Transurethral Resection in Saline

Vaporization: Evaluation of Clinical

Efficacy and Prostate Volume
Author links open overlay
panelHideoOtsukiaYoshitakaKuwaharaaTakeoKosakaaTakujiTsukamotoaKenzoNaka
muraaRyoichiShirokibKiyotakaHoshinagab
https://doi.org/10.1016/j.urology.2011.09.044Get rights and content

Objective

To assess the efficacy and safety of transurethral resection in saline vaporization for
symptomatic bladder outlet obstruction and the change in prostate volume.

Methods

A total of 106 patients with symptomatic bladder outlet obstruction underwent

transurethral resection in saline vaporization. The effectiveness of the treatment was
evaluated using the International Prostate Symptom Score (IPSS), quality of life
score, urinary peak flow, and prostate volume preoperatively and at 1, 3, 6, and 12
months postoperatively. To assess the treatment effect, the patients were divided into
3 groups according to the preoperative prostate volume: group 1 (<45 cm3, n = 40),
group 2 (45 but <65 cm3, n = 34), and group 3 (65 cm3, n = 32).

Results

The mean perioperative hemoglobin loss was 1.2 g/dL. The mean IPSS, quality of life
score, and prostate volume decreased significantly from 24.3, 5.2, and 52.8 cm3 to
11.1, 2.7, and 29.9 cm3, respectively (P < .01) and the mean urinary peak flow had
increased significantly from 7.3 to 15.1 (P < .01) at 1 month. Moreover, the IPSS,
quality of life score, and prostate volume had significantly decreased to 8.8, 2.3, and
26.1 cm3 at 3 months (P < .05). The investigation of groups classified by prostate size
demonstrated that the IPSS in group 3 continued at a significantly lower level than
that in groups 1 and 2. The prostate volume decreased gradually and resulted in 52.8%
volume reduction for 12 months. No significant complications were seen; however,
irritative symptoms occurred frequently (11.3%).

Conclusion

Transurethral resection in saline vaporization was a safe and effective treatment

option and was more efficacious for patients with a larger prostate. The bother scores
and prostate volume gradually decreased for 12 months.

Benign prostatic hyperplasia increases with age.1 Lower urinary tract symptoms due
to bladder outlet obstruction, which cannot be controlled with medical therapy,
require surgical treatment. Transurethral resection (TUR) of the prostate (TURP) has
been the standard treatment of bladder outlet obstruction and has demonstrated long-
term efficacy2; however, operative morbidities (ie, bleeding complications or TUR
syndrome) cannot be ignored and less-invasive therapies have been desired. Although
laser techniques using potassium titanyl phosphate, holmium, or diode have recently
been introduced in practice and their effectiveness has been reported, they have not
taken the place of TURP because of problems, such as the high cost of the laser
devices,3,4 technical complexity, and surgical complications.5

TUR in saline (TURis, Olympus Medical Systems, Tokyo, Japan), using a bipolar
electrical technique with normal saline as an irrigant, has become widely accepted in
recent years. One of the benefits of this device is that it is not associated with TUR
syndrome.6-10 TURis vaporization (TURisV) was introduced to Japan in 2008,
enabling us to perform bipolar plasma vaporization of the prostate with a button
electrode. Reich et al11 reported their initial experience. The aim of the present study
was to evaluate the clinical efficacy of TURisV within 1 year of follow-up.

Material and Methods

The institutional review board approved the study. A total of 123 patients with lower
urinary tract symptoms due to benign prostatic hyperplasia underwent TURisV at
Nagakubo Hospital. Of these, 17 patients were lost to follow-up for various reasons,
and 106 were followed up for >12 months. The preoperative evaluation comprised the
medical history, physical examination, blood tests, including prostate-specific antigen
determination, prostate volume measured using transrectal ultrasonography (TRUS),
urinary peak flow rate, postvoid residual urine volume, bother scores, such as the
International Prostate Symptom Score (IPSS) and quality of life (QOL) score, and
erectile function. A blood transfusion was prepared for 2 patients with anemia
preoperatively.

