Trans-urethral procedures

Nd:YAG lasers cause coagulation and have been used for trans-urethral laser ablation of the prostate in both the contact and the non-contact modes. In addition to coagulation of the prostatic tissue, adequate haemostasis is achieved as the coagulation extends into the blood vessels as well. The major disadvantages are, however, postoperative irritative voiding symptoms,49 and delayed unpredictable tissue sloughing. Vaporisation can be carried out with the CO2 or the Holmium laser. The Holmium laser at a wavelength of 2100 nm has both ablative and haemostatic properties. It has been used in combination with the Nd:YAG laser to resect the prostate gland.50 The latest in bloodless laser surgery of the prostate is the high power KTP laser.51 This laser, although expensive, has been reported to have excellent haemostatic properties. The superficial depth of penetration avoids delayed irritative symptoms that may be seen with other lasers.

Electrosurgical desiccation has also made a comeback in recent times and is a much more affordable energy source than laser. Thick loop resection offers the advantage of improved surgical vision during resection. This enables more accurate and safer resection and slightly improved haemostasis.52 A variety of modified loop electrodes (thicker, with mini-rollers, oval shape) Trans-Urethral Vapor-Resection of the Prostate (TUVRP), using a vapor resection loop (Wing trade mark; Richard Wolf, Germany) and a Martin ME401® electrosurgical generator (Gebruder Martin, Tuttlingen, Germany), has been suggested in one study as an alternative to standard loop resection. This is due to the reduction in operating time, blood loss, irrigant requirement, nursing contact time, and catheterisation duration offered by the alternative technique. Other advantages include clear vision during surgery and ease of resection.53 Another study comparing TURP with TUVRP, however, showed no significant difference in blood loss between the two groups, although more patients in the TURP group required blood transfusions.54

Super-pulsed radio frequency, a new way of applying electrosurgical energy, has been developed and applied in TURP using a regular thin wire cutting loop. It has been shown to be safe and effective and showed reduced intra-operative and postoperative bleeding. It may be superior to high frequency surgical units or high frequency coagulating intermittent cutting. 55

A study evaluating the technique, efficacy, and safety of a new electrosurgical modified roller electrode (VaporTrode VE-B; Circon ACMI, USA) showed effective intra-operative haemostasis along with the lack of bleeding or fluid absorption. It also reported the lack of need for high-cost equipment like a laser. This device takes advantage of a combination of electrosurgical cutting and simultaneous electro-desiccation through unique modified electrode design. The electrode (Fig. 5) is mounted on a working element that fits a regular resectoscope and is connected to a high frequency electrosurgical unit with efficient power curve design to achieve the best results. The concentration of high current density at multiple small points of contact with the prostatic tissue on the active electrode surface,

Fig. 5 Resectrode for Trans-Urethral Vaporisation of the Prostate.

leads to a thermal reaction through Ohmic heating. This causes the tissue temperature to rise rapidly until vaporisation occurs. At the same time, low current density areas on the barrel electrode surface provide superficial tissue coagulation and simultaneous haemostasis.56

Bipolar trans-urethral prostate electro-surgery resection systems have also been developed to enable longer resection times, with a lower morbidity from irrigant absorption and a lower incidence of TUR syndrome. These come with both loop and roller electrodes and are similar to TURP in that respect. Watch for activated plasma orange glow around the activated loop, during cutting. For coagulation, however, power may need to be slightly reduced depending on the generator design. Flow reduction also helps the superficial coagulation effect. With a double loop system (Vista Controlled Ablation®), one must position centre of the thicker back loop closer to the bleeding vessel and apply gentle downward pressure with both loops into the tissue bed around the bleeding vessel. The coagulation pedal is activated until bleeding stops, keeping loops still. Longer activation time is required than that with monopolar coagulation (Figs. 6 and 7).57 As yet, there are no randomized controlled trials with these new devices that show reduced blood loss compared to the monopolar equivalents.

Fig. 6 Bipolar double-loop activated orange glow.
Fig. 7 Vista coblation loop.

