2264 BIPOLAR PLASMA VAPORIZATION VERSUS MONOPOLAR AND BIPOLAR TURP &endash; RESULTS OF A PROSPECTIVE, RANDOMIZED, LONG-TERM COMPARISON

Vol. 185, No. 4S, Supplement, Wednesday, May 18, 2011

Benign Prostatic Hyperplasia: Surgical Therapy and New Technology Podium 56 Wednesday, May 18, 2011

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2262 RANDOMIZED, PLACEBO-CONTROLLED TRIAL SHOWING THAT FINASTERIDE REDUCES BLOOD LOSS & PROSTATIC VASCULARITY RAPIDLY WITHIN 2 WEEKS. Aziz Abdullahⴱ, Navin Faridi, Karachi, Pakistan INTRODUCTION AND OBJECTIVES: To measure expression of vascular endothelial growth factor (VEGF) and microvessel density (MVD) in the prostates of men after transurethral resection of the prostate (TURP) following 2 weeks of treatment with finasteride. METHODS: Forty men scheduled to undergo TURP were randomized to receive 5 mg of finasteride or placebo daily for 2 weeks before surgery. Sections of prostatic urothelium were stained for VEGF expression and for CD31 to assess MVD. Ten consecutive, nonoverlapping high-power fields were analysed in a blinded fashion. Also their blood loss was measured by calculating Hb. Of irrigant fluid. RESULTS: In all, 18 men received finasteride and 20 placebo; the groups were similar in patient age, resected prostate weight, preoperative catheterization, prostate-specific antigen level, aspirin use, spinal anaesthesia and postoperative diagnosis of prostate cancer. Blood loss was significantly lower in finasteride group. The mean (95% confidence interval) MVD was significantly lower in the finasteride group (60, 55-65) than in the placebo group (71, 64-78; P ⬍ 0.01). Similarly, the mean expression of VEGF was significantly lower in the finasteride group (47, 43-52 vs 61, 54-67; P ⬍ 0.001) CONCLUSIONS: Finasteride inhibits angiogenic growth factors leading to reduced vascularity, and this is the basis of its action in reducing haematuria of prostatic origin. The present study shows that finasteride influences the prostatic microvasculature after only 2 weeks exposure. Source of Funding: None

2263 CARDIOVASCULAR MORBIDITY ASSOCIATED WITH THE DISCONTINUATION OF ANTICOAGULATION PRIOR TO TRANSURETHRAL RESECTION OF THE PROSTATE (TURP). Mariolyn Rajⴱ, Andrew Brooks, Malcolm Drummond, Howard Lau, Manish Patel, Simon Bariol, Audrey Wang, Henry Woo, Sydney, Australia INTRODUCTION AND OBJECTIVES: Men requiring surgery for bladder outflow obstruction who are taking anticoagulants create a challenge for urologists. The risks of peri-operative bleeding needs to be balanced against the risks of post-operative cardiovascular & cerebrovascular morbidity, which anticoagulation therapy aims to avoid. The incidence of morbidity directly associated with discontinuing anticoagulants is not well understood. The objective of this study was to retrospectively evaluate the impact of discontinuing anticoagulants medications for TURP. METHODS: Retrospective series of 305 patients undergoing TURP at a tertiary referral hospital between 2006 & 2010. All men were evaluated in preadmission clinics with defined protocols with a low threshold for cardiovascular investigation. Incidence of post-operative & peri-operative bleeding & cardiovascular & cerebrovascular events was determined, for two patient cohorts; Group A; where anticoagulants were ceased pre-operatively and Group B; who were not receiving any anticoagulants. RESULTS: N⫽305. Mean Age: 69.5y⫾ 8.3. Median ASA 2 (IQR 2-3). Mean Operative time: 55.6 min⫾ 28.7. Patients not receiving any anticoagulation 64% (194/305), vs. 35.4% (108/305) where anti-

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coagulation ceased pre-TURP and 0.98% (3/305) where TURP was performed whilst on aspirin. Anticoagulants: Aspirin 22.6%, Warfarin 4.9%, Antiplatelets 4.9%, Combination treatments 3.9%. Incidence of post-op hemorrhage (early & delayed) was not statistically significant (P⫽0.69) between Group A (10/108) compared to Group B (7/194). Transfusion rate was 0.6% (2/305). Overall incidence of cardiovascular events 0.98% (Group A n⫽1 vs. Group B n⫽ 2) and overall incidence of deep vein thrombosis 0.32% (Group A n⫽ 0 vs. Group B n⫽1) was not statistically significant (P⫽0.30)& P⫽0.37) respectively. Overall incidence of cerebrovascular events 0.65% (Group A n⫽1 vs. Group B n⫽1) was not significant (P ⫽1.00). There were no deaths. CONCLUSIONS: Men undergoing TURP who have anticoagulation therapy discontinued prior to surgery do not appear to have a higher risk of cardiovascular morbidity, compared to men not taking anticoagulants. This result suggests that cardiovascular risk associated with discontinuing anticoagulation prior to TURP may be overstated. These positive outcomes should be considered in the context of experienced high volume surgeons, and well defined protocols for management of these high-risk men in a tertiary center. Source of Funding: None

