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

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214 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
September 2011 KUWAIT MEDICAL JOURNAL 215 increasingly attractive in endoscopic stone therapy [5-7] . Although the operation time of holmium laser is shorter than BL treatment, it is also the most expensive method for stone fragmentation. Compared to laser lithotripsy, BL is the most common and the most economical method for the treatment of BC in the clinical practice. The choice of modality when deciding on BL is based on many factors, including urinary level, stone type, available lithotriptor unit, the presence or absence of infection in a potentially obstructed system, as well as the overall patient condition. In this study, from a cost, safety, and efficacy point of view, we chose the best method of lithotripsy for stone fragmentation. Transurethral resection of prostate (TURP) is still known as the “gold standard” for the treatment of benign prostatic hyperplasia (BPH). However, problems of TURP include absorption of the irrigation fluid, bleeding, transurethral resection syndrome, the incidence of bladder neck contracture and others [8] . Endoscopic treatment of BPH using PKRP is a new technology. The basic principle of PKRP is the current loop through the RF electrode and the formation of the bipolar loop electrode. RF energy will convert conducting media (NS) ionization into an ion beam, and this ion beam plays the role of cutting the target tissue. The changed principle of power cutting, and the lower temperature of power cutting (40-70 °C) contribute to an increase in surgical safety. Despite the limitation of our work (the follow-up time of patients with BPH is not long enough), the results of this study are as good as those previously reported in the literature [9,10] . All scores (IPSS, QOL, Qmax and RUV) showed significant improvement and achieved the better prognosis in comparison to preoperative scores. The incidence of stricture, shortterm urinary incontinence, recurrent calculi, and BPH recurrence was low, and 89.0% cases did not have any complications. Consequently, combined BL and PKRP is an effective, safe, and economical way of treating patients with BC and BPH simultaneously, and is suitable for patients who have a good overall condition, better urinary level, not very hard stones and belong to a poor economic class. CONCLUSION Our study demonstrated that the combination of BL and transurethral PKRP has a satisfactory outcome and is an effective, safe, and economical method of treating patients with BC associated with BPH. ACKNOWLEDGMENT The authors would like to thank Prof. Changxing Ke and Dr. Hui Zhan for their encouraging support and valuable technical discussion. REFERENCES 1. Omur Elcioglu, Hilmi Ozden, Gul Guven, Sahin Kabay. Urinary bladder stone extraction and instruments compared in textbooks of Abul-Qasim Khalaf Ibn Abbas Alzahrawi (Albucasis) (930–1013) and Serefeddin Sabuncuoglu (1385–1470). J Endourol 2010; 24:1463-1468. 2. Shah HN, Hegde SS, Shah JN, Mahajan AP, Bansal MB. Simultaneous transurethral cystolithotripsy with holmium laser enucleation of the prostate: a prospective feasibility study and review of literature. BJU Int 2007; 99:595-600. 3. Meissner A, Mamoulakis C, Laube N. Urinary tract infections and Urolithiasis. Urologe A 2010; 49:623-628. 4. O’Connor RC, Laven BA, Bales GT, Gerber GS. Nonsurgical management of benign prostatic hyperplasia in men with bladder calculi. Urology 2002; 60:288-291 5. Healy K, Chamsuddin A, Spivey J, Martin L, Nieh P, Ogan K. Percutaneous endoscopic holmium laser lithotripsy for management of complicated biliary calculi. JSLS 2009; 13:184-189. 6. Maghsoudi R, Amjadi M, Norizadeh D, Hassanzadeh H. Treatment of ureteral stones: A prospective randomized controlled trial on comparison of Ho:YAG laser and pneumatic lithotripsy. Indian J Urol 2008; 24:352-354. 7. Kara C, Resorlu B, Cicekbilek I, Unsal A. Transurethral cystolithotripsy with holmium laser under local anesthesia in selected patients. Urology 2009; 74:1000- 1003. 8. Yang Kun, Zhang Feng , Liu Si-kuan , Yu Jiang. TURS during transurethral vaporization of the prostate (report of 19 cases). Chinese Journal of Urology 2004; 25:121-123. 9. Rahman MH, Islam MA, Joarder AI. Uroflowmetry before and after transurethral resection of prostate for bladder outlet obstruction. Mymensingh Med J 2010; 19:601-607. 10. Woo HH, Hossack TA. Photoselective vaporization for prostatic obstruction with the 120-W lithium triborate laser: 1-year clinical outcomes. Int J Urol 2011; 18:162- 165.
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