Standard Transurethral Resection Research Articles

A TECHNIQUE FOR RESECTION OF SMALL BLADDER TUMORS USING A FLEXIBLE CYSTOSCOPE ON AN OUTPATIENT BASIS: BLADDER TUMOR RESECTION WITH NEWLY DESIGNED HOT CUP FORCEPS

We describe a technique for resecting small papillary superficial bladder tumors using a new device and flexible cystoscope. In a 79-year-old man 3 small recurrent papillary bladder tumors were resected transurethrally on an outpatient basis. The procedure was performed using a flexible cystoscope and a newly designed type of cup forceps with the patient under topical anesthesia. No urethral catheter remained indwelling after surgery and the patient was discharged home the same day. Bladder tumor resection using this technique was tolerable to the patient and postoperative bladder hemorrhage was not noted. Resected specimens were adequate for pathological tumor evaluation, which revealed grade 1 stage Ta superficial transitional cell carcinoma of the bladder. This easy technique seems to be tolerated well by the patient. Resected specimens should be adequate for evaluating the pathological grade and depth of stage Ta or T1 superficial bladder cancer. This technique may be an alternative to standard transurethral resection for removing small recurrent bladder lesions in select patients who prefer outpatient management of bladder tumors.

Is Transurethral Vaporesection of the Prostate Better Than Standard Transurethral Resection?

Objective: The aim of this study was to undertake an evaluation of the comparative efficacy and morbidity of transurethral vaporesection (TUVRP) and standard transurethral resection (TURP), two resection techniques using loops of different thickness and power settings. Methods: In a prospective study, 185 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction and benign prostatic enlargement were randomized to undergo either TUVRP or standard TURP. Inclusion criteria were benign prostatic enlargement, moderate or severe lower urinary tract symptoms and/or a significant urinary residual (>60 ml), while patients with previous prostatic surgery, prostate cancer or neurogenic bladder disorders were excluded. Prostate size, residual urine, urinary flow rate and symptoms as well as associated bother (using the International Prostate Symptom Score (IPSS) and the American Urological Association Bother Score (AUA–BS)) were assessed preoperatively. Intraoperative blood loss and fluid absorption were evaluated by measuring serum hemoglobin and respiratory alcohol concentration. Patients were followed for 1 year with the evaluation of flow rates, residual urine volumes, symptom scores and complications at 3, 6 and 12 months. Results: A significant difference was seen in the weight of the resected tissue (TURP 30.3 g vs. TUVRP 21.9 g, p<0.003). There were no significant differences in blood loss, intraoperative fluid absorption or procedure time between TUVRP and TURP, although more patients in the TURP group required blood transfusions (13 vs. 7) and mean procedure time was longer for TUVRP (71.0 vs. 65.9 min). The postoperative improvements in IPSS, AUA–BS, residual and Q_max were significant in both groups (p<0.01 for each) but without difference between the two groups. The rate of complications (urinary tract infections, urethral stricture, reintervention rate) during follow–up was the same in both groups. Conclusions: In this prospective randomized comparison of the clinical outcome and morbidity of standard TURP versus TUVRP, there were no significant differences in any of the parameters evaluated except for the weight of the resected tissue.

