Treatment of Benign Prostatic Hyperplasia: Modern Alternative to Transurethral Resection of the Prostate

© Springer Science+Business Media New York 2015

Bilal Chughtai, Alexis E. Te and Steven A. Kaplan (eds.)Treatment of Benign Prostatic Hyperplasia: Modern Alternative to Transurethral Resection of the Prostate10.1007/978-1-4939-1587-3_1

1. Introduction

Bilal Chughtai¹  , Claire Dunphy¹  , Alexis E. Te¹   and Steven A. Kaplan¹  

(1)

Department of Urology, Weill Cornell Medical College, 425 East 61st Street, 12th Floor, New York, NY, USA

Bilal Chughtai (Corresponding author)

Email: [email protected]

Claire Dunphy

Email: [email protected]

Alexis E. Te

Email: [email protected]

Steven A. Kaplan

Email: [email protected]

History of TURP

The modern TURP originated from an apparatus constructed by McCarthy in 1932, which had an oblique lens system cystoscope with a tungsten loop for resection [1]. Technological advances in the 1970s allowed for the development of the Hopkins rod lens system as well as fiber-optic lighting systems, which allowed for significant improvements in visualization [2]. After the use of video became an invaluable instructional tool for the education of urologists in the 1980s, additional developments in the use of video cameras greatly improved surgical visualization. Advances in electrical generators have likewise enhanced the surgical process by allowing for more precision and efficiency during resection. Higher-power generators allow for improved vaporization and appropriate coagulation and desiccation of tissue during the procedure. This has led to the TURP being known as the gold standard to relieve LUTS secondary to BPH, making it one of the most commonly performed procedures by urologists.

Indications for Surgical Intervention for Bladder Outlet Obstruction (BOO)

Absolute indications for surgical intervention for BOO have included refractory urinary retention, azotemia secondary to bladder outlet obstruction, gross hematuria from the prostate, and bladder stone formation, but the most common indication for TURP is relief of symptoms secondary to outlet obstruction.

A previous study found that 81 % of patients who underwent TURP from 1991 to 1998 had lower urinary tract symptoms only. The five most common indications were urinary retention (15 %), recurrent prostatitis (10 %), gross hematuria (4 %), and bladder stones (6 %) [3].

A contrasting transurethral prostatectomy outcomes study reported by Mebust and colleagues in 1989, which included men from 13 operating centers from 1978 to 1987, found lower urinary tract symptoms alone in 30 % of men at TURP. They found that 27 % of men had recurrent retention, 12 % suffered from recurrent prostatitis, 12 % underwent TURP for hematuria, and 3 % for bladder stones [4]. Less than a decade later, the indications for TURP shifted toward improving symptoms and quality of life.

As subjective decisions about quality of life should be made collaboratively by patient and physician, the Agency for Health Care Policy and Research created clinical guidelines to aid urologists and patients in the decision-making process [5]. Generally, patients with minimal symptoms (i.e., an AUA symptom score less than seven or a urinary flow rate greater than 15 mL/s) should be counseled to undergo watchful waiting. Men with higher symptom scores (greater than seven) or impaired urinary flow (flow rate less than 15 mL/s) with symptoms are to be considered for intervention, after discussing possible therapeutic benefits and risks. Those with the most severe preoperative voiding symptoms report the greatest postoperative improvements after TURP [6].

This book presents an up-to-date review of modern techniques used to treat benign prostatic hyperplasia. This review spans both office and operating room techniques, including both electrosurgical and laser-based methods. Among these are photoselective laser vaporization of the prostate (PVP), holmium laser enucleation/ablation of the prostate (HoLEP/HoLAP), and bipolar electrovaporization of the prostate (bipolar EVP/bipolar TURP). A comprehensive review of therapies currently being developed is also included. All techniques are presented in a balanced fashion with a focus on modern literature.

References

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Nesbit RM. A history of transurethral prostatectomy. Rev Mex Urol. 1975;35:349–62.

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Fitzpatrick JF, Mebust WK. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In: Walsh PC, Retik AB, Vaughan Jr ED, Wein A, editors. Campbell’s urology, vol. 2. 8th ed. Philadelphia: Saunders; 2003. p. 1379–422.

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McConell J, Barry M, Bruskewitz R, et al. In: Services AFH, editor. Benign prostatic hyperplasia: diagnosis and treatment, Clinical practice guidelines no. 8. AHCPR publication 94–0582. Rockville: U.S. Department of Health and Human Services; 1994.

