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Immunohistochemical Evaluation of the Safety of Transurethral Electrovaporization of the Prostate and Its Clinical Results

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Immunohistochemical Evaluation of the Safety of Transurethral Electrovaporization of the Prostate and Its Clinical Results Prostate Cancer and Prostatic Diseases (1999) 2, 16±20 ß 1999 Stockton Press All rights reserved 1365±7852/99 $12.00 http://www.stockton-press.co.uk/pc Immunohistochemical evaluation of the safety of transurethral electrovaporization of the prostate and its clinical results A Tizzani1, P Gontero*3, G Casetta1, P Piana1, C Baima1, A de Zan1, G Bodo1 and D Pacchioni2 Departments of 1Pathologic Urology and 2Pathology, University of Torino, Torino, Italy; and 3Department of Urology, King's College Hospital, London, UK Short term follow up studies on transurethral electrovaporization (TUEVP) have shown a relative low morbidity over TURP. The use of high power current has been claimed as a source of possible damage on the neuronal structures surrounding the prostate. The aims of our study were to assess longer follow up results as well as the safety of this technique. Over an 18 month mean follow up period symptom relief remained relatively stable. Postoperative dysuria was detected in a higher percentage of patients and was seen for a longer period in comparison with previous reports. Immunohistochemical staining performed using S-100 and NF monoclonal antibodies showed anatomical integrity of the prostatic neuronal ®bres sur- rounding the vaporization edge. In conclusion, although the effectiveness and safety of TUEVP are con®rmed by the present study, the occurrence of a signi®cant rate of long-lasting post- operative irritative symptoms must be taken into account. Keywords: prostate electrovaporization; side effects; safety; neuronal damage; immunohistochemistry Introduction advantage over TURP is a reduction of the morbidity associated with the procedure.7 The technique employs a Transurethral resection of the prostate (TURP) is generally special resectoscope `loop' (Vaportrode) that uses existing recognized as the `gold standard' treatment of benign electrosurgical generator sources.8 By using high-fre- prostatic hyperplasia (BPH) because, in spite of numerous quency cutting current, synchronous vaporization and other treatment options available, it can achieve better, coagulation of the prostatic tissue are obtained.9 The use more durable results at a more cost-effective rate.1 How- of high power levels has raised concerns about the ever, about a quarter of men selected on the basis of possible damage to adjacent tissues due to elevated symptoms and ¯ow rates fail to do well after TURP2 and tissue temperatures in proximity to the electrode. Inter- in the long term, about a ®fth undergo a second opera- stitial temperature changes during the use of Vaportrode tion.3 Causes of early morbidity include peri- and post- are transient and highly localized.8 However no clear operative bleeding requiring blood transfusion in 2 ± 5% demonstration of the anatomical integrity of periprostatic of patients4 and clinical manifestations of ¯uid absorption neuronal bundles has been reported so far. Short term occurring in 2% of cases.5,6 follow up studies have shown clinical improvements in Transurethral electrovaporization of the prostate symptoms and ¯ow rates close to those obtained with (TUEVP) is a modi®cation of TURP. The main potential standard TURP.10,11 The aims of our study were to assess relief of obstruc- tive symptoms durability in a longer follow up period Correspondence: *Dr P Gontero, Urology Research Registrar, (more than one year) and complication rate after TUEVP. Urology Of®ce, King's College Hospital, Denmark Hill, SE5 9RS London, UK. At the same time an immunohistochemical study was Received 28 May 1998; revised 27 August 1998; accepted performed in order to demonstrate histological integrity 23 September 1998 in nerve ®bers surrounding the vaporized prostatic tissue. Complications and safety of prostate electrovaporization A Tizzani et al 17 Patients and methods that they had provided informed consent. To de®ne long term results, all patients were interviewed at a minimum follow-up period of 1 y on IPSS, and asked speci®cally One hundred and seventy-seven TUEVP procedures were about side effects and complaints or satisfaction with the performed between January and December 1996 in our operation. institution, and assessed at the Department of Pathologic Urology, University of Torino. Selection criteria included all patients with moderate to severe symptoms as de®ned Immunohistochemistry by the International Symptoms Score (IPSS), a peak ¯ow Immunohistochemical evaluation of nervous structures rate less than 15 ml/s and a prostatic adenoma weight was carried out on 12 patients' tissue samples obtained usually not exceeding 40 gm. Patients with prostatic