[Endoscopic enucleation of the prostate]. / Endoskopische Enukleation der Prostata.

The spectrum of surgical procedures for the minimally invasive treatment of benign prostatic hyperplasia (BPH) has significantly increased over the last two decades. The simple suprapubic prostatectomy (subtotal prostatectomy, SP) has largely lost relevance in current practice. On the other hand, transurethral resection of the prostate (TURP) has been further standardized and potentially made safer by the introduction of the bipolar technique and low-pressure systems.Transurethral (endoscopic) enucleation techniques (endoscopic enucleation of the prostate, EEP) are increasingly competing with the current gold standard TURP and are replacing SP for treatment of larger adenomas. This approach is especially related to the rapid development of laser technology, which has sustainably changed the face of modern BPH treatment in a similar way to stone therapy. This has been incorporated in the clinical patient management, clinical studies and standardization of numerous surgical techniques that are systematically described in this article. Additionally, efforts have also been made to use other energy sources, such as bipolar current in EEP. With respect to scientific objectivity, high-quality clinical trials are regularly published which further strengthen the position of EEP.

[Transurethral prostatectomy: management of complications]. / Transurethrale Resektion der Prostata: komplikationsmanagement.

BACKGROUND: Transurethral resection of the prostate (TURP) is still the most common surgical method for the treatment of benign prostatic syndrome. Despite a significant reduction of mortality rate, the morbidity of TURP is still about 15%. OBJECTIVES: Based on current data, the goal of this article is to analyze which complications are expected today from the standpoint of improved high-frequency surgery and loop technology and what preventive or therapeutic measures should be undertaken. RESULTS: The use of the bipolar resection technique reduces the risk of TUR syndrome. However, cardiac risk due to possible irrigation fluid uptake remains unchanged. The blood transfusion rate has been reduced to 1% by a decreased risk of bleeding due to ongoing technical development in high-frequency surgery and a stricter indication for transfusion. Postoperative urethral strictures, which are generally caused by mechanical and electrical mucosal lesions, should be avoided by using an atraumatic surgical technique. To prevent bladder neck sclerosis, the additional routine incision of the internal sphincter is recommended for all smaller prostates. CONCLUSIONS: Due to a modern high-frequency technology, subsequently avoiding TUR syndrome and enabling a blood-sparing cut, a further reduction of complication rates can be expected.

Coagulating intermittent cutting. Improved high-frequency surgery in transurethral prostatectomy.

OBJECTIVES: Transurethral prostatectomy (TURP) is the gold standard in surgical therapy of symptomatic bladder outlet obstruction. TURP is characterised by immediate treatment success, due to the removal of obstruction combined with a long-lasting improvement of symptoms and voiding parameters. In spite of good long-term results of TURP, intraoperative blood loss produces morbidity. We investigated a blood-sparing cut using a new high-frequency technology. METHODS: (1) A standard high frequency generator was extended in its function by additional electronics. (2) The possibility of a blood-sparing cut using 'coagulating intermittent cutting' (CIC cocut BMP) was quantified ex vivo using a blood-perfused porcine kidney. Four cuts next to each other were performed through the parenchyma using a standard resectoscope with a standard loop. This was done with a commercially available generator and CIC cocut BMP. The blood loss was determined semiqantitatively. RESULTS: (1) In a first step 'coagulating cutting' with coagulating and cutting periods (10/94-- 08/96) was developed. During each cut, phases with predominant cutting effect alternate with coagulating phases of defined duration. As a disadvantage, operation time increased due to lower cutting speed. In a second step cutting combined with coagulation effect with high voltage pulses -- 'coagulating intermittent cutting' (08/96--06/97) -- was developed. In this technique, the output signal consists of a pulse-modulated sinusoidal voltage with high amplitudes. But gas bubbles impaired vision. This finally resulted in the 'coagulating intermittent cutting' with constant voltage pulses and control of pulse intervals (CIC cocut BMP, since 07/97 up to now). (2) Comparing the function of the high-frequency generators in vitro, the Wilcoxon test for paired samples revealed a significant reduction of the observed bleeding with the CIC cocut BMP (p = 0.002). CONCLUSIONS: 'Coagulating intermittent cutting' improves the gold standard of TURP with reduced blood loss. The procedure is feasible with a standard resection equipment. The already trained surgeon has no further learning cure, and teaching of classical TURP is maintained.

Coagulating intermittent cutting: improved high-frequency surgery in transurethral prostatectomy.

PURPOSE: Despite the good long-term results of transurethral resection of the prostate (TURP), intraoperative blood loss and TUR syndrome produce morbidity. Thus, TURP is still considered invasive therapy. Many minor invasive alternative treatment modalities have been developed in recent years. MATERIAL AND METHODS: To minimize the risk of bleeding, we have improved on the high-frequency technology. The output signals of commercially available high-frequency generators were modulated such that each cut results in an efficient coagulation zone in the tissue with excellent cutting quality. RESULTS: Laboratory and in vitro studies using porcine kidneys as well as clinical trials showed good cutting characteristics accompanied by a significant reduction of bleeding. As a result, blood transfusions were less necessary, TUR syndrome occurred less often, the indwelling catheter could be removed earlier in the postoperative period, and hospitalization time was reduced. CONCLUSIONS: We believe that this improved high-frequency technology, termed coagulating intermittent cutting, results in blood-sparing tissue resection and reduction of morbidity.

New technologies in transurethral resection of the prostate.

Different ablative treatments are in clinical use to lower perioperative morbidity and to maintain efficacy of transurethral resection of the prostate. Modifications to electrodes or high frequency units, or both, as well as improvements in laser technology have been tried. Transurethral resection is performed with a modified high frequency generator. The technique of 'coagulating intermittent cutting' allows reduction in morbidity and maintains the advantages of classical transurethral resection.

[Coagulating intermittent cutting. Improved high-frequency surgery in transurethral prostatectomy]. / Koagulierendes Intermittierendes Schneiden. Weiterentwicklung der Hochfrequenzchirurgie bei der TURP.

In spite of the high and lasting efficiency of transurethral prostatectomy, intraoperative blood loss results in increased morbidity in this procedure. This led to the development of many alternative treatment modalities in the last years. To minimize the risk of bleeding, we improved the high-frequency technology in several steps. To achieve this, the output signals of commercially available high-frequency generators were modulated to the effect that each cut results in an efficient coagulation zone in the tissue at excellent cutting quality. Laboratory and in vitro studies using porcine kidneys as well as clinical trials showed good cutting characteristics accompanied by a significant reduction of bleeding. As a result, blood transfusions were less necessary, the transurethral catheter could be removed earlier in the postoperative period, and hospitalization time was significantly reduced. In conclusion, the improved high-frequency technology in form of the "coagulating intermittent cutting" results in a blood-sparing tissue resection with a consecutive reduction of morbidity.