A total of 46 patients with a prostate-specific antigen level >4 ng/mL underwent

TRUS-guided prostate biopsy. We usually take 18-22 cores of prostate biopsy to
document the absence of prostate cancer. A urethral catheter had been placed
preoperatively in 13 patients with urinary retention.

TURisV was performed by 3 surgeons with the patient under lumber (n = 81, 76.4%)
or general (n = 25, 23.6%) anesthesia. A bipolar high-frequency generator (HF
Surgery System, Olympus Medical Systems, Tokyo, Japan) was applied for plasma
vaporization. The power output was set at 320 W for plasma vaporization and 100 W
for the coagulation mode. A 24F resectoscope with a button electrode and isotonic
0.9% sodium chloride solution as an irrigant were used. Using a near-contact
technique (hovering technique), we started TURisV at the lateral lobe from the
bladder neck to the apex, then the anterior and floor were vaporized. After confirming
the functioning external sphincter, we decided on an apical edge of vaporization.
Finally, a TURP-like cavity was created. After confirming hemostasis, a 24F urethral
catheter was inserted. Blood tests, including hemoglobin and serum sodium, were
performed after surgery. The urethral catheter was removed as soon as the urine
cleared, and the patient was discharged when he had no major urination problems.
All the patients were evaluated at 1, 3, 6, and 12 postoperative months for IPSS, QOL
score, urinary peak flow, postvoid residual urine volume, and prostate volume. They
were divided into 3 groups to assess the efficacy according to the preoperative
prostate volume: group 1 (<45 cm3, n = 40), group 2 (45 but <65 cm3, n = 34), and
group 3 (65 cm3, n = 32). In patients with an obvious intraprostatic cavity created
during TURisV at the prostate volume evaluation with TRUS, the capacity of the
cavity was excluded to calculate the actual prostate volume. All types of
complications relating to surgery were systematically recorded. The vaporization
effectiveness was calculated using the formula prostate volume (preoperative
prostate volume 12-month prostate volume)/operating time. The postoperative
prostate-specific antigen was obtained at 12 months.

All data were analyzed using Student's t test for statistical validation of 2 objects or
the Kruskal-Wallis test for 3 objects, with P < .05 considered statistically significant.

Results
The patients' backgrounds and perioperative outcomes are summarized in Table 1.
The operating time and amount of irrigant increased in proportion to prostate size.
The mean postoperative decrease in hemoglobin was 1.2 g/dL (P < .05), but no blood
transfusion was needed postoperatively. No significant difference was seen between
the preoperative and postoperative serum sodium level. TURisV was performed
successfully in all cases without any mechanical or technical problems. The mean
catheterization and postoperative hospitalization time was 2.08 days and 3.54 nights,
respectively, and no significant difference was observed among the 3 groups (P = .49
and P = .27).

Table 1. Patient characteristics and perioperative results

Group
Variable Overall
1 2 3
Patients (n) 106 40 34 32
Age (y) 71.4 6.9 70.9 7.2 71.5 6.9 71.9 6.7
Prostate volume (cm3)
Mean SD 53.5 21.1 34.6 6.5 51.6 4.6 77.6 15.9
Range 20.344.6 45.064.8 65.0123
PSA (ng/mL) 5.46 6.49 3.05 3.02 4.96 5.75 9.22 8.53
Operating time (min)
Mean SD 63.0 28.7 41.5 14.3 60.6 13.5 93.5 27.9
Range 2267 3695 48157
Irrigation volume (L) 22.9 10.8 14.9 4.8 22.2 5.3 34.1 11.3
Hemoglobin (g/dL)
Preoperative 14.3 1.4 14.2 1.4 13.8 1.2 14.7 1.4
Postoperative 13.1 1.9 13.1 1.3 12.9 1.1 13.0 1.6
Catheterization (d) 2.08 0.56 2.00 0.56 2.09 0.53 2.17 0.58
Admission (nights) 3.54 1.00 3.38 0.87 3.50 1.09 3.80 1.01
 Group
Variable Overall
1 2 3
Effectiveness (mL/min) 0.44 0.35 0.45 0.48
Postoperative PSA (ng/mL) 1.85 1.51 0.94 0.64 1.73 1.22 2.86 1.75

SD, standard deviation; PSA, prostate-specific antigen.

