term results of a multi-modal approach consisting in narrow band imaging (NBI) cystoscopy and bipolar plasma vaporization (BPV) when compared to the standard protocol represented by white light cystoscopy (WLC) and transurethral resection of bladder tumors (TURBT).

MATERIALS & METHODS

A total of 260 patients with apparently at least one bladder tumor over 3 cm were included in the trial. In the first group, 130 patients underwent conventional and NBI cystoscopy followed by BPV, while in a similar number of cases of the second arm, classical WLC and TURBT were applied. In all non-muscle invasive bladder tumors' (NMIBT) pathologically confirmed cases, standard monopolar Re-TUR was performed at 4-6 weeks after the initial intervention, followed by one year' BCG immunotherapy. The follow-up protocol included abdominal ultrasound, urinary cytology and WLC, performed every 3 months for a period of 2 years.

RESULTS

The obturator nerve stimulation, bladder wall perforation, mean hemoglobin level drop, postoperative bleeding, catheterization period and hospital stay were significantly reduced for the plasma vaporization technique by comparison to conventional resection. Concerning tumoral detection, the present data confirmed the NBI superiority when compared to standard WLC regardless of tumor stage (95.3% vs. 65.1% for CIS, 93.3% vs. 82.2% for pTa, 97.4% vs. 94% for pT1, 95% vs. 84.2% overall). During standard Re-TUR the overall (6.3% versus 17.4%) and primary site (3.6% versus 12.8%) residual tumors' rates were significantly lower for the NBI-BPV group. The 1 (7.2% versus 18.3%) and 2 (11.5% versus 25.8%) years' recurrence rates were substantially lower for the combined approach.

CONCLUSIONS

NBI cystoscopy significantly improved diagnostic accuracy, while bipolar technology showed a higher surgical efficiency, lower morbidity and faster postoperative recovery. The combined technique offered a reduced rate of residual tumors at Re-TUR, both globally as well as for orthotopic tumors. Substantially lower recurrence rates were found at 1 and 2 years among the NBI-BPV cases.

NBI cystoscopy in routine urological practice - from better vision to improve therapeutic management

OBJECTIVES

A single centre, retrospective trial was performed trying to assess the impact of NBI cystoscopy in cases of non-muscle invasive bladder tumors (NMIBT) by comparison to the standard approach. Our goal was to determine the superiority of the new method in terms of detection rates and subsequent postoperative treatment changes.

MATERIALS AND METHODS

A total of 320 NMIBT suspected consecutive cases were enrolled in the study. The inclusion criteria were represented by hematuria, positive urinary cytology and/or ultrasound suspicion of bladder tumors. All patients underwent WLC and NBI cystoscopy. Standard transurethral resection of bladder tumors (TURBT) was performed for all lesions visible in WL and NBI guided resection for solely NBI observed tumors.

RESULTS

The overall NMIBT and CIS patients' detection rates were significantly improved for the NBI evaluation ((94.9% versus 88.1% and 95.7% versus 65.2%). Also, on a lesions' related basis, NBI cystoscopy emphasized a significantly superior diagnostic accuracy concerning the CIS, pTa and overall NMIBT formations ((95.2% versus 60.3%, 92.8% versus 83.9% and 94.1% versus 82%). Additional tumors were diagnosed by NBI in a significantly higher proportion of CIS, pTa, pT1 and NMIBT patients (56.6% versus 8.7%, 28% versus 10.3%, 30.3% versus 10.6% and 31.6% versus 9.4%). As a result of these supplementary findings, the postoperative treatment was significantly improved in a substantial proportion of cases (15.4% versus 5.1%).

CONCLUSIONS

NBI cystoscopy represents a valuable diagnostic alternative in NMIBT patients, with significant improvement of tumor visual accuracy as well as detection rates. This approach provided a substantial amelioration to the risk category stratification and subsequent bladder cancer therapeutic management.

"Tips and tricks" in secondary bladder neck sclerosis' bipolar plasma vaporization approach

INTRODUCTION

Secondary bladder neck sclerosis (BNS) represents a common late complication of prostate surgery, however so far insufficiently assessed in the available literature. More over, the previously attempted and analyzed therapeutic modalities failed to achieve acknowledgement as standard treatment for this particular pathology.

