Transurethral bipolar vaporization of the prostate: Technical outcomes in the treatment of benign prostatic hyperplasia

Nội dung text: Transurethral bipolar vaporization of the prostate: Technical outcomes in the treatment of benign prostatic hyperplasia

1. Journal of military pharmaco-medicine n o5-2017 TRANSURETHRAL BIPOLAR VAPORIZATION OF THE PROSTATE: TECHNICAL OUTCOMES IN THE TREATMENT OF BENIGN PROSTATIC HYPERPLASIA Do Ngoc The*; Tran Van Hinh**; Pham Quang Vinh** Summary Objectives: To evaluate technical outcomes of bipolar transurethral vaporization of the prostate (B-TUVP) in the treatment of benign prostatic hyperplasia (BPH). Subjects and methods: From August 2013 to June 2015, a prospective and cross-sectional case-series study was performed on 106 patients with BPH treated with B-TUVP at Department of Urology, Military Hospital 103. Results: The mean age was 71.1 years old, the mean mass of prostate was 48.8 grams. The rate of patients admitted to hospital due to acute urinary retention was 39.6%. Mean operation time was 38.2 mins, mean postoperative urethral catheterization time was 3.3 days, mean hospital stay was 4.9 days. There was neither complication-related mortality nor the transurethral syndrome. No transurethral resection syndrome was met with during and after the operation. There were some intra-operative complications including bleeding accounted for 1.9%, prostatic capsule perforation accounted for 1.9%. Early post- operative complications were fever due to urinary tract infection at 5.7%; bleeding at 2.8% (incl. transfusion 0.9%), clot retention at 0.9%, acute urinary retention (after urethral catheter removed) at 5.7%, transient incontinence at 0.9%. Membranous urethral stricture was found in 2 patients. Conclusion: B-TUVP is an effective procedure for surgical-indication benign prostatic hyperplasia with prostate weight under 75 grams. * Key words: Prostate; Bipolar transurethral vaporization. INTRODUCTION bothered by these symptoms...”. In Vietnam, Tran Ngoc Sinh et al have first applied Vaporization of the prostate was first this procedure in the treatment of BPH described in the early 1990s using either since 1998. conventional electrical surgery, termed electrovaporization, or laser technique. Bipolar transurethral vaporization of Subsequently, transurethral vaporization the prostate (B-TUVP) was first described of the prostate (TUVP) was first introduced in 2001 by Botto et al [1]. Since then, by Kaplan in 1995 [1, 2 10]. American numerous urological centers have Urological Association (2010) commented reported that the outcomes as well as the that “TUVP is an appropriate and effective efficacy of B-TUVP was comparable with treatment alternative in men with moderate conventional transurethral resection of the to severe LUTS and/or who are signigicantly prostate (TURP). * 108 Hospital ** 103 Hiospital Corresponding author: Do Ngoc The (dongocthe@yahoo.com) 217
2. Journal of military pharmaco-medicine n o5-2017 SUBJECTS AND METHODS - Intra- as well as post-operative complications were monitored and identified. 1. Subjects. SPSS 20.0 was used for statistical 106 patients with BPH treated with B- TUVP at Department of Urology, Military analysis; p < 0.05 was considered statistically Hospital 103. significant. * Criteria for selection of patients: RESULTS - Patients with BPH were indicated to 1. Patients’ characteristics. take transurethral endoscopic surgery. - Average age: 71.1 ± 8.53 (50 - 90) - International Prostate Symptom Score years old. (IPSS) ≥ 20. - Average prostate weight: 48.6 ± 12.2 - Peak Flow Rate (Qmax) < 15 mL/s. grams (25 - 75). - Prostate weight ≤ 75 gam. - There were 42 patients (39.6%) who - Postoperative histology: benign prostatic admitted to the hospital with acute urinary hyperplasia. retention (AUR) requiring urethral catheter. 2. Methods. 2. Technical outcomes. * Study design : prospective, cross- sectional case-series. * Operation time: * Main criteria : Mean operation time 38.2 ± 13 minutes (15 - 75). - Operation time and the relation with age, preoperative urinary retention and * Group of operation time: prostate weight. Urethral catheterization 15 - 29 minutes: 24 patients (22.6%); time, postoperative hospital stay and 30 - 44 minutes: 44 patients (41.5%); 45 - conditions after removing the catheter. 