Vol 43 # 3 September 2011 - Kma.org.kw

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Combination of Ballistic Lithotripsy and Transurethral Plasmakinetic Resection ...
September 2011
Table 1: Clinical data before and after surgery
Period
IPSS
(scores)
QOL
(scores)
Qmax
(ml/s)
RUV
(ml)
Preoperative
25.4 ± 4.1
(17 - 34)
4.2 ± 1.1
(3 - 6)
8.5 ± 4.2
(4.3 - 14.2)
78.6 ± 13.3
(12 - 410)
Postoperative
5.5 ± 4.3*
(0 - 13)
1.3 ± 0.8*
(0 - 2)
23.1 ± 5.7*
(17.2 - 27.1)
17.2 ± 4.1*
(0 - 26)
* Statistically significant; p < 0.01
anterograde resection, divided anterograde resection,
divided retrograde enucleation and total retrograde
enucleation of the prostate, respectively.
Fig. 1: Bar diagram showing IPSS, QOL, Qmax and RUV scores
before and after surgery
cases of grade III and 24 cases of grade IV, respectively.
The size of BC was from 0.7 cm × 0.3 cm × 0.4 cm to
5.5 cm × 6.4 cm × 6.9 cm. There were 68 patients with
single calculus and 132 patients with multiple calculi
(2 - 31). International prostate symptom score (IPSS)
was (25.4 ± 4.1). Quality of life scores (QOL) was (4.2 ±
1.1). Maximum flow rate (Qmax) was (8.5 ± 4.2) ml / s.
Residual urine volume (RUV) was (78.6 ± 13.3) ml. Out
of the 200 cases, there were 43 cases of hypertension,
11 cases of diabetes, six cases of hemiplegia caused by
infarction or hemorrhage of urethral canal and three
cases of cardiac pacemaker.
Treatment
Before surgery, physicians, surgeons or
anesthesiologists would correct patients’ disorders of
heart, brain, lung, kidney or other important organs in
order to make patients fit for anesthesia. We installed
temporary or permanent pacemakers into patients
with grade II atrioventricular block, controlled arterial
oxygen partial pressure > 50 mmHg in pulmonary
insufficiency patients, gave one week of preoperative
withdrawal for patients on anticoagulant therapy.
The simultaneous BL and PKRP were performed
under spinal or general anesthesia in 186 cases (93%).
General anesthesia and tracheal intubation were used
in 14 cases (7%). Using a probe passed through a 27F
rigid resectoscope (Gyrus), the pneumatic lithotripter
was used for the management of BC. We passed the
ureteric catheters probe through the working channel,
and carried out the fragmentation using short bursts of
the probe. We broke the stone (s) sequentially until the
size of the stone(s) was less than 0.6 cm in diameter. The
litholapaxy was performed by Ellik washer. After this
operation, PKRP surgery was performed. Depending
on the volume of the hyperplastic prostate and
whether the prostate was adherent with the capsule
or not, PKRP was performed by the methods of simple
Statistical analysis
SPSS 17.0 statistical package was used for analysis
of all data. The results were reported as means ±
standard deviation and a p-value of < 0.05 was
considered statistically significant.
RESULTS
Out of 200 patients, the transurethral BL was
performed within 16 - 195 (mean 65.3 ± 21.6) min, and
stone fragmentation was complete. PKRP operation
time was 31 - 195 (mean 72.3 ± 23.2) min. The weight
of the removed gland tissue was 19 - 200 g (mean
63.4 ± 23.7). There was no transurethral resection
syndrome, no rectal perforation and no bladder
perforation during surgery. Blood transfusion was
required in two cases during surgery and in one case
after surgery. No deaths occured in this group. After
surgery, IPSS was (5.5 ± 4.3), QOL was (1.3 ± 0.8),
Qmax was (23.1 ± 5.7) ml / s. and RUV was (17.2 ± 4.1)
ml. These were statistically significant improvements
over preoperative scores (p < 0.01).
During the two-year follow-up, urethral stenosis
occured in 12 cases, out of which 10 cases were treated
by urethral dilation and two cases were treated by
internal urethrotomy. There were four cases of shortterm
incontinence of urine that spontaneously resolved
within four weeks. Permanent urinary incontinence
and secondary bleeding did not occur. Clinical
improvements after surgical treatment are shown in
Table 1 and Fig. 1.
DISCUSSION
BC associated with BPH is fairly common. The
reported formation rate of BPH inducing BC was about
2 - 10%, and BC inducing BPH was nearly 80% [2] . In
China, BC occurs usually in men over 50 years of age
and is associated with BPH. Removal of stones and
correction of the causes are advocated by most experts
in urology [3,4] .
A variety of mechanical and shockwave devices
have become available to accomplish endoscopic
stone fragmentation. Laser lithotripsy has become