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.
Journal of military pharmaco-medicine no5-2017 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 postoperative 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 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 Vaporization of the prostate was first described in the early 1990s using either conventional electrical surgery, termed electrovaporization, or laser technique Subsequently, transurethral vaporization of the prostate (TUVP) was first introduced by Kaplan in 1995 [1, 10] American Urological Association (2010) commented that “TUVP is an appropriate and effective treatment alternative in men with moderate to severe LUTS and/or who are signigicantly bothered by these symptoms ” In Vietnam, Tran Ngoc Sinh et al have first applied this procedure in the treatment of BPH since 1998 Bipolar transurethral vaporization of the prostate (B-TUVP) was first described in 2001 by Botto et al [1] Since then, numerous urological centers have reported that the outcomes as well as the efficacy of B-TUVP was comparable with conventional transurethral resection of the prostate (TURP) * 108 Hospital ** 103 Hiospital Corresponding author: Do Ngoc The (dongocthe@yahoo.com) 217 Journal of military pharmaco-medicine no5-2017 SUBJECTS AND METHODS Subjects 106 patients with BPH treated with BTUVP at Department of Urology, Military Hospital 103 * Criteria for selection of patients: - Patients with BPH were indicated to take transurethral endoscopic surgery - International Prostate Symptom Score (IPSS) ≥ 20 - Peak Flow Rate (Qmax) < 15 mL/s - Prostate weight ≤ 75 gam - Postoperative histology: benign prostatic hyperplasia Methods * Study design: prospective, crosssectional case-series * Main criteria: - Operation time and the relation with age, preoperative urinary retention and prostate weight Urethral catheterization time, postoperative hospital stay and conditions after removing the catheter - Intra-operative complications - Early and complications late - Intra- as well as post-operative complications were monitored and identified SPSS 20.0 was used for statistical analysis; p < 0.05 was considered statistically significant RESULTS Patients’ characteristics - Average age: 71.1 ± 8.53 (50 - 90) years old - Average prostate weight: 48.6 ± 12.2 grams (25 - 75) - There were 42 patients (39.6%) who admitted to the hospital with acute urinary retention (AUR) requiring urethral catheter Technical outcomes * Operation time: Mean operation time 38.2 ± 13 minutes (15 - 75) * Group of operation time: 15 - 29 minutes: 24 patients (22.6%); 30 - 44 minutes: 44 patients (41.5%); 45 59 minutes: 29 patients (27.4%): 60 - 75 minutes: patients (8.5%) post-operative Nearly all of the patients underwent under 60 mins of procedure; operation time exceeding 60 mins accounted for only 8.5% - Patients were examined clinically; IPSS, QoL score and uroflow test were evaluated to measure Qmax, and post void residual (PVR) There was no correlation between operation time and patient’s age (n = 106; r2 = 0.001; p = 0.713) But there was a positive correlation between operation time and prostate weight: bigger prostate, longer operation time (n = 106; r2 = 0.396, p = 0.0001) * Treatment process: - B-TUVP was performed - Technical criteria were monitored and evaluated 218 Journal of military pharmaco-medicine no5-2017 Table 1: Comparison of operation time of groups (AUR and non-AUR) Group n Mean operation time Pre-op AUR 42 38.2 ± 13.6 p-value 0.97 Non-AUR 64 Total 106 38.1 ± 12.7 The differences of mean operation time between groups (AUR and nonAUR) were not statistically significant (p = 0.97 > 0.05) * Catheterization time, postoperative hospital stay and conditions after the catheter removed: Mean catheterization time 3.3 ± 1.5 days (2 - 12) * Catheterization time: days: 20 patients (18.9%); days: 65 patients (61.3%); days: 12 patients (11.3%); ≥ days: patients (8.5%) Most of patients had 3-day urethral catheter (61.3%) * Conditions after the urethral catheter removed: Urinate continent: 100 patients (94.3%): acute urinary retention: patients (5.7%) After the catheter had been removed, 93.3% of patients urinated immediately continent, except for patients (5.7%) who had to be re-catheterized the second time due to urinary retention, and patient with gross hematuria was recatheterized to re-irrigate the bladder Mean postoperative hospital stay: 4.9 ± 1.7 day (3 - 17) Most of patients had and days in hopital p after the operation (47.2% and 25,5%, respectively) The main reason for long hospital stay (≥ days) was urinary retention after the catheter had been removed, so patients had to be re-catheterized * Post-operative hospital stay: days: patients (4.8%); days: 50 patients (47.2%); days: 27 patients (25.5%); days: 10 patients (9.4%); days: patients (8.5%); ≥ days: patients (4.7%) In addition, there were patients with UTI (1.9%), patients with dysuria (1,9%), patients with cardiovascular problems (acute coronary syndrome in patient and patient was suspected of having chemic myocardium), the patient who had the drainage in right iliac region due to capsular perforation suffered from 7-day catheter Complications of B-TUVP * Intra-operative complications: Table 2: Intra-operative complications n % TUR-syndrome 0 Bleeding 1.9 Prostate capsule perforation 1.9 Conversion to other surgical procedures 0 Total 3.8 Prostatic capsule perforation occurred in patients, but we had to place a right iliac region drainage in one patient because irrigating fluid was pervasive into peritoneal cavity 219 Journal of military pharmaco-medicine no5-2017 Intra-operative bleeding occurred in patients, patient was given 500 ml of red blood cell (RBC) transfusion No conversion to other procedures during BTUVP was met with After the catheter had been removed, patients (5.7%) were re-catheterized the second time due to urinary retention; other patients with capsular infection were treated conservatively * Early post-operative complications after B-TUVP: Table 5: month complication (n = 102) Table 3: Early postoperative complications in catheterization duration (n = 106) Complications postoperative Complications n % Late acute urinary retention 0.98 n % Membranous urethral stricture 0.98 Urinary tract infection (UTI) 5.7 Transient urinaryincontinence (UI) 0.98 Bleeding 2.8 Total 2.9 Clot retention 0.9 Left chest pain 0.9 Total 11 10.3 Fever occurred in patients during catheterization time, in which was due to an acute throat infection, were due to UTI Post-operative bleeding occurred in patients: were conserved and (0.9%) had to be re-operated with B-TUVP as well as 750 mL RBC transfusion Clot retention occurred in patient so we had to replace a new catheter There was also patient with left chest pain postoperatively, but ruled out acute coronary syndrome Table 4: Early postoperative complication after removing the catheter (n = 106) Complications n % Acute urinary retention 5.7 Prostatic fossa infection 2.8 Total 8.5 220 After 1-week discharge, patient returned due to acute urinary retention and was treated by re-catheterization After the catheter had been removed, he could urinate successfully Transient UI occurred in patient He self-recovered after months Membranous urethral stricture occurred in patient when he took a medical check after month The urethra dilated using 16 to 20 Fr Benique sound * Late postoperative complications of B-TUVP: Membranous urethral stricture occurred in patient at 18th month He underwent internal urethrotomy DISCUSSION Success, failure B-TUVP is regarded as a successful procedure because the patients not only underwent the operation safely and urinated successfully at the time of discharge, but also had no conversion to other procedure Journal of military pharmaco-medicine no5-2017 The success rate of B-TUVP in most recent reports was 100% But Robert (2012) converted to TURP in patient due to intra-operative bleeding [011] Kranzbühler (2013) converted to B-TURP in patient with prostate weight 110 grams due to intra-operative bleeding [0]; Falahatkar (2014) repeated this procedure in patient due to urinary retention after the catheter had been removed [3] In this study, success rate was 100%, but patient needed to take the ‘second-look’ with B-TUVP due to postoperative bleeding Age, prostate weight and operation time The mean age of the patients was 71.1 years old, slightly higher than the other reports However, the data analysis showed that there was no correlation between operation time and patient’s age (n = 106; r2 = 0.001; p = 0.713) Similarly, there was no statistical significant difference of mean operation time between preoperative AUR group and the non-AUR group But we found that there was not the same compared to other earlier reports The average prostate weight in this study was 48.6 grams The figure was lower compared to most of other research In this study, the prostate was nearly 75 grams, while some prostates weighted over 80 grams have been performed previously [5, 7, 9, 10, 11] It was supported by Dincel’s report [2], in which the statistical analysis demonstrated the bigger prostate, the longer operation time Similarly, Robert (2012) provided that the mean B-TUVP time of the ≤ 30 gram group (51 mins) was statistically shorter than that of the ≥ 45 gram group (65.6 mins) (p = 0.03) [11]; Otsuki (2012) also reported that the operation time increased from 41.5 mins (for prostate < 45 gram) to 