Data presented as mean SD.

Changes in the bother scores and objective parameters are summarized in Table 2.
Clinical improvements at 1 month were obvious for every item (P < .01). Moreover,
the subjective scores had improved and the prostate volume had decreased
significantly at 1-3 months in every group (P < .05). A stepwise decrease was
observed in the IPSS, QOL score, and prostate volume but not in the urinary peak
flow or postvoid residual urine volume. No significant difference was observed in
surgical efficacy and complications among the 3 surgeons.

Table 2. Progress of subjective and objective voiding parameters

Postoperative
P Value
(mo)
Variable Preoperative
Pre vs 1 1 mo vs 3
1 3 6 12
mo mo
Overall (n = 106)
IPSS 24.3 11.1 8.8 8.2 7.85 <.01 <.01
QOL score 5.2 2.7 2.3 2.1 2.1 <.01 <.01
Qmax.(mL/s) 7.3 15.1 15.2 16.6 16.5 <.01 .71
PVR (mL) 151 33.9 29.2 31.8 29.4 <.01 .06
Prostate volume
52.8 29.9 26.1 25.2 24.9 <.01 <.01
(cm3)
Group 1 (n = 40)
IPSS 24.2 11.8 9.1 8.8 7.8 <.01 <.01
QOL score 5.4 2.9 2.5 2.4 2.4 <.01 .07
Qmax.(mL/s) 7.4 13.1 13.1 15.0 14.5 <.01 .78
PVR (mL) 107 34.2 25.0 33.8 24.6 <.01 .16
Prostate volume
34.6 23.1 20.4 19.6 20.0 <.01 <.01
(cm3)
Group 2 (n = 34)
IPSS 24.3 12.1 11.0 9.4 9.6 <.01 <.01
QOL score 5.1 2.7 2.5 2.4 2.3 <.01 <.05
Qmax.(mL/s) 8.7 16.6 17.1 17.8 17.2 <.01 .93
PVR (mL) 129 18.6 31.7 36.9 28.6 <.01 .11
Prostate volume
51.6 31.0 26.9 25.0 24.4 <.01 <.01
(cm3)
 Postoperative
P Value
(mo)
Variable Preoperative
Pre vs 1 1 mo vs 3
1 3 6 12
mo mo
Group 3 (n = 32)
IPSS 24.5 8.9 6.5 6.2 6.1 <.01 <.05
QOL score 5.1 2.3 1.8 1.4 1.5 <.01 <.05
Qmax.(mL/s) 5.7 16.4 16.2 17.5 18.5 <.01 .54
PVR (mL) 231 28.4 32.7 23.6 36.6 <.01 .88
Prostate volume
77.6 39.0 33.5 33.0 32.2 <.01 <.01
(cm3)

IPSS, International Prostate Symptom Score; QOL, quality of life; Qmax, urinary
peak flow rate; PVR, postvoid residual urine volume.

Student's t test.

The operative complications are listed in Table 3. All the complications related to the
surgery were within grade IIIa according to the Clavien classification of surgical
complications. Gross hematuria requiring bladder irrigation with recatheterization was
noted in 5 men (4.7%). Acute urinary retention (5.7%) was relieved with a transient
urethral catheter. Irritative symptoms after catheter removal occurred in 12 patients
(6, 4, and 2 patients in groups 1, 2, and 3, respectively). Among these 12 patients, 3
received 1-blockers and 2 anticholinergic agents but healed gradually within 2
months. Persistent perineal or urethral pain was present in 3 patients (2.8%). The 8
patients (7.5%) with urethral stricture (4 urethral meatus, 3 bulbar, and 1 pendulous
urethra) underwent urethral dilation 1-4 months after surgery. Three patients (2.8%)
developed vesicoprostatic stones, which required transurethral lithotripsy at 9, 16, and
18 postoperative months. Although transurethral incision of the bladder neck was
performed for 1 patient with bladder neck contracture 11 months after TURisV, no
case requiring reoperation for residual benign prostatic hyperplasia has yet been
identified.

