SEARCH

SEARCH BY CITATION

Keywords:

  • transurethral resection of prostate;
  • Gyrus;
  • bipolar

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Authors from Detroit assess the use of the bipolar TURP against the monopolar technique; there were relatively few patients, reflecting the decreasing requirement for TURP in the USA. In addition, the amount of resected tissue was not particularly large, almost certainly a reflection of the decreasing size of resected prostatic tissue in that country. They found the bipolar TURP to have many advantages over standard monopolar TURP, and these are described.

Acute urinary retention is a common urological emergency, and authors from London found that it had a measurable impact on the health-related quality of life of patients who develop this problem. They describe particularly how painful a condition it is, and that it had a significant economic burden.

OBJECTIVE

To assess bipolar transurethral prostatectomy (TURP) using the Gyrus system (Gyrus Medical, Maple Grove, MD) compared with a standard monopolar TURP.

PATIENTS AND METHODS

All 43 patients undergoing TURP from November 2000 to August 2002 were reviewed retrospectively; the 1.5-year observation period allowed for the detection of late complications. In all, 18 consecutive patients had standard and 25 had bipolar TURP.

RESULTS

The resection was 18 g for standard and 15 g for the Gyrus TURP (part of the Gyrus chips are vaporized during resection). The Foley catheter was removed sooner (1.8 vs 3.2 days) and the hospital stay was less in the Gyrus group (1.2 vs 2.1 days). Acute complications occurred in a third of the standard group and four (16%) of the Gyrus group. Long-term complications were comparable, at two each in the standard and Gyrus groups. Four patients (15%) with small glands went home on the day of surgery, needing no bladder irrigation after Gyrus TURP.

CONCLUSION

Few innovations in TURP technique have been described in the past few decades but comparing Gyrus to standard TURP showed that the former allows earlier removal of the urinary catheter and earlier discharge from hospital, while decreasing complications. The Gyrus system also has other benefits; it allows coagulation of tissue during resection, resulting in excellent intraoperative visualization, and normal saline is used as the irrigant fluid, reducing the potential for TUR syndrome. The shorter stay after Gyrus TURP can result in cost savings of up to $1200/patient/day at our institution.


Abbreviations
MIT

minimally invasive therapy

CBI

continuous bladder irrigation.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

LUTS are a common problem affecting older men and the prevalence of LUTS related to BPH increases with age, approaching 50% by age 60 years and 90% by age 85 years [1,2]. There are numerous therapies available for patients for their bothersome symptoms and BPH-related complications (e.g. azotaemia, recurrent UTI, bladder calculi, acute retention, and recurrent haematuria) [3,4], including watchful waiting, pharmacological therapy, minimally invasive therapy (MIT), TURP and open prostatectomy. Each patient should have individualized therapy and decisions to intervene based upon symptom bother and development of BPH-related complications [5]. Of the 8 million men in the USA with moderate to severe BPH and who are candidates for intervention, it is estimated that 30% of men aged >65 years will require urological intervention [1,2]. Despite advances in MIT, TURP remains the reference standard to which all other surgical therapies are compared. However, TURP most often requires hospital admission and is associated with various complications, including bleeding, TUR syndrome, incontinence, impotence, urethral stricture, bladder neck contracture and prolonged catheterization [3,5,6]. The purpose of the present study was to compare monopolar TURP with bipolar TURP (using the Gyrus PlasmaKinetic System, Gyrus Medical, Maple Grove, MD) to determine whether the complications and the overall ‘impact of surgery’ might be decreased by using a new TURP system. The Gyrus technology allows prostatic resection and vaporization with thermal energy, and continuous-flow saline irrigation, thus achieving rapid prostatic tissue removal with excellent haemostasis [7,8].