TRANSURETHRAL INCISION COMPARED WITH TRANSURETHRAL RESECTION OF THE PROSTATE FOR BLADDER OUTLET OBSTRUCTION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Transurethral prostatic resection is the gold standard surgical treatment in men with lower urinary tract symptoms suggestive of bladder outlet obstruction but it has also been related to some risks, such as a relatively high rate of blood transfusion, sexual function problems and so forth. Transurethral prostatic incision is a simpler and less invasive procedure than transurethral prostatic resection. However, it is underused. We systematically reviewed all published randomized controlled trials comparing the effectiveness of transurethral prostatic incision with standard transurethral prostatic resection for bladder outlet obstruction and performed a meta-analysis of the available relevant data. Nine randomized controlled trials comparing the treatment effectiveness of transurethral prostatic resection and transurethral prostatic incision were identified, evaluated and reviewed in a meta-analysis. The quality of these studies was also appraised. Each treatment achieved clear improvements in subjective and objective outcomes. The improvement in symptoms was equivalent 12 months postoperatively for transurethral prostatic incision and resection. For maximum flow rate transurethral prostatic resection resulted in greater improvement than transurethral prostatic incision. However, transurethral prostatic incision had several advantages over transurethral prostatic resection, such as lower incidence of complications, fewer blood transfusions, decreased risk of retrograde ejaculation, and shorter operative time and hospital stay. Also, the treatments had an equivalent incidence of postoperative catheterization duration and reoperation rate within the first 12 months. Furthermore, patients in each group had a similar subjective view of the treatments received. In the first 12 months after surgery transurethral prostatic incision has effectiveness that is equivalent to transurethral prostatic resection for treating patients with suspected benign prostatic obstruction who have a relatively small prostate. However, there is little evidence on the relative long-term effectiveness of the 2 treatments 2 to 5 or 10 years after surgery. There is no clear cutoff point for prostate size that leads to good results after transurethral prostatic incision. A large-scale, multicenter randomized controlled trial is now required to evaluate comprehensively the effectiveness, impact on quality of life and overall cost of transurethral prostatic incision compared with transurethral prostatic resection.

Experimental study of transurethral robotic laser resection of the prostate using the LaserTrode lightguide.

A longer operating time and steeper learning curve in mastering the techniques for transurethral laser resection of the prostate are the main problems faced by surgeons in addition to the existing ones in standard transurethral resection of the prostate (TURP). However, these disadvantages can be alleviated with the introduction of a treatment procedure designed and developed based on an integrated system of computer, robotics and laser technology. In vitro experiments were carried out to determine variables affecting the vaporization and coagulation lesions, in order to study the effectiveness and feasibility of robotics for this procedure. Human cadaveric prostates and fresh tauted chicken breast tissues were irradiated with different parameters using the LaserTrode lightguide in contact with the tissue. The effects of irrigant flow rate, fiber/tissue angle of inclination, number of passes, direction, speed and power of lase on the volume of tissue vaporized and coagulated, were assessed. The final phase of the experiments includes executing the robotic motion plan for the laser resection procedure on the human cadaveric prostate tissue embedded in an anatomically alike prostate phantom. It was concluded from our study that power and speed of lase are the most significant parameters influencing the volume of the vaporized and coagulated lesion. Comparison of removal rate using the new treatment procedure of robotic laser resection of the prostate with TURP and HoLRP evinced equivalent results.

IMPACT OF INTERVENTIONAL THERAPY FOR BENIGN PROSTATIC HYPERPLASIA ON QUALITY OF LIFE AND SEXUAL FUNCTION: A PROSPECTIVE STUDY

Treatment for benign prostatic hyperplasia (BPH), including minimally invasive therapy, can impair the quality of life. We prospectively determined the impact of 4 different interventional therapies on quality of life and sexual function. A total of 173 patients were prospectively evaluated between February 1995 and August 1997. Treatment modalities consisted of standard transurethral resection of the prostate in 55 cases, transurethral microwave thermotherapy in 34, interstitial laser coagulation of the prostate in 42 and transurethral needle ablation in 42. Disease specific quality of life was assessed using the International Prostate Symptom Score quality of life assessment index and BPH impact index. In addition, a self-reporting questionnaire was completed before and 3 months after treatment to determine the impact on sexual function. All 4 treatment groups showed significant improvement in the symptom score, International Prostate Symptom Score quality of life assessment score and BPH impact index score. Satisfaction with treatment was highest in patients treated with transurethral resection or laser coagulation. A mild to moderate decrease in erectile function was noted in 26.5%, 18.2%, 18.4% and 20.0% of the transurethral resection, microwave thermotherapy, laser coagulation and needle ablation groups, respectively, but there was no significant difference of mean pretreatment and posttreatment erectile function or libido scores in any group. Ejaculation loss or severe decrease in ejaculate volume was reported by 48.6%, 28.1%, 21.6% and 24.3% of the patients, respectively. Interestingly, 20 of the 44 patients (45. 5%) with loss of ejaculation or severe decrease in ejaculate reported deterioration of the sex life, while only 2 (3.6%) of the 56 without any change in ejaculate volume reported such deterioration. The association of ejaculatory dysfunction with an adverse impact on sexual activity was highly significant (p <0.0001). Significant improvement in quality of life could be achieved with the present assessed interventional therapies. There was no significant change in sexual desire or erectile function with these therapies. Posttreatment sexual dysfunction appears to be mainly related to impaired ejaculatory function. Urologists should provide proper counseling regarding the possibility of this complication even in patients receiving minimally invasive treatment.

