title: Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc.
abstract: OBJECTIVE
  The morbidity of transurethral vesection of the prostate (TURP) necessitates constant attempts at modifications to the standard equipment and technique. Patients with larger prostates (>40 cc) need a longer time for the procedure, and the blood loss, requirement for irrigation fluid, and incidence of postoperative complications tend to be greater. We report on the safety and efficacy of TURP with the thick vapor resection loop compared with the standard wire loop in comparable groups of patients with prostates >40 cc.
  
  
  METHODS
  We randomized 100 patients with benign prostatic hyperplasia (BPH) into two groups of 50 each which were similar in age. The inclusion criteria included an indication for prostatectomy and prostate size >40 cc. Patients who were on finasteride preoperatively (six) and those who had histopathologic adenocarcinoma of the prostate (three) were excluded. Preoperative evaluation included assessment of International Prostate Symptom Score (IPSS), prostate volume by abdominal ultrasonography, maximum flow rate (Q(max)), and residual urine volume. The two groups were similar in the signs and symptoms of BPH. Patients in Group 1 underwent transurethral vapor resection of the prostate (TUVRP) using the vapor resection loop (Wing trade mark; Richard Wolf, Germany), while patients in Group 2 underwent TURP using a standard wire loop. All procedures were performed by consultant urologists with equivalent experience. We used a Martin ME 401 (Gebruder Martin, Tuttlingen, Germany) electrosurgical generator with settings of 120 to 150 Watts and 50 to 70 W for cutting and coagulating, respectively, for the thick loop and 70 to 80 W and 40 to 50 W for the standard loop. Operating time, resected tissue weight, duration of catheterization, nursing contact time, hospital stay, hemoglobin change, serum sodium concentrations, and any complications were noted and analyzed using the Kruskal-Wallis paired variables test, and P values were calculated. P value <0.04 was considered significant. The IPSS, Q(max), and residual urine volume were reevaluated at 6 months and 1 year after the procedure and compared for the two groups.
  
  
  RESULTS
  The median prostate volume was 63 cc and 54 cc in Groups 1 and 2, respectively, and the median resected weight was 20 and 19 g, respectively (P = NS). The differences in operating time (median 45 v 60 minutes; P < 0.0001), intraoperative irrigant use (15 v 21 L; P < 0.0001), and intraoperative blood loss (median 52.5 v 150 mL; P < 0.0001) in the two groups were statistically significant. Peroperative blood loss was estimated by the indicator dilution method of Freedman et al in three 5-mL samples of the irrigant fluid and arriving at the average of the three values and adjusted for the volume of irrigant fluid used. The differences in postoperative irrigant (P < 0.01) and catheter duration (P = 0.04) were also significant. Two patients received blood transfusion in Group 2 and none in Group 1. The difference in the change in hemoglobin and serum sodium postoperatively in the two groups was not statistically significant. The complications were dysuria in six patients lasting for a month and one capsular perforation in Group and incontinence lasting for 6 months in two patients and stricture in one patient in Group 2. The efficacy, assessed with IPSS, Q(max), and residual urine volume, was comparable at 6 months and at 1 year.
  
  
  CONCLUSIONS
  The use of a thick vapor resection loop for TURP coupled with higher generator settings as recommended for them, especially for prostates >40 cc, is beneficial, as it significantly reduces operating time, blood loss, irrigant requirement, nursing contact time, and duration of catheterization, besides providing clear vision during surgery and ease of resection. There was no reduction in efficacy or increase in complications.
authors.affiliation: Department of Urology, All India Institute of Medical Sciences, New Delhi, India. narmadagupta@hotmail.com
authors.forename: N P
authors.initials: NP
authors.lastname: Gupta
authors.forename: D
authors.initials: D
authors.lastname: Doddamani
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: A K
authors.initials: AK
authors.lastname: Hemal
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D004598:Electrosurgery / Q000379:methods*; D006488:Hemostasis, Surgical; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011470:Prostatic Hyperplasia / Q000601:surgery*; D007507:Therapeutic Irrigation; D013997:Time Factors; D020728:Transurethral Resection of Prostate / Q000379:methods*; D014525:Urethral Stricture / Q000209:etiology; D001748:Urinary Bladder Neck Obstruction / Q000601:surgery; D014546:Urinary Catheterization; D014549:Urinary Incontinence / Q000209:etiology; D014555:Urination Disorders / Q000209:etiology; D014835:Volatilization