Riskfactors for postoperative stress incontinence include prostatic scarringfrom prior prostate surgery, radiation, and prostate cancer, all of whichhave the potential to obscure the ver
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U RINARY T RACT I NFECTION AND U RINARY R ETENTION
Recently studies have shown that urinary tract infections occur inapprox 2% of patients during the postoperative period, although it had
been reported to occur in as many as 60% of patients (11,21) As stated
above, the use of prophylactic antibiotics during TURP is unquestionedwhen the patient is managed with continuous or intermittent catheter-ization because bacteriuria can be expected to occur in these situations.Recently, it has been established that all patients undergoing TURP willlikely benefit from the use of prophylactic antibiotics administered
preoperatively and perioperatively (14) Urinary retention has been reported to occur in approx 7% of patients after TURP (21) This can
usually be managed with continuous or intermittent catheterization Thelatter is generally preferable because it allows the patient an opportunity
to spontaneously void Nevertheless, most patients eventually regainthe ability to void unless there is underlying detrusor dysfunction
M ORTALITY
Mortality associated with TURP is generally low according to moststudies Over the last several decades, the mortality rates have droppedsignificantly from over 2% in the 1960s to well below 1% more recently
(3,20) Roos et al compared the mortality rate between open
prostatec-tomy and TURP, finding that it was higher in the TURP group, approx 3%
(22) A potential explanation for this difference may be that patients
undergoing TURP in this study were more likely to have significantcomorbidities Other studies have found that mortality rates following
TURP are no different from those of age-matched controls (23,24) These
data suggest that TURP is a safe treatment for the treatment of BPH
Long-Term Complications
Long-term complications following TURP primarily include urinarytract infection, obstruction, incontinence, and erectile dysfunction,although there is debate about whether the latter is truly associated withthe procedure Interestingly, despite the use of prophylactic andperioperative antibiotics, delayed genitourinary infection is still a signifi-cant problem after TURP, accounting for nearly half of long-term com-
plications (4%) (21) This is probably not a result of persistent bacteriuria
from the procedure but is more likely the result of some of the tions discussed below, including obstruction and incontinence
complica-B LADDER N ECK C ONTRACTURE /U RETHRAL S TRICTURE
Recurrent obstruction can occur at the level of the bladder neck andurethra following TURP In either case, patients return with symptoms
Trang 2Chapter 11 / TURP 187
similar to their original ones, in particular the obstructive symptomssuch as retention, hesitancy, and weak stream Bladder neck contracture
(BNC) has been reported to occur in approx 2% of patients (21)
Meth-ods thought to help prevent this complication include avoiding sive resection of the bladder neck, limiting cauterization at this site, anddecreasing the duration of catheter traction in the postoperative period.BNC can be treated using a variety of techniques Although not gener-ally successful in the long term, soft dilation can sometimes be effective.More often, however, some type of incision or resection of the fibroustissue is necessary to achieve a durable response Bladder neck incisionwith either electrocautery or the laser is thought to be preferable because
aggres-it theoretically reduces the likelihood of recurrence as the result of lesstissue being damaged by the procedure Urethral strictures followingTURP are relatively uncommon (1%), however, they can be problem-
atic when they develop (21) Often they occur in the bulbous urethra and
fossa navicularis Preventative strategies include adequate calibrationand lubrication of the urethra during TURP Similar to BNC, the occur-rence of urethral strictures following TURP can be treated with urethraldilation, but they generally require visual urethrotomy In situationswhere these treatments are unsuccessful and recurrence is frequent,open urethroplasty may be required, although insertion of urethral stentsrepresents another possibility
B LEEDING
Bleeding requiring return to the hospital occurs in 1.4% of patients
(21) This can usually be avoided by controlling the initial bleeding
during hospitalization as described above and discharging the patientonly when the urine is essentially clear Patients are counseled to restrictheavy lifting for 4–6 wk and to avoid constipation by maintainingadequate fluid intake and taking stool softeners However, the inherentincrease in activity with departure from the hospital inevitably putspatients at risk for recurrent hematuria When hematuria does recur, itgenerally can be managed conservatively by restricting activity andincreasing fluid intake If hematuria is more significant, clot formationcan occur, with a strong potential for obstruction and urinary retention
In this situation, all clots should be removed with a large irrigatingcatheter, after which continued bleeding can be managed with continu-ous bladder irrigation and catheter traction Continued bleeding usuallyrequires repeat transurethral fulguration, although the use of clot-pro-moting drugs such as aminocaproic acid can be considered Recurrenthematuria not requiring surgical intervention can sometimes be suc-cessfully managed with 5α-reductase inhibitors (25)
Trang 3188 Foster and Jacobs
I NCONTINENCE
Because TURP includes the removal of tissue at the bladder neck thatencompasses smooth muscle of the internal sphincter, stress urinaryincontinence can result if care is not taken to protect the external urethralsphincter complex As described earlier, critical in avoiding injury tothis sphincteric complex is the identification of the verumontanum andthe resection of prostate tissue only proximal to this landmark Stressurinary incontinence should be uncommon after TURP when the proce-dure is performed correctly, with an incidence well below 1% Riskfactors for postoperative stress incontinence include prostatic scarringfrom prior prostate surgery, radiation, and prostate cancer, all of whichhave the potential to obscure the verumontanum, making resection moredifficult and increasing the likelihood of injury to the external sphincter
In fact, patients with a history of advanced prostate cancer who requireTURP for relief of obstructive symptoms have an approx 20% risk for
the development of postprostatectomy stress incontinence (26)
Man-agement of this complication generally requires insertion of an artificialurinary sphincter, although newer techniques such as the male slingprocedure may provide a suitable alternative Transurethral injectiontherapy with collagen and other agents has not demonstrated similarefficacy or durability Finally, when addressing the issue of inconti-nence after TURP, it is important to recognize that detrusor abnormali-ties (i.e., detrusor instability and/or poor compliance) related to theoriginal bladder outlet obstruction may be the cause For this reason,urodynamic studies should play an important role in the evaluation ofpostoperative incontinence in these patients, certainly before any surgi-cal intervention
S EXUAL D YSFUNCTION
Sexual dysfunction, in particular erectile and ejaculatory bances, has been reported with varying incidences after TURP, occur-ring in approx 13% and 75% of patients, respectively, according to
distur-recent systematic reviews (2,27) The risk of retrograde ejaculation is
substantial because the muscle of the bladder neck/internal sphincter isfrequently disrupted, allowing entrance of ejaculate into the bladder,thereby interfering with emission The cavernous nerves run in the neu-rovascular bundles at approximately the 4 and 8 o’clock positions pos-terior to the prostate These nerves are potentially susceptible to injuryfrom the electrocautery current during the resection Therefore, it hasbeen suggested that maintaining an appropriate depth of resection isimportant, particularly posteriorly, to prevent this complication Menwith relatively small prostates have in some instances been shown to
Trang 4Chapter 11 / TURP 189
be at greater risk for perforation of the capsule and thus may be
more susceptible to problems with erection (28) Rates of new-onset
erectile dysfunction are debatable, ranging from 5 to 33% depending on
the study and risk factors of the patient (28,29) Wasson et al found no
differences in the incidence between men with BPH managed with either
watchful waiting or with TURP (30) Interestingly, a most recent study
found that erectile function actually worsened with conservative agement in men with LUTS and improved in men who underwent TURP
man-(31) Furthermore, following TURP, pain and discomfort on ejaculation
improved compared with baseline Clearly, there are conflicting dataregarding the incidence of erectile dysfunction after TURP; however,
if it does occur, it is probably uncommon
OUTCOME STUDIES
TURP has been in practice since the early 20th century, and there is
a fair amount of outcome data available for analysis The results of thisprocedure have been scrutinized over the years, largely by patient feed-back and surgeon reporting, and in the latter half of the last century byuroflowmetry and urodynamic parameters as well These studies areuseful in measuring the efficacy of TURP, particularly when comparing
it to pharmacotherapy and the use of minimally invasive procedures.Assessment of the symptoms of BPH has been greatly improved bythe development of the various symptom questionnaires such as theAUA Symptom Index These questionnaires have allowed for objectivecharacterization of subjective symptoms The symptom score can
be obtained before and after treatment, ultimately providing reliableand accurate information on changes in response to intervention.Although the patient’s assessment of symptoms (i.e., by means of symp-tom indices) is paramount in determining the success of the procedure,using this parameter as an indicator of treatment success has some short-comings The symptoms of BPH are not specific for the disease, andtherefore, symptom scores can be confounded by concomitant disor-ders As a result, later in the course of follow-up, it can be difficult todetermine whether symptom severity is increasing because of BPH orbecause of another disease process When urinary symptoms recur, it isuseful to compare the severity of symptoms with those present preop-eratively In addition, several clinical tools provide additional informa-tion to corroborate with the qualitative patient symptom score Theseinclude postvoid residual urine measurements and urodynamic studies.Some of the most effective analyses on outcome of TURP have beenurodynamic studies, either simple uroflow (primarily maximum flowrate) or pressure/flow studies
Trang 5190 Foster and Jacobs
Multiple studies have demonstrated the superiority of TURP inimproving symptoms associated with BPH Data from randomized clini-cal trials are very convincing When compared to watchful waiting over
3 yr, TURP resulted in more men improving (90% vs 39%), as indicated
by a reduced bother of difficulty from urinary symptoms (30) During
the course of the study, 24% of men in the watchful waiting arm went TURP Further follow-up of these patients for 5 yr was reported byFlanigan et al., demonstrating treatment failure rates of 10 and 21% for
under-patients managed by TURP and watchful waiting, respectively (32).