93.5 mins (for prostate > 65 gram) [9] In this study, the prostate weight was lower than that in other reference publications; the operation time was also shorter; 91.5% of the operations lasted within 60 minutes (table 1) The catheterization time and postoperative hospital stay varied in some research published In general, patients who were discharged after the catheter had been removed got urine flow test, so that the hospital stay was longer than catheterization time Except for Falahatkar’s report, in which the patients were discharged with urethral catheter and returned to remove few days later The reasons why the urethral catheter was placed after transurethral surgery for BPH were as follows: 1/Getting prostatic fossa hemostasis by Foley balloon; 2/ Ensuring the urine flow while the patient cannot self-urinate due to pain, prostatic fossa edema, or detrusor muscle dysfunction, and 3/ Monitoring the urine The urethral catheter should be removed within 48 hours to 72 hours after the operation If there is no postoperative complication, it will not be good for the patients with longer catheterization time Besides, it depends on individual experience to remove the catheter within 24 hours after surgery (Botto, Geavlete, Robert, Karakose) 221 Journal of military pharmaco-medicine no5-2017 In this study, mean catheterization time was 3.2 days (2 to days in 80.2%, days in 11.3%) There were patients with over days catheterization time (8.5%) due to intra- and post-operative complications Finally, all of patients urinated successfully Intraoperative complications of BTUVP Up to now, no mortality as well as transurethral resection syndrome has been reported due to B-TUVP The rate of bleeding during B-TUVP was low and not frequent Geavlete (2011), Robert (2012) and Kranzbühler (2013) reported that 1.8%, 0.9% and 1.2% of cases had intra-operative bleeding (respectively), no transfusion was indicated, but patient was converted to TURP (in Robert’s report) and patient to B-TURP (in Kranzbühler’s report) [4, 7, 11] In this study, intra-operative bleeding occurred in patients (1.9%), patient was transfused with 500 mL of RBC, but no conversion was met with Post-operative complications of B-TUVP * Postoperative bleeding and transfusion: Geavlete (2011) reported that patients had to be transfused due to anemia after B-TUVP (1.2%) [4] Robert (2012) reported that the postoperative bleeding occurred in patients (2.8%) but no transfusion was indicated [11] We also found patients with bleeding after B-TUVP, and patient was retreated hemostasis using B-TUVP 222 * Gross hematuria after removing the catheter: The gross hematuria after the urethral catheter had been removed was possible because of bleeding from prostatic fossa and bladder neck It may occur some following days or weeks The patient should be treated by medical conservation with bed-rest, oral hemostasis agents, antispam, antibiotics… In addition, the patients may take re-catheterization, Foley baloon traction, and even the ‘second-look’ to surgical hemostasis in severe or permanent bleeding Karakose’s study (2014) included transient hematuria [5] Otsuki (2012) reported that patients (4.7%) with gross hematuria were required to take recatheterization and bladder irrigation [9] In this report, there was no patient with gross hematuria after the catheter had been removed Some authors notified the late hematuria after B-TUVP Dincel (2004) reported that patient had returned the hospital on the 50th day after the surgery due to severe hematuria; he was treated by recatheterization, bladder irrigation, and then ‘second look’ [2] Similarly, Robert (2012) reported that patients underwent late bleeding during months just after BTUVP [11]; Kranzbühler (2013) reported that patients experienced bleeding and clot retention at the 4th week and the 6th week [0] * Urinary incontinence after B-TUVP: Permanent urinary incontinence after TUR-surgery is usually met with because of the consequence of external urethral sphincter injury and/or destrusor muscle instability Fortunately, it was reported Journal of military pharmaco-medicine no5-2017 that most of UI were transient and selfrecovered after a few days or weeks later, with types: stress UI and urge UI Urinary incontinence after B-TUVP was reported in few publications Reich (2010) revealed transient UI in patient (3.3%), Otsuki (2012) found it in patients (1.9%) and Karakose also found in patients (2.1%) This study reported transient and self-recovered UI months after the surgery * Acute urinary retention after removing the catheter: Acute urinary retention (AUR) after removing the catheter occurred frequently It may be the consequence of blood clot, residual clot, oedema of bladder neck