Transurethral Vaporization Resection of the Prostate

(TUVRP): An Alternative in the Management of Men with Prostatic Outflow Obstruction

Professor Riyadh F. Talic, MD

Professor of Urology & Andrology

Benign prostatic obstruction (BPO) is a

common cause of urinary symptoms in

men older than 40-years of age

Management Options for patients with BPO

• Medical therapy• Instrumental (minimally invasive)

therapy

• Surgical therapy

Medical Therapies for BPO is the first line of

management of patients with symptomatic BPO

Medical Therapies for BPO

• 5 α reductase inhibitors: – Finasteride (Proscar).

• Alpha- blockers:– Trazosin (Itrin).– Doxazosin (Cardura).– Alfuzosin (Xatral).– Tamsulosin (Flomax, Omnic).

Minimally Invasive Therapies for BPO

• TUIP (Incision)

• Prostate balloon dilatation

• Urethral (prostatic) stents

• Hyperthermia

• Cryosurgery

• TUNA

• Laser devices

Surgical Therapy for BPO• Based on removal & debulking of

the obstructing prostatic adenoma, indicated in:– Failed medical treatment– Complications:

• Urinary retention.• Renal back pressure changes.• Hematuria.• Large vesical stones.

Surgical Therapy of BPO

• Open prostatectomy

• Transurethral prostatectomy– TURP (Resection)

– TUVP (Vaporization)

– TUVRP (Vaporization-Resection)

Principles of Electrosugery

• The use of variable radiofrequency electrical current between 400,000

and 1,000,000 Hz, depending on the generator power to achieve cutting

(Vaporization), desiccation & fulguration of tissues

Principles of Electrosugery

• The magnitude of the electrocutting energy and the the design of the transurethral device

will determine whether an incision, vaporization, resection or

combination of both will result

Transurethral ElectrodesTransurethral Electrodes

Transurethral resection of the Prostate (TURP) using a standard wire loop and electrosurgical unit is still

regarded as the “Gold Standard” in the treatment

of men with BPO

Morbidity associated with TURP • Bleeding• TUR syndrome (Low serum sodium)

• Infection

• Urinary incontinence• Erectile dysfunction.

Transurethral vaporization of the prostate (TUVP)

• Rolling cylinder (The Vaportrode) provides enhanced contact with prostatic tissue using augmented electrocutting energy.

• Electrovaporization current maintained efficacy of TURP with minimal bleeding and electrolyte disturbances.

• Disadvantages: Slow & Lack of prostatic tissue for histopathological examination.

Transurethral Vaporization Resection Prostatectomy (TUVRP)

• Thick Loop (Resection)• Augmented Electocutting energy (Electrovaporization)• TUVRP = TURP + TUVP• Technique of operation!

The “Wedge” resection device for electrosurgical transurethral

prostatectomy

Perlmutter AP & Schulsinger DA

J Endourol 12: 75-79, 1998

Transurethral electrovaporization-resection of the prostate using the

“Wing” cutting electrode: Preliminary results of safety and efficacy in the

treatment of men with prostatic outflow obstruction

Riyadh F. Talic

Urology 53: 106-110, 1999

Conclusions of the Feasibility Studies on TUVRP

• TUVRP is a promising new modification of the standard TURP.

• TUVRP combines the excellent resection capabilities of TURP and the benefits of electrovaporization.

• No complications related to the augmented electrosurgical energy.

Safety & Efficacy of TUVRP

• Randomized study versus standard TURP.• Effects of High electrocutting energy on:

– Histopathological specimens.– Serum Prostate Specific Antigen (PSA).– Erectile function.

• Evaluate the role of the thick loop design.

Prospective Randomized Study of Transurethral

Vaporization Resection of the Prostate Using the Thick Loop

and Standard Transurethral Prostatectomy

R. F. Talic, A. E. El Tiraifi, S.H. Hassan, S. R. El

Faqih, R. A. Attassi, R. E. Abdel Halim

Urology 55: 886-890, 2000

TUVRP versus Wire-loop TURP

• A prospective randomized study.

• Sixty-eight patients in 2 equal treatment groups of TUVRP & TURP.

• Both groups were balanced for baseline variables including age, Presentation and prostate size

TUVRP versus Wire-loop TURP

• P=0.01

11.812

12.212.412.612.8

1313.213.413.6

TUVRPTURHb (gm/dL)

• P=0.03

138.4

138.6

138.8

139

139.2

139.4

139.6

139.8

140

Na (mEq/L)

Pre

Post

TUVRP versus Wire-loop TURP

TUVRP TURP

Resection weight (gms) 22.410.5 20.29.5

P=NS

Resection time (min) 42.415 35.912.8

P=0.02

Post-op Catheter (hrs) 23.110.3 3617.3P=<0.0001

TUVRP versus Wire-loop TURP

Complication TUVRP TURP

Urethral stricture 3 3

Clot retention 1 1

Meatal stenosis 0 1

Early post-op bleeding 0 1

Erectile dysfunction 0 0

TUVRP versus Wire-loop TURP

• IPSS

• Qmax

0

1

2

3

4

5

6

TUVRP TURP02468

101214161820

TUVRP TURP

P=0.03 & 0.01Efficacy Parameters Post-op

Transurethral Vaporization-Resection of the Prostate Versus Standard

Transurethral Prostatectomy: Comparative Changes in

Histopathological Features of the Resected Specimens

R. F. Talic & A. C. Al Rikabi

Eur Urol 37: 301-305, 2000

Histopathology post TUVRP

• Methods:– Fifty patients that underwent TUVRP &

TURP– One surgeon– One blinded Pathologist– Devised scoring system for severity of

cautery artifacts

Histopathology post TUVRP

• Electrocautery Artifacts (1 Point scoring):