METHODS

The bipolar plasma vaporization (BPV) was introduced as a viable mean of removing the obstructing scar formation in a gradual fashion. Several "tips and tricks" were described as particularly useful in optimizing the plasma corona vaporization effect. The proper BPV technique is simple and safe while closely relying on certain surgical steps, the simultaneous vaporization and coagulation processes and a superior endoscopic vision. Recent technological advances created the premises for further improvements.

RESULTS

The plasma-button vaporization is characterized by a satisfactory surgical speed, remote intraoperative bleeding risks, high-quality endoscopic visibility as well as the achievement of a complete sclerotic tissue removal. Within a short learning curve, a superior final aspect of the prostatic fossa and bladder neck is obtained at the end of surgery. The continuous plasma vaporization mode provides additional technical advantages. The previously described drawbacks of transurethral incision or resection seem to have been overcome by the practical features of the plasma vaporization process.

CONCLUSIONS

The BPV technique outlines a promising modality of efficiently ablating the obstructing fibrous tissue in secondary BNS patients. The simplicity and safety of the bipolar vaporization approach, together with the thorough obstructing scar removal in a radical fashion, create the premises for a favorable long term BPV clinical outcome.

NBI cystoscopy and bipolar electrosurgery in NMIBC management - An overview of daily practice

INTRODUCTION

The standard non-muscle invasive bladder cancer (NMIBC) endoscopic diagnosis suffers from the frequently unsatisfactory white light evaluation accuracy leading to residual lesions being left behind. Monopolar transurethral resection of bladder tumors (TURBT) is marked by a substantial morbidity rate requiring further amelioration.

METHODS

Small size tumors (under 1 cm) are feasible for "en bloc" resection. Bipolar TURBT was defined as being able to challenge the gold-standard status of monopolar resection due to the reduced complication rates. Plasma-button vaporization was introduced as a promising large bladder tumors' ablation modality. Narrow band imaging (NBI) cystoscopy became an increasingly popular method of enhancing tumor detection.

RESULTS

The "en bloc" resection of small size or thin pedicle tumors provides the conditions for avoiding tumoral tissue scattering. Bipolar resection is characterized by decreased perioperative bleeding risks and faster patient recovery. Plasma-button vaporization gained confirmation as an innovative approach, able to dispose large tumor bulks under complete control while minimizing the associated morbidity. NBI cystoscopy is a useful tool in identifying CIS lesions, small papillary tumors or extended margins of large tumor formations. As a cost-free technique, it may be extensively used both during the NMIBC initial diagnostic as well as during follow-up evaluation protocol.

CONCLUSIONS

Having in mind the various modalities of ameliorating the bladder cancer diagnostic and treatment, NMIBC management should be tailored in accordance with the particularities of each case.

Medium term outcome of bipolar plasma vaporization in prostate cancer patients--a palliative modality of preserving spontaneous voiding

OBJECTIVES

This retrospective analysis evaluated the efficiency, safety, and medium term postoperative results of bipolar plasma vaporization (BPV) in prostate cancer (PCa) cases associating complete urinary retention.

MATERIALS AND METHODS

A series of 40 patients diagnosed with locally advanced or metastatic PCa and complete urinary retention requiring a Foley catheter indwelling underwent BPV aiming to restore spontaneous voiding. A total of 35 patients completed the one year evaluation protocol consisting of International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Q(max)) and post-voiding residual urinary volume (PVR), measured at 1, 3, 6 and 12 months after surgery.

RESULTS

BPV was successfully performed in all cases with satisfactory efficiency, as confirmed by the mean operation time (42.8 minutes) and hemoglobin drop (0.7 g/dl). A fast and safe postoperative recovery period was described in this series (hematuria rate--7.5%; mean catheterization period--36 hours; mean hospital stay--2.5 days; early-irritative symptoms' rate--15%). At 1, 3, 6 and 12 months, satisfactory values were determined in terms of IPSS, Qmax, QoL and PVR. These parameters emphasized a stable evolution throughout the entire follow-up, as 88.6% of the patients maintained spontaneous voiding.

