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  • Bipolar “Button” Plasma Vaporization of the Prostate (BPVP) for Benign Prostate Hyperplasia (BPH)

    About the authors:

    Dr. Mattew J. Maurice (Link)

    Susan Dong, MD.

    Dr. Lee Ponsky (Link)

    Procedure (See video above)

    Patient positioning / Special instrumentation

    Following the induction of anesthesia, the patient is positioned in dorsal lithotomy (see ‘patient positioning’ for transurethral resection of bladder tumors Link). The patient is prepped and draped in the usual standard sterile manner.

    The standard setup for bipolar button plasma vaporization of the prostate (BPVP) includes a 24/26-French continuous-flow resectoscope (with corresponding visual obturator and Iglesias working element), lenses (12° and 30°), and a video camera. A new, single-use button-shaped electrode is opened for each case (adjunctively, a bipolar resectoscope loop can be used to supplement the resection), and a bipolar generator supplies the energy for vaporization. Saline, preferably warmed to body temperature, is used as the irrigant.

    Visual Inspection

    Using the visual obturator with a 30° lens, the resectoscope is inserted into the bladder transurethrally. The size and length of the prostate is noted, including the presence of a median lobe. The presence of bladder stones, tumors or other pathologies should be ruled out, and if identified, managed prior to proceeding with management of the benign prostatic enlargement.

    Defining Landmarks

    Prior to commencing vaporization, the anatomic landmarks are defined. The distal limit of vaporization is the verumontanum, which lies just proximal to the external urethral sphincter. The proximal limit of vaporization is the bladder neck. A median lobe may obscure visualization of the bladder neck. The location of the ureteral orifices should be identified and kept in mind throughout the entire case.

    Button Setup

    After completing the inspection, the visual obturator is exchanged for the Iglesias working element with the 12° lens and button electrode attached. The power generator automatically defaults to the appropriate settings for cutting and coagulation. These functions are controlled using a foot pedal. Unlike a traditional monopolar transurethral resection of the prostate (TURP), saline irrigation can be utilized; therefore, resection time is not limited as it is with a traditional TURP.

    Basic BPVP Skills

    With the cutting current activated, vaporization is achieved by sweeping the button electrode over the prostatic tissue. As the tissue is vaporized, bubbles are generated, and the electrode becomes visibly red-hot. Because vaporization requires contact between the electrode and the prostate, as tissue is vaporized, pressure must be continually applied to the button to deepen the vaporization trough.

    With the resectoscope stabilized, the electrode is swept over the tissue in an “in and out” fashion, vaporizing with each pass of the button. Unlike laser vaporization, the technique for BPVP is remarkably intuitive. It replicates the motion used for standard TURP and transurethral resection of bladder tumors with the exception that vaporization can be performed with both forward and backward passes of the button.

    It is important to develop a rhythm when vaporizing. Once the landmarks have been safely established, the strokes should be made as long as possible to maximize the amount of tissue vaporized with each stroke. Contact is maintained between the active electrode and the prostate at all times to improve efficiency.

    Throughout the procedure, the ureteral orifices, verumontanum, and external urethral sphincter are monitored to avoid inadvertent injury.

    BPVP Technique

    Since BPVP closely simulates traditional TURP, many of the same techniques used for resection can be applied to vaporization. One such method is described here. As with any transurethral procedure for benign prostatic enlargement, vaporization is performed in a systematic fashion.

    If a median lobe is present, vaporization often begins here first. A trough is created in the median lobe at the 6 o’clock position, and it is extended on either side until the floor has been flattened.

    After treating the median lobe or if a median lobe is not present, vaporization proceeds with creation of a central channel, which helps improve irrigant flow. The channel is created between the 5 o’clock and 7 o’clock positions, beginning at the bladder neck and extending back to the level of the verumontanum.