– Abnormal cellular orientation & spindling

– Abnormal cellular detachment from underlying basement membrane

– Atypical cytological changes– Stromal coagulative necrosis with or without

smooth muscle fiber, nerves and vascular injury

Histopathology post TUVRP

Grade Total sum of points

Mild 1

Moderate 2

Severe 3-4

Results of Histopathology Study

Grade of cautery artifact TUVRP TURP

Mild 1 (4%) 0 (0%)

Moderate 21(84%) 21(84%)

Severe 3 (12%) 4 (16%)

P=NS

Histopathology post TUVRP• Conclusions:

– The quality of histopathological specimens produced by TUVRP are similar to TURP.

– The higher electrocutting energy used in TUVRP does not result in greater thermal injury to the tissues possibly because of the cooling effect of the irrigation fluid used during the procedure

CHANGES OF SERUM PROSTATE-SPECIFIC

ANTIGEN (PSA) FOLLOWING HIGH ENERGY

THICK LOOP PROSTATECTOMYR. F. Talic & A. E. El-Tiraifi

International Urol & Nephrol, 2000, 32(2): 271-4

Serum PSA post TUVRP

• Objectives:– Evaluate the response of PSA to Augmented

electrocuting energy.

– Does delayed healing of prostatic cavity lead to delayed decline of serum PSA?

Methods for the PSA Study

– Fifty patients with BPO were included. – Thirty-five patients had TUVRP using the “Wing”

thick resection electrode. – Fifteen patients (control) had TURP.– Serum PSA was measured before, 1 day and 6

weeks in the morning post TUVRP.– The samples were analyzed using the Enzyme-

Test PSA (Boehringer Mannheim). Normal PSA values for the assay are 0.0-4.0 ng/ml.

Results for the PSA Study

02468

101214161820

Pre-op 24 hrs PSA 6 wks PSA

TUVRPTURP

PSA Study• Conclusions:

– TUVRP produces a reversible increase in serum PSA value.

– The pattern of elevation and decline of the PSA is similar to standard TURP.

– Evaluating patients with persistently elevated PSA at 6 weeks should take into consideration their baseline PSA values.

ERECTILE FUNCTION FOLLOWING HIGH-

ENERGY THICK LOOP PROSTATECTOMY

Riyadh F. Talic

Scand. J Urol & Nephrol, 2001, 35(4): 300-4

Erectile Function & TUVRP

• A prospective study of 70 men • Questionnaire based study • Questionnaire obtained both pre-operatively & 3

months post TUVRP• Adequate pre TUVRP counseling on sexual activity

in relation to prostatectomy

Erectile Function before and post TUVRP

Pre TUVRP Post TUVRP

Full potency 30 30

Reduced potency 8 6

Total # of patients 38 36 (94.7%)

32 patients were not sexually active at baseline

Conclusions for EF & TUVRP

• Patients that are fully potent pre TUVRP can expect to remain so post prostatectomy.

• The heat that is generated by the increased level of cutting energy is dissipated by the irrigation fluids used during resection and does not seem to adversely affect potency.

The “Wing” Versus the “Vapor cut” electrodes in transurethral

vaporization resection of the prostate: Comparative changes in

Safety Parameters

R. F. Talic, W. Al Kudair, A. E. El Tiraifi, N. M. Al Bogami, M. k. Mansi, S. Altaf & T. B. Hargreave

Urology Internationalis; 65: 95-99, 2000

“Wing” versus “Vapor cut”

• Methods:– Ninety patients at KKUH, WGH & KFNGH

– KKUH & WGH: The “Wing” & Eschman Unit

– KFNGH: The “Vapor cut” & Valley lab unit.

– Baseline variables were balanced.

Safety features: The “Wing” versus the “Vapor cut”

0

0.5

1

1.5

2

2.5

3

3.5

Hb Drop Hct drop Na drop

WingVaporcut

P=0.004 P=0.03 P=<0.0001

“Wing” versus “Vapor cut”

0

5

10

15

20

25

Resection wt.

TUVRPTURP

• Operation time (mins)

P=NS

0

5

10

15

20

25

30

35

40

45

50

P=0.003

47 37

“Wing” versus “Vapor cut”

• Conclusions:–Both thick loops, safe & efficacious

–Differences may be related to changes in the loop design!!

–Safety features that are related to the vaporization effect are influenced by the speed of resection

TUVRP CONCLUSIONS• TUVRP improves safety of

transurethral prostatectomy and has the potential to reduce the

main 2 morbidities that are associated with standard TURP namely; bleeding and electrolyte

disturbances.

TUVRP CONCLUSIONS

• The shorter post operative catheterization time that is noted

following TUVRP is clinically significant considering the demand

for lower morbidity profiles and hospitalization time by the patients

and health care providers

TUVRP CONCLUSIONS

• TUVRP maintains the efficacy of standard prostate

debulking procedures

TUVRP CONCLUSIONS

• The higher energy level that is used in TUVRP does not seem

to have an adverse effects, particularly in relation to erectile function, serum PSA levels and

quality of histopathological specimens

TUVRP CONCLUSIONS

• The change to using TUVRP is simple and does not

require capital investment in new technology.

TUVRP CONCLUSIONS

• Future work will need to further focus on the role of

the thick loop design