CONCLUSIONS

The present trial confirmed the plasma-button vaporization as a promising therapeutic approach in PCa cases associating complete urinary retention. The technique displayed good efficacy, low perioperative morbidity, short convalescence, and satisfactory urodynamics and symptom score parameters during the one-year follow-up period.

Bipolar plasma vaporization in secondary bladder neck sclerosis--initial experience with a new technique

INTRODUCTION

Secondary bladder neck sclerosis (BNS) represents one of the most common long-term complications after prostate surgical treatment. In this retrospective study, we aimed to evaluate our initial experience concerning the bipolar plasma vaporization (BPV) performed in patients with secondary BNS and to assess the efficiency, safety and short-term postoperative results of this approach.

MATERIALS & METHODS

Between May 2009 and May 2010, a total of 30 male patients with BNS underwent BPV and were followed for a period of 6 months. BNS was secondary to monopolar transurethral resection of prostate (TURP) in 19 cases, to open surgery for BPH (open prostatectomy) in 8 cases and to radical prostatectomy for prostate cancer in 3 cases. The follow-up protocol included the International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Qmax) and post-voiding residual urinary volume (RV) evaluated at 1, 3 and 6 months after surgery.

RESULTS

BPV was successfully performed in all cases. All patients were able to void spontaneously and were continent after catheter removal. The mean operating time was 9 minutes, the mean catheterization period was 18 hours and the mean hospital stay was 24 hours. Preoperatively and at 1, 3 and 6 months after surgery, the mean values for Qmax and RV were 7.2 ml/s and 110 ml, 23.9 ml/s and 20 ml, 23.8 ml/s and 28 ml, and 23.4 ml/s and 26 ml, respectively. Before surgery and at 1, 3 and 6 months, the IPSS and QoL scores were 22.6 and 4.1, 3.4 and 1.2, 3.6 and 1.4, and 3.7 and 1.4, respectively.

CONCLUSIONS

BPV represents a valuable endoscopic treatment alternative for secondary BNS with good efficacy, reduced morbidity, fast postoperative recovery and satisfactory follow-up parameters.

[Innovative technique in large benign prostatic hyperplasia--enucleation by plasma vaporization]

OBJECTIVES

The trial evaluated a new endoscopic treatment alternative for large benign prostatic hyperplasia (BPH) cases, the bipolar plasma enucleation of the prostate (BPEP), in terms of surgical efficiency, safety and short-term postoperative results.

MATERIALS AND METHODS

A total of 30 patients with prostates larger than 80 ml were included in the study. All cases were investigated preoperatively and at 1 and 3 months after surgery by international prostate symptoms score (IPSS), quality of life score (QoL), maximum flow rate (Q(max)) and abdominal and transrectal ultrasonography.

RESULTS

All procedures were successfully performed. The enucleation and morcellation times were 69.8 minutes and 18.5 minutes, while the morcellated tissue weight was 77 grams. The mean hemoglobin drop was 0.8 g/dl and the mean catheterization period and hospital stay were 26.5 hours and 2.3 days. The rate of early irritative symptoms was 10%. At 1 and 3 months, significant improvements were determined concerning the IPSS (5.3 and 4.8), QoL (1.2 and 1.1) and Q(max) (25.9 and 25.1 ml/s).

CONCLUSIONS

BPEP represents a promising endoscopic approach in large BPH cases, characterized by good surgical efficacy, reduced morbidity, fast postoperative recovery and satisfactory follow-up parameters.

