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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A few chips are resected for biopsy. The malignancies are generally in the peripheral zone, and hence it is better to take the chips after vaporizing for a while.

The advantages are that the vision is clear, and no damage is done because of this. There is hardly any bleeding, as tissues are vaporized. Since for a distance of few millimeters, a coagulum is formed, there is no significant bleeding even while cutting. (See Figure 2.)

figure 2 few chips are taken for biopsy

Figure 2: Few chips are taken for biopsy

Results

During the last two years, from April 2013 to March 2015, 38 patients were diagnosed with bladder outflow obstruction after a low-cost cystometrogram (3) showed a maximum voiding pressure of over 90 cm of water. These patients had operations during the surgical camps at various rural hospitals.

During the immediate post-operative period, three of them had an inability to void, and catheters were placed again. All three were able to void comfortably after one week, when they were given a trial of voiding. One patient had a blocked catheter due to a blood clot that cleared after wash. All of them had improvement in AUA symptom score during the subsequent follow-up, ranging from two months to six months. The smallest improvement in AUA symptom score was 3, and the average was 4.

Discussion

In an earlier study, we had found that vaporization of the prostate (TVP) is a surgery that could be carried out safely in rural and remote areas (3). Others also agree that TVP is a cheap and effective option (4, 5). Low-cost urodynamic studies help to choose the patients who need prostate surgery in a cost-effective manner in rural areas (6). Vaporization of the prostate offers a safe and efficient way of doing prostatic surgery, while the new method of electrovaporization using normal saline does away with even the minimal complications that are present, making it the safest method of prostate surgery for rural areas.

Gnanaraj-64 Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Jens Rassweiler, Dogu Teber, Rainer Kuntz, Rainer Hoffman. Complications of Transuretheral Resection of Prostate – Incidence, Management and Prevention. European Urology: Vo. 50 Issue 5 p 969-80.
  2. Moorthy H K, Philip S. TURP syndrome – current concepts in the pathophysiology and management. Indian J Urol 2001;17:97-102.
  3. Gnanaraj J. Low cost Urodynamic studies: A valuable Diagnostic tool for Rural Practitioners. mdCurrent-India, March 2015, Available from: http://mdcurrent.in/primary-care/low-cost-urodynamic-studies-a-valuable-diagnostic-tool-for-rural-practitioners/ (last accessed on April 18, 2015).
  4. Gnanaraj J, Lionel Gnanaraj. Transurethral electrovaporisation of prostate. A boon to the rural surgeon. Aust N Z J Surg 2007 Aug; 77 (8) 708.
  5. Nathan MS, Wickham JES. TVP: A cheaper and effective alternative to TURP. Available from: http://www.snathan.co.uk/articles/tvp.html (last accessed on April 15, 2015).
  6. Malik Masood Akthar, Nasir Orakzai, Abdul Manan Quereshi. Transuretheral electrovaporization of prostate as an alternative to transurethral resection of prostate for benign prostatic hyperplasia. Available from: http://ayubmed.edu.pk/JAMC/PAST/16-4/MalikOrakzai.htm (last accessed on April 15, 2015).
  7. J. Gnanaraj. Low-Cost Urodynamic Studies: A Valuable Diagnostic Tool for Rural Practitioners. mdCurrent-India, March 2015. Available from: http://mdcurrent.in/primary-care/low-cost-urodynamic-studies-a-valuable-diagnostic-tool-for-rural-practitioners/ (last accessed on April 15, 2015).


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