Post on 19-Dec-2015
Transurethral Vaporization Resection of the Prostate
(TUVRP): An Alternative in the Management of Men with Prostatic Outflow Obstruction
Professor Riyadh F. Talic, MD
Professor of Urology & Andrology
Benign prostatic obstruction (BPO) is a
common cause of urinary symptoms in
men older than 40-years of age
Management Options for patients with BPO
• Medical therapy• Instrumental (minimally invasive)
therapy
• Surgical therapy
Medical Therapies for BPO is the first line of
management of patients with symptomatic BPO
Medical Therapies for BPO
• 5 α reductase inhibitors: – Finasteride (Proscar).
• Alpha- blockers:– Trazosin (Itrin).– Doxazosin (Cardura).– Alfuzosin (Xatral).– Tamsulosin (Flomax, Omnic).
Minimally Invasive Therapies for BPO
• TUIP (Incision)
• Prostate balloon dilatation
• Urethral (prostatic) stents
• Hyperthermia
• Cryosurgery
• TUNA
• Laser devices
Surgical Therapy for BPO• Based on removal & debulking of
the obstructing prostatic adenoma, indicated in:– Failed medical treatment– Complications:
• Urinary retention.• Renal back pressure changes.• Hematuria.• Large vesical stones.
Surgical Therapy of BPO
• Open prostatectomy
• Transurethral prostatectomy– TURP (Resection)
– TUVP (Vaporization)
– TUVRP (Vaporization-Resection)
Principles of Electrosugery
• The use of variable radiofrequency electrical current between 400,000
and 1,000,000 Hz, depending on the generator power to achieve cutting
(Vaporization), desiccation & fulguration of tissues
Principles of Electrosugery
• The magnitude of the electrocutting energy and the the design of the transurethral device
will determine whether an incision, vaporization, resection or
combination of both will result
Transurethral ElectrodesTransurethral Electrodes
Transurethral resection of the Prostate (TURP) using a standard wire loop and electrosurgical unit is still
regarded as the “Gold Standard” in the treatment
of men with BPO
Morbidity associated with TURP • Bleeding• TUR syndrome (Low serum sodium)
• Infection
• Urinary incontinence• Erectile dysfunction.
Transurethral vaporization of the prostate (TUVP)
• Rolling cylinder (The Vaportrode) provides enhanced contact with prostatic tissue using augmented electrocutting energy.
• Electrovaporization current maintained efficacy of TURP with minimal bleeding and electrolyte disturbances.
• Disadvantages: Slow & Lack of prostatic tissue for histopathological examination.
Transurethral Vaporization Resection Prostatectomy (TUVRP)
• Thick Loop (Resection)• Augmented Electocutting energy (Electrovaporization)• TUVRP = TURP + TUVP• Technique of operation!
The “Wedge” resection device for electrosurgical transurethral
prostatectomy
Perlmutter AP & Schulsinger DA
J Endourol 12: 75-79, 1998
Transurethral electrovaporization-resection of the prostate using the
“Wing” cutting electrode: Preliminary results of safety and efficacy in the
treatment of men with prostatic outflow obstruction
Riyadh F. Talic
Urology 53: 106-110, 1999
Conclusions of the Feasibility Studies on TUVRP
• TUVRP is a promising new modification of the standard TURP.
• TUVRP combines the excellent resection capabilities of TURP and the benefits of electrovaporization.
• No complications related to the augmented electrosurgical energy.
Safety & Efficacy of TUVRP
• Randomized study versus standard TURP.• Effects of High electrocutting energy on:
– Histopathological specimens.– Serum Prostate Specific Antigen (PSA).– Erectile function.
• Evaluate the role of the thick loop design.
Prospective Randomized Study of Transurethral
Vaporization Resection of the Prostate Using the Thick Loop
and Standard Transurethral Prostatectomy
R. F. Talic, A. E. El Tiraifi, S.H. Hassan, S. R. El
Faqih, R. A. Attassi, R. E. Abdel Halim
Urology 55: 886-890, 2000
TUVRP versus Wire-loop TURP
• A prospective randomized study.
• Sixty-eight patients in 2 equal treatment groups of TUVRP & TURP.
• Both groups were balanced for baseline variables including age, Presentation and prostate size
TUVRP versus Wire-loop TURP
• P=0.01
11.812
12.212.412.612.8
1313.213.413.6
TUVRPTURHb (gm/dL)
• P=0.03
138.4
138.6
138.8
139
139.2
139.4
139.6
139.8
140
Na (mEq/L)
Pre
Post
TUVRP versus Wire-loop TURP
TUVRP TURP
Resection weight (gms) 22.410.5 20.29.5
P=NS
Resection time (min) 42.415 35.912.8
P=0.02
Post-op Catheter (hrs) 23.110.3 3617.3P=<0.0001
TUVRP versus Wire-loop TURP
Complication TUVRP TURP
Urethral stricture 3 3
Clot retention 1 1
Meatal stenosis 0 1
Early post-op bleeding 0 1
Erectile dysfunction 0 0
TUVRP versus Wire-loop TURP
• IPSS
• Qmax
0
1
2
3
4
5
6
TUVRP TURP02468
101214161820
TUVRP TURP
P=0.03 & 0.01Efficacy Parameters Post-op
Transurethral Vaporization-Resection of the Prostate Versus Standard
Transurethral Prostatectomy: Comparative Changes in
Histopathological Features of the Resected Specimens
R. F. Talic & A. C. Al Rikabi
Eur Urol 37: 301-305, 2000
Histopathology post TUVRP
• Methods:– Fifty patients that underwent TUVRP &
TURP– One surgeon– One blinded Pathologist– Devised scoring system for severity of
cautery artifacts
Histopathology post TUVRP
• Electrocautery Artifacts (1 Point scoring):
– Abnormal cellular orientation & spindling
– Abnormal cellular detachment from underlying basement membrane
– Atypical cytological changes– Stromal coagulative necrosis with or without
smooth muscle fiber, nerves and vascular injury
Histopathology post TUVRP
Grade Total sum of points
Mild 1
Moderate 2
Severe 3-4
Results of Histopathology Study
Grade of cautery artifact TUVRP TURP
Mild 1 (4%) 0 (0%)
Moderate 21(84%) 21(84%)
Severe 3 (12%) 4 (16%)
P=NS
Histopathology post TUVRP• Conclusions:
– The quality of histopathological specimens produced by TUVRP are similar to TURP.