of prostatic fossa infection, under active bladder… Falahatkar (2014) found that AUR occurred in patients (7.7%) after the catheter had been removed; patients were re-catheterized and patient was re-operated by B-TUVP [3] In Kranzbühler’s study (2013), patients were discharged from the hospital with the urethral catheter After 13 days, the catheters were removed but patient was re-catheterized due to AUR and treated by permanent suprapubic cystostomy [7] Robert (2012) reported that late AUR occurred in patients (8.5%) from month to months after the surgery and re-operation were performed on patients (4 TURP and Greenlight laser) In this study, acute urinary retention after the catheter had been removed occurred in patients (5.7%) After week, patient returned to hospital due to AUR All were cured conservatively by recatheterization combining with α-blockers * Urethral stricture after B-TUVP: Urethral stricture after revealing the BTUVP was quite frequent It occurred commonly at membranous urethra Botto (2001) found patients (4.7%) with membranous urethra stricture month after B-TUVP requiring ‘cold-knife’ internal urethrotomy [1] Kaya (2007) reported that membranous urethra stricture occurred in patient (4%) after years follow-up [6] The same as in the Nuhoglu’s report [8], in which patient (2.3%) was also cured by internal urethrotomy In this study, membranous urethral stricture occurred in patients: patient after month (treated by urethral dilation) and patient after 18 months (treated by internal urethrotomy) CONCLUSION B-TUVP is an effective procedure for surgical-indication benign prostatic hyperplasia with prostate weight under 75 grams Mean operation time was 38.2 mins, mean postoperative urethral catheterization time was 3.2 days, mean hospital stay was 4.9 days There was no complication-related mortality as well as transurethral syndrome There were some intra-operative complications including bleeding (1.9%), prostatic capsule perforation (1.9%) In addition, early postoperative complications were met with including fever due to UTI (5.7%); bleeding (2.8%) (incl transfusion 0.9%), clot retention (0.9%), acute urinary retention (after removing the urethral catheter) (5.7%), transient incontinence (0.9%) Membranous urethral stricture was found in patients 223 Journal of military pharmaco-medicine no5-2017 REFERENCES Botto H, Lebret T et al Electrovaporization of the prostate with the Gyrus device Journal of Endourology 2001,15 (3), pp.313-316 Dincel C, Samli M.M, Guler C et al Plasma kinetic vaporization of the prostate: Clinical evaluation of a new technique Journal of Endourology 2004, 18 (3), pp.293-298 Falahatkar S, Mokhtari G et al Bipolar transurethral vaporization: a superior procedure in benign prostatic hyperplasia: a prospective randomized comparison with bipolar TURP Int Braz J Urol 2014, 40 (3), pp.346-355 Geavlete B, Georgescu D et al Bipolar plasma vaporization vs monopolar and bipolar TURP - A prospective, randomized, long-term comparison Urology 2011, 78 (4), pp.930-935 Karakose A, Aydogdu O, Atesci Y.Z BiVap saline vaporization of the prostate in men with benign prostatic hyperplasia: Our clinical experience Urology 2014, 83 (3), pp.570-575 Kaya C, Ilktac A et al The long-term results of transurethral vaporization of the 224 prostate using plasma kinetic energy BJU Int 2007, 99 (4), pp.845-848 Kranzbühler B, Wettstein M.S et al Pure bipolar plasma vaporization of the prostate: the Zurich experience J Endourol 2013, 27 (10), pp.1261-1266 Nuhoglu B, Balci M.B et al The role of bipolar transurethral vaporization in the management of benign prostatic hyperplasia Urol Int 2011, 87 (4), pp.400-404 Otsuki H, Kuwahara Y et al Transurethral resection in saline vaporization: Evaluation of clinical efficacy and prostate volume Urology 2012, 79 (3), pp.665-669 10 Reich O, Schlenker B, Gratzke C et al Plasma vaporization of the prostate: Initial clinical results European Urology 2010, 57 (4), pp.693-698 11 Robert G, Descazeaud A et Transurethral plasma vaporization of prostate: 3-month functional outcome complications BJU Int 2012, 110 (4), 555-560 al the and pp ... al The role of bipolar transurethral vaporization in the management of benign prostatic hyperplasia Urol Int 2011, 87 (4), pp.400-404 Otsuki H, Kuwahara Y et al Transurethral resection in saline... of the prostate in men with benign prostatic hyperplasia: Our clinical experience Urology 2014, 83 (3), pp.570-575 Kaya C, Ilktac A et al The long-term results of transurethral vaporization of. .. In this study, the prostate weight was lower than that in other reference publications; the operation time was also shorter; 91.5% of the operations lasted within 60 minutes (table 1) The catheterization