Tag Archive for: TURP

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Video: Full immersion simulation – validation of a distributed simulation environment for technical and non-technical skills training in Urology

 

Full immersion simulation: validation of a distributed simulation environment for technical and non-technical skills training in Urology

James Brewin, Jessica Tang*, Prokar Dasgup ta, Muhammad S. Khan, Kamran AhmedFernando Bello*, Roger Kneebone* and Peter Jaye

 

Kings Health Partners, Guys and St Thomas NHS Foundation Trust, and *Imperial College, London,UK

 

OBJECTIVE

To evaluate the face, content and construct validity of the distributed simulation (DS) environment for technical and non-technical skills training in endourology. To evaluate the educational impact of DS for urology training.

SUBJECTS AND METHODS

DS offers a portable, low-cost simulated operating room environment that can be set up in any open space. A prospective mixed methods design using established validation methodology was conducted in this simulated environment with 10 experienced and 10 trainee urologists. All participants performed a simulated prostate resection in the DS environment. Outcome measures included surveys to evaluate the DS, as well as comparative analyses of experienced and trainee urologist’s performance using real-time and ‘blinded’ video analysis and validated performance metrics. Non-parametric statistical methods were used to compare differences between groups.

RESULTS

The DS environment demonstrated face, content and construct validity for both non-technical and technical skills. Kirkpatrick level 1 evidence for the educational impact of the DS environment was shown. Further studies are needed to evaluate the effect of simulated operating room training on real operating room performance.

CONCLUSIONS

This study has shown the validity of the DS environment for non-technical, as well as technical skills training. DS-based simulation appears to be a valuable addition to traditional classroom-based simulation training.

 

Article of the week: No difference in sexual function seen between monopolar and bipolar TURP

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Bipolar vs monopolar transurethral resection of the prostate: evaluation of the impact on overall sexual function in an international randomized controlled trial setting

Charalampos Mamoulakis1,2, Andreas Skolarikos3, Michael Schulze4, Cesare M. Scoffone5, Jens J. Rassweiler4, Gerasimos Alivizatos3, Roberto M. Scarpa5 and Jean J.M.C.H. de la Rosette1

1Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, 2Department of Urology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece, 3Second Department of Urology, Sismanoglio Hospital, University of Athens Medical School, Athens, Greece, 4Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany, and 5Department of Urology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy

OBJECTIVE

• To compare monopolar and bipolar transurethral resection of the prostate (M-TURP and B-TURP, respectively) using a true bipolar system, for the first time in an international multicentre double-blind randomized controlled trial focusing on the overall sexual function quantified with the International Index of Erectile Function Questionnaire (IIEF-15). Other baseline/perioperative parameters potentially influencing erectile function (EF) after TURP were secondarily investigated.

MATERIALS AND METHODS

• From July 2006 to June 2009, consecutive TURP candidates with benign prostatic obstruction were prospectively recruited in four academic urological centres, randomized 1:1 into M-TURP/B-TURP arms and followed up at 6 weeks, 6 and 12 months after surgery. In all, 295 eligible patients were enrolled.

• Overall sexual function was quantified using self-administered IIEF-15 at baseline and at each subsequent visit.

•  Total IIEF/domain scores were calculated and EF score classified erectile dysfunction severity. Differences in erectile dysfunction severity at each visit compared with baseline (EF evolution), classified patients into ‘improved’, ‘stable’ or ‘deteriorated’.

•  Pre-postoperative IIEF/domain scores and differences in the distribution of EF evolution were compared between arms throughout follow-up.

RESULTS

• In all, 279 patients received the allocated intervention; 218/279 patients (78.1%) provided complete IIEF-15 data at baseline and were considered in sexual function analysis. Complete IIEF-15 data were available from 193/218 (88.5%), 186/218 (85.3%) and 179/218 (82.1%) patients at 6 weeks, 6 months and 12 months, respectively.

• Sexual function did not differ significantly between arms during follow-up (scores: IIEF, P = 0.750; EF, P = 0.636; orgasmic function, P = 0.868; sexual desire, P = 0.735; intercourse satisfaction, P = 0.917; overall satisfaction, P = 0.927).