A RANDOMIZED TRIAL COMPARING TRANSURETHRAL RESECTION OF THE PROSTATE, LASER THERAPY AND CONSERVATIVE TREATMENT OF MEN WITH SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC ENLARGEMENT: THE CLasP STUDY

We evaluated the effectiveness of a new technology (noncontact laser therapy) versus that of standard surgery (transurethral prostatic resection) and conservative management for lower urinary tract symptoms associated with benign prostatic enlargement. Men with uncomplicated lower urinary tract symptoms, that is no acute or chronic urinary retention, were randomized to receive laser therapy with a noncontact, side firing neodymium:YAG probe, standard transurethral prostatic resection or conservative management, including monitoring without active intervention, in a large multicenter pragmatic randomized controlled trial called the CLasP study. Primary outcomes were International Prostate Symptom Score (I-PSS), maximum urinary flow rate, a composite measure of success based on I-PSS and maximum urinary flow rate categories, I-PSS quality of life score and post-void residual urine volume. Secondary outcomes included treatment failure, hospital stay and major complications. Followup was 7.5 months after randomization. Intent to treat analysis was done using analysis of covariance, proportional odds models and the Newman-Keuls multiple comparisons procedure. Of symptomatic patients 117, 117 and 106 were randomized to receive laser therapy, transurethral prostatic resection and conservative management, respectively. Baseline characteristics were similar. All primary outcomes indicated that transurethral prostatic resection and laser therapy were superior to conservative management, and resection was superior to laser therapy. As measured by combined improved symptoms and maximum urinary flow, a successful outcome was achieved in 81%, 67% and 15% of men who underwent transurethral prostatic resection, laser therapy and conservative management, respectively. Hospital stay was significantly shorter and complications fewer for laser therapy than for resection but catheters were in place significantly longer. Men treated conservatively did not have deterioration or treatment failure. Laser therapy and transurethral prostatic resection are effective for decreasing lower urinary tract symptoms and post-void residual urine volume as well as improving quality of life and maximum urinary flow in the short term in men presenting with moderate to severe symptoms. Transurethral prostatic resection is superior to laser therapy in terms of effectiveness but some patients may elect laser therapy due to the shorter hospital stay and lower risk of complications. Conservative management may be acceptable and safe in men with lower urinary tract symptoms since we observed no marked deterioration in the short term.

Transurethral vaporization of the prostate: Current techniques

Electrovaporization has quickly become a popular procedure for treating benign prostatic hyperplasia. By using standard transurethral electrosurgical technology, electrovaporization offers standard transurethral loop-like resection and transurethral prostatectomy (TURP)-like efficacy with less morbidity than that associated with TURP. Through a combination of two electrosurgical effects (vaporization and desiccation), electrovaporization ablates significant volumes of prostatic tissue with each passage of the electrode. Newly designed thicker loop electrodes have led to a modification of the original electrovaporization technique. "Vaporizing-resection" adds the advantages of transurethral resection to those of electrovaporization with the use of one electrode. Very large glands can be treated efficiently, and prostatic tissue specimens are produced. Moreover, additional vaporization of tissue occurs with minimized bleeding. This report reviews basic electrosurgical principles, electrode design, and factors that affect vaporizing efficiency. Current long-term data on electrovaporization compared with TURP are summarized, and pilot studies evaluating vaporizing- resection have shown promising results. A new technology that has entered the market--bipolar electrovaporization--is also discussed. Finally, combination therapy and Columbia's 4-year experience with vaporization techniques are discussed.