intraoperatively by resecting the prostatic capsule cancer, proven neurogenic bladder, urethral stricture beneath the vaporization edge with a TURP loop. and previous prostate surgery were excluded from the Biopsy specimens from the re-epithelized prostatic cap- study. Preoperative evaluation included digital rectal sule were obtained from the same patients at one month examination (DRE), the completion of a standard IPSS and studied as well. Two patients from this group under- questionnaire, uro¯owmetry using a Oynatec uro¯ow went a cystoprostatectomy six months later for bladder machine, transrectal ultrasound (TRUS) and abdominal cancer and prostatic nerves in these cases were also ultrasound, urinalysis, urine culture as well as all blood evaluated by immunohistochemistry. investigations required for spinal anesthesia. Patients Histological sections of paraf®n-embedded tissue were showing a PSA in the `grey zone' (4 ± 10 ng/ml range) stained with haematoxylin-eosin (HE). Immunohisto- and over the age-related limit in spite of normal DRE and chemical reaction was performed using monoclonal anti- TRUS, underwent free-total PSA determination and sub- body anti-neuro®lament (DAKO-NF, 2F11, 1:50 dilution) sequent systematic sextant biopsies when PSA free ratio 12 which reacts with the 200 KD and the 70 KD component was < 20%. of the three major polypeptide subunits generally present All vaporization procedures were performed by one of in neuro®laments. We also employed monoclonal anti- four operators after a learning curve of at least 10 patients body anti-S100 protein (DAKO; 1:100 dilution) which has prior to entering the study. The Circom ACMI grooved shown to be strictly S-100 speci®c. Vapor Trode vaporization electrode was used for the ®rst The staining were developed by streptavidin-biotin- 120 procedures, while the Circon ACMI ¯uted Vapor peroxidase complex. Neuro®laments are present in neu- Trode was used for the remaining 57 patients. The elec- ronal processes and peripheral nerves as well as sympa- trosurgical unit was set at pure cutting current at 300 W, thetic ganglion cells of normal tissues. S-100 is a nuclear higher than the 250 W value generally regarded as the and cytoplasmatic protein present in Schwann cells of the standard level. The vaporization process was begun at the peripheral nervous system. Detection of both these struc- six o'clock position of the bladder neck, advancing the tures enables a morphological evaluation of nervous electrode to the level of the verumontanum after all tissue structures integrity, whose identi®cation is not possible between 5 o'clock and 7 o'clock at the bladder neck had with conventional methods.13,14 been vaporized. Lateral lobes were then vaporized with successive passes from the bladder neck to the veru montanum, gradually advancing to 12 o'clock of the Statistical methods ipsilateral lobe. This process was repeated until the char- acteristic white ®bres of the surgical capsule were Student's t-test analysis was employed, to compare IPSS revealed with minimal bleeding. The vaporization on and peak ¯ow velocity (PFV) distribution, before the the roof (12 o'clock) was minimal since very little tissue vaporization and during follow up. was usually present. The procedure was completed by using gentle retrograde and also anterograde movements to remove as much residual apical tissue as possible at the veru montanum level. Mean operative time was 50 min. Results By exercising slow movements and medium pressure with the electrode on the prostatic tissue a 2 ± 3 mm deep The 177 participants enrolled in the study demonstrated furrow of vaporization could be created. Maximal effects the following preoperative features: median age 66 y of TUEVP were sometimes limited by the increased (s.d. 9; range 47 ± 91), mean PSA 2.44 ng/ml resistance due to formation of charred tissue. After com- (s.d. 2.14; range 0.1 ± 11.6), prostatic weight mean plete coagulation obtained with several passes by mean of value of 36.4 gm (s.d. 17.3). Only 142 patients were the vaporizing loop, tissue was not removed when it was evaluated in a long-term follow-up (range 12 ± 33 situated adjacent to the pericapsular zone. A standard 22 months, mean 18.8 months, s.d. 7.15). The drop out Ch, 3-way catheter was placed at the end of procedure. rate was 20% (35 cases) while six patients were with- Saline irrigation was usually discontinued after a few drawn from the study (two deaths, one permanent cathe- hours since only slight haematuria was noted in the terization following the procedure, the urodynamic majority of cases. Soon after the vaporization blood ®nding of detrusor atony in one case, and a radical samples were taken for serum electrolytes and haemaglo- cystectomy performed at six months follow-up in two bin. IPSS and peak ¯ow rate were reassessed at one patients owing to the worsening of an histologically month post-operatively. The follow-up
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