1. 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

2. Benign prostatic obstruction (BPO) is a common cause of urinary symptoms in men older than 40-years of age

3. Management Options for patients with BPO Medical therapy Instrumental ( minimally invasive) therapy Surgical therapy

4. Medical Therapies for BPO is the first line of management of patients with symptomatic BPO

5. Medical Therapies for BPO 5 α reductase inhibitors: – Finasteride (Proscar). Alpha- blockers: – Trazosin (Itrin). – Doxazosin (Cardura). – Alfuzosin (Xatral). – Tamsulosin (Flomax, Omnic).

6. Minimally Invasive Therapies for BPO TUIP (Incision) Prostate balloon dilatation Urethral (prostatic) stents Hyperthermia Cryosurgery TUNA Laser devices

7. 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.

8. Surgical Therapy of BPO Open prostatectomy Transurethral prostatectomy – TURP (Resection) – TUVP (Vaporization) – TUVRP (Vaporization-Resection)

9. 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

10. 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

11. Transurethral Electrodes

12. 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

13. Morbidity associated with TURP Bleeding TUR syndrome (Low serum sodium) Infection Urinary incontinence Erectile dysfunction.

14. 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.

15. Transurethral Vaporization Resection Prostatectomy (TUVRP) Thick Loop (Resection) Augmented Electocutting energy (Electrovaporization) TUVRP = TURP + TUVP Technique of operation!

16. The “Wedge” resection device for electrosurgical transurethral prostatectomy Perlmutter AP & Schulsinger DA J Endourol 12: 75-79, 1998

17. 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

18. 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.

19. 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.

20. 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

21. 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

22. TUVRP versus Wire-loop TURP P=0.01 Hb (gm/dL) P=0.03 Na (mEq/L) Pre Post

23. TUVRP versus Wire-loop TURP TUVRP TURP Resection weight (gms) 22.4  10.5 20.2  9.5 P=NS Resection time (min) 42.4  15 35.9  12.8 P=0.02 Post-op Catheter (hrs) 23.1  10.3 36  17.3 P=<0.0001

24. 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

25. TUVRP versus Wire-loop TURP IPSS Qmax P=0.03 & 0.01 Efficacy Parameters Post-op

26. 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

27. Histopathology post TUVRP Methods: –Fifty patients that underwent TUVRP & TURP –One surgeon –One blinded Pathologist –Devised scoring system for severity of cautery artifacts

28. 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

29. Histopathology post TUVRP Grade Total sum of points Mild 1 Moderate 2 Severe 3-4

32. 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

34. 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

35. CHANGES OF SERUM PROSTATE-SPECIFIC ANTIGEN (PSA) FOLLOWING HIGH ENERGY THICK LOOP PROSTATECTOMY R. F. Talic & A. E. El-Tiraifi International Urol & Nephrol, 2000, 32(2): 271-4

36. 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?

37. 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.

38. Results for the PSA Study

39. 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.

40. ERECTILE FUNCTION FOLLOWING HIGH- ENERGY THICK LOOP PROSTATECTOMY Riyadh F. Talic Scand. J Urol & Nephrol, 2001, 35(4): 300-4

41. 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

42. Erectile Function before and post TUVRP Pre TUVRPPost TUVRP Full potency 30 30 Reduced potency 8 6 Total # of patients 38 36 (94.7%) 32 patients were not sexually active at baseline

43. 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.

44. 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

45. “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.

46. Safety features: The “Wing” versus the “Vapor cut” P=0.004P=0.03P=<0.0001

47. “Wing” versus “Vapor cut” Operation time (mins) P=NS P=0.003 47 37

48. “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

50. 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.

51. 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

52. TUVRP CONCLUSIONS TUVRP maintains the efficacy of standard prostate debulking procedures

53. 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

54. TUVRP CONCLUSIONS The change to using TUVRP is simple and does not require capital investment in new technology.

55. TUVRP CONCLUSIONS Future work will need to further focus on the role of the thick loop design