59 minutes: 29 patients (27.4%): 60 - 75 - Intra-operative complications. minutes: 9 patients (8.5%). - Early and late post-operative Nearly all of the patients underwent complications. under 60 mins of procedure; operation time * Treatment process : exceeding 60 mins accounted for only 8.5%. - Patients were examined clinically; There was no correlation between IPSS, QoL score and uroflow test were operation time and patient’s age (n = 106; evaluated to measure Qmax, and post r2 = 0.001; p = 0.713). But there was a void residual (PVR). positive correlation between operation - B-TUVP was performed. time and prostate weight: bigger prostate, - Technical criteria were monitored and longer operation time (n = 106; r 2 = 0.396, evaluated. p = 0.0001). 218
3. Journal of military pharmaco-medicine n o5-2017 Table 1: Comparison of operation time (47.2% and 25,5%, respectively). The main of 2 groups (AUR and non-AUR). reason for long hospital stay ( ≥ 7 days) was urinary retention after the catheter Group n Mean operation p-value had been removed, so patients had to be time re-catheterized. Pre-op. AUR 42 38.2 ± 13.6 * Post-operative hospital stay: 0.97 Non-AUR 64 38.1 ± 12.7 3 days: 5 patients (4.8%); 4 days: 50 patients (47.2%); 5 days: 27 patients Total 106 (25.5%); 6 days: 10 patients (9.4%); 7 The differences of mean operation days: 9 patients (8.5%); ≥ 8 days: 5 time between 2 groups (AUR and non- patients (4.7%). AUR) were not statistically significant In addition, there were 2 patients with (p = 0.97 > 0.05). UTI (1.9%), 2 patients with dysuria (1,9%), * Catheterization time, postoperative 2 patients with cardiovascular problems hospital stay and conditions after the (acute coronary syndrome in 1 patient catheter removed: and 1 patient was suspected of having chemic myocardium), the patient who had Mean catheterization time 3.3 ± 1.5 the drainage in right iliac region due to days (2 - 12). capsular perforation suffered from 7-day * Catheterization time: catheter. 2 days: 20 patients (18.9%); 3 days: 65 patients (61.3%); 4 days: 12 patients 3. Complications of B-TUVP. (11.3%); ≥ 5 days: 9 patients (8.5%). * Intra-operative complications: Most of patients had 3-day urethral Table 2: catheter (61.3%). Intra-operative complications n % * Conditions after the urethral catheter removed: TUR-syndrome 0 0 Urinate continent: 100 patients (94.3%): Bleeding 2 1.9 acute urinary retention: 6 patients (5.7%). Prostate capsule perforation 2 1.9 After the catheter had been removed, 93.3% of patients urinated immediately Conversion to other surgical 0 0 procedures continent, except for 6 patients (5.7%) who had to be re-catheterized the second Total 4 3.8 time due to urinary retention, and 1 patient with gross hematuria was re- Prostatic capsule perforation occurred catheterized to re-irrigate the bladder. in 2 patients, but we had to place a right Mean postoperative hospital stay: 4.9 iliac region drainage in one patient ± 1.7 day (3 - 17). Most of patients had 4 because irrigating fluid was pervasive into and 5 days in hopital p after the operation peritoneal cavity. 219
4. Journal of military pharmaco-medicine n o5-2017 Intra-operative bleeding occurred in After the catheter had been removed, 2 patients, 1 patient was given 500 ml of 6 patients (5.7%) were re-catheterized the red blood cell (RBC) transfusion. No second time due to urinary retention; 3 conversion to other procedures during B- other patients with capsular infection were TUVP was met with. treated conservatively. * Early post-operative complications Table 5: 1 month postoperative after B-TUVP: complication (n = 102). Table 3: Early postoperative complications Complications n % in catheterization duration (n = 106). Late acute urinary retention 1 0.98 Complications n % Membranous urethral stricture 1 0.98 Urinary tract infection (UTI) 6 5.7 Transient urinaryincontinence (UI) 1 0.98 Bleeding 