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A prospective randomised study between transurethral vaporisation using plasmakinetic energy and transurethral resection of the prostate
Every year, an increasing quantity of new information is presented at the major urologic and oncologic congresses such as the European Association of Urology (EAU), the American Urological Association (AUA), the American Society of Clinical Oncology (ASCO), and so forth. Because of the delay until final publication of these data, it is very difficult for urologists to keep up to date with the new scientific information relevant for their own clinical practise. In light of this difficulty, a closed expert meeting “New Horizons in Urology” (NHU) was held in October 2006 in Marbella, Spain. The objective of this meeting was to provide practising urologists with the most important information with practical clinical relevance to urologists presented during the major urologic and oncologic meetings. This information was selected and presented by leading experts in the field of functional and oncologic urology. Nonmalignant disease areas that were considered were surgical interventions for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), benign bladder diseases, and stone disease. Malignant disease topics were prostate cancer, bladder cancer, and kidney cancer. Each session started with a clinical case workshop during which the attendee's opinion on the management of the clinical case was assessed via interactive voting, followed by a discussion of the expert panel. The sessions were closed with a brief update lecture. The current paper summarises the highlights of the closed expert meeting.
To explore the clinical value of preserving the integrity of the bladder neck in plasmakinetic vaporization of the prostate (PKVP) in protecting the erectile function and improving the quality of life of patients with benign prostatic hyperplasia (BPH) below 60 years of age.
Thirty-two patients with BPH, with a mean age of 55.4 years (range 50-60 years), were enrolled the study to undergo PKVP with Gyrus bipolar systems, in which the transverse fiber muscle area of the bladder neck were carefully preserved. The erectile function and the quality of life of the patients were evaluated with the International Index of Erectile Function (IIEF)-5 and Quality of Life (QoL) before and after the operation. Retrograde ejaculation was also observed after the operation.
In the 6-month follow-up, only 1 (3.13%) patient was found to have erectile dysfunction. Five patients (15.6%) reported retrograde ejaculation 3 months after the surgery, and only 3 patients (9.4%) had retrograde ejaculation at 6 months.
Preserving the bladder neck in PKVP may protect the erectile function with BPH below 60 years of age.
Objectives: This manuscript reviews the strengths and weaknesses of alternatives to transurethral resection of the prostate (TURP) to treat lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). Methods: The majority of data discussed in this paper were presented at the 2006 annual meetings of the European Association of Urology and the American Urological Association. Data from randomised controlled trials (RCTs) comparing surgical interventions for LUTS/BPH versus TURP, from studies including >100 patients and with at least 1 yr of follow-up were included. The participants' opinions on two representative clinical cases were assessed via interactive voting. Results: Short-term efficacy of therapy analogues to TURP (bipolar transurethral resection in saline [TURIS], transurethral vaporisation of the prostate [TUVP], and holmium laser resection/enucleation [HoLRP/HoLEP]) seems comparable to TURP, with good safety profiles. Various direct comparative studies show that energy-based ablative techniques (transurethral needle ablation [TUNA], transurethral microwave therapy [TUMT], and photoselective vaporisation of the prostate [PVP]) may be an effective alternative to TURP and are associated with fewer complications. Mechanical stenting seems to be a solution for patients who cannot undergo general anaesthesia. Initial data on the use of botulinum toxin for LUTS/BPH looks promising. However, in all cases, more long-term data (>5 yr of follow-up) are needed to confirm these short-term outcomes. Conclusions: Accumulating evidence is reported in favour of several alternatives to TURP. However, in all cases, prospective, long-term RCTs are needed to evaluate if these promising short-term outcomes are sustained over time.
Blockade of the sciatic nerve is necessary for complete analgesia of the lower extremity using peripheral nerve blocks. We identified the sciatic nerve in relation to the ischial tuberosity in fresh cadaver dissections as well as in patients to compare sciatic nerve blockade using the conventional approach versus our experimental approach. Specifically, we tested the hypothesis that in patients in the prone position, our novel approach (changing the point of needle insertion to 3 cm lateral from the ischial tuberosity) requires fewer needle passes and less time.
The location of the sciatic nerve in relation to the ischial tuberosity was identified in 20 cadavers; this information was used to devise an alternative approach to the sciatic nerve. In a randomized, controlled, crossover patient study, we compared a prone subgluteal approach (conventional approach, n = 19) with an experimental approach with the insertion point 3 cm lateral to the midpoint of ischial tuberosity with patients in prone position (n = 20). We recorded the number of passes and the time taken to obtain an initial sciatic nerve twitch at a current of 1.5 mA and a twitch at <0.5 mA.
The sciatic nerve averaged 2.8 +/- 0.4 cm from the midpoint of ischial tuberosity in cadavers in prone position. When needles were inserted from surface landmarks, those inserted through the experimental insertion point consistently transected the sciatic nerve. In contrast, needles inserted through the conventional approach were 2.27 +/- 0.47 cm lateral to the sciatic nerve. Clinically, our experimental approach required fewer passes to obtain a sciatic nerve twitch than the conventional approach. We were unable to obtain a twitch in 55% of patients with the conventional approach and converted them to the experimental approach. In patients originally assigned to the experimental approach and those switched to the experimental approach after failure with the conventional approach, we obtained the first sciatic nerve twitch in 1 pass in 45% of the patients and in 3 passes in 85%.
We describe a landmark that is more effective for identifying the location of the sciatic nerve than that used for the prone subgluteal approach.