Transurethral Vaporization–Resection of the Prostate versus Standard Transurethral Prostatectomy: Comparative Changes in Histopathological Features of the Resected Specimens

Objectives: Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral resection of the prostate (TURP). TUVRP uses a band electrode coupled to a high electrocuting energy to achieve simultaneous resection, vaporization and coagulation of the prostate. We evaluated the histopathological resection specimens of patients treated with TUVRP to see whether the higher energy used will result in thermal artifacts that will interfere with the pathological evaluation of the prostate, and compared the results to TURP specimens. Material and Methods: The histopathological specimens of 50 patients that underwent TUVRP or TURP were reviewed. Artifactual pathological patterns that were identified in the specimens included: abnormal cellular orientation and spindling, artifactual cellular detachment from the underlying basement membrane, atypical cytological changes or areas of stromal coagulative necrosis. Each identified pattern was awarded 1 point. The severity of cautery artifact was graded into mild, moderate or severe according to the sum of points in each specimen. Results: Mild cautery artifact changes were noted in 1 patient who underwent TURP. Moderate changes were noted in 21 patients in each TURP and TUVRP groups while severe changes were noted in 4 and 3 patients undergoing TUVRP and TURP respectively. There were no statistically significant differences between the groups with regard to the severity of the cauterization– induced changes. Conclusions: The quality of histopathological specimens produced by TUVRP is similar to the standard TURP. It seems that the higher energy use in electrovaporization technique does not result in greater thermal injury to the tissues possibly because of the cooling effect of the irrigation fluids used intraoperatively.

Clinical features and management of anterior intraurethral prostatic cyst

We report on a symptomatic anterior intraurethral prostatic cyst in a 46-year-old man without clinical evidence of benign prostatic hyperplasia. The anterior location of this cyst makes it unique to all previously reported cases of prostatic cysts which are located posteriorly. Transurethral resection of the cyst with limited resection of the anterior prostatic tissue at the base of the cyst was performed with successful resolution of voiding symptoms. In the absence of lateral lobe hypertrophy, standard transurethral resection of the prostate should be avoided to ensure preservation of erectile and ejaculatory function.

Electrosurgery: VaporTrode

Despite subjective and objective success rates approaching 90%, significant morbidity is well documented using a wire loop for standard transurethral resection of the prostate (TURP). In an effort to minimize patient morbidity as well as limit future healthcare costs, several alternative instrumental techniques have been examined. Recent studies of transurethral electrovaporization of the prostate, a modification of existing transurethral technology, appear encouraging. The modifications which enable larger volumes of tissue to be vaporized with concurrent desiccation and coagulation are an increase in the surface area of the electrode and effective delivery of high electrical energy by electrical generators. The most extensively studied instrument is the VaporTrode. Promising early published reports of TURP-like efficacy without significant morbidity, as well as low cost, have fueled the popularity and wide application of this technique.

A Prospective Randomized Study of Transurethral Resection of the Prostate and Transurethral Vaporization of the Prostate as a Therapeutic Alternative in the Management of Men with BPH