Ureteroscopy--an essential modern approach in upper urinary tract diagnosis and treatment

In recent years, urology has seen a real explosion in the development of new technologies. Modern treatment techniques replaced classic therapeutic methods, among which open surgery had an important role. Endourologic therapies led to effective and safe interventions, increased patient comfort and reduced costs. The "Saint John" Emergency Clinical Hospital Department of Urology always intended to align to the new standards of urological treatment including, primarily, minimally invasive techniques, some of them being performed as national premieres. Ureteroscopy is one of them, thus introducing the rigid and semi rigid endoscopes as part of the therapeutic arsenal of our clinic in 1994 and flexible ureteroscopy in 2002. If the targeted pathology was initially limited to stone disease, ureteroscopy currently covers a wide range of affections, being used both for therapeutic but also for diagnostic purposes. Thus, the ureteroscopic approach can diagnose and treat a wide range of upper urinary tract pathologies (lithiasis, tumors, malformations, iatrogenic injuries, etc.). The new technology acquisitions made by our clinic, increased performance, resulting in a complete and fast resolution in many cases, previously implying additional effort from the surgeons. If at first the ureteroscopies' share of daily practice was modest, in recent years it has achieved an extraordinary growth, thus becoming available to both experienced surgeons and young urologists. We believe that our extensive experience in endourological approach is significant and will have a say in the technological developments, which will help both the patients and the practicing urologists.

[Bipolar plasma vaporization--new endoscopic technique in non-invasive bladder cancer]

OBJECTIVES

The aim of our study was to evaluate the efficacy and safety of a newly introduced endoscopic technique in the treatment of non-muscle invasive bladder cancer (NMIBC), the bipolar plasma vaporization of bladder tumors (BPV-BT).

MATERIALS AND METHODS

Between May and November 2009, 72 consecutive patients presenting papillary bladder tumors over 1 cm underwent BPV-BT and a 3 months follow-up. Initial biopsy followed by plasma vaporization of the tumor and biopsies of the tumoral bed were performed in all cases. The follow-up protocol included abdominal ultrasonography, urinary cytology and cystoscopy at 3 months.

RESULTS

BPV-BT was successfully performed in all cases. Multiple tumors were found in 45.9% and tumors over 3 cm in 33.3% of the cases. The mean tumoral volume was 10.5 ml. The mean operative time was 16 minutes, the mean hemoglobin decrease was 0.4 g/dl, the mean catheterization period was 2.3 days and the mean hospital stay was 3.4 days. There was no major intra- or postoperative complications. The pathological exam diagnosed 58.3% pTa, 30.6% pT1 and 11.1% pT2 cases. No tumoral base biopsies were positive for malignancy. The recurrence rate was 15.6% for the NMIBC patients, 13.3% for patients with single tumor under 3 cm and 16.3% in cases of single tumors over 3 cm or multiple tumors. Orthotopic recurrent tumors were encountered in 3.1% of the cases.

CONCLUSIONS

BPV-BT seems to represent a promising endoscopic treatment alternative for NMIBC patients, with good efficacy, reduced morbidity, fast postoperative recovery and satisfactory follow-up parameters.

TURis plasma vaporization in non-muscle invasive bladder cancer--the first Romanian experience with a new technique

INTRODUCTION

The development of bipolar resection using saline irrigation provided significant improvements in NMIBT treatment. The aim of our study was to evaluate the efficacy and safety of a newly introduced endoscopic technique, the bipolar transurethral resection in saline-plasma vaporization of bladder tumors (TURis-PVBT).

MATERIALS AND METHODS

Between May and October 2009, 57 consecutive patients presenting papillary bladder tumors larger than 1 cm underwent TURis-PVBT and a 3 months follow-up. Initial tumor biopsy, followed by plasma vaporization of the tumor and biopsies of the tumoral bed were performed in all cases. Complementary treatment was applied according to risk indications. The follow-up protocol included abdominal ultrasonography, cytology and cystoscopy at 3 months.

RESULTS

TURis-PVBT was successfully performed in all cases. Multiple tumors were found in 45.6% of the cases and 50.9% of the patients presented tumors larger than 3 cm. The mean tumoral volume was of 11 ml. The mean operative time was of 17 minutes, the mean hemoglobin decrease was of 0.4 g/dl, the mean catheterization period was of 2.5 days and the mean hospital stay was of 3.5 days. The pathological exam diagnosed 57.9% pTa cases, 31.6% pT1 cases and 10.5% pT2 cases. No tumoral base biopsies were positive for malignancy. The recurrence rate at 3 months for the 51 NMIBT patients was of 15.7%. Orthotopic recurrent tumors were encountered in 5.9% of the cases.