– The higher electrocutting energy used in TUVRP does not result in greater thermal injury to the tissues possibly because of the cooling effect of the irrigation fluid used during the procedure
CHANGES OF SERUM PROSTATE-SPECIFIC
ANTIGEN (PSA) FOLLOWING HIGH ENERGY
THICK LOOP PROSTATECTOMYR. F. Talic & A. E. El-Tiraifi
International Urol & Nephrol, 2000, 32(2): 271-4
Serum PSA post TUVRP
• Objectives:– Evaluate the response of PSA to Augmented
electrocuting energy.
– Does delayed healing of prostatic cavity lead to delayed decline of serum PSA?
Methods for the PSA Study
– Fifty patients with BPO were included. – Thirty-five patients had TUVRP using the “Wing”
thick resection electrode. – Fifteen patients (control) had TURP.– Serum PSA was measured before, 1 day and 6
weeks in the morning post TUVRP.– The samples were analyzed using the Enzyme-
Test PSA (Boehringer Mannheim). Normal PSA values for the assay are 0.0-4.0 ng/ml.
Results for the PSA Study
02468
101214161820
Pre-op 24 hrs PSA 6 wks PSA
TUVRPTURP
PSA Study• Conclusions:
– TUVRP produces a reversible increase in serum PSA value.
– The pattern of elevation and decline of the PSA is similar to standard TURP.
– Evaluating patients with persistently elevated PSA at 6 weeks should take into consideration their baseline PSA values.
ERECTILE FUNCTION FOLLOWING HIGH-
ENERGY THICK LOOP PROSTATECTOMY
Riyadh F. Talic
Scand. J Urol & Nephrol, 2001, 35(4): 300-4
Erectile Function & TUVRP
• A prospective study of 70 men • Questionnaire based study • Questionnaire obtained both pre-operatively & 3
months post TUVRP• Adequate pre TUVRP counseling on sexual activity
in relation to prostatectomy
Erectile Function before and post TUVRP
Pre TUVRP Post TUVRP
Full potency 30 30
Reduced potency 8 6
Total # of patients 38 36 (94.7%)
32 patients were not sexually active at baseline
Conclusions for EF & TUVRP
• Patients that are fully potent pre TUVRP can expect to remain so post prostatectomy.
• The heat that is generated by the increased level of cutting energy is dissipated by the irrigation fluids used during resection and does not seem to adversely affect potency.
The “Wing” Versus the “Vapor cut” electrodes in transurethral
vaporization resection of the prostate: Comparative changes in
Safety Parameters
R. F. Talic, W. Al Kudair, A. E. El Tiraifi, N. M. Al Bogami, M. k. Mansi, S. Altaf & T. B. Hargreave
Urology Internationalis; 65: 95-99, 2000
“Wing” versus “Vapor cut”
• Methods:– Ninety patients at KKUH, WGH & KFNGH
– KKUH & WGH: The “Wing” & Eschman Unit
– KFNGH: The “Vapor cut” & Valley lab unit.
– Baseline variables were balanced.
Safety features: The “Wing” versus the “Vapor cut”
0
0.5
1
1.5
2
2.5
3
3.5
Hb Drop Hct drop Na drop
WingVaporcut
P=0.004 P=0.03 P=<0.0001
“Wing” versus “Vapor cut”
0
5
10
15
20
25
Resection wt.
TUVRPTURP
• Operation time (mins)
P=NS
0
5
10
15
20
25
30
35
40
45
50
P=0.003
47 37
“Wing” versus “Vapor cut”
• Conclusions:–Both thick loops, safe & efficacious
–Differences may be related to changes in the loop design!!
–Safety features that are related to the vaporization effect are influenced by the speed of resection
TUVRP CONCLUSIONS• TUVRP improves safety of
transurethral prostatectomy and has the potential to reduce the
main 2 morbidities that are associated with standard TURP namely; bleeding and electrolyte
disturbances.
TUVRP CONCLUSIONS
• The shorter post operative catheterization time that is noted
following TUVRP is clinically significant considering the demand
for lower morbidity profiles and hospitalization time by the patients
and health care providers
TUVRP CONCLUSIONS
• TUVRP maintains the efficacy of standard prostate
debulking procedures
TUVRP CONCLUSIONS
• The higher energy level that is used in TUVRP does not seem
to have an adverse effects, particularly in relation to erectile function, serum PSA levels and
quality of histopathological specimens
TUVRP CONCLUSIONS
• The change to using TUVRP is simple and does not
require capital investment in new technology.
TUVRP CONCLUSIONS
• Future work will need to further focus on the role of
the thick loop design