28 European Urology Today October/November 2008

“Surgical intervention is indicated in patients with benign prostatic hyperplasia, when their quality of life is impaired and their symptoms cannot be alleviated by medical therapy,” Professor Jean de la Rosette of the University Medical Centre in Amsterdam, the Netherlands, explained at this year’s Congress of the German Society of Urology (DGU), held from 24 to 27 September 2008 in Stuttgart. Throughout Europe nearly 30% of men over the age of 65 suffer from bothersome LUTS2 and need effective therapy.

“Given the high prevalence, a safe and cost-effective method is direly needed”

Looking at the large number of cases it becomes clear how important the efficacy, safety and cost-efficiency of therapy has become. Transurethral resection of the prostate (TUR-P) has been the most effective therapy option to date. Now, TURis (Transurethral resection in saline) plasma vaporization offers a minimally invasive therapeutic alternative to conventional TUR-P which substantially enhances safety in the surgical management of benign prostate syndrome and does so without sacrificing efficacy or cost-efficiency. Dr Oliver Reich, lecturer and consultant at the Grosshadern University Hospital, Munich, Germany, explained what is paramount in BPH therapy: “The challenge of minimally invasive methods is combining high efficacy and optimal therapeutic outcome with the lowest possible side effects. Particularly, peri- and postsurgical complications like bleeding or TUR syndrome are at the forefront of our interest here. But also the duration of catheterization and hospitalization times are becoming increasingly relevant for patients.”

“Plasma vaporization minimizes the risk of bleeding”

Thanks to the development of the TURis plasma vaporization electrode and its addition to the current selection of TURis electrodes, it is now possible to combine the advantages of vaporization with the benefits of bipolar resection. As part of the bipolar TURis resection system, plasma vaporization offers advantages over conventional monopolar devices. The electrical current mainly flows directly from the electrode loop to the electrode tube as the electrical impedance of the surrounding saline solution is significantly lower compared to the human tissue (1:10). Thus the current flow is locally limited and in comparison to the monopolar technique the leakage current is reduced by 70%. A patient plate is not required and there is a reduced risk of obturator nerve stimulation.

Furthermore, the use of 0.9% sodium chloride solution as irrigation fluid theoretically eliminates the risk of TUR syndrome (Fig. 1). The bipolar-guided high-frequency current creates a plasma field around the electrode. The energy emitted by the plasma is conducted to the surrounding prostate tissue, thereby leading to safe vaporization (see text box). Through simultaneous vaporization and coagulation of the tissue surface, bleeding is, for the most part, prevented during plasma vaporization, while a smooth, evenly structured tissue surface is left behind (prostatic compartment). Any potentially occurring bleeding can be stopped quickly with the large surface of the semi-spherical electrode. This means that, due to its good coagulation properties, plasma vaporization is even possible in patients with an elevated bleeding risk.

Just how gentle this method appears was shown by a new video presentation about an observation of use study conducted under the direction of Dr Alexander Mueller, Triemli City Hospital, Zurich, Switzerland. Thus far, this series has enrolled 14 patients suffering from obstructive BPH and concomitantly taking anticoagulants. The conventional TUR-P is usually not performed on these multi-morbid patients. But in this case, by way of exception, plasma vaporization was conducted even while continuing their oral anticoagulation. Coumarin derivatives or in some cases a combination of clopidogrel and acetylsalicylic acid were the anticoagulants given. The results obtained so far indicate that plasma vaporization can be used safely; in this remarkable study, surgery was performed successfully even on patients with quick tests up to 20%. In both the intra- and postoperative phases, no patient suffered any postoperative bleeding that required an intervention or even a blood transfusion. “Plasma vaporization of the prostate appears to be beneficial, especially for anticoagulated patients with obstructive BPH needing surgery. We can surgically manage these patients

whilst keeping them on their oral anticoagulant medication and without altering their blood thinning; this in turn helps lower the rate of potential thrombo-embolic complications,” Mueller stressed.

Basically, the method is in fact well-suited for all patients, because – owing to its both safe and effective tissue resection – it is associated with short catheterization times and thus short hospital stays.

“Initial study data confirm efficacy and safety”

The initial clinical data presented by Dr Michel Naudin of the Hospital Ambroise Paré Mons in Belgium at this year’s meeting of the American Urological Association (AUA) in Orlando, USA, confirm the efficacy and safety of plasma vaporization3: In 90% of the men with an average prostate volume of 53 ml, the international prostate symptom score (IPSS) declined from 22 (+/- 7) to 8 (+/- 3) three weeks after treatment. The catheterization time in this study was under 24 hours; sometimes it was possible to avoid a catheter altogether.

The experience Reich has already gathered with the new plasma vaporization electrode likewise confirms its effectiveness: “We have been using this method for a good half year now. In terms of efficacy, TURis plasma vaporization proves very promising. With this new method, we have achieved high resection rates across the board,” he stressed.

