BERKELEY, CA (UroToday.com) - From the perspective of benign prostatic hyperplasia (BPH) pathology, it was observed that while a variety of therapeutic solutions and technical innovations focused on bringing improvements to bladder outlet obstruction endoscopic treatment, large-size BPH cases (> 80 mL) continued to have open prostatectomy (OP) as the first line alternative, and in accordance with EAU guidelines. The downside of this invasive approach included substantial perioperative morbidity as well as generally extended hospitalization and convalescence periods. Under these circumstances, a number of techniques were introduced in an attempt to replace open surgery for prostates over 80 mL. Until recently, some therapeutic modalities followed the concept of electrosurgical enucleation of the prostate, but after acquiring a relative degree of success, it failed to become part of the routine medical care.
| "...BPEP was found to represent a promising endoscopic approach in large BPH cases, presumably capable of challenging the “gold-standard” status of open prostatectomy." |
In the context of plasma vaporization of the rapid development of the prostate, it was agreed that this procedure was sometimes effective in dealing with high-volume BPH formations, but that a new use of the plasma-button treatment alternative would most likely be required. Therefore, while considering the already proven advantages of enucleating large quantities of BPH tissue, a modified endoscopic approach was introduced, the bipolar plasma enucleation of the prostate (BPEP). The premise for a viable alternative relied on the practical advantages provided by the “button” electrode -- mainly the large surface creating the conditions for a fast enucleation process, continuous vaporization, and superior haemostasis.
Following the path of clinical research, a prospective, medium-term, randomized comparison between the bipolar plasma enucleation and standard open transvesical prostatectomy was performed while aiming to establish the eventual differences between the two methods with regard to surgical efficacy, perioperative morbidity, and follow-up parameters. As far as the primary endpoints of the study were concerned, the viability of the two types of approaches was comparatively assessed from the perspectives of perioperative and safety characteristics, as well as follow-up symptom scores and urodynamic results determined during a one-year evaluation period. In this clinical setting, a total of 70 patients were distributed in each study arm, while the inclusion criteria consisted of maximum flow rate (Qmax) under 10 mL/s, International Prostate Symptom Score (IPSS) higher than 19, and prostate volumes over 80 ml.
The two study arms emphasized similar preoperative parameters in terms of the mean prostate volume, IPSS, quality of life (QoL) score, Qmax, post-voiding residual urinary volume (PVR), as well as haemoglobin and PSA levels. The plasma enucleation and standard transvesical prostatectomy techniques were successfully completed in all included cases and statistically similar data were gathered with regard to the mean operation time and resected tissue weight. Pathologically confirmed prostate cancer patients, as well as those that failed to complete the one-year evaluation protocol, were excluded from the continuation of the trial. All patients were evaluated preoperatively and at 1, 3, 6 and 12 months after surgery by IPSS, QoL, Qmax, and PVR, while the postoperative prostate volume and PSA level were measured at 6 and 12 months.
During the immediate postoperative period, the plasma-button enucleation resulted in a substantially decreased rate of surgically-induced bleeding. As a result, the BPEP series displayed significantly reduced mean haemoglobin level drop (1.7 versus 3.1 g/dL) and postoperative hematuria (2.9% versus 12.9%) rates when compared to the standard OP study group. Also, the difference in blood transfusion rate (1.4% versus 8.6%) was at the limit of statistical significance in favour of the BPEP approach. Moreover, the plasma enucleation patients benefited from a shorter postoperative recovery, as significantly lower mean catheterization period (1.5 versus 5.8 days) and hospital stay (2.1 versus 6.9 days) were described by comparison to the OP series.
From the point of view of the surgery, related patient comfort, and functional outcomes, similar symptom scores and voiding parameters were established as subsequent to BPEP and OP. Therefore, at the 1, 3, 6 and 12 months follow-up assessment, no statistically significant difference was determined regarding the mean values of IPSS, QoL, Qmax, and PVR specific for the two series of patients.
Also, at the 6 and 12 months check-ups, similar data were obtained for the mean PSA level and prostate volume. Consequently, at the respective time intervals, the calculated prostate volume decrease (83.0% versus 82.1% and 83.9% versus 82.8%) and PSA level reduction (90.6% versus 90.1% and 91.1% versus 90.7%), by comparison to the preoperative measurements, were statistically equivalent for the plasma enucleation and transvesical prostatectomy study groups.
In conclusion, BPEP was found to represent a promising endoscopic approach in large BPH cases, presumably capable of challenging the “gold-standard” status of open prostatectomy, in comparison to which it displayed satisfactory surgical efficiency and safety as well as similar BPH tissue removal capabilities. The plasma-button enucleation technique emphasized an overall significantly lower periopearative morbidity and an improved postoperative recovery when compared to standard OP. Furthermore, BPEP patients benefited from a similar 12-month outcome from the perspectives of follow-up symptom score data and urodynamic features when drawing a parallel to open surgery results, thus underlining the rather reliable viability of this type of approach.
Written by:
Bogdan Geavlete, MD, PhD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
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