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Greene LF, Holcumb GR. Transurethral resection in special situations. In: Greene LF, Segura JW, editors. Transurethral surgery. Philadelphia: WB Saunders; 1979. p. 216.

© Springer Science+Business Media New York 2015

Bilal Chughtai, Alexis E. Te and Steven A. Kaplan (eds.)Treatment of Benign Prostatic Hyperplasia: Modern Alternative to Transurethral Resection of the Prostate10.1007/978-1-4939-1587-3_2

2. Principles of Electrocautery-Based Techniques

Alexander M. Sarkisian¹, Aaron M. Bernie²   and Richard Lee³

(1)

Department of Urology, Weill Cornell Medical College, New York, NY, USA

(2)

Department of Urology, Weill Cornell, New York Presbyterian Hospital, 525 East 68th Street, 94, New York, NY 10032, USA

(3)

Urology and Public Health, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA

Aaron M. Bernie

Email: [email protected]

Introduction

Electrosurgery was first described in great detail by A.J. McLean, who provided histological analysis and interpretation of the healing process in various animal tissues subjected to electrosurgery [1]. McLean also extensively studied principles regarding current density and heat transfer governing the effects of electrical current on tissue [1]. Since its initial description, electrosurgery has evolved into a widely used technology that allows surgeons to obtain a surgical effect such as cutting or coagulation by applying a high-frequency electrical current to a target tissue [1, 2]. This chapter will focus on the technical aspects of several electrosurgical techniques used in the treatment of BPH.

Basic Principles

The core principles of electrosurgery revolve around the fact that human tissue introduced into an incomplete circuit will conduct current, therefore closing the circuit and resulting in heating of the tissue [3–5]. In an electrical circuit, current generated in an electrosurgical generator flows from a positive (active) electrode to a negative (return) electrode to form a complete circuit [4]. The amount of heat produced increases with increased current density, tissue resistance, and time as described by the following modification of Joule’s Law (Eq. 2.1) [5].

(2.1)

A small surface on an active electrode leads to a current density sufficient to cause the desired tissue effect in a short amount of time, while a larger electrode would require a stronger current or more time to achieve the same degree of heating [2, 5]. In fact, the given effect on the tissue largely depends on the rate of temperature rise in tissue that can be varied by adjusting the settings of the electrosurgical generator [4, 5].

Cutting of tissue may be achieved by the application of a high-current, low-voltage continuous wave form causing a quick increase in tissue temperature [4]. Rapid rise in tissue temperature leads to the vaporization of tissue water and subsequent fragmentation [1, 4]. Coagulation can be achieved by using a wave form that is dampened, therefore delivered in short interrupted bursts with current-free intervals between the bursts [2, 4]. The slow temperature rise achieved by the dampened current leads to coagulation by thermal denaturizing of the tissue and with further time desiccation may subsequently occur [1, 4]. Various blend settings often exist on modern electrosurgical generators that can achieve a combination of cutting and coagulation by producing variations of dampened currents based on the surgeon’s preference and desired outcome. Fulguration is a technique using a high-voltage interrupted current in which the active electrode is held a few millimeters away from tissue and passed over in a sweeping motion as sparks bridging the air gap lead to broad and superficial coagulation [2, 6]. As these tissue effects are a result of tissue heating, they can all be achieved with both monopolar and bipolar configurations.

Electrosurgical generators typically produce currents at a frequency ranging from 0.3 to 5 MHz for safety reasons [2]. At lower frequencies near or less than 100 kHz, electrical currents can cause neuromuscular stimulation resulting in muscle contraction and adverse effects in the patient [2]. At higher-range frequencies near 5 MHz or greater, the current can be more difficult to contain, and leak becomes a threat to the safety of both the patient and operator [2]. The output frequency of a given electrosurgical generator is typically a variable inherent to the device and manufacturer’s specifications and is not adjusted by the user [7].

