Transurethral Vaporization of the Prostate with Normal Saline: A Safe and Convenient Procedure for Rural Areas

Bladder outflow obstruction due to enlargement of the prostate is a common condition in men. TURP (Trans-Urethral Resection of the Prostate) is still the “gold standard” for treatment (1). It is an excellent procedure that has considerably reduced the mortality of open prostatic surgery, which is a relatively blind procedure.

TURP, however, has some drawbacks. It requires special skills, and hence, Urologists and very few general surgeons have the skills of performing the surgery. It has about 3% morbidity due to dilutional hyponatremia, due to blood loss, clot retention, infection, etc. The incidence of these outcomes has significantly declined, thanks to technological improvements (1). The procedure did not become popular in rural areas because of the steep learning curve and the difficulty in obtaining glycine or sterile water for irrigation. Some of the Indian studies report 20% morbidity and significant mortality (2).

We describe the transurethral vaporization procedure, which overcomes both of the problems – namely the steep learning curve and the problems of using glycine.

Method

After spinal anesthesia, the patient is placed in the lithotomy position. The patient plate need not be used for this technique of vaporizing the prostate, using the bipolar electro-cautery machine.

The machine that we use is made by Alan Company, based in Bombay. This cautery machine differs from the regular ones in that it produces a high-energy pulse that forms a layer of plasma around the electrode, which prevents conduction of the current by the normal saline.

The prostate and the bladder are inspected. It is important to identify the veru montanum early, and to keep this landmark in view all the time. This is because any cut distal to the veru would damage the sphincter and cause incontinence.

The first step is to create a passage at the 6 o’clock position so that the scope can move freely. While vaporizing, the process starts distally and proceeds proximally, unlike the usual cutting of the prostate. This makes it safer.

The vaporizing process continues until the white capsule is reached. The dissection proceeds on one side and then the other, vaporizing in all directions.

The setting for ideal vaporization is high cut 3 and at 250 watts power. While vaporizing in the ideal way, a glow of vapor is seen nicely around the electrode. (See Figure 1.)

figure 1 vaporization in progress

Figure 1: Vaporization in progress

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