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ORIGINAL ARTICLE
Year : 2001  |  Volume : 18  |  Issue : 1  |  Page : 45-48
 

Prospective randomized comparison of transurethral resection of prostate using vapor resection (WedgeTM) loop and standard loop in prostates larger than 40 CC


Department of Urology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
N P Gupta
Department of Urology, All India Institute of Medical Sciences, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Purpose: Transurethral resection of the prostate (TURP) is the gold standard for treatment of benign pro static hyperplasia (BPH). However; the morbidity of this procedure necessitates constant attempts at modifications to the standard equipment and technique. We report on the safety and efficacy of TURP with the thick vapor resection WEDGE'" loop (Microvasive0, Boston Scientific Corporation, USA) compared with the standard wire loop in comparable groups of patients with prostates larger than 40 cc.
Material and Methods: We prospectively randomized 60 patients with bladder outflow obstruction due to BPH into 2 groups of 30 each. The inclusion criteria included an indication for prostatectomy and prostate size larger than 40 cc. The exclusion criteria included carcinoma prostate and neurovesical dysfunction. Pre-operative evaluation included assessment of International prostate symptom score (IPSS), prostate volume (in cc), maximum fow rate (Qmax) and residual urine (in ml). Patients in group 1 underwent transurethral vapor resection of the prostate (TUVRP) using the WEDGE" loop while patients in group 2 underwent TURP using a standard wire loop. Operating time, resected tissue weight, duration of catheterization, nursing contact time, hospital stay, haemoglobin change, serum sodium levels, and any complications were noted and compared in the 2 groups. The IPSS maximum f ow rate and residual urine were re-evaluated at 6 months after the procedure and compared in the 2 groups.
Results: Both groups were comparable in terms of age, IPSS, prostate volumes, Qmax and residual urine. The mean prostate volume in group I and 2 was 63.6 cc and 58.48 cc respectively. The mean resected weight in group 1 and 2 was 20.30 gin and 17.52 gin respectively.
Irrigant (1.5% ghvcine) volume used was 14.65L and 19.12L and the operating time was 47 min and 68.6 min in the 2 groups respectively. Estimated mean intra-operative blood loss was 50 (30-50 ml) and 250 (100-300 ml) respectively. Duration of post-operative catheterization was 1.56 days and 2.28 days and haemoglobin change was +/- 1.32 g and +/- 1.96 g respectively. The differences in duration of hospital stay and the change in serum sodium were not significant. Post operative catheterization duration, post operative irrigant requirement was significantly different in both the groups. The incidence of complications was similar and the efficacy assessed with IPSS, Qmax and residual urine was comparable at 6 months.
Conclusion: The use of a thick vapor resection loop for TURP significantly reduces operating time, blood loss, irrigant requirement, nursing contact time, and duration of catheterization, besides providing a clew vision during surgery without affecting the efficacy and complications.


Keywords: Prostate; Resection; TURP; Complications; Catheterization.


How to cite this article:
Gupta N P, Doddamani D, Hemal AK, Aron M. Prospective randomized comparison of transurethral resection of prostate using vapor resection (WedgeTM) loop and standard loop in prostates larger than 40 CC. Indian J Urol 2001;18:45-8

How to cite this URL:
Gupta N P, Doddamani D, Hemal AK, Aron M. Prospective randomized comparison of transurethral resection of prostate using vapor resection (WedgeTM) loop and standard loop in prostates larger than 40 CC. Indian J Urol [serial online] 2001 [cited 2020 Sep 23];18:45-8. Available from: http://www.indianjurol.com/text.asp?2001/18/1/45/37416



   Introduction Top


Transurethral resection of the prostate (TURP) remains one of the most common procedures performed by a urologist. However, this procedure carries a significant morbidity that has necessitated a constant attempt at modifications in the equipment and techniques.[1] Kaplan and Te reported using electrovaporisation of the prostate using a dessicating probe and cutting current in 1995.[2] The roller hall electrode was developed to effect vaporisation of prostatic tissue using cutting current. Recently, various modifications of the standard resection loops have been devised which combine vaporization and resection using high frequency current at settings of 200-300 w. These devices also reduce bleeding by instant coagulation of vessels, provide good visibility. reduce operative time and fluid absorption.[2],[3],[5] Postoperative bladder irrigation and duration of catheterization is also reduced. Various studies have demonstrated the efficiency of electrovaporisation and vapor resection of the prostate.[4],[5] We used the thick vapor resection WEDGETM loop (Microvasive®, Boston Scientific Corporation, USA) in our study for transurethral vapor resection of the prostate (TUVRP) and compared this with standard wire loop TURP.