Table 3. Complications (n = 106)

Complication n (%)
Irritative symptoms 12 (11.3)
Urethral stricture 8 (7.5)
Acute urinary retention 6 (5.7)
Gross hematuria 5 (4.7)
Urinary tract infection 4 (3.8)
Perineal or urethral pain 3 (2.8)
Stones 3 (2.8)
Transient incontinence 2 (1.9)
 Complication n (%)
Blood transfusion 2 (1.9)
Bladder neck contracture 1 (0.9)

Of the 106 patients, 48 were potent before surgery. Of these, 33 (69%) had retrograde
ejaculation and 9 (19%) experienced deterioration of erectile dysfunction (ED)
postoperatively. The erectile function scores according to the scoring algorithm for
the International Index of Erectile Function on average decreased from 14.1 (range 8-
24) preoperatively to 7.4 (range 0-15) postoperatively in 9 patients who experienced a
decline in erectile function.

A total of 88 patients (83%) were satisfied with the treatment according to the results
of a questionnaire survey performed >12 months after surgery.

Comment
The advantage of TURis is a lower incidence of bleeding and absence of TUR
syndrome; thus, TURis has become widely adopted in recent years.6-10 TURisV was
introduced to Japan in 2008. The benefits of TURisV include better visualization of
the surgical field owing to a greater hemostatic efficiency than resection by loop
electrode, lower initial cost than laser devices, and the facility to learn because it
requires a similar technique to TURP.

Clinical efficiency was significant for all parameters at 1 month (P < .01) and
compared favorably with other treatment options. Furthermore, the bother scores had
improved significantly at 1-3 months (P < .05) and gradually decreased thereafter.
This tendency appeared to run parallel with the change of prostate volume, which also
showed a gradual decrease for 12 months.

A gradual volume decrease occurred during the postoperative course of TURisV.

Overall, a 12.7% reduction was observed at 1-3 months (11.7%, 13.2%, and 14.1% in
groups 1, 2, and 3, respectively). An average rate of reduction was 43.4%, 50.6%, and
52.3% at 1, 3, and 6 months, respectively. Finally, a 52.8% volume reduction was
attained at 12 months. This was greater than that achieved with TURP (28%-49%)12,13
or photoselective vaporization (44%).4 This is the first report to elucidate the
postoperative changes of prostate volume treated with TURisV. Reich et al14 reported
that the coagulation depth was 2.1 mm with transurethral vaporization. We assumed
that the vaporizing energy emitted during TURisV might conduct considerable heat to
provide deeper coagulation and thermal effect into the prostate and surrounding tissue
and might cause edema, which remains during the early stage of the postoperative
period.

No significant differences were found in the preoperative bother scores among the 3
groups. A comparison of bother scores between groups 1 and 2 did not show
significant differences at each month; however, the improvements of the scores in
group 3 were greater than those in groups 1 and 2 at and after 3 months (P < .05, data
not shown). Considering that the decrease in the hemoglobin level did not differ
depending on the prostate volume, TURisV can provide better treatment efficiency,
especially in patients with a larger prostate.
The average catheterization period was 2.08 days, and 84% of the patients were
catheter free within 2 days. This was similar to the results from Robert et al.15 The
postoperative stay of 3.54 nights was slightly longer than that previously reported.15,16
One of the causes was postoperative irritative symptoms present at catheter removal.