Objective: The common goals of new surgical treatment for benign prostatic hyperplasia (BPH) are to improve subjective and objective symptoms, to decrease the risk of postoperative complications and short hospitalization. Transurethral electrovaporization of the prostate (TUVP) is a new, minimally invasive and a promising alternative to standard transurethral resection of the prostate (TURP) in the treatment of BPH. The aim of this study is to compare the efficacy and safety of these two treatment alternatives. Methods: A prospective randomized trial of 60 patients with symptomatic BPH was performed. Preoperative and postoperative International Prostate Symptom Score (IPSS), maximum flow rates (Q_max) and complications were recorded in each patient. The volume of the prostate was measured preoperatively and postoperatively using transrectal ultrasound. Results: Of the 30 patients who underwent TURP, mean hospital stay was 4.5 days. The Foley catheter was removed on postoperative day 4 following surgery. IPSS decreased from 21.6 to 5.2, Q_max increased from 9.2 to 19.2 ml/s at 3 months. Mean prostatic volume at 3 months decreased from 51.7 to 26.2 g, a 49.3% reduction. Of 30 patients undergoing TUVP, mean hospital stay was 2.5 days and the catheter was removed within 2 days following surgery. Postoperative urinary retention did not occur in any patient. IPSS decreased from 19.4 to 4.1 and Q_max increased from 7.9 to 17.7 ml/s at 3 months. Mean prostatic volume decreased from 48.9 to 27.8 g, a 43.1% reduction at 3 months. In the TUVP group, none of the patients required blood transfusions or developed clinical transurethral resection syndrome. There were no major complications. Sphincteric incontinence, urethral strictures or bladder neck contractures were not recorded. At 3 months postoperatively, 13 patients in the TURP group and 7 patients in the TUVP group had retrograde ejaculation. Conclusion: Our initial experience of TUVP suggests advantages over conventional TURP through reduced blood loss and shorter hospital stay. It appears to be an effective treatment for BPH; however, long-term results should be evaluated.

CURRENT AND FUTURE TRENDS IN INTERVENTIONAL THERAPY FOR BENIGN PROSTATIC HYPERPLASIA IN JAPAN

Purpose Procedures of Japanese urologists of interventional therapy for benign prostatic hyperplasia (BPH) should be defined for resource economy and policy establishment. Materials and Methods A questionnaire was mailed to the urology departments of 80 medical schools in Japan for clarification of surgical procedures presently in use for treating bladder outlet obstruction due to BPH. Prospects for the next 5 years (year 2002) were also requested. Results We received 76 questionnaire responses from medical school urology facilities (95%) by the end of January 1997. Standard transurethral resection of the prostate gland is and will continue to be the most common surgical procedure. Open adenectomy is the first choice for large glands but may be replaced by other interventional procedures. Laser prostatectomy and transurethral electrovaporization will be used more often for treating all severities of BPH. Conclusions Even with increasing interest in new techniques, transurethral resection of the prostate will continue to serve as the standard therapy for BPH during the next 5 years. Transurethral electrovaporization may become established in the near future.

High-power potassium-titanyl-phosphate (KTP/532) laser vaporization prostatectomy: 24 hours later

Objectives. To study the feasibility and immediate postoperative outcome of vaporization prostatectomy by high-power potassium-titanyl-phosphate (KTP/532) laser in 10 men with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) and to evaluate their clinical and voiding outcome 24 hours postoperatively. Methods. The KTP/532 laser at 60 W was produced by a prototype Laserscope generator and delivered through a side-deflecting fiber with a 22F continuous-flow cystoscope. Sterile water was used for irrigation. The prostatic lobes were readily vaporized to within capsular fibers. The mean lasing time was 29 ± 8 minutes, during which a mean of 104.6 ± 30 kJ of energy was delivered. Results. The prostate volumes ranged from 22 to 60 mL (mean 38.4 ± 9.7). None of the 10 patients had any significant blood loss or any fluid absorption. Foley catheters were removed in less than 24 hours postoperatively. All patients were satisfied with their voiding outcome. The mean peak urine flow rate increased from 8 ± 1.3 mL/s preoperatively to 19.4 ± 8.4 mL/s (142%, P = 0.003266) 24 hours postoperatively. Postvoid residual volumes remained essentially unchanged from their preoperative levels, as expected ( P = 0.767423). One patient had urgency, but none had dysuria, hematuria, or incontinence or required recatheterization. Three patients have returned for 3-month follow-up; all 3 patients have had excellent results and are very satisfied with the outcome. Conclusions. Our very early and limited experience indicates that high-power KTP/532 laser vaporization prostatectomy is feasible and appears to be safe and effective for quickly relieving bladder outlet obstruction due to BPH. Larger randomized clinical trials to compare this technique with standard transurethral resection of the prostate and more follow-up data are needed to determine its long-term efficacy and durability.