   Materials and Methods Top


We prospectively randomized 60 patients with bladder outflow obstruction due to BPH into 2 groups of 30 each. The inclusion criteria included an indication for prostatectomy and prostate size larger than 40 cc. The exclusion criteria included carcinoma prostate and neurovesical dysfunction. Pre-operative evaluation included a detailed history, physical examination including digital rectal examination (DRE), renal function tests, serum prostate specific antigen and assessment of 3 specific parameters including: International prostate symptom score (IPSS), maximum flow rate (Qmax) and residual urine (in ml). Patients in group 1 underwent TUVRP using the WEDGETM loop while patients in group 2 underwent TURP using a standard wire loop. All procedures were performed under a spinal anaesthetic (0.5% bupivacaine) using a 25F continuous flow resectoscope and a Martin ® ME 401 (Gebruder Martin, Tuttlingen, Germany) electrosurgical generator. The power settings used were 220w and 50w in group 1 and 80w and 50w in group 2 for cutting and coagulating currents respectively. All patients received a single dose of an intravenous third generation cephalosporin one hour prior to surgery. Intraoperative blood loss was estimated by measuring the volume and hematocrit in the effluent irrigation fluid. At the end of the procedure a 22F 3-way foley catheter was indwelled and continuous irrigation commenced with saline at a rate sufficient to maintain a clear return. Irrigation was ceased after 12-24 hours depending on the colour of the returning fluid and the catheter removed as soon as the urine became clear after cessation of irrigation. Postoperative estimation of haemoglobin and electrolytes was performed within 12 hours after the procedure. Nursing contact time was calculated according to the time estimated for irrigation fluid and intravenous fluid changes for each patient. Operating time, resected tissue weight, duration of catherization, nursing contact time, hospital stay, haemoglobin change, serum sodium levels, and any complications were noted and compared in the 2 groups. The 3 parameters assessed pre-operatively were re-evaluated at 6 months after the procedure and compared in the 2 groups.


   Results Top


Both groups of patients were comparable in terms of age, duration of symptoms, IPSS, episodes of acute retention, Qmax, prostate volume and residual urine volume as assessed by ultrasonography, and comorbid conditions [Table - 1]. The operative and post-operative parameters including the average duration of TURP, the average weight of prostate resected and amount of glycine used are shown in [Table - 2]. Operative bleeding was minimal (30-50 ml) in group 1 and substantial (50-200 ml) in group 2. Post operative haemoglobin change was +/- 1.32 gm in Gpl and +/- 1.96 gm in Gp2, but was not statistically significant. The change in serum sodium in both groups was similar (+/- 3.5 and 3.36) and was also not significant. All patients except one each in both groups voided successfully. 6 patients in group 1 had dysuria, which lasted from 1 day to I week. 1 patient had a small capsular perforation that resolved spontaneously. In group 2, only 2 patients had mild dysuria, 2 had post prostatectomy incontinence, but both of them regained continence within 6 months. I patient had a residual adenoma that necessitated repeat resection a month later and another developed a stricture requiring dilatation. The average duration of catheterization was 1.56 and 2.2 days in the 2 groups respectively, which was significant (P<.00 1). Nursing contact time and post operative ir-igant used was also significantly different between the two groups. Postoperatively all patients were followed up for 6 months. Postop Qmax, IPSS, and PVR were evaluated. None of the patients in either group developed any late complications till 6 months of follow-up.