2264 BIPOLAR PLASMA VAPORIZATION VERSUS MONOPOLAR AND BIPOLAR TURP &endash; RESULTS OF A PROSPECTIVE, RANDOMIZED, LONG-TERM COMPARISON Bogdan Geavleteⴱ, Razvan Multescu, Florin Stanescu, Dragos Georgescu, Marian Jecu, Petrisor Geavlete, Bucharest, Romania INTRODUCTION AND OBJECTIVES: This study aimed to evaluate a prospective, long term, randomized comparison between the bipolar plasma vaporization (BPV), monopolar and bipolar transurethral resection of the prostate (TURP) with regard to surgical efficacy, complication rate and follow-up results. METHODS: A total of 510 patients with benign prostatic hyperplasia (BPH), Qmax ⬍ 10 ml/s, IPSS ⬎ 19 and prostate volume between 30 and 80 ml were enrolled in the trial. All cases were evaluated preoperatively and at 1, 3, 6, 12 and 18 months after surgery by International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Qmax) and post-voiding residual urinary volume (RV). RESULTS: Each study arm including 170 cases emphasized similar preoperative parameters. The operation time was significantly shorter for BPV patients and similar in the other study arms (39.7 versus 52.1 and 56.3 minutes), while the catheterization period and hospital stay were reduced for BPV, followed by bipolar and monopolar TURP (23.5 versus 46.3 and 72.8 hours; 46.9 versus 73.0 and 95.4 hours). The mean hemoglobin drop, intraoperative bleeding and the capsular perforation rate were significantly reduced in the BPV series by comparison to the bipolar and monopolar TURP study arms (0.5 versus 1.2 and 1.6 g/dl; 1.8% versus 8.2% and 13.5%; 1.2% versus 7.1% and 9.4%). The postoperative hematuria and blood transfusion rates were higher in the monopolar TURP group. The rate of irritative symptoms was similar in the 3 study arms (12.4% versus 11.2% and 10.6%). During the 1, 3, 6, 12 and 18 months follow-up, the BPV group emphasized significantly superior parameters in terms of IPSS, QoL and Qmax. The mean RV, PSA level and prostate volume decrease were similar in the 3 series. The bladder neck sclerosis and retreatment rates were significantly reduced in the BPV group (2.4% versus 5.9% and 6.5%; 1.8% versus 4.7% and 5.3%). CONCLUSIONS: BPV represents a valuable endoscopic treatment alternative for BPH patients, with superior efficacy and satisfactory complication rate. The long term follow-up emphasized durable improvements in terms of postoperative parameters for BPV, with significant progresses by comparison to monopolar and bipolar TURP.

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BPVP

Bipolar TURP

Monopolar TURP

1 month

4.6

7.2

7.2

3 month

4.3

7.1

7.5

6 month

4.2

7.3

7.6

HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP): LONG TERM DURABILITY OF CLINICAL OUTCOMES AND COMPLICATION RATES OVER 10 YEARS FOLLOW UP IN A LARGE PATIENT COHORT

12 month

4.5

7.5

8.0

Hazem Elmansyⴱ, Ahmed Kotb, Mostafa Elhilali, Montreal, Canada

18 month

5.0

7.9

8.3

1 month

24.8

21.7

20.9

3 month

24.9

21.6

20.8

6 month

24.5

21.4

20.6

12 month

24.0

21.1

20.3

18 month

23.7

20.6

20.2

INTRODUCTION AND OBJECTIVES: HoLEP has demonstrated good short- to midterm clinical improvement. However, longterm durability (⬎5 years) is still lacking. The aim of our study is to assess the long term durability of the subjective and objective outcomes and complication rates. METHODS: A retrospective analysis of 952 patients treated with HoLEP between March 1998 and September 2010, in a single center. Study variables included measurement of maximum urinary flow rate (Qmax), post void residual urine (PVR), international prostate symptom score (IPSS) and quality of life (QoL). Follow-up evaluations were done for the patients during their visits over 10 years follow up postoperatively. Complications rates were also recorded. RESULTS: The median age of the patients, pre and post operative PSA, prostate volume and operative time were 70 years, 4.3 ng/ml, 0.6 ng/ml, 81 grams and 96 minutes respectively. The mean follow up period was 62 months. The mean preoperative PVR, Qmax, IPSS and Qol were 310 ml, 7.9 ml/sec, 19 and 3.8 respectively. Postoperatively; all the variables showed a significant improvement starting at first month of follow up, and kept significantly low over the whole duration of follow up. At 1 month, 1 year and 10 years follow up, the mean PVR was 48, 31 and 28 c.c, mean Qmax was 22, 24 and 27, mean IPSS was 7, 4 and 3.6 and mean Qol was 1.5, 1 and 1 respectively. Patients with acute urinary retention represent 36% (343 patients) of our cohort. Postoperatively; the mean PVR was 45, 25 and 52, mean Qmax was 21, 24 and 23, mean IPSS was 7.3, 4.4 and 3.8 and mean Qol was 1.6, 1 and 0.7 at 1 m, 1 y and 10 y respectively. Transient urinary stress incontinence was found in 47 men (4.9%) in the first 3 months follow up visit. with only 5 patients (0.5%) still have SUI up to the last follow up visit. Persistent urge incontinence was found in 1% of our cohort. Bladder neck contracture and urethral stricture developed in 0.8% and 1.6% of patients, respectively. The reoperation rate as a result of recurrent obstruction because of residual adenoma was 0.7% of patients. CONCLUSIONS: HoLEP represents an effective treatment modality for men with symptomatic benign prostatic hyperplasia, with very low rate of complications over a long duration of follow up. Patients who improve from baseline to early follow-up will maintain improvement at later follow-up.

IPSS

Qmax (ml/s)

Source of Funding: None

2265 HISTOPATHOLOGIC CHANGES AFTER BIPOLAR RESECTION OF THE PROSTATE: DEPTH OF PENETRATION OF BIPOLAR THERMAL INJURY Simone Thavaseelan, Akanksha Mehtaⴱ, Gyan Pareek, George Haleblian, Providence, RI INTRODUCTION AND OBJECTIVES: Bipolar circuitry allows for transurethral resection (TURP) to be performed without the risk of dilutional hyponatremia and TUR syndrome. Standard monopolar resection has a reported penetration depth of 0.68mm. The power required to initiate biopolar vaporization is higher than conventional monoploar resection. However, after initiation of the plasma arc, the energy required to maintain bipolar vaporization is significantly lower than monopolar resection and may thus result in less thermal tissue injury. This may have implications for long-term tissue regrowth, scarring, and the associated recurrence of lower urinary tract symptoms. The objective of this study is to assess histopathologic changes, specifically the depth of thermal penetration, in prostatic tissue after bipolar TURP. METHODS: Inclusion criteria consisted of men ⬎40 years old with a diagnosis of benign prostatic enlargement (BPE) or urinary retention, who elected to undergo bipolar transurethral vaporization of the prostate. Patients were excluded if they had a history of previous TURP or brachytherapy. An Olympus button vaporization electrode was used to vaporize prostate tissue after which a loop electrode was used to obtain a deep resection specimen of the same tissue. The vaporized and loop resection surfaces were inked and then sent for pathologic analysis to determine the depth of penetration of the bipolar vaporization current, and any histologic changes such as cautery artifact or char formation. RESULTS: A total of 6 men underwent bipolar TURP at standard settings of 280A cutting and 145A coagulation current. Mean age was 73.8 yrs, mean surgical time was 62 minutes and mean depth of thermal tissue injury by the bipolar vaporization electrode was 2.4mm. Histopathologic evaluation demonstrated thermal injury in all specimens but no gross char was encountered. CONCLUSIONS: In bipolar systems, coagulation takes place at much lower peak voltages compared to monopolar systems (80&endash;100 V vs. 500&endash;800 V). The effects of bipolar electrosurgery occur at lower temperatures than monopolar surgery. This may lead to less collateral thermal damage and tissue char. Previous studies have found the depth of bipolar electrosurgery to be 141␮m. Our study shows the button vaporization electrode achieves a much larger depth of penetration than previous studies. This may be because thermal injury represents a gradual continuum of histologic changes which makes a discrete cutoff measurement subject to variability. Duration of vaporization may also influence depth of penetration. Source of Funding: none

Source of Funding: none

2267 PROSTATIC ARTERY EMBOLIZATION TO TREAT BENIGN PROSTATIC HYPERPLASIA - SHORT AND MEDIUM TERM OUTCOMES Luis Campos Pinheiroⴱ, Joao Pisco, Tiago Bilhim, Vitor Vaz Santos, Joao O’Neill, Lisbon, Portugal INTRODUCTION AND OBJECTIVES: Evaluate the short and medium term results of prostatic artery embolization (PAE) in patients with symptomatic benign prostatic hyperplasia (BPH) with Polivinyl Alcohol (PVA) particles 100 ␮m or 200 ␮m. METHODS: Prostatic artery embolization (PAE) was indicated in 57 patients with symptomatic BPH, after failure of medical treatment; age ranged between 60 and 82 years (mean 72.6 years). Twelve patients had urinary retention with bladder catheter. Prostate volume, PSA, uroflowmetry , IPSS, IIEF were evaluated before PAE and 1, 3, 6 and every 6 months thereafter. The mean prostate volume before PAE was 94.6cc. The procedure was performed under local anaesthesia by a single femoral approach with a