• Resection type was not a predictor of any sexual function changes observed.

• Distribution of EF evolution did not differ between arms at any time (M-TURP vs B-TURP at 12 months: improved, 23/87 [26.4%] vs 18/92 [19.6%]; stable, 53/87 [60.9%] vs 56/92 [60.8%]; deteriorated, 11/87 [12.7%] vs 18/92 [19.6%]; P = 0.323).

CONCLUSION

• There were no differences between M-TURP/B-TURP in any aspect of sexual function.

 

Read Previous Articles of the Week

 

Editorial: Equivalent outcomes for monopolar and bipolar TURP; but are we overlooking the potential for improvement in sexual function after surgery?

Both BPH and sexual function (SF) have a major impact on quality of life in older men. Sexual dysfunction is a complex process encompassing both erectile and ejaculatory dysfunction, as well as reduced libido and difficulty achieving orgasm. Whilst retrograde ejaculation is an almost inevitable consequence of TURP, the evidence that TURP causes erectile dysfunction is conflicting. This is probably attributable, at least in part, to a lack of high-quality historical data. Studies now show that LUTS is a risk factor for sexual dysfunction, and we are becoming increasingly aware of the relationship that exists between LUTS, depression and sexual dysfunction.

Given the favourable safety profile of bipolar TURP (b-TURP), it is perhaps a surprise that this latest study from Mamoukalis et al. has failed to demonstrate any difference in outcomes with regard to the deterioration in SF after surgery. The authors should be praised for their attempts to examine in fine detail (using the International Index of Erectile Function [IIEF]-15 in this case) any potential differences between b-TURP and monopolar TURP (m-TURP).

The design of the bipolar system is such that tissue is removed at a lower temperature and therefore the likelihood of damage to surrounding tissues and nerves is reduced. Several randomized trials have compared b-TURP with m-TURP, but only a small number have looked specifically at sexual variables in a randomized setting. This multicentre study by Mamoukalis et al. randomized 279 men to one of the two resection techniques, looking specifically at overall SF quantified by the IIEF-15. No differences were detected in any aspect of SF; erectile function (EF) improved in 26.4% of patients in the m-TURP group compared with 19.6% in the b-TURP group, and remained stable in 60.9 and 60.8% of patients, respectively. A deterioration in EF was apparent in 12.7% of the m-TURP group compared with 19.6% of the b-TURP group (P = 0.323). These results mirror those of a similar randomized study by Akman et al. comparing a quasi-bipolar system with m-TURP. They demonstrated equivalence for all measured variables except for operating time and a 1.4% incidence of TUR syndrome in the m-TURP group. In their study, the EF domain of the IIEF-15 was measured before and after surgery. EF worsened in 17% of men, improved in 28.2% and was unchanged in 54.8%. A comparative evaluation of EF was performed in a sub-group of 188 sexually active non-catheterized men of whom 18.2% developed de novo erectile dysfunction.

The explanation for the equivalent outcomes is unclear and further investigation is required. Does the failure of bipolar TURP to demonstrate a benefit with regard to SF leave the door open for the competing minimally invasive laser technologies? The overall impact of the holmium laser compared with that of TURP appears to be equivalent, with a mean of 7.5 and 7.7% of patients reporting decreased erectile function, and 7.1 and 6.2% of patients reporting increased function after each surgery. From the data available thus far, it would also appear that photoselective vaporization of the prostate similarly has no overall deleterious impact on SF when compared with TURP in a randomized trial. Further randomized data are pending and are of course of great importance if we are to understand better how the procedures we perform for symptomatic BPH affect our patients. As technological advances are made the hope is that the ‘damaging’ effects of BPH surgery on overall SF (particularly EF) will reduce further, but it may indeed be that we are searching for small margins when our attention might be better focused on maximizing the likelihood of a positive outcome, facilitated by considering the preoperative status (general health as well as urinary and sexual function), aided by the use of validated questionnaires. A better appreciation and understanding of the factors that may increase the risk of ED after surgery (age, diabetes, metabolic syndrome, obesity, cardiovascular disease and psychological factors) will enable us to manage expectations more effectively. A shorter hospital stay with minimal postoperative discomfort and an early return to normal activities, coupled with good symptomatic improvement in the longer term can only serve to be of benefit with regard to improving SF outcomes.