   Discussion Top


We selected patients with prostates larger than 40 cc for this study. Though the number is small, thick loop or vapor resection loop TURP has advantages over standard TURP. The use of high energy electrocuting current for electrovaporisation of the prostate was described by Kaplan in 1995.[2] Perlmutter et al described the use of the WEDGE initially in a canine study and followed it up with its use in 65 patients.[3] They noted that the average time of resection was similar to that of standard TURP, the chips were removed at a slower pace, but less time was needed for haemostasis and resectoscope orientation. Other studies using similar loops have used a cutting current ranging from 250 to 300w and report a slower drag time for resection.[4],[5],[6] However we used a cutting current of 220w and did not notice any reduction in speed of resection. The WEDGE is shaped like a wedge in cross section tapering from the front to back and probably, this helped in preventing slower drag speed. The vision is usually excellent with hardly any bleeding and tissue interface between prostatic tissue and the capsule, the bladder sphincter muscle can be adequately distinguished. Though the HPE changes showed a slightly thicker zone of tissue coagulation, this did not affect the histological differentiation between benign and malignant tissue. Vessels upto a diamater of 0.5 mm were coagulated in the specimens as compared to the thickness of the loop. None of the patients required a blood transfusion. Postoperative bladder irrigation was significantly reduced in the WEDGE group since the urine was usually clear immediately postop. Nursing contact time was reduced and catheters were removed earlier than in the standard loop group. Postoperatively there was a higher incidence of dysuria in group 1. However the long term follow-up parameters are similar in both groups. The results of our study are comparable to other studies using similar thick resection loops reported.[6],[8]

However, the reduction in blood loss, excellent vision, reduced operating time, less glycine used and reduced hospital stay significantly reduces the cost of surgery and is also beneficial to patients with significant comorbid conditions. Some studies have not found any significant advantages over the standard loop.[7]


   Conclusion Top


WEDGE loop or vapor resection loop TURP is comparatively better than standard loop TURP in terms of bleeding, reduced irrigant requirement, clear vision, minimal hospital stay, catheter duration and outcome. Though the cost of the loop is more, it is offset by the shorter operative time, less blood loss and amount of glycine used. Its use is considerably beneficial to patients with significant comorbid conditions. Long term results are comparable to the standard loop TURP.

 
   References Top

1.Mebust WK, Holtgrewe HL, Cockett ATK, Petters PC. Transurethral prostatectomy: Immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3885 patients. J Urol 1989: 141: 243-247.  Back to cited text no. 1    
2.Kaplan SA, Te AE. Transurethral electrovaporisation of the prostate: A novel method for treating men with benign prostatic hyperplasia. Urology 1995:45: 566-572.  Back to cited text no. 2    
3.Perlmutter AP, Schulsinger DA. The WEDGE Resection device for electrosurgical transurethral prostatectomy. J Endourol 1998; 12: 1.  Back to cited text no. 3    
4.Riyadh F Talic, Abdul-Moneim El Tiraifi et al. Prospective randomised study of transurethral vaporisation resection of the prostate using the thick loop and standard transurethral prostatectomy. Urology 2000; 55: 886-891.  Back to cited text no. 4    
5.Patel A, Fuchs GJ, Gutterez AJ, Perez AP. Transurethral electrovaporisation and vapour-resection of the prostate: an appraisal of possible electrosurgical alternatives to regular loop resection. BJU Int 2000; 85: 201-210.  Back to cited text no. 5    
6.Talic RR Al Kudair WK et al. The `WING' versus the Vaporcut Electrodes in Transurethral Electrovaporisation - resection of the prostate: Comparative changes in safety parameters: Urol Int 2000; 65: 95-99.  Back to cited text no. 6    
7.Holmes M, Cox J, Wright W et al. Thick vs thin loop resection of the prostate: a randomised blinded trial. BJU Int 2000; 85 (Suppl. 5): 1-78.  Back to cited text no. 7    
8.Cynk M, Woodham S. Mostafid H, Popert P. A prospective randomised controlled trial comparing Vaportome prostatic with TURP. BJU Int 1999; 83 (Supple 4):  Back to cited text no. 8    



 
 
    Tables

  [Table - 1], [Table - 2]



 

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    Abstract
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