    Next, attention is focused on the lateral lobes. In a similar sweeping fashion, the lateral lobes are vaporized between the 2 o’clock-to-5 o’clock positions and the 7 o’clock-to-11 o’clock positions. We prefer to treat from the bottom upwards to avoid unwanted bleeding from the anterior prostate obscuring vaporization. Vaporization is continued until the lateral lobes are resected satisfactorily. Treatment of the apical prostatic tissue adjacent to the verumontanum is temporarily postponed.

    In the process of vaporizing the lateral lobes, a mass of tissue may become apparent anteriorly at the 12 o’clock position. This tissue can be vaporized, keeping in mind that the adenoma is thinnest in this position.

    At this time, the apical tissue is addressed. With the resectoscope positioned just proximal to the verumontanum, the apical tissue is vaporized bilaterally using short sweeps of the button. When treating apical tissue that extends beyond the verumontanum, vaporization and coagulation is minimized in this area in order to avoid inadvertent injury to the external urethral sphincter.

    Lastly, the bladder neck is vaporized until it is level with the floor of the bladder. A ring of muscle fibers is seen, exposing the bladder neck and signaling completion of the vaporization.

    Achieving Hemostasis

    Bleeding vessels are controlled as they are encountered. To achieve hemostasis, the bleeding vessel is located and temporarily occluded with the button (or bipolar resection loop). With the bipolar button (or loop) still in contact with the vessel, the coagulating current is applied briefly. This process is repeated as needed until the bleeder is controlled.

    After completing the vaporization, the treated adenoma is inspected thoroughly for hemostasis. Any bleeders are coagulated. It is important to empty the bladder completely and re-inspect the prostate for any venous bleeding that may have been tamponaded by high-pressure irrigant flow.

    Final Look

    Under minimal irrigant flow, the prostate is inspected one final time. The prostatic urethra should be widely patent; however, it is not unusual for the tissue to appear somewhat ragged due to remaining adenoma collapsing into the vaporized cavity. Additional vaporization is not required. A clear view of the bladder from the verumontanum ensures a complete vaporization.

    Procedure Completion and Recovery

    After removing the resectoscope, a urethral catheter is inserted, and the bladder is drained. Most patients are observed overnight and discharged the following morning after a successful trial of void. Motivated patients may be given the option to undergo a trial of void in the recovery room with the understanding that they may require re-catheterization if they are unable to void. If they are able to void spontaneously, they can be discharged home without a catheter. Alternatively, patients may be discharged home with a catheter and follow up for removal.

    Complications

    complications following various procedures for benign prostate enlargement

    Table of complications following various procedures for benign prostate enlargement including bipolar button TURP.

     

     

    Outcomes following various procedures performed for benign prostate hyperplasia

    Table of outcomes following BPVP, TURis, and TURP.

    REFERENCES

    (1) Geavlete B, Georgescu D, Multescu R, Stanescu F, Jecu M, Geavlete P. Bipolar plasma vaporization vs monopolar and bipolar TURP-A prospective, randomized, long-term comparison. Urology 2011 Oct;78(4):930-935.

    (2) Lee YT, Ryu YW, Lee DM, Park SW, Yum SH, Han JH. Comparative Analysis of the Efficacy and Safety of Conventional Transurethral Resection of the Prostate, Transurethral Resection of the Prostate in Saline (TURIS), and TURIS-Plasma Vaporization for the Treatment of Benign Prostatic Hyperplasia: A Pilot Study. Korean J Urol 2011 Nov;52(11):763-768.

    (3) Geavlete B, Multescu R, Dragutescu M, Jecu M, Georgescu D, Geavlete P. Transurethral resection (TUR) in saline plasma vaporization of the prostate vs standard TUR of the prostate: ‘the better choice’ in benign prostatic hyperplasia? BJU Int 2010 Dec;106(11):1695-1699.

    (4) Zhang SY, Hu H, Zhang XP, Wang D, Xu KX, Na YQ, et al. Efficacy and safety of bipolar plasma vaporization of the prostate with “button-type” electrode compared with transurethral resection of prostate for benign prostatic hyperplasia. Chin Med J (Engl) 2012 Nov;125(21):3811-3814.