One recent study reporting both the short-, medium- and long-term effects of TURP on SF highlighted the high incidence of LUTS before treatment with 57% overall reporting ED before surgery. Those with severe LUTS were much more likely to have significant sexual dysfunction before surgery. This study also demonstrated a 15% improvement in pre-existing ED which was related to the improvement in LUTS after TURP.

On reflection, therefore, it would seem reasonable to conclude from the evidence presented that, although retrograde ejaculation frequently occurs after outflow surgery, erectile function is as likely to improve as it is to deteriorate. By focusing on the specific patient characteristics for each individual case before surgery it is possible we can improve the proportion of patients achieving a favourable outcome. When counselling patients before surgery regarding SF we should therefore remember to include the potential benefits as well as the risks. Furthermore, for those patients particularly anxious about the possibility of worsening SF, a ‘lesser’ surgical procedure, which might not achieve a transurethral resection-like cavity should perhaps be considered as a compromise. However, a surgical alternative which is not equivalent to TURP may indeed reduce the likelihood of improving erectile function, given the interrelationship that appears to exist between LUTS and SF.

Richard Hindley
Department of Urology, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK.

Radiotherapy for Leukaemic infiltration of Prostate

We present an 81 year old gentleman with haematuria and LUTS who had TURP for his outflow symptoms. Radiotherapy is an excellent option for local symptom control as evidenced in this patient.

 

Authors: Venugopal S, Das.S,  Hamid BN, Doyle.G, Leggat H, Powell CS. Countess of Chester Hospital NHS Foundation Trust
 
Corresponding Author: Suresh Venugopal, Countess of Chester Hospital NHS Foundation Trust Email: [email protected]

Abstract
Haemopoietic malignant infiltration of the prostate is unusual. When present, it brings about the dilemma on the best approach to manage it. Usually, chronic lymphocytic leukaemia is an indolent process that waxes and wanes in its course and when present with lymphadenopathy and clinical symptoms would warrant treatment with chemotherapy. When organ confined, it has a more favourable course and would be amenable to local treatments.
We present an 81 year old gentleman with haematuria and LUTS who had TURP for his outflow symptoms. The histology had confirmed a malignant lymphocytic infiltration of the prostate and he had elevated lymphocytic count and peripheral blood marker study confirming chronic lymphocytic leukaemia. He was treated with radiotherapy of his prostate. His presenting WBC count was 19.2 and PSA was 4.41 and presently his white count is 10.3 and PSA is 1.77.  He was treated with 24 Gray external beam radiotherapy to the prostate.
As we encounter an aging population, we will be seeing more of these cancers with higher incidence in the elderly. Radiotherapy is an excellent option for local symptom control as evidenced in this patient.

 

Case Report
 
Presentation
 
An 81 year old gentleman had simultaneous referral to the haematologist for low haemoglobin and raised white count and the urologist for visible haematuria and LUTS. A digital rectal examination revealed a smooth, benign-feeling prostate with a normal age-specific PSA. A CT scan done to evaluate his haematuria had picked up a large mass in the pelvis. It was difficult to differentiate whether it was of bladder or prostate origin (Figure-1).

 

Figure 1: CT scan showing pre treatment pelvic mass (left) and post treatment pelvic mass (right).

 

Trans-urethral resection of the mass showed diffuse infiltration of the prostate gland by a malignant B-cell type lymphoid infiltrate. His peripheral blood markers for chronic lymphocytic leukaemia were positive. He did not have generalised lymphadenopathy, splenomegaly or B type symptoms of leukaemia.

 

Pathology
 
The trans-urethral resection chippings of prostate showed large foci of basal cell hyperplasia and extensive infiltration with monotonous population of small lymphoid cells (Figure-2).