The tissue ablation rate of bipolar vaporization reported by Reich et al14 was
approximately 3.8 mL/min in vitro.14 However, it was much lower than that reported
by Robert et al15 (0.5 mL/min in a clinical study). They suggested the cause of such
low effectiveness was a lack of training for surgeons or tissue conductivity. Our
vaporization rate was 0.44 mL/min. One of the causes of this low effectiveness was
probably the size of the resectoscope; we used a 24F resectoscope, which was not
capable of continuous irrigation. Thus, it took longer to achieve TURisV and resulted
in low effectiveness. However, high ablative energy and a larger resectoscope were
credible reasons for the risk of urethral stricture.17 We considered a 26F or 27F scope
to be a little large for Japanese men; therefore, we used a 24F scope.

In the present study, no significant complications occurred; however, irritative

symptoms were the most frequent adverse events. The incidence of these symptoms
ranged from 9.3% to 19.8% in previously published data11,15,16; and 12 patients
(11.3%) experienced this phenomenon. They tended to occur more frequently in
patients with smaller prostates. The same complications were also reported with the
monopolar vaporization technique.13,18 Six patients experienced urinary retention, and
we assumed that 1 possible cause was edema of the prostate caused by heat generated
during bipolar plasma vaporization.

In contrast, 3 patients had persistent perineal or urethral pain similar to that of chronic
prostatitis, which was also identified in 3 patients reported by Robert et al.15 The
cause of this pain is unknown, but we assume that the intense heat conducted from the
electrode during surgery might have caused a chronic inflammatory process (ie,
intraprostatic ductal reflux, immunologic alteration, or neural degeneration in or
around the prostate).

Three cases of vesicoprostatic stone were identified during follow-up. Because all 3
men had a history of urinary stone disease, this might have been a risk factor for the
occurrence of the stones. Although their postoperative course of IPSSs and QOL
scores was good, latent voiding dysfunction might have existed after surgery.

The reported prevalence of urethral strictures after TURP is 2.2%-9.8%, and the
causes are multifactorial.19 Urethral stricture occurred at a relatively high rate (7.5%)
despite using a 24F resectoscope. The probable reason was not only the size of the
resectoscope or urethral trauma during surgery, but also electric matter. The energy
required for plasma vaporization is 19 times greater than that for TURP,14 and 2 cases
of urethral fistula possibly caused by a current leakage were reported.15 An electric
current leaking out along the resectoscope might have affected the urethra by causing
electric burns.

In our study, 69% of the men experienced retrograde ejaculation, and this was greater
than that in previous reports.10,17,20 Possible causes include a large amount of
vaporization at the bladder neck, a high rate of volume reduction, and remaining open
fossa vaporized during surgery. The incidence of ED after monopolar TURP was
reported to be 11%-28% of patients,20-23 consistent with the findings in the present
study (19%). Although several possible reasons for ED have been proposed, we
speculate 3 possible causes. First, is that the button electrode provoked thermal or
electric damage to the cavernous nerves or arteries. Second was a psychological
effect: ejaculatory failure deprived of sexual satisfaction, which led to a disincentive
for sexual desire. The third cause, and this might be the most credible reason, was that
the average age of these patients was 71.8 years, and older age is a large risk factor
for ED progression.

Kaya et al24 reported that the results of plasmakinetic vaporization at 36 months were
not comparable with the results after TURP. However, they did not refer to the
reduction rate of the prostate, and their vaporization might have been insufficient. We
have continued to follow-up not only the clinical efficacy but also the prostate volume
with TRUS; therefore, it will be possible to elucidate the postoperative changes in the
prostate size and predict the possible recurrence of lower urinary tract symptoms and
the need for reoperation.

Conclusion
TURisV is an excellent treatment option for endoscopic bladder outlet obstruction
surgery because of its excellent efficacy, similar to that of TURP and less invasive
than TURP. TURisV might suit patients with larger prostates within 1 year. Irritative
symptoms were frequent and notable complications of TURisV.

Acknowledgment
We sincerely thank the late Ichiro Nagakubo (previous president of Nagakubo
Hospital) for introducing and administering TURisV in our institution and
enthusiastically taking care of many patients.

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