BERKELEY, CA (UroToday.com) - As modern urology faces a tremendous competition between the various modalities of BPH endoscopic treatment, according to the EAU Guidelines, monopolar TURP still represents the “gold-standard” therapeutic approach in cases of average size prostates.
Despite the fact that standard resection is marked by a significant but apparently decreasing perioperative time as well as long-term morbidity, the short and particularly the long term outcomes of TURP arguably continue to remain unsurpassed.
Following the perspective of TURis plasma vaporization being introduced as a viable therapeutic modality in cases of bladder outlet obstruction related lower urinary tract symptoms (LUTS), the present study aimed to perform a prospective, randomized, long term comparison between bipolar plasma vaporization of the prostate (BPVP), bipolar transurethral resection in saline (TURis) and monopolar transurethral resection (TURP) concerning the perioperative and follow-up parameters.
Consequently, a total of 510 patients diagnosed with prostate volume between 30 and 80 ml, Qmax <10 ml/s and IPSS >19 were enrolled under approved written informed consent, randomized by means of sealed envelopes and were blinded to treatment.
From the surgical technique point of view, the classical surgical steps of transurethral resection were applied both for TURP and TURis. During BPVP, the hemispherical shape electrode displaying a plasma corona on its surface was gradually moved in close contact with the prostatic tissue, which was vaporized layer by layer until reaching the prostatic capsule (the so-called “hovering” technique).
Each of the 3 study arms was comprised of 170 patients with similar preoperative parameters, which were evaluated preoperatively and at 1, 3, 6, 12 and 18 months after surgery by IPSS, QoL, Qmax and post-voiding residual urinary volume (RV). Also, the prostate volume and PSA level were measured at 6, 12 and 18 months.
Concerning the perioperative features, the mean hemoglobin drop (0.5 versus 1.2 and 1.6 g/dl), intraoperative bleeding (1.8% versus 8.2% and 13.5%), and capsular perforation (1.2% versus 7.1% and 9.4%) rates were significantly decreased in the BPVP group by comparison to the TURis and TURP study arms. Also, the operation time was significantly shorter for BPVP patients and similar for TURis and monopolar TURP (39.7 versus 52.1 and 55.6 minutes), while the catheterization period (23.5 versus 46.3 and 72.8 hours) and hospital stay (1.9 versus 3.1 and 4.2 days) were significantly reduced for BPVP, followed by TURis. Furthermore, the rates of early irritative symptoms in general and dysuria, urgency, frequency, and nocturia in particular were similar in the 3 study arms.
During the long term follow-up, the re-treatment (3.5% versus 9.4% and 8.8%) and bladder neck sclerosis (0.6% versus 3.5% and 4.1%) rates were significantly reduced for BPVP by comparison to TURis and TURP.
As far as the follow-up parameters were concerned, at 1, 3, 6, 12 and 18 months, the IPSS and Qmax were significantly improved for the BPVP patients and similar in the TURis and TURP series, while the QoL score and RV values were statistically similar in the 3 study arms. On the other hand, at 6, 12 and 18 months, the PSA level and the postoperative prostate volume emphasized a similar evolution regardless of the initial treatment approach.
We may conclude that BPVP seems to represent a viable alternative in BPH endoscopic treatment, apparently able to challenge the “gold-standard” status of monopolar TURP and to bring significant improvements to the bipolar electrosurgical approach. In terms of hemorrhagic risks, the significantly reduced intraoperative bleeding and mean hemoglobin drop confirmed the superior haemostatic capabilities of the plasma vaporization and bipolar resection.
From the surgical safety and efficacy as well as the patients’ comfort points of view, the significantly lower capsular perforation rate, operation time, catheterization period, and hospital stay may constitute reliable arguments in favor of BPVP, while TURis only provided smaller progresses concerning these parameters.
During the 18 months’ follow-up, patients undergoing plasma vaporization benefited from significantly improved IPSS and Qmax, thus confirming the long-term efficacy of BPVP with regard to LUTS and voiding characteristics by comparison to the monopolar and bipolar TURP.
- De la Rossette J, Alivizatos G, Madersbacher S et al. Guidelines on Benign Prostatic Hyperplasia. European Association of Urology Guidelines, 2009 edition:35-36.
- Rassweiler J, Teber D, Kuntz R et al. Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention. Eur Urol. 2006;50(5):969-79.
- Marszalek M, Ponholzer A, Pusman M et al. Transurethral Resection of the Prostate. Eur Urol Suppl. 8(2009):504–512.
- Reich O, Schlenker B, Gratzke C et al. Plasma vaporisation of the prostate: initial clinical results. Eur Urol. 2010;57(4):693-7.
Bogdan Geavlete, MD, PhD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.