 

Figure 2: Prostate tissue infiltrated by lymphocytes staining strongly for CD20 (left) and H&E staining showing sheets of monotonous lymphocytic infiltration of prostate (right). 

The abnormal lymphoid infiltrate stained positively for CD5, CD20, CD79a but was negative for CD3, CD10, BCL2 and BCL6. This is keeping in with a picture of Chronic Lymphocytic Leukaemia of Prostate. There was no evidence of high grade PIN or adenocarcinoma of prostate.

 

Radiotherapy
 
In view of his symptomatic haematuria and potential for the lesion to cause local symptoms of persistence of haematuria and possible obstruction of adjacent structures, he was considered for radiotherapy after due discussion at the multidisciplinary team meeting. The pros and cons of the treatment was discussed with the patient and he opted to have the treatment. He received standard 24 Gray in 12 fractions for low grade lymphoma of the prostate (1).

 

Follow-up
 
He has since been regularly followed up at the urology clinic for his lower urinary tract symptoms with a flow rate and rectal examination on the six monthly visits as well as a yearly PSA test. He does not have any lower urinary tract symptoms. His six monthly follow-up in the haematology clinic for his Chronic Lymphocytic Leukaemia involves assessing the presence or absence of B symptoms of leukaemia as well as a peripheral blood smear assessment. At the end of three years a re-biopsy of the prostate revealed the presence of a residual malignant lymphomoid infiltrate (Figure 3).

 

Figure3: Core biopsy specimen showing lymphocytes staining strongly for CD 20 (left) and H&E staining showing monotonous lymphocytic infiltration of the core biopsy specimen of prostate (right).

 

A rescan showed the persistence of the pelvic mass but without increase in size and without any accompanying symptomatic haematuria or obstructive features.

 

Discussion
Infiltration of prostate by Chronic Lymphocytic Leukaemia is not an uncommon finding in patients with CLL. Autopsy studies have revealed CLL as the commonest secondary tumour of the prostate. Leukemic infiltration is symptomatic in only 1% of them (2). They usually present with outflow obstructive features. Chronic lymphocytic leukaemia has an indolent course with waxing and waning of the white cell count. As a haemopoietic malignancy involving the prostate, it cannot be cured by local therapies, though this has been claimed on short term follow-up in literature (3,4,5).
The prostatic component of the disease is best dealt with by radiotherapy if local problems are anticipated. Chemotherapy is reserved for patients who have systemic disease progression. Outflow obstruction is best relieved by Trans-urethral resection of the prostate. Though various doses have been cited for curative treatment of this disease, this claim is to be disputed. We currently recommend a dose of 24 Gray in 12 fractions for palliative control of symptoms as per the recommendation for a low-grade non Hodgkin’s lymphoma.
Urological follow-up of these patients is as that of other patients with outflow symptoms, who generally get a flow rate and rectal examination assessment. In addition they need to have continuous follow-up at a haematology clinic for monitoring their systemic symptoms, which may dictate the need for further intervention.
 

Lesson learnt:
• Leukaemic infiltration is not uncommon.
• It usually presents as bladder outflow obstruction requiring TURP.
• Radiotherapy is indicated only if local complications are anticipated and is not always curative.

 

References
1) https://www.rcr.ac.uk/docs/oncology/pdf/DoseFract_49_Lymphoma.pdf
2) E. H. Eddes et al, Urinary symptoms due to leukemic infiltration of the prostate A case report, Ann Haematol 1993, 66:323 – 324.
3) Mitch Jr et al, Leukemic infiltration of the prostate: A reversible form of urinary obstruction, Cancer 1970, 26: 1361-1365.
4) Belis JA, Lizza EF, Kim JC, Raich PC, Acute leukemic infiltration of the prostate. Successful treatment with radiation, Cancer 1983, 51: 2164–2167.
5) Belhiba H et al, Prostatic involvement in leukemia. Report of a case Progrès en Urologie 1992, Aug-Sep;2(4):650-2.

 

Date added to bjui.org: 15/12/2010


DOI: 10.1002/BJUIw-2010-063-web

 

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