Fundamentals of Monopolar Endoscopic Techniques

Monopolar endoscopic techniques feature an active resection electrode typically in the form of a loop, a large dispersive pad located on the patient that acts as the return electrode and a continuous irrigating resectoscope [4]. The ideal irrigating fluid in monopolar procedures should be clear in color, chemically inert, and electrolyte free to avoid dispersion of current away from the targeted tissue, similar in osmolality to serum and able to be detected by the surgeon when absorbed into the intravascular compartment [8]. Classically, glycine has represented the irrigation fluid of choice in monopolar transurethral resection of the prostate (TURP) although mannitol, sorbitol, and glucose-based solutions are also used as alternatives [8–11]. The most commonly used irrigating fluid, 1.5 % glycine, is hypotonic to serum and has been known to cause TUR syndrome in a small portion of patients after TURP. Maintenance of body temperature is also an issue with continuous irrigation; therefore, pre-warming or continuous warming of irrigation solutions is helpful to avoid large perioperative decreases in body temperature and the potential adverse effects associated with hypothermia [12, 13].

TURP, initially developed as a monopolar technique, utilizes monopolar current to resect hypertrophied prostatic tissue through a variety of resection strategies. Monopolar transurethral electrovaporization of the prostate (TUVP) is a modification of the standard TURP; the first peer-reviewed study demonstrating its safety and efficacy was published by Kaplan and Te in 1994. A separate prospective, randomized controlled trial which compared TUVP to TURP in 150 men demonstrated improvements in the international prostate symptom score (IPSS), quality of life questionnaire (QoL), symptom problem index (SPI), and BPH impact index (BII) after TUVP which were comparable with TURP and endured at 10 years of follow-up [14]. With adjustment in the power and equipment, TUVP enables a surgeon to achieve a combination of vaporization, desiccation, and coagulation of prostate tissue using standard TURP equipment fitted with a grooved roller electrode [9, 15]. Electrovaporization is generally accomplished at a cutting current that is approximately 25 % higher power and a slower resection speed than the standard TURP [15]. As the roller electrode is moved along the surface of the prostate, cutting is achieved at the leading edge by the high current density that rapidly heats tissue leading to vaporization, while coagulation is produced at the trailing edge by a more diffuse current [15]. The difference in current density is based on the principle that electricity flows via the path of least resistance, and as the tissue is vaporized, the underlying tissue experiences a certain degree of desiccation and therefore has a reduced conductance to current. Advantages to the simultaneous vaporization and coagulation include reduced blood loss, less fluid absorption, and reduced incidence of TUR syndrome [16, 17]. Monopolar transurethral electrovapor resection of the prostate (TUVRP) is similar to TUVP with the exception of using a thick loop to perform the vaporization at depth, which allows for the resection of prostate chips which may be sent for histological analysis, if desired.

Fundamentals of Bipolar Techniques

In contrast to monopolar techniques, bipolar electrosurgery features both active and return electrodes built into the instrument a small distance apart from each other [18]. This allows current to pass through the target tissue and return to the return electrode in the resectoscope, negating the need for a dispersive pad on the patient [4, 5, 18]. Additionally, resection can be carried out in a saline medium, which removes the risk of TUR syndrome and dilutional hyponatremia [7, 18, 19]. While the risk for TUR syndrome is theoretically reduced, one must still be cautious in patients with cardiac comorbidities, as the risk for fluid overload does exist with isotonic saline use [7].

The estimated depth of penetration for bipolar techniques is 0.5–1 mm, compared to an estimated 3–5 mm for monopolar techniques [20, 21]. The lower voltage and reduced depth of penetration result in reduced damage to surrounding tissues, which in principle reduces the risk of postoperative erectile dysfunction or adjacent organ damage [7, 20]. Bipolar setups have been used to perform bipolar TURP (B-TURP) which has shown to be an effective method of prostate resection and also can achieve vaporization of prostatic tissue while providing favorable hemostatic results [18, 22, 23]. Table 2.1 provides a detailed comparison of the differences between bipolar and monopolar technology.

Table 2.1

Side-by-side comparison of features of monopolar and bipolar transurethral resection of the prostate

Plasma kinetic vaporization of the prostate (PKVP) is an additional bipolar modality that utilizes radiofrequency energy in an electroconductive irrigation medium to create an ionized plasma layer to vaporize prostate adenoma [18, 19, 24]. A bipolar configuration may also be used to perform a TUVP or TUVRP.

Conclusion

Advancements in electrosurgical techniques have certainly had a significant impact on the practice of surgery. To achieve desired outcomes and protect patient safety, the operator must be aware of the technology and its appropriate use. In the electrosurgical management of BPH, the surgeon must choose from a wide range of techniques with the same goal in mind. Selection of the desired technique and technology may depend on several factors including patient characteristics, availability of equipment, operator experience, and preference. It is important to keep up to date with the body of available technologies to ensure that the chosen method will allow for the best possible outcome and patient safety profile.