“A simple and safe method provides great benefits for both doctor and patient”

The main concern for both patients and doctors is to achieve a nearly bloodless tissue resection and low side effects rate – that way the catheterization time can be lowered to under 24 hours and the general hospital stay can be shortened considerably.3 Yet even more advantages are decisive for surgeons: because they are already familiar with the proven TURis method, handling the electrode is no problem and they can adapt their technique easily. Furthermore, the nearly contact-free resection and the specially shaped semi-spherical design of the electrode make it easy to guide and control the device along the tissue surface. This enables the operating surgeon to reach all regions of the prostate without any problems. Reich can testify to the simple and convenient handling of the plasma vaporization electrode: “Because the plasma vaporization electrode can be used with conventional bipolar high-frequency generators and our familiar instruments, its handling is no problem.”

In addition, during the entire procedure the surgeon has a clear and manageable view of the surgical field; due to the fact that resection by plasma vaporization does not leave any prostate tissue chips, the irrigation fluid is not blurred by blood, and there are also no laser flashings that impair the visual field.

“Cost-efficiency through low investment and operating costs”

“One further advantage of the new plasma vaporization method is that the costs, not only for upgrading pre-existing bipolar systems, but also for the single-use electrode, are markedly lower than the expenditure for conventional laser vaporization methods,” de la Rosette added. In fact, the costs are minimal given that this method is an extension of the pre-existing bipolar resection system (TURis). To convert the system, all one has to do is simply exchange the pre-existing bipolar TURis cutting electrodes for the new vaporization electrode.

Thus far, several thousand patients have been successfully treated with TURis plasma vaporization; however, the follow-up period is too short for

- Advertorial -

Plasma vaporization: effective, safe and cost-efficientAn innovative method offers both patients and doctors substantial advantages in BPH therapy

Fig. 2: The plasma vaporization electrode vaporizes the tissue fast and effectively by means of “cold vaporization”. The tissue is coagulated and bleeding is prevented at the same time.

Fig. 1: TURis Safety Concept – Current flow chart of the TURis system, offering additional safety by using the complete surface of the resectoscope as large return electrode (lower energy density per square centimetre).

Stuttgart – Benign prostatic hyperplasia (BPH) is the most common cause ofvoiding disorders in men. The hyperplastic tissue constricts the urethra and leads to lower urinary tract symptoms (LUTS) that can be differentiated into irritative and obstructive symptoms. These can impact the quality of life of affected persons quite dramatically. Since the beginning of the year, an effective, safe and cost-efficient vaporization method for managing BPH has become available, and the first clinical studies have meanwhile demonstrated its benefits. A new study conducted by Dr Alexander Mueller of the Triemli City Hospital in Zurich, Switzerland, showed how safe this method actually is; in his study, BPH patients were exceptionally treated with plasma vaporization whilst continuing to receive their oral anticoagulation medicine.1

Fig. 3: The surgeon has a clear view throughout the entire procedure. The semi-spherical design of the plasma vaporization electrode lets the surgeon control and guide the electrode precisely over the tissue.

Fig. 4: Within three weeks of treatment, the patients’ international prostate symptom score declined from 22 to an average of 8.3

any conclusive statements to be made. Nevertheless, everybody who has used the system so far sees its great promise: “In principle, plasma vaporization shows huge potential, which nevertheless has to be confirmed by clinical studies and long-term experience,” Reich summed up.

Plasma vaporization: high resection rates with minimal heat generation

Plasma vaporization takes place practically without direct contact between electrode and tissue and without generating strong heat (“cold vaporization”). By vaporizing the irrigation fluid, the bipolar-guided high-frequency current produces a thin gas coating around the electrode that allows it to glide over the tissue (“hovering technique”). Following a short initial electrical impulse (<100 ms), the gas creates a constant plasma field. The energy emitted by the plasma is conducted to the first cell layers of the prostate tissue, thereby leading to its locally circumscribed vaporization. During this process, the accumulation of cells is dissolved gently.Whereas conventional vaporization methods do not remove the tissue effectively or they require very high amounts of energy, plasma vaporization, despite being a gentle method, achieves high ablation rates and good therapeutic outcomes. Hence, plasma vaporization is indicated in patients with both small and large prostate volumes.

Source:Press conference on “TURis plasma vaporization – an innovation in the therapy of benign prostatic hyperplasia” on 26 September 2008 at the 60th Congress of the German Society of Urology, International Congress Centre Stuttgart (ICS).

For further information please contact Olympus at info@plasma-vaporization.com.

References:1. Mueller A et al. Effiziente operative Behandlung der

prostatogenen Blasenentleerungsstörung unter Beibehaltung der oralen Antikoagulation: transurethrale Elektrovaporisation der Prostata in Kochsalzlösung; SGU 2008.

2. Chapple CR. BPH disease management. Eur Urol 1999;36(Suppl 3):1-6.

3. Naudin NM et al. Transurethral bipolar vaporization of prostate in saline (TUVPis). A new resection system for benign prostatic hyperplasia; AUA 2008.