Plasmakinetic Vapoenucleation of the Prostate by Nesbit Technique

Abstract

Introduction: Transurethral resection of the prostate (TURP) has been the gold standard in surgical management of patients with benign prostatic hyperplasia (BPH). The procedure has stood the test of time. The place of conventional TURP has come under scrutiny with emergence of bipolar electrosurgical systems that utilize normal saline for cutting. Plasmakinetic (bipolar) energy has demonstrated several advantages over conventional monopolar TURP. There has been an increasing trend favoring enucleation procedures using laser.1 The argument given is that they do more complete removal of prostatic adenoma up to the capsule. Recently, bipolar “enucleation” and “vapoenucleation” procedures have been proposed as advancements in the technology.2 We have tried to modify this technique of “vapoenucleation” by enucleating the lobes in a simple way using Nesbit's technique, which is simpler and easy to reproduce. We use the plasmakinetic button electrode for doing vaporization. Patients and Methods: The study was conducted at our center from January 2016 till June 2016 for a 6-month period and included 35 consecutive patients with obstructive lower urinary tract symptoms associated with BPH. Patients with moderate to severe enlargement (between >50 g and <100 g) of the prostate were included in the study. Any patients with renal failure, upper tract dilation, or secondary bladder stones were excluded from the study. Complete preoperative assessment with IPSS score, postvoid residual urine (PVRU) volume, and maximum flow rate (Qmax) were done in all cases. Patients' consent was obtained in all cases. The classical Nesbit approach was used for enucleation of the prostatic lobes. The equipment used was bipolar resectoscope (Olympus medical systems). An initial vaporization/resection was done at 12 o' clock position followed by vapoenucleation of right lateral lobe from 12 o' clock position till 7 o' clock position in anticlockwise manner. Similarly the procedure was repeated on the left side from 12 o' clock position till 5 o' clock position in clockwise manner. In the end, the lobes lying at the base devoid of most of the blood supply were resected quickly with a cutting loop. No morcellator was used for removal of prostatic tissue, thereby reducing procedure time. Finally, hemostasis is secured. Postoperative assessment was done at 3 months and included IPSS score, PVRU volume, and Qmax. Immediate postoperative outcomes such as catheter-free trial, blood loss, operative time, and hospital stay were recorded. Late complications during the 3 months follow-up were recorded. Results: Thirty-five patients underwent plasmakinetic vapoenucleation of the prostate (PKVEP). The mean prostate volume on preoperative ultrasonography was 65.7 cc and mean operative time was 55 minutes. Mean catheterization time was 37.6 hours, whereas mean hospital stay was 64 hours. The mean resected tissue weight was 32 g. There was a significant improvement from baseline in terms of IPSS, Qmax, and PVRU volume in all the patients. No significant complications were noted within the short follow-up of 3 months. Conclusions: Transurethral PKVEP is a safe and effective method in management of BPH. In our study, we found the learning curve to be more flat as it mimics the Nesbit's technique of monopolar TURP. No competing financial interests exist. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 7 mins 12 secs Presented as video at the World Congress of Endourology 2016 held at Cape Town, South Africa on November 8–12, 2016.