3 2.8 Total 3 2.9 Clot retention 1 0.9 After 1-week discharge, 1 patient Left chest pain 1 0.9 returned due to acute urinary retention Total 11 10.3 and was treated by re-catheterization. After the catheter had been removed, he Fever occurred in 7 patients during could urinate successfully. Transient UI catheterization time, in which 1 was due occurred in 1 patient. He self-recovered to an acute throat infection, 6 were due to after 3 months. UTI. Post-operative bleeding occurred in Membranous urethral stricture occurred 3 patients: 2 were conserved and 1 in 1 patient when he took a medical check (0.9%) had to be re-operated with after 1 month. The urethra dilated using B-TUVP as well as 750 mL RBC 16 to 20 Fr Benique sound. transfusion. Clot retention occurred in 1 * Late postoperative complications of patient so we had to replace a new B-TUVP: catheter. There was also 1 patient with Membranous urethral stricture occurred left chest pain postoperatively, but ruled in 1 patient at 18 th month. He underwent out acute coronary syndrome. internal urethrotomy. Table 4: Early postoperative complication DISCUSSION after removing the catheter (n = 106). 1. Success, failure. Complications n % B-TUVP is regarded as a successful procedure because the patients not only Acute urinary retention 6 5.7 underwent the operation safely and Prostatic fossa infection 3 2.8 urinated successfully at the time of Total 9 8.5 discharge, but also had no conversion to other procedure. 220
5. Journal of military pharmaco-medicine n o5-2017 The success rate of B-TUVP in most gram group (51 mins) was statistically recent reports was 100%. But Robert shorter than that of the ≥ 45 gram group (2012) converted to TURP in 1 patient (65.6 mins) (p = 0.03) [11]; Otsuki (2012) due to intra-operative bleeding [011] also reported that the operation time Kranzbühler (2013) converted to B-TURP increased from 41.5 mins (for prostate < in 1 patient with prostate weight 110 45 gram) to 93.5 mins (for prostate > 65 grams due to intra-operative bleeding [0]; gram) [9]. In this study, the prostate Falahatkar (2014) repeated this procedure weight was lower than that in other in 1 patient due to urinary retention after reference publications; the operation time the catheter had been removed [3]. In was also shorter; 91.5% of the operations this study, success rate was 100%, but 1 lasted within 60 minutes (table 1). patient needed to take the ‘second-look’ The catheterization time and postoperative with B-TUVP due to postoperative bleeding. hospital stay varied in some research 2. Age, prostate weight and operation published. In general, patients who were time. discharged after the catheter had been The mean age of the patients was 71.1 removed got urine flow test, so that the years old, slightly higher than the other hospital stay was longer than reports. However, the data analysis showed catheterization time. Except for that there was no correlation between Falahatkar’s report, in which the patients operation time and patient’s age (n = 106; were discharged with urethral catheter r2 = 0.001; p = 0.713). Similarly, there was and returned to remove few days later. no statistical significant difference of mean The reasons why the urethral catheter operation time between preoperative AUR was placed after transurethral surgery for group and the non-AUR group. But we BPH were as follows: 1/Getting prostatic found that there was not the same fossa hemostasis by Foley balloon; 2/ compared to other earlier reports. Ensuring the urine flow while the patient The average prostate weight in this cannot self-urinate due to pain, prostatic study was 48.6 grams. The figure was fossa edema, or detrusor muscle dysfunction, lower compared to most of other and 3/ Monitoring the urine. research. In this study, the prostate was The urethral catheter should be removed nearly 75 grams, while some prostates within 48 hours to 72 hours after the weighted over 80 grams have been operation. If there is no postoperative performed previously [5, 7, 9, 10, 11]. complication, it will not be good for the It was supported by Dincel’s report [2], patients with longer catheterization time. in which the statistical analysis demonstrated Besides, it depends on individual the bigger prostate, the longer operation experience to remove the catheter within time. Similarly, Robert (2012) provided 24 hours after surgery (Botto, Geavlete, that the mean B-TUVP time of the ≤ 30 Robert, Karakose). 221