We tested the hypothesis that ultrasound (US) guidance may reduce the minimum effective anesthetic volume (MEAV(50)) of 1.5% mepivacaine required to block the sciatic nerve with a subgluteal approach compared with neurostimulation (NS).
After premedication and single-injection femoral nerve block, 60 patients undergoing knee arthroscopy were randomly allocated to receive a sciatic nerve block with either NS (n = 30) or US (n = 30). In the US group, the sciatic nerve was localized between the ischial tuberosity and the greater trochanter. In the NS group, the appropriate muscular response (foot plantar flexion or inversion) was elicited (1.5 mA, 2 Hz, 0.1 ms) and maintained to <or=0.5 mA. The volume of the injected local anesthetic was varied for consecutive patients based on an up-and-down method, according to the response of the previous patient. The initial volume was 12 mL. An independent observer evaluated the occurrence of complete loss of pinprick sensation and motor block: positive or negative responses within 20 min after the injection determined a 2-mL decrease or increase for the next patient, respectively.
The mean MEAV(50) for sciatic nerve block was 12 mL (95% confidence interval [CI], 10-23 mL) in Group US and 19 mL (95% CI, 15-23 mL) in Group NS (P < 0.001). The effective dose in 95% of cases was 14 mL (95% CI, 12-17 mL) in Group US and 29 mL (95% CI, 25-40 mL) in Group NS (P = 0.008).
US provided a 37% reduction in the MEAV(50) of 1.5% mepivacaine required to block the sciatic nerve compared with NS.
We evaluated our results with bipolar plasma kinetic electrovaporization in the treatment of benign prostatic hyperplasia (BPH).
Twenty-one patients with infravesical obstruction by BPH have been treated with bipolar plasma kinetic electrovaporization. International Prostate Symptom Score (IPSS) with a quality of life (QOL) scoring questionnaire, uroflowmetry (maximum flow rate; Qmax), transrectal ultrasonography (TRUS), and residual urine volume and prostate specific antigen (PSA) measurements had been performed before surgery. The IPSS scores, prostate volumes, and residual urine volumes were reevaluated during the third postoperative month. Uroflowmetry was repeated on postoperative days 7, 15, 30, and 90. Total PSA and free PSA measurements were repeated on postoperative days 3, 5, 7, 15, 30, and 90.
The results of 20 patients could be evaluated. The median age of these patients was 61 years. The median volume of the prostates was 42 cc (95% CI 56-53). The median operation time and postoperative hospitalization were 55 minutes (95% CI 40-65) and 3 days (95% CI 3-5), respectively. The mean period of time needed for vaporizing 1 g of tissue was calculated as 2.8 +/- 1.3 minutes. Postoperative day 90 values of IPSS, QOL, prostate volume, residual urine volume, and Qmax showed significant improvement compared with preoperative values (p < 0.05). The median preoperative PSA value was 1.64 mg/mL (95% CI 1-3.6). The value showed a statistically significant increase 24 hours after the intervention (p < 0.0001), but the PSA values on the 30th (p = 0.041) and 90th (p = 0.025) days were below preoperative values.
The IPSS with QOL scores, prostate volumes, and residual urine volumes showed significant decreases and Qmax values showed a significant increase after bipolar plasma kinetic electrovaporization. This treatment modality causes a temporary increase in the PSA concentration, as do other interventional treatment methods, but the measurements on the 30th and 90th days were below preoperative values.
To assess the long-term efficacy and the safety of plasmakinetic vaporization of prostate (PKVP, Gyrus Medical Ltd., Bucks, UK) against standard transurethral resection of the prostate (TURP) for symptomatic prostatic obstruction.
Of 75 patients admitted to our clinic with symptomatic prostatic obstruction between 2001 and 2003, 40 who were randomized to undergo either TURP or PKVP, and who had returned for the follow-up, were included in this study. All treated patients completed the 36-months of follow-up; 25 had had PKVP and 15 a standard TURP. After surgery the treatment outcome was evaluated using the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Q(max)) and long-term complications of surgery.
The two groups had similar baseline characteristics. The improvement in both groups was statistically significant for the IPSS and Q(max) at 24 and 36 months vs the baseline values (P < 0.05). The mean (sd) IPSS decreased from 21 (3.4) to 7.1 (1.5) and 7.6 (1.4) after PKVP and from 22 (3.8) to 5.2 (1.1) and 5.7 (1.2) after TURP, at 24 and 36 months, respectively. The mean Q(max) for the both groups increased significantly from baseline values at 2 and 3 years, respectively, at 20.8 (2.4) and 21.8 (3.1) mL/s after TURP, which was statistically significantly better than after PKVP, at 12.5 (2.1) and 14.4 (2.6) mL/s, respectively (P < 0.05). Although three patients (12%) in the PKVP group had TURP at 14, 20 and 36 months, respectively, for residual adenoma tissue, one patient had an additional operation after TURP. Bulbar urethral strictures occurred in one patient in each group, requiring internal optical urethrotomy. Erectile dysfunction was reported by three patients after PKVP (12%) and by two of 15 after TURP who were potent before surgery (P > 0.05). The retrograde ejaculation rates in patients with erectile function were similar in both groups (56% and nine of 15, respectively; P > 0.05). In the PKVP and TURP groups, 12 (48%) and nine of 15 patients were satisfied overall.
Although early results showed that PKVP was a good alternative technique among the minimally invasive methods for surgically managing prostatic obstruction, the clinical outcome of PKVP in the long term was not comparable to the results after TURP.
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