BERKELEY, CA (UroToday.com) - The present paper addresses a well-known, yet poorly-evaluated, late complication of prostate surgery, secondary bladder neck sclerosis (BNS). While affecting the results of a wide range of interventions (BPH (endoscopic and open approaches) and radical prostatectomy), this adverse event has thus far been minimally evaluated in the literature. On the other hand, despite the various treatment alternatives presented over the years (monopolar or bipolar encircling resection and bladder neck incision by either cold-knife or laser), the available publications suffered from a relatively reduced number of cases, disappointing long-tern results in general, and elevated recurrence rates.
After having already attained a significant degree of success in cases of BPH-related bladder outlet obstruction and large bladder tumors, bipolar plasma vaporization (BPV) began to be successfully applied, in our experience, to this particular pathology as well. To our knowledge, this is the first prospective, randomized trial to be published on the subject of bladder neck sclerosis.
A single-centre, prospective, medium-term, randomized study was performed, aiming to compare the plasma vaporization and standard monopolar resection in secondary BNS patients and having as primary endpoint a detailed evaluation of the perioperative features and follow-up parameters. The inclusion criteria were represented by Qmax <10 ml/s and IPSS > 19, and, subsequently, a total of 70 patients with secondary BNS and severe LUTS were equally randomized for BPV and TUR.
From the perspective of surgical technique, after an initial urethrocystoscopic assessment, plasma-button vaporization was used for opening up the obstructed bladder neck. Basically, the fibrous tissue was gradually vaporized, layer-by-layer, until reaching the prostatic capsule (the so-called “hovering” technique), while coagulation with the same “button” was rarely necessary. At all times, a close contact between the hemispheric electrode and the sclerotic surface was maintained in order to produce a constant vaporization effect. The complete ablation of the sclerotic tissue was confirmed by the clear visualization of the capsular muscular fibers, as a wide prostatic fossa with a neat surface and no irregularities, debris, or obstruction was obtained, thus creating the conditions for an effective prevention of recurrences to be achieved.
As part of the follow-up protocol, all cases were assessed at 1, 3, 6, 12, and 18 months after the initial procedure by IPSS, QoL, Qmax and PVR.
Both types of procedures were successfully performed in all cases. As far as the intraoperative complications were concerned, the prostatic capsule perforation (8.5%) and intraoperative bleeding (5.7%) were only present in the TUR study arm. With regard to the perioperative features, the mean operation time, catheterization period, and hospital stay were significantly shorter for BPV in comparison to standard resection (10.3 versus 14.9 minutes, 0.75 versus 2.1 days and 1.1 versus 3.2 days).
During the immediate postoperative follow-up, hematuria (2.8%) and re-catheterization for acute urinary retention (5.7%) only occurred in the TUR group. From the perspective of the short-term adverse events, similar rates of early irritative symptoms (still more frequent secondary to BPV – 14.2% versus 11.4%) and urinary tract infection (2.8% versus 2.8%) were described. Moreover, the medium term re-treatment requirements due to BNS recurrence were substantially reduced when the plasma vaporization technique was initially applied (2.8% versus 8.5%), despite the lack of statistical significance caused by the insufficient number of cases.
At the 1, 3, 6, 12, and 18 months check-ups, statistically similar parameters were found concerning the IPSS and QoL symptom scores specific for the two therapeutic alternatives. Also, no significant difference was outlined with regard to the urodynamic features provided by BPV and TUR in terms of maximum flow rate. Additionally, similar PVR values were established at the respective ultrasound evaluations.
In conclusion, BPV was found to constitute a valuable endoscopic treatment alternative for secondary BNS patients. In a randomized analysis, the method emphasized superior efficacy and satisfactory surgical safety as well as a similar medium-term improvement in follow-up parameters by comparison to standard TUR. Naturally, an additional long-term evaluation of this technique will be required before actually establishing its true place in the therapeutic armamentarium of bladder neck sclerosis. However, the statistical similarity of BPV and TUR results with regard to symptom scores and voiding parameters supported the viability of this new type of approach.
Written by:
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.
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