6. Journal of military pharmaco-medicine n o5-2017 In this study, mean catheterization time * Gross hematuria after removing the was 3.2 days (2 to 3 days in 80.2%, 4 catheter: days in 11.3%). There were 9 patients The gross hematuria after the urethral with over 4 days catheterization time catheter had been removed was possible (8.5%) due to intra- and post-operative because of bleeding from prostatic fossa complications. Finally, all of patients and bladder neck. It may occur some urinated successfully. following days or weeks. The patient should be treated by medical conservation with 3. Intraoperative complications of B- bed-rest, oral hemostasis agents, anti- TUVP. spam, antibiotics In addition, the patients Up to now, no mortality as well as may take re-catheterization, Foley baloon transurethral resection syndrome has traction, and even the ‘second-look’ to been reported due to B-TUVP. surgical hemostasis in severe or permanent The rate of bleeding during B-TUVP bleeding. Karakose’s study (2014) included was low and not frequent. Geavlete 2 transient hematuria [5]. Otsuki (2012) reported that 5 patients (4.7%) with gross (2011), Robert (2012) and Kranzbühler hematuria were required to take re- (2013) reported that 1.8%, 0.9% and 1.2% catheterization and bladder irrigation [9]. of cases had intra-operative bleeding In this report, there was no patient with (respectively), no transfusion was indicated, gross hematuria after the catheter had but 1 patient was converted to TURP (in been removed. Robert’s report) and 1 patient to B-TURP Some authors notified the late hematuria (in Kranzbühler’s report) [4, 7, 11]. In this after B-TUVP. Dincel (2004) reported that study, intra-operative bleeding occurred in 1 patient had returned the hospital on the 2 patients (1.9%), 1 patient was transfused 50 th day after the surgery due to severe with 500 mL of RBC, but no conversion hematuria; he was treated by re- was met with. catheterization, bladder irrigation, and 4. Post-operative complications of then ‘second look’ [2]. Similarly, Robert B-TUVP. (2012) reported that 4 patients underwent late bleeding during 3 months just after B- * Postoperative bleeding and transfusion: TUVP [11]; Kranzbühler (2013) reported Geavlete (2011) reported that 2 that 2 patients experienced bleeding and patients had to be transfused due to clot retention at the 4 th week and the 6 th anemia after B-TUVP (1.2%) [4]. Robert week [0]. (2012) reported that the postoperative * Urinary incontinence after B-TUVP: bleeding occurred in 3 patients (2.8%) but Permanent urinary incontinence after no transfusion was indicated [11]. We TUR-surgery is usually met with because also found 3 patients with bleeding after of the consequence of external urethral B-TUVP, and 1 patient was retreated sphincter injury and/or destrusor muscle hemostasis using B-TUVP. instability. Fortunately, it was reported 222
7. Journal of military pharmaco-medicine n o5-2017 that most of UI were transient and self- * Urethral stricture after B-TUVP: recovered after a few days or weeks later, Urethral stricture after revealing the B- with 2 types: stress UI and urge UI. TUVP was quite frequent. It occurred Urinary incontinence after B-TUVP commonly at membranous urethra. Botto was reported in few publications. Reich (2001) found 2 patients (4.7%) with (2010) revealed transient UI in 1 patient membranous urethra stricture 1 month (3.3%), Otsuki (2012) found it in 2 after B-TUVP requiring ‘cold-knife’ internal patients (1.9%) and Karakose also found urethrotomy [1]. Kaya (2007) reported that in 2 patients (2.1%). This study reported 1 membranous urethra stricture occurred in transient and self-recovered UI 3 months 1 patient (4%) after 3 years follow-up [6]. after the surgery. The same as in the Nuhoglu’s report [8], * Acute urinary retention after removing in which 1 patient (2.3%) was also cured the catheter: by internal urethrotomy. In this study, Acute urinary retention (AUR) after membranous urethral stricture occurred in removing the catheter occurred frequently. 