CONCLUSIONS

TURis-PVBT seems to represent a promising endoscopic treatment alternative for NMIBT patients, with good efficacy, reduced morbidity, fast postoperative recovery and satisfactory follow-up parameters.

Bipolar resection of the bladder and prostate--initial experience with a newly developed regular sized loop resectoscope

OBJECTIVE

Bipolar transurethral resection (TUR) has been introduced in the clinical practice nowadays. Benefits from bipolar TUR are represented by the use of saline irrigation, which avoids hypoosmotic hyperhydration (TUR-Syndrome), as well as by the reduced risk of obturator nerve stimulation. However, the previously introduced smaller bipolar resection loop caused prolonged operating-time. We report our initial experience with a newly developed regular sized loop for a bipolar resectoscope.

MATERIALS AND METHODS

Different loop calibers and configurations were tested and compared to a previously introduced bipolar system and conventional resection devices in TUR of benign prostate hyperplasia (BPH) and bladder tumors (TURP and TURBT). The resected tissue was pathologically examined for thermal damage and compared to a control group of monopolar conventionally resected tissue.

RESULTS

The handling of the resectoscope was comparable to that of the conventional ones. Cutting control, cutting speed and coagulation effectiveness were excellent, and no obturator nerve stimulation occurred. The resection area could easily be assessed and tissue examination showed no differences in terms of quality and quantity of thermal damages, since tissue carbonization was reduced. There was no sticking of the resected tissue on the loop.

CONCLUSION

Regular sized loop bipolar resection is safe and efficient. Coagulation and cutting extent control seem superior to conventional TUR. Due to reduced carbonization, the resection ground can be easily assessed. The risk of obturator nerve stimulation is reduced. The histological quality of the tissue is not impaired. This device combines the advantage of a regular size resection loop with bipolar resection in normal saline. It has the potential to become a valuable alternative to monopolar TUR.

[Percutaneous approach in postureteroenterostomy ureteral stenosis. Experience of the Urological Department of Sf. Ioan Emergency Hospital, Bucharest]

INTRODUCTION

Uretero-enteric stenosis may raise some specific problems due to difficulties concerning the retrograde access. The aim of our study was to evaluate the effectiveness of antegrade flexible ureteroscopic approach for this specific pathology.

MATERIAL AND METHODS

Between January 2002 and June 2008, a number of 7 patients underwent antegrade flexible ureteroscopy for uretero-enteric stenosis: 3 patients with stenosis of the uretero-neobladder anastomosis (Group I), 2 patients with stenosis of the uretero-sigmoidian implantation (Group II) and 2 patients with stenosis of the ureteral implantation in an ileal conduit (Group III). In Group I, we performed antegrade Nd:YAG laser star incision in 2 cases and balloon dilation in 1 case. In Group II, the antegrade Nd:YAG laser star incision was applied in 1 case and balloon dilation was performed in the other one. In Group III, we performed antegrade insertion of the guidewire followed by retrograde cold-knife incision in one case, and bipolar ureteral approach (cut-to-the-light technique) in 1 case.

RESULTS

The mean operative time was 58 min. (range 25 to 120 min). We didn't describe major intraoperative complications. Ultrasonography, IVP and isotopic renogram (in selected cases) have been the follow-up evaluation methods. Postoperatively, 2 cases from Group I and all cases from Groups II and III had a good evolution, with significant reduction of the hydronephrosis degree at 6, 12 and 18 months. One patient from Group I, in which balloon dilation of the stenosis was performed, developed recurrence at 6 months.

CONCLUSIONS

According to our experience, antegrade flexible ureteroscopic approach may represent an efficient and safe technique in uretero-enteric stenosis treatment. Being a minimally invasive approach, this procedure has a reduced rate of complications and good anatomical and functional results.

[Percutaneous approach in the treatment of matrix lithiasis. Experience of the urological department of "Saint John" Emergency Clinical Hospital]

INTRODUCTION

Matrix lithiasis has been relatively rarely described. Our goal was to establish the value of percutaneous approach in this pathology.