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The charts of all patients undergoing TURP between November 2000 and August 2002 were reviewed retrospectively. All operations were performed by one surgeon (R.A.S.) and all patients had moderate to severe LUTS, as assessed by the IPSS/AUA symptom score, a DRE and serum PSA measurements to exclude any suspicion of prostatic malignancy. Patients had an extended trial of pharmacological therapy with α-adrenergic antagonists, with persistence or progression of bothersome voiding symptoms. Eighteen consecutive patients had a conventional TURP using monopolar electrocautery, and 26 consecutive patients resections using the Gyrus bipolar system. The principles of this system were described previously [7]; it consists of a generator with 200 W capability, a radiofrequency range of 320–450 kHz, and a voltage range of 254–350 V, and a plasmakinetic resectoscope, with a TUR loop of 80/20 platinum/iridium alloy electrode, with the active and return electrode on the same axis (axipolar) separated by a ceramic insulator [7]. TURP was conducted according to the well described principles of endoscopic electrosurgery [9,10]. Most patients were admitted after surgery for continuous bladder irrigation (CBI) and observation. CBI was continued until the urine was clear, typically within 24 h after surgery. The catheter was removed if the urine was clear in the absence of irrigation, and the patient was then given a voiding trial and discharged home if voiding spontaneously.

Results were analysed for length of hospital stay, catheterization, complications during and after TURP, and weight of tissue resected. Patients were observed during a 1.5-year follow-up to allow for the detection of late complications. Results were assessed statistically using Student's t-test.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The mean (range) age in the standard and bipolar TURP groups was 65 (41–82) and 65 (48–81) years, respectively; the respective mean size of prostatic resection was 18 g and 15 g (according to Gyrus Medical, up to 5% of the resected prostatic tissue is vaporized during the procedure and not available for pathological analysis). The respective duration of catheterization was 3.2 (1–15) and 1.8  (1–5) days (P = 0.12) and the hospital stay 2.1 (1–7) and 1.2 (0–5) days (P = 0.11). One patient in the Gyrus group was excluded from the catheterization analysis, as he had direct internal visual urethrotomy of two bulbar urethral strictures at the same time as his TURP. His catheter was left indwelling for 5 days to comply with the standards of treatment after such urethrotomy, and was removed without sequelae in the office.

Four of 26 (15%) patients were discharged home on the day of surgery after bipolar TURP, as they required no CBI. These patients had the catheter removed on the following day in the office; all these patients had relatively small resections (5, 5 and 10 g) and had clear urine in the recovery room, with no irrigation.

Acute complications comprised significant hyponatraemia in two patients after standard TURP (serum sodium concentrations of 124 and 130 mmol/L) and one in the Gyrus group (serum sodium 113 mmol/L). These patients were successfully managed with frusemide, normal saline hydration and observation in the surgical intensive-care unit. Other short-term complications were limited to inability to void, requiring re-catheterization, in four after standard TURP and three (12%) after Gyrus TURP. The total acute complication rate was six of 18 (33%) in the standard TURP group and four (16%) of the Gyrus group. There were no major bleeding complications in either group.

For long-term complications, one patient in each group developed a bulbar urethral stricture which was treated successfully with internal urethrotomy. One patient in the Gyrus group later had external beam radiation therapy for the interval development of prostate cancer, and subsequently developed a bladder neck contracture. Last, one patient developed stress urinary incontinence after monopolar TURP, which was managed successfully with a periurethral bulking agent (DurasphereTM, Advanced Carbon Medical Technologies, St. Paul, MN). Thus there were two of 18 (11%) long-term complications after standard TURP and two (8%) after Gyrus TURP (not significant).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Despite new advances in MIT for LUTS related to BPH, TURP remains the standard surgical therapy [3]. Nonetheless, significant improvements in TURP technique have not often been reported. TURP remains associated with morbidity, the need for catheterization and for hospitalization with CBI. The present new TURP system appears to decrease the negative effects of surgery on the patient; the duration of catheterization was 44% shorter, hospital stay 43% less, acute complications 52% less common, and long-term complications 30% less common.