Transurethral electrovaporization of the prostate versus transurethral prostatic resection: a comparison of postoperative hemorrhage

Objectives. To determine the acute and delayed hemorrhage rate of transurethral electrovaporization of the prostate (TEVP) versus standard transurethral resection of the prostate (TURP). Methods. A retrospective review of 524 consecutive patients who underwent TURP and 302 consecutive patients who underwent TEVP was conducted. The indications for both procedures were identical and based on history, physical examination, American Urological Association symptom score, and uroflowmetry. Parameters of evaluation included the incidence of both initial and delayed hemorrhages, the time until a delayed bleed occurred, blood transfusion rates, and the average length of stay in hospital after a bleed. Results. The overall hemorrhage rate for TURP and TEVP was 4.8% and 4.0%, respectively. In the TURP group, there was a 1.1% incidence of acute bleads and 3.6% incidence of delayed bleeds. For the TEVP group, 0.3% had an acute hemorrhage, and 3.6% were readmitted for clot retention. The average length of time from original discharge to readmission was 12.9 days for the TURP group with a mean repeat stay of 5.7 days. For the TEVP group, the average interval to readmission was 15.4 days with a stay of 3.1 days. Conclusions. The overall rate of hemorrhage for the TEVP group was slightly lower than for the TURP group due to fewer acute bleeds. However, the incidence of delayed bleeds and clot retention between the two was identical at 3.6%. Because of improved hemostasis intraoperatively with similar functional results in the long term as shown by other investigators, we foresee TEVP continuing as a viable alternative to TURP.

Transurethral Resection of the Prostate With Microprocessor Controlled Electrosurgical Unit

Purpose We analyzed the efficacy and side effects of a microprocessor controlled high frequency unit for transurethral resection of the prostate. Materials and Methods A high frequency device with microprocessor control was used in 934 consecutive patients undergoing transurethral resection of the prostate. Indications for transurethral resection, medical history, preoperative findings, operative parameters, operative and immediate postoperative complications, and postoperative peak flow rate and residual urine were evaluated. Results Postoperative peak flow rate and residual urine were comparable to those with standard transurethral resection of the prostate. One patient died on postoperative day 1 for a mortality rate of 0.1%. The immediate morbidity rate was 6.9%. Conclusions Morbidity and mortality in this study were lower than those in previous series on transurethral resection of the prostate.

Electrovaporization of the Prostate: Electrosurgical Modification of Standard Transurethral Resection in 93 Patients with Benign Hyperplasia

To determine the safety and efficacy of transurethral vaporization of the prostate (TVP) in the management of men with lower urinary tract symptoms, we reviewed the records of 93 consecutive patients (mean age 65.2 +/- 5.7 years) with mild to moderate lower urinary tract symptoms who underwent TVP since August 1994. The patients were assessed at baseline for both safety and efficacy and in follow-up at 1 week (N = 93) and 1 (N = 87), 3 (N = 71), 6 (N = 59), 9 (N = 44), and 12 (N = 33) months. The mean American Urological Association Symptom Score decreased from 18.6 preoperatively to 8.9, 7.9, 8.1, and 6.3 at 1, 3, 6, and 12 months, respectively (P < 0.01). The peak uroflow rate (Qmax) increased from 7.9 mL/sec to 16.4, 14.1, 14.7, and 17.3 mL/sec at 1, 3, 6, and 12 months, respectively (P < 0.02). The mean operating time was 47.3 minutes; 96% of patients had the catheter removed within 24 hours and were discharged home the first postoperative day. There was a mean 1.1 mL/dL decrease in hematocrit and a 1.4 mEq/L decline in serum sodium. Complications included mild hematuria (46%), clot retention (5%) (all necessitating transient recatheterization), and distal bulbar urethral stricture (N = 1). There was an 8% incidence of significant postprocedure irritative symptoms. No previously potent patient reported erectile dysfunction, but there was a 92% rate of retrograde ejaculation. Transurethral vaporization is a potentially useful modification of transurethral resection. There has been significant clinical improvement maintained with minimal morbidity. This early clinical experience highlights several potential advantages of TVP, including significantly lower cost and minimal postoperative irritative symptoms. Currently, a multicenter clinical trial is under way to determine the long-term efficacy and safety of TVP.