MATERIAL AND METHODS

Between July 1995 and January 2008 in Department of Urology of "Saint John" Emergency Clinical Hospital in Bucharest, 11 patients with pyelocaliceal matrix lithiasis (seven females and four males) were treated by percutaneous approach. The mean age was 55 years old (between 41 and 83 years old). The rigid nephroscope was exclusively used in seven cases. The approach of caliceal fragments imposed the flexible nephroscopic approach in the other four cases. The mean follow-up period was 48 months (range two to 86).

RESULTS

10/11 patients (90,9%) were stone-free at the end of procedures. In the other case, the spontaneous passage of the remaining matrix lithiasis fragments was encountered. No major complications were recorded. Recurrences occurred in two cases (18.2%), despite the long-term antibiotic therapy.

CONCLUSIONS

Percutaneous approach may represent an effective and safe therapy of matrix lithiasis. The management of this pathology must associate the preoperative treatment and postoperative prophylaxis of the urinary tract infections.

HAL fluorescence cystoscopy and TURB one year of Romanian experience

Hexaminolevulinate blue light cystoscopy (HAL-BLC) represents an increasingly acknowledged method in bladder cancer diagnostic. We aimed to evaluate the importance of this procedure in cases of non-invasive bladder tumors (NIBT), to compare it with standard white light cystoscopy (WLC), and to establish the efficiency of blue light transurethral bladder resection (BL-TURB). Between December 2007 and December 2008, WLC and BLC were performed in 70 cases. WL-TURB was performed for all lesions visible in WL, and BL-TURB for those only detected in BL. Patients diagnosed with NIBT were followed-up after an average period of 5 months (between 18 and 22 weeks) by WLC and BLC. The control group included the same number of consecutive cases of NIBT, which underwent only WLC and WL-TURB, as well as the same follow-up protocol as the study group. WLC correctly identified 115 tumors, and BLC, 157 tumors. The detection rate was 68.8% for WLC, with a 9.4% rate of false-positive results, and 94% for BLC, with a 14.6% rate of false-positive results. The diagnostic accuracy in CIS lesions was 57.3% for WLC and 95% for BLC, while in pTa tumors; it was 68.8% for WLC and 94% for BLC. 62 cases of the study group diagnosed with NIBT emphasized a recurrence rate of 6.4% after 5 months. The control group described a recurrence rate of 24.2%. HAL fluorescence cystoscopy is a valuable diagnostic method for patients with NIBT, with considerably improved accuracy by comparison to WLC, and a significant impact upon the short-term recurrence rate.

TURIS plasma vaporization--initial Romanian experience with a new technology

Bipolar electrosurgical approach represents an increasingly acknowledged technology in the treatment of benign prostatic hyperplasia (BPH), and a promising alternative to standard transurethral resection of the prostate (TURP). In this study, we aimed to evaluate a new method, transurethral resection in saline - plasma vaporization of the prostate (TURIS-PVP), by determining its efficiency, safety and short-term postoperative results. In May 2009, TURIS-PVP was performed in 25 cases of BPH. The investigative protocol included digital rectal examination (DRE), prostatic specific antigen (PSA), International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum flow rate (Qmax) and abdominal ultrasonography assessing prostate volume and post-voiding residual urinary volume (RV). All patients were investigated 1 month after surgery using IPSS, QoL, Qmax and RV. TURIS-PVP was successfully performed in all cases. The average BPH size was 53 ml, the mean operating time was 28 minutes, the median catheterization time was 24 hours and the mean hospital stay was 48 hours. No patient required blood transfusions or re-catheterization, and there were no significant intra- or postoperative complications. Preoperatively, the mean value of IPSS was 21.4, the mean QoL score was 4, the mean RV was 72 ml and the mean Qmax was 9.7 ml/s. The 1 month follow-up emphasized a mean IPSS of 4, a mean QoL score of 1.4, a mean RV of 14 ml and a mean Qmax of 21.5 ml/s. TURIS-PVP represents a valuable endoscopic treatment alternative for patients with BPH, with good efficacy, reduced morbidity, satisfactory follow-up parameters and fast postoperative recovery. IPSS, QoL, Qmax and RV measurements showed significant improvements at the 1 month follow-up.