Other studies have already confirmed the utility of the Gyrus technique, yielding success rates comparable to conventional TURP. In a French study comprising 42 patients, the mean peak flow rate increased from 7.9 to 19.7 mL/s at 3 months of follow-up, and the IPSS decreased from 16 to 9 at 3 months after Gyrus TURP. There were no postoperative bleeding episodes, the mean catheterization time was 1.4 days, and the mean hospital stay 2.2 days [7]. In another study with 1 year of follow-up comparing standard and Gyrus TURP, both groups had no statistically significant differences in postvoid residual urine, flow rates, symptom score, quality of life, length of stay and period of catheterization. Re-catheterization rates were higher in the Gyrus cohort (30% vs 5%), which was not so in the present series. Clot evacuation rates were higher in the monopolar TURP group (19% vs none), as might be expected in view of the haemostatic advantages of the Gyrus technique [8]. While these studies support the clinical efficacy of bipolar TURP, we endeavoured to determine if Gyrus TURP was also associated with less surgical ‘impact’ on the patient, i.e. shorter hospital stay and catheterization, and fewer complications. In the present series, while resected weights were similar, these three measures were all better in the Gyrus cohort, although they only approached statistical significance (P = 0.1).

There were no major bleeding complications or episodes of clot retention requiring evacuation. While there were two cases of hyponatraemia in the monopolar TURP group, it was unexpected to find a case of hyponatraemia and pulmonary oedema in a patient who had TURP using the Gyrus system. The mechanism of this hyponatraemia cannot be fully explained by absorption of isotonic irrigation, and may be secondary to fluid shifts between the intravascular and extracellular compartments unrelated to the irrigant.

The present patients treated by Gyrus TURP had their catheter removed a mean of 1.4 days earlier than the standard group. The mean hospital stay was also almost a day (0.9) less. When the burden of catheterization and need for bladder irrigation is reduced, patient comfort, the hospital stay and costs also improve. Discharge 1 day earlier results in an anticipated saving of $1200 at our institution. Four patients with small prostates treated with the Gyrus system went home on the same day, effectively making their operation an outpatient procedure. This illustrates that in selected patients, CBI is not mandatory with the Gyrus system, further decreasing the effect of surgery on some patients.

In conclusion, these results for Gyrus TURP support previous reports that it is safe and effective. In this series the new system allowed us to discharge patients sooner and remove their catheters earlier, which benefits both patients and healthcare system, by reducing overall costs and the effects of surgery. There were fewer acute and long-term complications than with standard TURP. Because of these benefits and the tendency for less intraoperative bleeding associated with the Gyrus TURP, it has become the new standard of care at our institution. These data are promising, but a longer follow-up and larger series are needed before the Gyrus method becomes universally accepted for managing BPH.

CONFLICT OF INTEREST

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Richard Santucci is a study investigator funded by sponsor. Source of funding: Gyrus Medical.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  • 1
    Roberts RO, Jacobsen SJ, Jacobson DJ, Reilly WT, Talley NJ, Lieber MM. Natural history of prostatism: high American Urological Association Symptom scores among community-dwelling men and women with urinary incontinence. Urology 1994; 43: 6218
  • 2
    Roehrborn CG, McConnell J, Bonilla J et al. Serum prostate specific antigen is a strong predictor of future prostate growth in men with benign prostatic hyperplasia. PROSCAR long-term efficacy and safety study. J Urol 2000; 163: 1320
  • 3
    Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med 1995; 332: 759
  • 4
    AUA Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia. Chapter 1: Diagnosis and treatment recommendations. J Urol 2003; 170: 53074
  • 5
    Gee WF, Holtgrewe HL, Albertsen PC et al. Practice trends in the diagnosis and management of benign prostatic hyperplasia in the United States. J Urol 1995; 154: 2056
  • 6
    McCullough DL. Minimally invasive treatment of benign prostatic hyperplasia. In WalshP, RetikAB, VaughanED, WeinA eds, Campbell's Urology, Vol. 2, 7th edn. Philadelphia: WB Saunders, 1998: 1479–509
  • 7
    Botto H, Lebret T, Barre P, Orsoni JL, Herve JM, Lugagne PM. Electrovaporization of the prostate with the Gyrus device. J Endourol 2001; 15: 3136
  • 8
    Dunsmuir WD, McFarlane JP, Tan A et al. Gyrus bipolar electrovaporization vs transurethral resection of the prostate: a randomized prospective single-blind trial with 1 y follow-up. Prostate Cancer Prostatic Dis 2003; 6: 1826
  • 9
    Nesbit RM. Transurethral Prostatectomy. Springfield IL: CC Thomas, 1943
  • 10
    Perrin P, Barnes R, Hadley H, Bergman RT. Forty years of transurethral prostatic resections. J Urol 1976; 116: 7578