References

1.

McLean A. The Bovie electrosurgical current generator: some underlying principles and results. Arch Surg. 1929;18(4):1863–73. doi:10.​1001/​archsurg.​1929.​01140130965064.CrossRef

2.

Taheri A, Mansoori P, Sandoval LF, Feldman SR, Pearce D, Williford PM. Electrosurgery: Part I. Basics and principles. J Am Acad Dermatol. 2014;70(4):591 e591–591 e514. doi:10.​1016/​j.​jaad.​2013.​09.​056.

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Morris ML. Electrosurgery in the gastroenterology suite: principles, practice, and safety. Gastroenterol Nurs. 2006;29(2):126–32. Quiz 132–124.PubMedCrossRef

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Jones CM, Pierre KB, Nicoud IB, Stain SC, Melvin 3rd WV. Electrosurgery. Curr Surg. 2006;63(6):458–63. doi:10.​1016/​j.​cursur.​2006.​06.​017.PubMedCrossRef

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Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: history, principles, and current and future uses. J Am Coll Surg. 2006;202(3):520–30. doi:10.​1016/​j.​jamcollsurg.​2005.​11.​017.PubMedCrossRef

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Wang K, Advincula AP. Current thoughts in electrosurgery. Int J Gynecol Obstet. 2007;97(3):245–50. doi:10.​1016/​j.​ijgo.​2007.​03.​001.CrossRef

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Smith D, Khoubehi B, Patel A. Bipolar electrosurgery for benign prostatic hyperplasia: transurethral electrovaporization and resection of the prostate. Curr Opin Urol. 2005;15(2):95–100.PubMedCrossRef

8.

Collins JW, MacDermott S, Bradbrook RA, Keeley FX, Timoney AG. A comparison of the effect of 1.5 % glycine and 5 % glucose irrigants on plasma serum physiology and the incidence of transurethral resection syndrome during prostate resection. BJU Int. 2005;96(3):368–72. doi:10.​1111/​j.​1464-410X.​2005.​05633.​x.PubMedCrossRef

9.

Akgul KT, Ayyildiz A, Nuhoglu B, Caydere M, Ustun H, Germiyanoglu C. Comparison of transurethral prostate resection and plasmakinetic prostate resection according to cautery artefacts in tissue specimens. Int Urol Nephrol. 2007;39(4):1091–6. doi:10.​1007/​s11255-007-9174-1.PubMedCrossRef

10.

Dawkins GPC, Miller RA. Sorbitol-mannitol solution for urological electrosurgical resection – a safer fluid than glycine 1.5 %. Eur Urol. 1999;36(2):99–102. doi:10.​1159/​000067978.PubMedCrossRef

11.

Hahn RG. Irrigating fluids in endoscopic surgery. Br J Urol. 1997;79(5):669–80. doi:10.​1046/​j.​1464-410X.​1997.​00150.​x.PubMedCrossRef

12.

Pit MJ, Tegelaar RJ, Venema PL. Isothermic irrigation during transurethral resection of the prostate: effects on peri-operative hypothermia, blood loss, resection time and patient satisfaction. Br J Urol. 1996;78(1):99–103. doi:10.​1046/​j.​1464-410X.​1996.​04819.​x.PubMedCrossRef

13.

Jin YH, Tian JH, Sun M, Yang KH. A systematic review of randomised controlled trials of the effects of warmed irrigation fluid on core body temperature during endoscopic surgeries. J Clin Nurs. 2011;20(3–4):305–16. doi:10.​1111/​j.​1365-2702.​2010.​03484.​x.PubMedCrossRef

14.

Hoekstra RJ, van Melick HHE, Kok ET, Bosch JLHR. A 10-year follow-up after transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia; long-term results of a randomized controlled trial. BJU Int. 2010;106(6):822–6. doi:10.​1111/​j.​1464-410X.​2010.​09229.​x.PubMedCrossRef

15.

Kaplan SA, Te AE. Transurethral electrovaporization of the prostate: a novel method for treating men with benign prostatic hyperplasia. Urology. 1995;45(4):566–72. doi:10.​1016/​s0090-4295(99)80044-2.PubMedCrossRef

16.

