la-resection-trans-urethrale

Variants to conventional transurethral resection of the prostate

Since the description of the first transurethral prostate resection (TURP) in 1901, the development of the technique has made it the reference treatment of benign prostatic hyperplasia (BPH). Although high adenomectomy (AVH) provides a better anatomical result, TURP is proposed as a first-line treatment because of its lower morbidity. Classically performed using a monopolar electric current in glycocolla, TURP is limited by the risk of intracellular hyperhydration (TURP syndrome) and can therefore be proposed only to patients whose prostatic volume allows a lower operating time to 60 minutes. Moreover, the hemorrhagic risk linked to the TURP raises the problem of the management of the patients under anti-aggregating or anti-coagulant treatment.

 

The development of bipolar electric current and electrical vaporization have made it possible to propose endoscopic alternatives.

1. Transurethral Electrovaporization of the Prostate (TUEVP or DVT)

Like TURP, transurethral electrovaporation (DVT) of the prostate involves introducing an endoscopic resector into the urethra of the patient; However, instead of cutting off excess tissue with an electrical circuit, the surgeon heats them and sprays them with a spherical electrode. This spherical electrode offers the advantage of cauterizing the tissues to minimize bleeding.

 

electrovaporisation-transuretrale-de-la-prostate-tuevp-ou-tvp

 

This intervention is only really indicated and realizable in the case of weak hypertrophies of the gland.

A meta-analysis including 20 scientific studies made it possible to compare the safety and efficacy of PST and TURP in these conditions. This study concluded that the effects of the two techniques on urinary symptoms were similar. However, men who underwent DVT had less need for blood transfusion, and their duration of hospitalization and bladder sampling was lower. Nevertheless, patients with TURP had a lower risk of urinary retention after surgery and were less likely to resort to further intervention.

 

2. Transurethral cervico-prostatic incision (ICP)

Transcutaneous cervical prostatic incision (ICP) is a technique in which the surgeon performs one or more incisions in the prostate instead of cutting or spraying excess tissue. These incisions along the urethra relieve pressure on the urethra and improve urinary flow. This procedure usually requires spinal or general anesthesia and may be performed on an outpatient basis or with a one-day hospital stay. However, not all patients can benefit from this procedure, which is mainly reserved for men whose prostate is very moderately hypertrophied. The best indication of this cervico-prostatic incision is the hypertrophy of the neck of the bladder without hypertrophy of the lateral lobes.

 

incision-transurethrale-cervico-prostatique-icp
Over a five-year period, 8 to 10% of patients require further intervention, compared with approximately 5% for TURP, almost twice as much. On the other hand, PCI seems to result in fewer complications, such as retrograde ejaculation, urinary incontinence, or blood loss. Only a quarter of men using this technique experience retrograde ejaculation problems, compared with more than 70% after a TURP. The benefit of PCI on fertility explains that this technique is preferred in most patients still wanting to have children and whose size of the prostate still allows the use of this technique.

 

3. Bipolar resection

The main technological evolution of TURP by electrical coagulation concerns the development of resistors delivering a bipolar electric current. These resectors were designed for use in physiological saline, with the goal of eliminating the risk of TURP syndrome.

In the technique of mono-polar resection, the electric current starts from the generator, passes through the electrode represented by the handle of the receiver, is absorbed by the patient’s body, and finally emerges through the plate of the electric scalpel usually attached to the thigh Of the patient and is connected to the ground.

The intervention requires the use of Glycocolle to pass the electric current.

In the Bipolar technique, the current flows from the generator to the resistor. The resection loop actually comprises two superimposed loops, and the electric current flows from one pole to the other before returning to the generator.

 

 

resection-bipolaire

The RTUP with the bipolar current has the advantage of reproducing the same conditions as the traditional resection monopolize but using the physiological serum as liquid of irrigation.

A study carried out on 16 patients in 2009 demonstrated an equivalent efficiency between the TURP techniques using the traditional monopolar resector and those using a bipolar resector. This study also confirmed that the interventions performed with the bipolar resector with saline caused less TURP syndrome and less formation of blood clots able to block the urinary flow at the exit of the bladder.

A European study carried out in 2011 on 510 randomized patients made it possible to compare the techniques of TURP with monopolar or bipolar resectors and the laser interventions. The results were comparable in terms of quality of life and prostate size, but the bipolar resector procedure was found to give better results in the duration of bladder probe maintenance, bleeding during surgery and The presence of blood subsequently in the urine.

A 2013 study based on a standard questionnaire on desire, sexual satisfaction and other aspects of sex life, compared TURP techniques with monopolar resonator and bipolar resector without revealing Difference between them in terms of side effects on sexual function.

There is also a definite advantage in patients with a pacemaker (monopolar current that can disrupt the pace maker).

Nevertheless, there appears to be a more frequent, more prolonged and more frequent post-operative irritation syndrome (pollakiuria, urgenturia) than by monopolar current.

 

4. Bipolar prostatic vaporization

The electrode is no longer a loop but a ball that combines the effects of vaporization and resection in bipolar current. The prostatic tissue is vaporized and will not be recovered for pathological examination.

 

la-vaporisation-prostatique-bipolaire

 

The advantages still relate to the reduction of bleeding and the use of sodium chloride as an irrigation liquid.

 

Bibliography :

  • Akman T, Binbay M, Tekinarslan E, et al. Effects of Bipolar and Monopolar Transure-thral Resection of the Prostate on Urinary and Erectile Function: A Prospective Randomized Comparative Study. BJU Inter-national 2013; 111:129–36. PMID: 22672229.
  • Geavlete B, Georgescu D, Multescu R, et al. Bipolar Plasma Vaporization Versus Mono-polar and Bipolar TURP: A Prospective, Randomized, Long-Term Comparison. Urology 2011; 78:930–35. PMID: 21802121.
  • Huang X, Wang L, Wang XH, et al. Bipolar Transurethral Resection of the Prostate Causes Deeper Coagulation Depth and Less Bleeding Than Monopolar Transurethral Prostatectomy. Urology 2012 ; 80:1116–20. PMID: 22990062.
  • Mamoulakis C, Ubbink DT, De la Rosette JJ. Bipolar Versus Monopolar Transurethral Resection of the Prostate: A Systematic Review and Meta-Analysis of Random-ized Controlled Trials. European Urology 2009 ; 56:798–809. PMID: 19595501.
  • Omar MI, Lam T, Alexander CE, et al. Systematic Review and Meta-Analysis of the Clinical Effectiveness of Bipolar Compared to Monopolar Transurethral Resection of the Prostate. BJU International 2014; 113:24–35. PMID: 24053602.
  • Poulakis V, Dahm P, Witzsch U, et al. Transurethral Electrovaporization Versus Transurethral Resection for Symptomatic Prostatic Obstruction: A Meta-Analysis. BJU International 2004; 94:89–95. PMID: 15217438.