Transurethral electrovaporization of the prostate: the year in review

Using standard transurethral electrosurgical technology, electrovaporization has quickly become a popular procedure for treating benign prostatic hyperplasia. It offers standard transurethral loop-like resection or transurethral resection-like efficacy without significant morbidities associated with the latter procedure. By combining two electrosurgical effects, vaporization and desiccation, into one motion, electrovaporization has the potential to surpass the standard transurethral resection as a gold standard. This review examines the clinical and technical advances developed in optimizing the surgical outcome of an electrovaporative resection. In addition to a review of ongoing clinical investigations by several institutions, an analysis of factors affecting electrovaporization and the subsequent refinement of technology resulting in new generators, surgical techniques, and electrode configurations are reported.

Mechanism of healing of the human prostaticurethra following thermal injury

Objectives. To characterize histopathologically the healing response of the prostatic urethra after laser thermal coagulation and standard transurethral resection of the prostate (TURP). Methods. The study included 31 patients who underwent radical prostatectomy because of malignancy. Twenty-two (first group) had laser radiation either at the time of surgery (18 patients) or from 1 to 12 weeks prior to prostatectomy (4 patients). Nine patients (second group) had TURP from 6 to 96 weeks prior to prostatectomy. Results. Coagulation necrosis followed by sloughing was observed during the first 10 weeks after laser radiation. After the first 10 weeks, the healing response was otherwise stereotypical and comparable for both groups of patients. Re-epithelialization was prominent and resulted from migration of proliferating epithelial cells from the remaining acinar and ductal epithelium. Squamous metaplasia was conspicuous and present indefinitely. Development of inflammatory reaction followed by granulation tissue and well-organized fibroblastic stroma were sequentially recognized, but less prominent. Complete re-epithelialization and wound sealing was not observed before the first 12 weeks of healing. Conclusions. Our study suggests that laser thermal coagulation and TURP are partial-thickness injuries.Because of the abundant germinal epithelium in the remaining prostatic glands and ducts, the healing response of the prostatic urethra is relatively unimpeded and free of contractures, analogous to second-degree skin burns.

Neodymium:YAG laser ablation of the prostate gland--acute perioperative morbidity and short-term outcome.

Twenty-three patients with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia were successfully treated with laser prostatectomy using the Urolase right-angle firing neodymium: Yttrium Aluminum Garnet laser fiber. Most of the patients had health problems of moderate severity. Their conditions were compared preoperatively and 3 mo postoperatively. Symptom scores decreased from an average of 23.9 to 7.0. Symptomatic relief was achieved in 95.7% of patients. Peak urinary flow rates increased from an average of 6.4 to 17.0 ml/s. The residual urine decreased from an average of 45.2 to 22.9 ml. The volume of the prostate gland measured by sonography decreased from an average of 32.8 to 25.7 ml. Virtually no blood loss was noted intraoperatively. Acute urinary retention occurred immediately following removal of the catheter in 3 out of 17 (17.6%) patients without a percutaneous cystostomy tube. Acute epididymitis developed in 5 out of 20 (25.0%) patients without bilateral vasectomy. Based on these results, laser prostatectomy may be concluded to be a safe and effective alternative to standard transurethral resection of the prostate gland, particularly in the case of high-risk patients.

Prophylaxis in urological surgery.

Prophylaxis in urological surgery is usually taken to mean antibacterial agents. However, in this study, other factors such as the environment, patient risk and surgical risk factors are also taken into account. Because patients have a wide variety of possible risk factors, individual variations must be possible. In standard transurethral resection in non-risk patients, single-dose preoperative prophylaxis may be sufficient. In open surgery prophylactic measures should be varied according to the extent of the procedure.