Hammadeh MY, Madaan S, Hines J, Philp T. 5-year outcome of a prospective randomized trial to compare transurethral electrovaporization of the prostate and standard transurethral resection. Urology. 2003;61(6):1166–71.PubMedCrossRef

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Hammadeh MY, Philp T. Transurethral electrovaporization of the prostate (TUVP) is effective, safe and durable. Prostate Cancer Prostatic Dis. 2003;6(2):121–6. doi:10.​1038/​sj.​pcan.​4500654.PubMedCrossRef

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Wendt-Nordahl G, Hacker A, Reich O, Djavan B, Alken P, Michel MS. The Vista system: a new bipolar resection device for endourological procedures: comparison with conventional resectoscope. Eur Urol. 2004;46(5):586–90. doi:10.​1016/​j.​eururo.​2004.​07.​018.PubMedCrossRef

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Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)–incidence, management, and prevention. Eur Urol. 2006;50(5):969–79. doi:10.​1016/​j.​eururo.​2005.​12.​042. Discussion 980.PubMedCrossRef

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Sinanoglu O, Ekici S, Tatar MN, Turan G, Keles A, Erdem Z. Postoperative outcomes of plasmakinetic transurethral resection of the prostate compared to monopolar transurethral resection of the prostate in patients with comorbidities. Urology. 2012;80(2):402–6. doi:10.​1016/​j.​urology.​2012.​02.​029.PubMedCrossRef

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Botto H, Lebret T, Barre P, Orsoni JL, Herve JM, Lugagne PM. Electrovaporization of the prostate with the Gyrus device. J Endourol/Endourol Soc. 2001;15(3):313–6. doi:10.​1089/​0892779017501619​17.CrossRef

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Starkman JS, Santucci RA. Comparison of bipolar transurethral resection of the prostate with standard transurethral prostatectomy: shorter stay, earlier catheter removal and fewer complications. BJU Int. 2005;95(1):69–71. doi:10.​1111/​j.​1464-410X.​2005.​05253.​x.PubMedCrossRef

23.

Bach T, Herrmann TR, Cellarius C, Geavlete B, Gross AJ, Jecu M. Bipolar resection of the bladder and prostate–initial experience with a newly developed regular sized loop resectoscope. J Med Life. 2009;2(4):443–6.PubMedPubMedCentral

24.

Dincel C, Samli MM, Guler C, Demirbas M, Karalar M. Plasma kinetic vaporization of the prostate: clinical evaluation of a new technique. J Endourol/Endourol Soc. 2004;18(3):293–8. doi:10.​1089/​0892779047735829​21.CrossRef

© Springer Science+Business Media New York 2015

Bilal Chughtai, Alexis E. Te and Steven A. Kaplan (eds.)Treatment of Benign Prostatic Hyperplasia: Modern Alternative to Transurethral Resection of the Prostate10.1007/978-1-4939-1587-3_3

3. Monopolar TURP

Jeffrey D. Branch¹  , Grace B. Delos Santos¹ and Bethany A. Kearns¹

(1)

Department of Urology, Loyola University Chicago, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153, USA

Jeffrey D. Branch

Email: [email protected]

Introduction

Endoscopic resection of the prostate was borne from a need to improve upon the highly morbid procedure of open prostatectomy, which conferred a mortality rate of 20–30 % [1]. In their 1932 editorial, Caulk and Wiseman outlined the necessary components for a procedure such as TURP to be the successor of open prostatectomy, namely, simplicity of operative technique, applicability, freedom from complications and disabling sequelae, a negligible mortality rate, and above all uniformly satisfactory and lasting results. Even the evolution of TURP in the first quarter of the twentieth century was tempered by editorial discussions. Miley B. Wesson, AUA president from 1934 to 1935, cautioned urologists not to be swept up in the band wagon of cystoscopic resection but instead stating that large hypertrophies can be removed much quicker and with less shock by open prostatectomy [2]. This sentiment is much the opposite today, with open prostatectomy being performed much less often than transurethral resection. Herman Kretschmer, a strong proponent of transurethral resection, observed in 1936 that there were three different points of view toward selection of cases for resection: the first group who took up TURP with enthusiasm and who believed that surgical prostatectomy had been completely replaced, the second group who believed that surgical prostatectomy remained the method of choice, and the third group who believed that both TURP and surgical prostatectomy had their place in the urologist’s armamentarium [3]. In this chapter we will discuss the early days of monopolar TURP and its evolution to what we see today as the gold standard for endoscopic management of bladder outlet obstruction (BOO) secondary to BPH. The technique for monopolar TURP will be discussed in detail, as well as short term and long term outcomes. Monopolar TURP remained the gold standard for several decades, with various modifications to address adverse events such as bleeding complications and transurethral resection (TUR) syndrome. Just as TURP challenged open prostatectomy, new modalities have been introduced to address its shortcomings.