Withdrawal of ASA and NSAID one week prior to TURP and prostate biopsies has been recommended to reduce the risk of bleeding.58 This may, however, be controversial in terms of risk-benefit depending on the indication, and the risk of secondary bleeding is higher probably only in the larger glands.

Preoperative use of Finasteride (a 5a-reductase inhibitor) for three to six months prior to Trans-Urethral Resection of the Prostate

(TURP) has also been shown to reduce intra-operative blood loss and postoperative complications, by one study.59 Another study suggests that the preoperative use of Finasteride for two weeks could help reduce the bleeding during TURP.60

Tranexamic acid is useful in a wide range of haemorrhagic conditions and has been used following trans-urethral prostatic surgery to reduce blood loss and postoperative transfusion requirement. It is more cost-effective and tolerated better than aprotinin.61

Open prostate surgery

Open prostatic adenomectomies are still performed in many centres. One study describes a technique for haemostasis, following Freyer's prostatectomy. The technique involves the use of an indwelling catheter with the balloon inflated in the prostatic bed to achieve haemostasis.62 Phenol injection into the prostate may help reduce the blood loss, and a prospective study done on 100 open prostatectomies concluded that blood loss was minimised in the group that had 5% phenol injected into their prostates, pre-operatively.63

Adopting the appropriate position for surgery may help in reducing blood loss. A study evaluating radical retro-pubic prostatectomies showed a decrease in intra-operative blood loss by 80%, when a Trendelenberg position with flexion of the hips was adopted.64 One of the most important steps in preventing blood loss during radical prostate surgery is the securing of the deep dorsal venous complex. The superficial branch of the deep dorsal vein should be identified and ligated early to prevent accidental tearing of this vessel and subsequent bleeding. A Babcock may be used for en bloc bunching of the wide dorsal venous complex,65 to secure it. These veins can then be controlled with figure-of-eight suture ligatures placed proximally at the bladder neck to reduce back-bleeding66 and distally near the point of attachment of the pubo-prostatic ligaments. Several technical modifications have been described to control the complex. A modified Babcock clamp has been developed (Munster clamp), which the authors claim significantly reduces haemorrhage during dissection of the deep dorsal veins in radical retro-pubic prostatectomy or cystoprostatectomy.67 A large needle may also be used to undermine this structure and facilitate en masse ligation, but this may come off later. It is often better to take smaller bites of tissue with running locking sutures in conjunction with piecemeal division of the complex. After satisfactory ligation has been achieved, transection can be carried out proximal to the ligatures. Any back bleeding may be controlled by temporary tamponade or a few Vicryl running suture ligatures. If the sutures on the complex are inadequate and bleeding does occur, haemosta-sis may be achieved with additional figure-of-eight sutures.66 There is a lower risk of bleeding in laparoscopic prostatectomy, due to the venous tamponade provided intra-operatively by the pressure of the pneumoperitoneum. Therefore, patients require less blood transfu-sion.68 Studies till date have shown that patient outcomes are similar and there is reduction in postoperative analgesia.

The LigaSure device has also been described for use in radical prostatectomy, for the superficial and the deep dorsal venous complex of the prostate, lateral vascular bundles of the prostate, pelvic lymphatics, and vessels to the seminal vesicles. This study showed shorter operative times and significantly lower blood loss in the group of patients in which LigaSure was used. In addition, there were no instances of haemorrhage or lymphocoele formation, and no transfusions were required.14 Endoscopic GIA staplers have also been tried for minimising blood loss during radical prostatectomy, and while they did reduce the amount of blood loss, there was an increase in incidence of anastomotic strictures in this group.69 Finally, a double blind placebo controlled randomised trial done in patients undergoing retro-pubic prostatectomies showed decreased blood loss in the group that received an injection of recombinant factor VIIa in the early operative phase and eliminated the need for transfusion.70 This Scandanavian study, however, did have rather excessive blood loss in the control group compared with most large series from the USA.

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