2 patients: 1 patient after 1 month (treated It may be the consequence of blood clot, by urethral dilation) and 1 patient after 18 residual clot, oedema of bladder neck of prostatic fossa infection, under active months (treated by internal urethrotomy). bladder CONCLUSION Falahatkar (2014) found that AUR occurred in 3 patients (7.7%) after the B-TUVP is an effective procedure for catheter had been removed; 2 patients surgical-indication benign prostatic were re-catheterized and 1 patient was hyperplasia with prostate weight under 75 re-operated by B-TUVP [3]. In grams. Mean operation time was 38.2 Kranzbühler’s study (2013), 3 patients mins, mean postoperative urethral were discharged from the hospital with catheterization time was 3.2 days, mean the urethral catheter. After 13 days, the hospital stay was 4.9 days. There was no catheters were removed but 1 patient was complication-related mortality as well as re-catheterized due to AUR and treated transurethral syndrome. There were some by permanent suprapubic cystostomy [7]. intra-operative complications including Robert (2012) reported that late AUR bleeding (1.9%), prostatic capsule occurred in 9 patients (8.5%) from 1 perforation (1.9%). In addition, early post- month to 9 months after the surgery and operative complications were met with re-operation were performed on 5 patients (4 TURP and 1 Greenlight laser). including fever due to UTI (5.7%); bleeding (2.8%) (incl. transfusion 0.9%), In this study, acute urinary retention clot retention (0.9%), acute urinary after the catheter had been removed occurred in 6 patients (5.7%). After 1 retention (after removing the urethral week, 1 patient returned to hospital due to catheter) (5.7%), transient incontinence AUR. All were cured conservatively by re- (0.9%). Membranous urethral stricture catheterization combining with α-blockers. was found in 2 patients. 223
8. Journal of military pharmaco-medicine n o5-2017 REFERENCES prostate using plasma kinetic energy. BJU Int. 2007, 99 (4), pp.845-848. 1. Botto H, Lebret T et al. Electrovaporization 7. Kranzbühler B, Wettstein M.S et al. Pure of the prostate with the Gyrus device. Journal of Endourology. 2001,15 (3), pp.313-316. bipolar plasma vaporization of the prostate: the Zurich experience. J Endourol. 2013, 27 2. Dincel C, Samli M.M, Guler C et al. (10), pp.1261-1266. Plasma kinetic vaporization of the prostate: Clinical evaluation of a new technique. Journal 8. Nuhoglu B, Balci M.B et al. The role of of Endourology. 2004, 18 (3), pp.293-298. bipolar transurethral vaporization in the 3. Falahatkar S, Mokhtari G et al. Bipolar management of benign prostatic hyperplasia. transurethral vaporization: a superior procedure Urol Int. 2011, 87 (4), pp.400-404. in benign prostatic hyperplasia: a prospective 9. Otsuki H, Kuwahara Y et al. Transurethral randomized comparison with bipolar TURP. resection in saline vaporization: Evaluation of Int Braz J Urol. 2014, 40 (3), pp.346-355. clinical efficacy and prostate volume. Urology. 4. Geavlete B, Georgescu D et al. Bipolar 2012, 79 (3), pp.665-669. plasma vaporization vs monopolar and bipolar 10. Reich O, Schlenker B, Gratzke C et al. TURP - A prospective, randomized, long-term comparison. Urology. 2011, 78 (4), pp.930-935. Plasma vaporization of the prostate: Initial clinical results. European Urology. 2010, 57 5. Karakose A, Aydogdu O, Atesci Y.Z. BiVap saline vaporization of the prostate in (4), pp.693-698. men with benign prostatic hyperplasia: Our 11. Robert G, Descazeaud A et al. clinical experience. Urology. 2014, 83 (3), Transurethral plasma vaporization of the pp.570-575. prostate: 3-month functional outcome and 6. Kaya C, Ilktac A et al. The long-term complications. BJU Int. 2012, 110 (4), pp. results of transurethral vaporization of the 555-560. 224