History

From its pre-twentieth century days, surgical treatment of BPH has undergone gradual refinement. Figure 3.1 shows a timeline of the development of endoscopic equipment and medical therapies for BPH. Early accounts showed surgical excision of the median portion of the prostate, often called the prostatic bar, either suprapubically via an incision or perineally. In addition to these direct-vision procedures, various instruments were introduced per urethra in a blind fashion in order to create a prostatic channel. In 1913 Hugh Hampton Young introduced the punch resectoscope which had the advantage of direct visualization of the tissue to be excised through the cystoscopic sheath [4]. In 1910 Edwin Beer introduced the application of high-frequency current via an insulated copper wire through a cystoscope with the purpose of cauterizing a symptomatic inoperable bladder tumor [5]. Maximilian Stern in 1926 described the transurethral resectoscope with the application of bipolar energy through a tungsten loop [6]. And John Francis McCarthy modified the resectoscope into the apparatus largely as we know it today [7].

Fig. 3.1

Timeline of the development of endoscopic equipment and medical therapies for BPH

Monopolar TURP Versus Open Prostatectomy

Traditional indications for performing open prostatectomy in the modern era were for glands over 100 g and when concomitant procedures were needed, including cystolithotomy and bladder diverticulectomy, though some endoscopists have challenged this size constraint by tackling larger glands. Consequently there have not been many contemporary series which compare monopolar TURP to open prostatectomy. A 1990s series from Italy featured a cohort with a median prostate volume of 70 cm³. Their early complications include bleeding requiring blood transfusion (8.2 %), sepsis (8.6 %), urinary incontinence (3.7 %), and death (0.06 %). Bladder neck stricture occurred in 4.8 %, and reinterventions during a follow-up period of 2 years, primarily due to bladder neck stenosis, accounted for 3.6 % of patients [8]. In a small randomized trial comparing transvesical prostatectomy to monopolar TURP for glands larger than 80 g, the operative time between the two groups was not significantly different, but the resected tissue weight (69.7 g vs. 116.8 g) favored transvesical prostatectomy, while the postoperative irrigation time and admission time favored TURP. Complication rates were not significantly different between the two groups [9].

Changes in Practices

Monopolar TURP usage has declined worldwide since the 1990s. An analysis at one institution in the United Kingdom showed a 31.6 % decrease in the number of monopolar TURPs from 1990 to 2000, as well as more cases performed for urinary retention on an older cohort of patients [10]. Yu et al. analyzed the total number of BPH procedures claimed through Medicare, the US federally administered health insurance for patients over 65 years old, from the years 1999 through 2005 [11]. They found a 44 % increase in the total number of procedures performed for BPH but a steady decrease in TURP by approximately 5 % annually. Procedures such as microwave therapy, transurethral needle ablation, transurethral laser coagulation, or laser vaporization constituted the remainder. Elliott et al. also conducted a Medicare database analysis from the years 2000 to 2008 and found a decline in the number of TURP procedures done annually per 100,000 persons [12]. Although TURP remained the most commonly performed procedure, in aggregate thermotherapy and laser modalities were implemented more frequently. The factors that determined whether patients underwent TURP versus laser prostatectomy included age and health status, but surgeon preference has also been determined to be a major contributor to the decline in TURP usage [13].

Surgeon training may have an effect as well on which procedure is ultimately performed. In a study by Lowrance et al., case logs submitted by urologists applying for certification or recertification for the American Board of Urology from 2004 to 2010 showed an increase in the number of endoscopic laser vaporization or enucleation procedures performed [14]. On the other hand, older surgeons were not as likely to perform laser procedures.

The number of TURPs performed by resident training programs parallels this trend. Several factors have been proposed to explain the trend, including patient preference for new and highly advertised procedures, increased use of medical therapy and acceptance of medical therapy as a first-line therapy, and learning curve for surgeons. In a study based on a review of ACGME case logs from 2001 to 2007, the number of electrosurgical TURPs performed has declined despite a stable number of graduating residents [15]. The number of TURPs logged decreased from 58 per resident in 2001 to 43 per resident in 2007. In contrast, the number of laser procedures performed rose, beginning in 2004, from 2 to 3 per