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The Transurethral Vaporization of the Prostate Enlargement with Green-Laser or with the Bipolar Plasma Vaporization Technique


Semir A. S. Al Samarrai

 


Benign prostatic hyperplasia (BPH) is highly prevalent disease in men over 50 year of age. The enlargement of this secondary sexual gland is the major etiology of lower urinary tract symptoms (LUTS) in men.

The symptoms are usually assessed by the subjective bothersome micturation as frequency, hesitancy and urgency. In cases of moderate to severely bothersome symptoms, medical treatment is appropriate with 5-a-reductase inhibitors in combination with a-adrenergic inhibitors. Surgical therapy, aiming at relieving obstruction is indicated after the failure of maximal drug therapy or with complications of the disease (1,2).

Transurethral resection of the prostate (TURP) remains the reference standard, with which any new surgical innovation should be compared (3).

Photoselective Vaporization of the Prostate (PVP) using the 80-W Potassium-Titanyl-Phosphate (KTP) 532-nm Laser is a recent technological development in the use of Lasers as an alternative to Transurethral Resection of the Prostate (TURP) for treatment of symptomatic benign prostatic hyperplasia. Originally introduced by Malek et al in 1998. Utilizing a 80-W KTP Laser, a subsequent pilot study of PVP with the 80-W KTP Laser showed a good outcome and minimal side effects in men with prostate volumes of 24-76 ml (4). Further progress with PVP has been the introduction of the high-performance system (HPS) 120-Watt Laser, which aim to reduce Lasing time and improve clinical outcomes while maintaining the same degree of safety for patients (4).

General Principles: 

Several factors have to be considered when using the Greenlight HPS 120-W Laser. The new HPS system operates with a fibre that emits a beam that is more collimated and more powerful than the 80-W KTP Laser.

Photoselective vaporization of the prostate (PVP) by Greenlight Laser has been presented as a minimally invasive surgical alternative to TURP, with several advantages such as reduced bleeding complications and short hospital stay (5-7). 

Whereas Transurethral Resection of the Prostate (TURP) removes tissue by resection of the prostatic tissue and causes hemostatis by fulguration, transurethral vaporization of the prostate (TUVP) is brought about by combining the concepts of vaporization and desiccation. Desiccation is the drawing out of water from tissue, by drying out, rather than vaporizing the cells.

The Mechanism of Action:

With TUVP, low electrosurgical effects are combined; vaporization and desiccation. Vaporization steams tissue away using high heat, and coagulation uses lower heat to dry out tissue 

The bipolar plasma vaporization of the prostate using the “button” electrode was described as a safe and efficient treatment modality for average size (30-80 ml) of the benign prostate enlargement patients.

According to some short-term (8) as well as medium-term (9) prospective randomized trials, the plasma vaporization technique produced significantly improved symptom scores and voiding parameters compared with either standard monopolar (8,9) or bipolar (9) resection. It was found that simple bipolar vaporization was only slightly effective for dealing with high volume prostatic enlargement and that a new use of the plasma-button concept would most probably required.

A vaporization technique that uses a spherical shape of a PlasmaButton Vaporization Electrode (TUR-PVP-System: Olympus) which utilizes a plasma corona created by a controlled pulsing, ultra-low voltage and high current energy, reducing penetration and resulting in well-coagulated smooth tissue performed safely in normal physiological saline, avoiding hyponatremia (TUR-Syndrome). This Vaporization technique is peculiar for the treatment of the prostate enlargement for average size (30-80 ml) was recently introduces; this technique resulted in superior efficacy and lower complication rates than previous techniques (TURP), patients who underwent Plasma Vaporization of the prostate have less bleeding during or after the PVP and reduced post operative urethral-stricture than Post (TUR-P) (10).

The PlasmaButton Vaporization technique emphasized an overall significantly lower peri-operative morbidity and an improved postoperative recovery compared with standard operations of the Prostate. In terms of haemorrhagic risks, the substantially reduced post-operative haematuria, mean haemoglobulin drop and blood-transfusion rates confirmed the superior hemostatic capabilities of BPVP. Moreover, the significantly decreased catheterization period and hospital stay may constitute reliable arguments in favour of the clearly shorter convalescence period related to the Plasma Vaporization Procedure.


Figure 1. Endoscopic Image of the enlarged Prostate and the PlasmaButton   

Figure 2. Endoscopic Image of the start of Vaporization

Figure 3. Vaporization on the middle lobe of the prostate   

Figure 4. Aspect of large passage in the prostatic fossa, without obstruction after the PlasmaButton Vaporization    

BIBLIOGRAPHY:

[1] Wei JT, Calhoun E, Jacobsen SJ. Urologic Diseases in America project: benign prostatic hyperplasia. J Urol 2008; 179 (Suppl): S75-80.
[2] Oelke M, Bachmann A, Descazeaud A, et al. Guidelines on the treatment of non-neurogenic male LUTS. European Association of Urology Web site. http://www.uroweb.org/gls/pdf/12_Male_LUTS.pdf. Accessed October 16, 2011.
[3] Jones C, Hill J, Chapple C, Guideline Development Group. Management of lower urinary tract symptoms in men: summary of NICE guidance. BMJ 2010; 340:c2354.
[4] Hai MA, Malek RS. Photoselective vaporization of the prostate: initial experience with a new 80 W KTP laser for the treatment of benign prostatic hyperplasia. J Endourol 2003; 17:93-6.
[5] Al-Ansari A, Younes N, Sampige VP, et al. Greenlight HPS 120-W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a randomized clinical trial with midterm follow-up. Eur Urol 2010; 58:349-55.
[6] Ruszat R, Wyler S, Forster T, et al. Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation. Eur Urol 2007; 51:1031-41, discussion 1038-41.
[7] Geavlete B, Stanescu F, Iacoboaie C, Geavlete P. Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia cases- a medium term, prospective, randomized comparison ©2013 BJU International; 111: 793-803.
[8] Geavlete B, Multescu R, Dragutescu M, Jecu M, Georgescu D, Geavlete P. Transurethral resection (TUR) in saline plasma vaporization of the prostate vs standard TUR of the prostate: ‘the better choice’ in benign prostatic hyperplasia? BJU Int 2010; 106:1695-9.
[9] Geavlete B, Georgescu D, Multescu R, Stanescu F, Jecu M, Geavlete P. Bipolar plasma vaporization vs monopolar and bipolar TURP – a prospective, randomized, long-term comparison. Urology 2011; 78: 930-5.
[10]Alivizatos G. Skolarikos A, Chalikopoulos D et al. Transurethral photoselective vaporization versus transvesical open enucleationfor prostatic adenomas > 80 ml: 12-mo results of a randomized prospective study. Eur Urol 2008; 54: 427-37.

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae