Prostatic Diseases and Male Voiding Dysfunction Plasmakinetic Enucleation of the Prostate vs Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia: Comparison of Outcomes According to Prostate Size in 310 Patients Yu-Hui Luo, Ji-Hong Shen, Run-Yun Guan, Hao Li, and Jia Wang OBJECTIVE
MATERIALS AND METHODS
RESULTS
CONCLUSION
To compare the safety and efficiency of plasmakinetic enucleation of the prostate (PKEP) with that of plasmakinetic resection of the prostate (PKRP) in the treatment of benign prostatic hyperplasia (BPH). Three hundred ten patients diagnosed to have BPH were randomized to undergo either PKEP or PKRP. The perioperative data and postoperative outcomes followed at 1, 3, 6, 12, 18, and 24 months after surgery were recorded and compared in the groups classified according to the baseline prostate volume: 60 mL and >60 mL. There were no significant differences in the preoperative data. Compared with PKRP, PKEP costs longer operative time (56.1 14.6 vs 41.3 9.6 min; P 60 mL, and compared PKEP and PKRP in 310 patients with different prostate sizes during a 24-month follow-up. As far as we know, this study is the first report that http://dx.doi.org/10.1016/j.urology.2014.06.025 0090-4295/14
compares outcomes of PKEP with that of PKRP in patients with different prostate sizes.
MATERIALS AND METHODS Patients From October 2009 to October 2011, 310 patients with BOO diagnosed to have BPH in our department were enrolled in this study. After obtaining ethical approval and signed written informed consent, a total of 310 patients were randomized in a 1:1 ratio to undergo either PKEP or PKRP. All patients were preoperatively evaluated with digital rectal examination, International Prostate Symptom Score (IPSS), quality of life (QOL) score, maximum uroflow rate (Qmax), prostate-specific antigen level, and transrectal ultrasonography (TRUS) volume. The inclusion criteria were Qmax 12, medical therapy failure, and TRUS volume >20 mL with no upper limit. The exclusion criteria were abnormal digital rectal examination, increased serum prostate-specific antigen level, a known neurogenic bladder, and a history of prostatic or urethral surgery. For analysis, the patients in either PKEP or PKRP group were divided on the basis of prostate size by TRUS volume: 60 mL and >60 mL (prostate volume ¼ 1/6 p transverse diameter anteroposterior diameter axial diameter).
Surgical Procedures All patients underwent epidural anesthesia and were placed in the lithotomy position. A 27F Storz continuous-flow resectoscope (Karl Storz, Tuttlingen, Germany) with the loop of the Gyrus Plasmakinetic SuperPulse System (Gyrus Medical, Cardiff, United Kingdom) was used in each procedure, with a cutting power of 160 W and a coagulating power of 80 W. Physiologic saline fluid was used for irrigation, and the liquid height was 60 cm. In PKEP, bladder neck, verumontanum, and the ureteral orifices were observed first. Then a circular groove to the surgical capsule at the proximal part of the verumontanum and the distal edge of the prostate lobes was made by incising with the cutting loop. The tip of the resectoscope was inserted from the circular groove at the 5-o’clock and 7-o’clock positions to make a cleavage plane between the adenoma and surgical capsule. The middle and lateral lobes were dissected in retrograde fashion from the apex toward the bladder by the resectoscope sheath along the cleavage plane 7- to 12-o’clock and 5- to 12-o’clock, respectively. Then the whole adenoma was spin-off 360 from the surgical capsule, like a finger ring, and only attached to the bladder neck in the 6-o’clock position. Because vessels to the prostatic adenoma in the cleavage plane were clear, bleeding was easy to be handled by the cutting loop. The devascularized adenoma could be rapidly resected into pieces by the cutting loop. The PKRP procedure applied the classic surgical steps of transurethral resection. The resection was started at the bladder neck to the proximal of the verumontanum at the 6-o’clock position and reached the surgical capsule. After the middle lobes were resected, lateral lobes were resected in sequence to completely remove the prostate adenoma. After the resection of the prostate, operative time, resected tissue weight, blood loss (blood loss [mL] ¼ hemoglobin in irrigation fluid [g/L] volume of irrigation fluid [L]/preoperative hemoglobin of patient [g/L] 1000) were recorded, a 22F 3-way Foley catheter was inserted into the bladder and continuous bladder irrigation was started. After catheter drainage became UROLOGY 84 (4), 2014
clear, bladder irrigation was stopped. If catheter drainage was still clear, the catheters were removed within 24 hours. All patients were discharged from the hospital within 24 hours after decatheterization. Catheterization time, postoperative hospital stay, and complications were recorded. All patients were followed at 1, 3, 6, 12, 18, and 24 months postoperatively and accessed IPSS, QOL, Qmax, and complications at each point.
Statistical Analysis The IBM SPSS 19.0 software package was used for the statistical analysis. The perioperative and postoperative data presented as mean standard deviation were statistically analyzed with the Student t test. The postoperative complications were analyzed with the 2-tailed chi-square test. Statistical significance was considered at P 60 mL. In 155 PKRP patients, there were 93 patients (60%) with prostate volume 60 mL and 62 patients (40%) with prostate volume >60 mL. Regardless of prostate size, there were no significant differences in the preoperative data between the PKEP and PKRP groups (Table 1). All patients received successful PKEP or PKRP operation. The histologic examination was BPH in all PKEP and PKRP cases. The perioperative data are summarized in Table 2. Regardless of prostate size, less blood loss was recorded in the whole PKEP group than in the whole PKRP group (120.5 56.2 vs 142.2 76.6 mL; P ¼ .005). There were no significant differences in resected tissue weight, operative time, catheterization time, and the length of hospital stay (P >.05). However, considering the prostate size in the 2 surgical groups, PKEP costs longer operative time for prostate volume 60 mL (56.1 14.6 vs 41.3 9.6 minutes; P .05) were found in IPSS, QOL, and Qmax. Postoperative early complications and late complications are listed in Table 4. No patient had TURS and needed blood transfusion in each group. Nine patients in 905
IPSS, International Prostate Symptom Score; PKEP, plasmakinetic enucleation of the prostate; PKRP, plasmakinetic resection of the prostate; QOL, quality of life; Qmax, maximal flow rate; SD, standard deviation.
.664 .534 .486 .846 .807 5.6 11.4 4.5 0.7 2.3 70.8 82.2 22.7 4.9 7.8 5.0 10.3 4.6 0.8 2.5 71.2 83.5 23.2 4.9 7.9 6.1 6.5 4.6 0.7 1.8 69.2 47.5 21.4 4.8 7.7 6.0 7.4 6.3 0.9 2.8 69.3 49.1 22.6 5.0 8.0 .800 .959 .089 .280 .421 5.9 19.0 4.6 0.7 2.0 69.8 61.7 21.9 4.9 7.8 5.7 18.7 5.1 0.9 2.6 70.0 61.8 22.8 4.9 8.0 Age, y Prostate volume, mL IPSS QOL score Qmax, mL/s
Parameters
P Value
.906 .237 .094 .231 .401
P Value PKRP (n ¼ 62), Mean SD P Value
Prostate Volume >60 mL (n ¼ 119)
PKEP (n ¼ 57), Mean SD PKRP (n ¼ 93), Mean SD
Prostate Volume 60 mL (n ¼ 191)
PKEP (n ¼ 98), Mean SD PKRP (n ¼ 155), Mean SD
Overall (n ¼ 310)
PKEP (n ¼ 155), Mean SD
Table 1. Preoperative data in PKEP and PKRP groups 906
the PKEP group (6 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) and 8 patients in the PKRP group (5 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) were diagnosed with urinary tract infection (UTI) by urine cultures, and irritative symptoms resolved after the use of sensitive antibiotics. Four patients in the PKEP group (2 patients with prostate volume 60 mL and 2 patients with prostate volume >60 mL) and 5 patients in the PKRP group (2 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) had dysuria after catheter removal. After recatheterization for 3-5 days, all patients could urinate smoothly. Twenty-six patients in the PKEP group (16 patients with prostate volume 60 mL and 10 patients with prostate volume >60 mL) and 9 patients in the PKRP group (6 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) showed varying degrees of transient incontinence after catheter removal. After treatment with pelvic floor muscle training and tolterodine, all conditions improved within 2 months. Five patients in the PKEP group (3 patients with prostate volume 60 mL and 2 patients with prostate volume >60 mL) and 4 patients in the PKRP group (3 patients with prostate volume 60 mL and 1 patient with prostate volume >60 mL) developed urethral strictures. All eased with urethral dilation in the office. One patient with prostate volume 60 mL in the PKEP group and 2 patients with prostate volume 60 mL in PKRP group experienced bladder neck contracture. After bladder neck incision, dysuria was relieved. Between the groups classified according to the prostate size, TURS, blood transfusion, UTI, recatheterization, urethral stricture, and bladder neck contracture were not significantly different (P >.05). But regardless of prostate size, the incidence of transient incontinence in the PKEP group was higher than that in the PKRP group (P 60 ml
P Value
PKEP, n (%)
PKRP, n (%)
P Value
PKEP, n (%)
PKRP, n (%)
P Value
0 0 8 (5.2) 5 (3.2) 9 (5.8)
— — .782 .750 .002
0 0 6 (6.3) 2 (2.1) 16 (16.7)
0 0 5 (5.4) 2 (2.2) 6 (6.5)
— — .812 .966 .031
0 0 3 (5.4) 2 (3.6) 10 (17.9)
0 0 3 (4.8) 3 (4.8) 3 (4.8)
— — .898 .733 .024
4 (2.9) 2 (1.4)
.726 .566
3 (3.5) 1 (1.2)
3 (3.6) 2 (2.4)
.965 .539
2 (3.8) 0
1 (1.8) 0
.515 —
Overall
Early complications TURS Blood transfusion UTI Recatheterization Transient incontinence Late complications Urethral stricture Bladder neck contracture
PKEP, n (%)
PKRP, n (%)
0 0 9 (5.9) 4 (2.6) 26 (17.1) 5 (3.6) 1 (0.7)
TURS, transurethral resection syndrome; UTI, urinary tract infection; other abbreviations as in Table 1.
operation steps of PKRP were simpler than those of PKEP. So, both groups were similar with respect to blood loss but the operative time observed in the PKRP group was significantly shorter than in the PKEP group (41.3 9.6 vs 56.1 14.6 minutes, P 60 mL), the process of PKEP, that retrogradely enucleates whole prostatic adenomas along with the surgical capsule of prostate, is similar to enucleating the prostate with the index finger in open surgery, and this process can also block the blood supply of the prostatic adenoma to reduce the time of stopping bleeding, so shorter operative time (75.6 12.3 vs 88.7 14.3 minutes, P 60 mL) showed varying degrees of transient incontinence after catheter removal. All patients presented with urge incontinence, and some of them (9 patients in the PKEP group and 4 patients in the PKRP group) associated with stress urinary incontinence. After urodynamic evaluation, the outcomes showed that detrusor overactivity was the isolated cause in 13 patients UROLOGY 84 (4), 2014
(8 patients in the PKEP group and 5 patients in the PKRP group) and occurred in combination with urethral sphincter insufficiency in 22 patients (18 patients in the PKEP group and 4 patients in the PKRP group). Compared with PKRP, the number of the patients with detrusor overactivity and urethral sphincter insufficiency in PKEP group was more; thus, we speculated that the risk of external sphincter injury in PKEP was higher. One possible reason for these results was the blunt injury of the external sphincter by the movement of the resectoscope tip during the enucleation procedure rather than the electrical thermal effect, which could be avoided by mechanical retrograde dissection of the prostatic apex in PKEP procedure. Our results showed that the 2 surgical methods effectively solved the clinical symptoms caused by BPH, and had significant improvement in IPSS, QOL, and Qmax. There were no significant differences between the PKEP and PKRP groups in IPSS, QOL, and Qmax. No patient in both groups needed further treatment for recurrent BPH at 24-month follow-up. These results demonstrated that PKEP and PKRP are both durable procedures. In our experience, these 2 surgical methods are both good choices for the treatment of BPH. For large BPH, PKEP is superior to PKRP owing to shorter operative time and less blood loss. But PKEP should be avoided in some patients with the following: fibrous prostates, a history of prostatic injection or radiofrequency treatment, and invasive prostate cancers, as it is difficult to enucleate the prostate adenoma from the surgical capsule in these cases. Our single-center results indicated that PKEP and PKRP were both safe and effective for the surgical treatment option of BPH independent of prostate size. But the lack of cost-effectiveness and learning curve analyses of PKEP was a limitation of this study. The results of this study should be confirmed by multicenter randomized trials. Additionally, PKEP can be theoretically applied to different prostate sizes. But for patients with a large prostate during PKEP, the operative time is inevitably prolonged and the morbidity of the surgery increases. So the safe upper limit of gland size in PKEP should be validated in further studies. 909
CONCLUSION PKEP and PKRP are both safe and effective for the treatment of BPH independent of prostate size. Compared with PKRP, the incidence of transient incontinence after PKEP was higher regardless of prostate size. But PKEP was significantly superior to PKRP in operative time and blood loss for prostate volume >60 mL. Our results suggested that PKEP may become the modern alternative to PKRP for large BPH. References 1. Emberton M, Andriole GL, de la Rosette J, et al. Benign prostatic hyperplasia: a progressive disease of aging men. Urology. 2003;61: 267-273. 2. Rassweiler J, Teber D, Kuntz R, et al. Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention. Eur Urol. 2006;50:969-979. 3. Rao JM, Yang JR, Ren YX, et al. Plasmakinetic enucleation of the prostate versus transvesical open prostatectomy for benign prostatic hyperplasia >80 mL: 12-month follow-up results of a randomized clinical trial. Urology. 2013;82:176-181. 4. Liao N, Yu J. A study comparing plasmakinetic enucleation with bipolar plasmakinetic resection of the prostate for benign prostatic hyperplasia. J Endourol. 2012;26:884-888. 5. Zhao Z, Zeng G, Zhong W, et al. A prospective, randomised trial comparing plasmakinetic enucleation to standard transurethral resection of the prostate for symptomatic benign prostatic hyperplasia: three-year follow-up results. Eur Urol. 2010;58:752-758. 6. Zhu L, Chen S, Yang S, et al. Electrosurgical enucleation versus bipolar transurethral resection for prostates larger than 70 mL: a prospective, randomized trial with 5-year followup. J Urol. 2013;189:1427-1431. 7. Liu C, Zheng S, Li H, et al. Transurethral enucleation and resection of prostate in patients with benign prostatic hyperplasia by plasma kinetics. J Urol. 2010;184:2440-2445. 8. Madersbacher S, Lackner J, Br€ossner C, et al. Reoperation, myocardial infarction and mortality after transurethral and open prostatectomy: a nation-wide, long-term analysis of 23,123 cases. Eur Urol. 2005;47:499-504. 9. Smith RD, Patel A. Transurethral resection of the prostate revisited and updated. Curr Opin Urol. 2011;21:36-41. 10. Bhansali M, Patankar S, Dobhada S, et al. Management of large (>60 g) prostate gland: PlasmaKinetic Superpulse (bipolar) versus conventional (monopolar) transurethral resection of the prostate. J Endourol. 2009;23:141-146. 11. Alschibaja M, May F, Treiber U, et al. Recent improvements in transurethral high-frequency electrosurgery of the prostate. BJU Int. 2006;97:243-246. 12. Mamoulakis C, Trompetter M, de la Rosette J. Bipolar transurethral resection of the prostate: the ‘golden standard’ reclaims its leading position. Curr Opin Urol. 2009;19:26-32. 13. Eaton A, Francis R. The provision of transurethral prostatectomy on a day-case basis using bipolar plasma kinetic technology. BJU Int. 2002;89:534-537.
910
14. Qu L, Wang X, Wang H, et al. Properties in penetrating capsula of transurethral plasmakinetic resection: comparison with transurethral resection of the prostate in an ex vivo study. Urol Int. 2009;82: 97-100. 15. de Sio M, Autorino R, Quarto G, et al. Gyrus bipolar versus standard monopolar transurethral resection of the prostate: a randomized prospective trial. Urology. 2006;67:69-72. 16. Seckiner I, Yesilli C, Akduman B, et al. A prospective randomized study for comparing bipolar plasmakinetic resection of the prostate with standard TURP. Urol Int. 2006;76:139-143. 17. Yang S, Lin WC, Chang HK, et al. Gyrus plasmasect: is it better than monopolar transurethral resection of prostate? Urol Int. 2004; 73:258-261. 18. Patankar S, Jamkar A, Dobhada S, et al. PlasmaKinetic Superpulse transurethral resection versus conventional transurethral resection of prostate. J Endourol. 2006;20:215-219. 19. Erturhan S, Erbagci A, Seckiner I, et al. Plasmakinetic resection of the prostate versus standard transurethral resection of the prostate: a prospective randomized trial with 1-year follow-up. Prostate Cancer Prostatic Dis. 2007;10:97-100. 20. Nuhoglu B, Ayyildiz A, Karag€uzel E, et al. Plasmakinetic prostate resection in the treatment of benign prostate hyperplasia: results of 1-year follow up. Int J Urol. 2006;13:21-24. 21. Varkarakis I, Kyriakakis Z, Delis A, et al. Long-term results of open transvesical prostatectomy from a contemporary series of patients. Urology. 2004;64:306-310. 22. Oelke M, Bachmann A, Descazeaud A, et al. Guidelines on the Management of Male Lower Urinary Tract Symptoms (LUTS), Incl. Benign Prostatic Obstruction (BPO): EAU Guidelines, edition presented at the 27th EAU Annual Congress, Paris, 2012. 23. Naspro R, Suardi N, Salonia A, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70g: 24-month follow-up. Eur Urol. 2006;50:563-568. 24. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008;53:160-168. 25. Elzayat EA, Habib EI, Elhilali MM. Holmium laser enucleation of the prostate: a size-independent new “gold standard”. Urology. 2005; 66:108-113. 26. Shah HN, Mahajan AP, Sodha HS, et al. Prospective evaluation of the learning curve for holmium laser enucleation of the prostate. J Urol. 2007;177:1468-1474. 27. Montorsi F, Naspro R, Salonia A, et al. Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol. 2008;179(5 Suppl): S87-90. 28. Neill MG, Gilling PJ, Kennett KM, et al. Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Urology. 2006;68:1020-1024. 29. Xiong W, Sun M, Ran Q, et al. Learning curve for bipolar transurethral enucleation and resection of the prostate in saline for symptomatic benign prostatic hyperplasia: experience in the first 100 consecutive patients. Urol Int. 2012;90:68-74.
UROLOGY 84 (4), 2014
MATERIALS AND METHODS
RESULTS
CONCLUSION
To compare the safety and efficiency of plasmakinetic enucleation of the prostate (PKEP) with that of plasmakinetic resection of the prostate (PKRP) in the treatment of benign prostatic hyperplasia (BPH). Three hundred ten patients diagnosed to have BPH were randomized to undergo either PKEP or PKRP. The perioperative data and postoperative outcomes followed at 1, 3, 6, 12, 18, and 24 months after surgery were recorded and compared in the groups classified according to the baseline prostate volume: 60 mL and >60 mL. There were no significant differences in the preoperative data. Compared with PKRP, PKEP costs longer operative time (56.1 14.6 vs 41.3 9.6 min; P 60 mL, and compared PKEP and PKRP in 310 patients with different prostate sizes during a 24-month follow-up. As far as we know, this study is the first report that http://dx.doi.org/10.1016/j.urology.2014.06.025 0090-4295/14
compares outcomes of PKEP with that of PKRP in patients with different prostate sizes.
MATERIALS AND METHODS Patients From October 2009 to October 2011, 310 patients with BOO diagnosed to have BPH in our department were enrolled in this study. After obtaining ethical approval and signed written informed consent, a total of 310 patients were randomized in a 1:1 ratio to undergo either PKEP or PKRP. All patients were preoperatively evaluated with digital rectal examination, International Prostate Symptom Score (IPSS), quality of life (QOL) score, maximum uroflow rate (Qmax), prostate-specific antigen level, and transrectal ultrasonography (TRUS) volume. The inclusion criteria were Qmax 12, medical therapy failure, and TRUS volume >20 mL with no upper limit. The exclusion criteria were abnormal digital rectal examination, increased serum prostate-specific antigen level, a known neurogenic bladder, and a history of prostatic or urethral surgery. For analysis, the patients in either PKEP or PKRP group were divided on the basis of prostate size by TRUS volume: 60 mL and >60 mL (prostate volume ¼ 1/6 p transverse diameter anteroposterior diameter axial diameter).
Surgical Procedures All patients underwent epidural anesthesia and were placed in the lithotomy position. A 27F Storz continuous-flow resectoscope (Karl Storz, Tuttlingen, Germany) with the loop of the Gyrus Plasmakinetic SuperPulse System (Gyrus Medical, Cardiff, United Kingdom) was used in each procedure, with a cutting power of 160 W and a coagulating power of 80 W. Physiologic saline fluid was used for irrigation, and the liquid height was 60 cm. In PKEP, bladder neck, verumontanum, and the ureteral orifices were observed first. Then a circular groove to the surgical capsule at the proximal part of the verumontanum and the distal edge of the prostate lobes was made by incising with the cutting loop. The tip of the resectoscope was inserted from the circular groove at the 5-o’clock and 7-o’clock positions to make a cleavage plane between the adenoma and surgical capsule. The middle and lateral lobes were dissected in retrograde fashion from the apex toward the bladder by the resectoscope sheath along the cleavage plane 7- to 12-o’clock and 5- to 12-o’clock, respectively. Then the whole adenoma was spin-off 360 from the surgical capsule, like a finger ring, and only attached to the bladder neck in the 6-o’clock position. Because vessels to the prostatic adenoma in the cleavage plane were clear, bleeding was easy to be handled by the cutting loop. The devascularized adenoma could be rapidly resected into pieces by the cutting loop. The PKRP procedure applied the classic surgical steps of transurethral resection. The resection was started at the bladder neck to the proximal of the verumontanum at the 6-o’clock position and reached the surgical capsule. After the middle lobes were resected, lateral lobes were resected in sequence to completely remove the prostate adenoma. After the resection of the prostate, operative time, resected tissue weight, blood loss (blood loss [mL] ¼ hemoglobin in irrigation fluid [g/L] volume of irrigation fluid [L]/preoperative hemoglobin of patient [g/L] 1000) were recorded, a 22F 3-way Foley catheter was inserted into the bladder and continuous bladder irrigation was started. After catheter drainage became UROLOGY 84 (4), 2014
clear, bladder irrigation was stopped. If catheter drainage was still clear, the catheters were removed within 24 hours. All patients were discharged from the hospital within 24 hours after decatheterization. Catheterization time, postoperative hospital stay, and complications were recorded. All patients were followed at 1, 3, 6, 12, 18, and 24 months postoperatively and accessed IPSS, QOL, Qmax, and complications at each point.
Statistical Analysis The IBM SPSS 19.0 software package was used for the statistical analysis. The perioperative and postoperative data presented as mean standard deviation were statistically analyzed with the Student t test. The postoperative complications were analyzed with the 2-tailed chi-square test. Statistical significance was considered at P 60 mL. In 155 PKRP patients, there were 93 patients (60%) with prostate volume 60 mL and 62 patients (40%) with prostate volume >60 mL. Regardless of prostate size, there were no significant differences in the preoperative data between the PKEP and PKRP groups (Table 1). All patients received successful PKEP or PKRP operation. The histologic examination was BPH in all PKEP and PKRP cases. The perioperative data are summarized in Table 2. Regardless of prostate size, less blood loss was recorded in the whole PKEP group than in the whole PKRP group (120.5 56.2 vs 142.2 76.6 mL; P ¼ .005). There were no significant differences in resected tissue weight, operative time, catheterization time, and the length of hospital stay (P >.05). However, considering the prostate size in the 2 surgical groups, PKEP costs longer operative time for prostate volume 60 mL (56.1 14.6 vs 41.3 9.6 minutes; P .05) were found in IPSS, QOL, and Qmax. Postoperative early complications and late complications are listed in Table 4. No patient had TURS and needed blood transfusion in each group. Nine patients in 905
IPSS, International Prostate Symptom Score; PKEP, plasmakinetic enucleation of the prostate; PKRP, plasmakinetic resection of the prostate; QOL, quality of life; Qmax, maximal flow rate; SD, standard deviation.
.664 .534 .486 .846 .807 5.6 11.4 4.5 0.7 2.3 70.8 82.2 22.7 4.9 7.8 5.0 10.3 4.6 0.8 2.5 71.2 83.5 23.2 4.9 7.9 6.1 6.5 4.6 0.7 1.8 69.2 47.5 21.4 4.8 7.7 6.0 7.4 6.3 0.9 2.8 69.3 49.1 22.6 5.0 8.0 .800 .959 .089 .280 .421 5.9 19.0 4.6 0.7 2.0 69.8 61.7 21.9 4.9 7.8 5.7 18.7 5.1 0.9 2.6 70.0 61.8 22.8 4.9 8.0 Age, y Prostate volume, mL IPSS QOL score Qmax, mL/s
Parameters
P Value
.906 .237 .094 .231 .401
P Value PKRP (n ¼ 62), Mean SD P Value
Prostate Volume >60 mL (n ¼ 119)
PKEP (n ¼ 57), Mean SD PKRP (n ¼ 93), Mean SD
Prostate Volume 60 mL (n ¼ 191)
PKEP (n ¼ 98), Mean SD PKRP (n ¼ 155), Mean SD
Overall (n ¼ 310)
PKEP (n ¼ 155), Mean SD
Table 1. Preoperative data in PKEP and PKRP groups 906
the PKEP group (6 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) and 8 patients in the PKRP group (5 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) were diagnosed with urinary tract infection (UTI) by urine cultures, and irritative symptoms resolved after the use of sensitive antibiotics. Four patients in the PKEP group (2 patients with prostate volume 60 mL and 2 patients with prostate volume >60 mL) and 5 patients in the PKRP group (2 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) had dysuria after catheter removal. After recatheterization for 3-5 days, all patients could urinate smoothly. Twenty-six patients in the PKEP group (16 patients with prostate volume 60 mL and 10 patients with prostate volume >60 mL) and 9 patients in the PKRP group (6 patients with prostate volume 60 mL and 3 patients with prostate volume >60 mL) showed varying degrees of transient incontinence after catheter removal. After treatment with pelvic floor muscle training and tolterodine, all conditions improved within 2 months. Five patients in the PKEP group (3 patients with prostate volume 60 mL and 2 patients with prostate volume >60 mL) and 4 patients in the PKRP group (3 patients with prostate volume 60 mL and 1 patient with prostate volume >60 mL) developed urethral strictures. All eased with urethral dilation in the office. One patient with prostate volume 60 mL in the PKEP group and 2 patients with prostate volume 60 mL in PKRP group experienced bladder neck contracture. After bladder neck incision, dysuria was relieved. Between the groups classified according to the prostate size, TURS, blood transfusion, UTI, recatheterization, urethral stricture, and bladder neck contracture were not significantly different (P >.05). But regardless of prostate size, the incidence of transient incontinence in the PKEP group was higher than that in the PKRP group (P 60 ml
P Value
PKEP, n (%)
PKRP, n (%)
P Value
PKEP, n (%)
PKRP, n (%)
P Value
0 0 8 (5.2) 5 (3.2) 9 (5.8)
— — .782 .750 .002
0 0 6 (6.3) 2 (2.1) 16 (16.7)
0 0 5 (5.4) 2 (2.2) 6 (6.5)
— — .812 .966 .031
0 0 3 (5.4) 2 (3.6) 10 (17.9)
0 0 3 (4.8) 3 (4.8) 3 (4.8)
— — .898 .733 .024
4 (2.9) 2 (1.4)
.726 .566
3 (3.5) 1 (1.2)
3 (3.6) 2 (2.4)
.965 .539
2 (3.8) 0
1 (1.8) 0
.515 —
Overall
Early complications TURS Blood transfusion UTI Recatheterization Transient incontinence Late complications Urethral stricture Bladder neck contracture
PKEP, n (%)
PKRP, n (%)
0 0 9 (5.9) 4 (2.6) 26 (17.1) 5 (3.6) 1 (0.7)
TURS, transurethral resection syndrome; UTI, urinary tract infection; other abbreviations as in Table 1.
operation steps of PKRP were simpler than those of PKEP. So, both groups were similar with respect to blood loss but the operative time observed in the PKRP group was significantly shorter than in the PKEP group (41.3 9.6 vs 56.1 14.6 minutes, P 60 mL), the process of PKEP, that retrogradely enucleates whole prostatic adenomas along with the surgical capsule of prostate, is similar to enucleating the prostate with the index finger in open surgery, and this process can also block the blood supply of the prostatic adenoma to reduce the time of stopping bleeding, so shorter operative time (75.6 12.3 vs 88.7 14.3 minutes, P 60 mL) showed varying degrees of transient incontinence after catheter removal. All patients presented with urge incontinence, and some of them (9 patients in the PKEP group and 4 patients in the PKRP group) associated with stress urinary incontinence. After urodynamic evaluation, the outcomes showed that detrusor overactivity was the isolated cause in 13 patients UROLOGY 84 (4), 2014
(8 patients in the PKEP group and 5 patients in the PKRP group) and occurred in combination with urethral sphincter insufficiency in 22 patients (18 patients in the PKEP group and 4 patients in the PKRP group). Compared with PKRP, the number of the patients with detrusor overactivity and urethral sphincter insufficiency in PKEP group was more; thus, we speculated that the risk of external sphincter injury in PKEP was higher. One possible reason for these results was the blunt injury of the external sphincter by the movement of the resectoscope tip during the enucleation procedure rather than the electrical thermal effect, which could be avoided by mechanical retrograde dissection of the prostatic apex in PKEP procedure. Our results showed that the 2 surgical methods effectively solved the clinical symptoms caused by BPH, and had significant improvement in IPSS, QOL, and Qmax. There were no significant differences between the PKEP and PKRP groups in IPSS, QOL, and Qmax. No patient in both groups needed further treatment for recurrent BPH at 24-month follow-up. These results demonstrated that PKEP and PKRP are both durable procedures. In our experience, these 2 surgical methods are both good choices for the treatment of BPH. For large BPH, PKEP is superior to PKRP owing to shorter operative time and less blood loss. But PKEP should be avoided in some patients with the following: fibrous prostates, a history of prostatic injection or radiofrequency treatment, and invasive prostate cancers, as it is difficult to enucleate the prostate adenoma from the surgical capsule in these cases. Our single-center results indicated that PKEP and PKRP were both safe and effective for the surgical treatment option of BPH independent of prostate size. But the lack of cost-effectiveness and learning curve analyses of PKEP was a limitation of this study. The results of this study should be confirmed by multicenter randomized trials. Additionally, PKEP can be theoretically applied to different prostate sizes. But for patients with a large prostate during PKEP, the operative time is inevitably prolonged and the morbidity of the surgery increases. So the safe upper limit of gland size in PKEP should be validated in further studies. 909
CONCLUSION PKEP and PKRP are both safe and effective for the treatment of BPH independent of prostate size. Compared with PKRP, the incidence of transient incontinence after PKEP was higher regardless of prostate size. But PKEP was significantly superior to PKRP in operative time and blood loss for prostate volume >60 mL. Our results suggested that PKEP may become the modern alternative to PKRP for large BPH. References 1. Emberton M, Andriole GL, de la Rosette J, et al. Benign prostatic hyperplasia: a progressive disease of aging men. Urology. 2003;61: 267-273. 2. Rassweiler J, Teber D, Kuntz R, et al. Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention. Eur Urol. 2006;50:969-979. 3. Rao JM, Yang JR, Ren YX, et al. Plasmakinetic enucleation of the prostate versus transvesical open prostatectomy for benign prostatic hyperplasia >80 mL: 12-month follow-up results of a randomized clinical trial. Urology. 2013;82:176-181. 4. Liao N, Yu J. A study comparing plasmakinetic enucleation with bipolar plasmakinetic resection of the prostate for benign prostatic hyperplasia. J Endourol. 2012;26:884-888. 5. Zhao Z, Zeng G, Zhong W, et al. A prospective, randomised trial comparing plasmakinetic enucleation to standard transurethral resection of the prostate for symptomatic benign prostatic hyperplasia: three-year follow-up results. Eur Urol. 2010;58:752-758. 6. Zhu L, Chen S, Yang S, et al. Electrosurgical enucleation versus bipolar transurethral resection for prostates larger than 70 mL: a prospective, randomized trial with 5-year followup. J Urol. 2013;189:1427-1431. 7. Liu C, Zheng S, Li H, et al. Transurethral enucleation and resection of prostate in patients with benign prostatic hyperplasia by plasma kinetics. J Urol. 2010;184:2440-2445. 8. Madersbacher S, Lackner J, Br€ossner C, et al. Reoperation, myocardial infarction and mortality after transurethral and open prostatectomy: a nation-wide, long-term analysis of 23,123 cases. Eur Urol. 2005;47:499-504. 9. Smith RD, Patel A. Transurethral resection of the prostate revisited and updated. Curr Opin Urol. 2011;21:36-41. 10. Bhansali M, Patankar S, Dobhada S, et al. Management of large (>60 g) prostate gland: PlasmaKinetic Superpulse (bipolar) versus conventional (monopolar) transurethral resection of the prostate. J Endourol. 2009;23:141-146. 11. Alschibaja M, May F, Treiber U, et al. Recent improvements in transurethral high-frequency electrosurgery of the prostate. BJU Int. 2006;97:243-246. 12. Mamoulakis C, Trompetter M, de la Rosette J. Bipolar transurethral resection of the prostate: the ‘golden standard’ reclaims its leading position. Curr Opin Urol. 2009;19:26-32. 13. Eaton A, Francis R. The provision of transurethral prostatectomy on a day-case basis using bipolar plasma kinetic technology. BJU Int. 2002;89:534-537.
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