In addition, 36% of men in the watchful waiting arm eventually crossedover to invasive therapy Treatment failure was defined as death, acuteurinary retention, high residual urine volume, renal azotemia, vesicalcalculi, persistent urinary incontinence, or a high symptom score Themajor categories of treatment failure reduced by TURP were acute uri-nary retention, large bladder residual (>350 mL), and severe deteriora-tion in urinary symptoms
Several studies have attempted to clarify the usefulness of minimallyinvasive procedures compared with TURP In addition to assessing theeffectiveness of the procedures, these studies also provide useful infor-mation on the outcome of TURP When compared with transurethralincision of the prostate in the largest trial to date, with almost 3 yr of
follow-up, outcomes were similar for both treatments (33) This was
further confirmed in a meta-analysis of studies comparing the two
pro-cedures by Yang and co-workers (34) Although improvements in
symp-tom score were equivalent between the treatments, maximum urinaryflow rate was higher in the TURP group The authors correctly noted,however, that long-term information (i.e., 5–10 yr) on the effectiveness
of both procedures is lacking Recently, one group looked at a largenumber of patients in the ClasP study to determine the benefits of lasertherapy Donovan and colleagues randomized over 300 patients to
receive laser therapy, TURP, or conservative therapy (35) Using
maxi-mum urinary flow as the basis for evaluation, the study showed that lasertherapy was effective in 67% of patients and TURP was successful in81% Conservative therapy was effective in 15% of patients In addi-tion, the two other papers containing data from the CLasP study showedsignificantly better prostate symptom scores and significantly fewer
treatment failures with TURP than with laser therapy (36,37).
CONCLUSIONS
In summary, TURP should clearly be considered the gold standardtreatment for BPH The effectiveness of the procedure has withstood the
Trang 6Chapter 11 / TURP 191
test of time, despite advances in pharmacotherapy and the development
of minimally invasive techniques When performed correctly, the dence of intraoperative, perioperative, and late complication is low.When compared with other treatments, TURP is clearly superior andshould remain the mainstay of surgical treatment of BPH until data fromwell-performed prospective studies suggest otherwise
3 Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC, and Writing Committee Transurethral prostatectomy immediate and postoperative complications:
a cooperative study of 13 participating institutions evaluating 3,885 patients.
J Urol 1989;141:243–247.
4 Barry MJ, Fowler FJ, O’Leary MP, et al The American Urological Association’s symptom index for benign prostatic hyperplasia J Urol 1992;148:1549–1557.
5 Oesterling JE Retropubic and suprapubic prostatectomy In: Walsh PC, Retik
AB, Vaughan ED Jr, Wein AJ, eds., Campbell’s Urology, ed 7, vol 2, phia: WB Saunders, 1998, p 1529.
Philadel-6 Sinha B, Haikel G, Lange PH, Moon TD, Narayan P Transurethral resection of the prostate with local anesthesia in 100 patients J Urol 1986:135:719–721.
7 Birch BR, Gelister JS, Parker CJ, Chave H, Miller RA Transurethral resection
of prostate under sedation and local anesthesia (sedoanalgesia) Experience in
11 Madsen P, Larsen E, Dorflinger T The role of antibacterial prophylaxis in urological surgery Urology 1985;26:38–42.
12 McEntee GP, McPhail S, Mulvin D, Thomson RW Single dose antibiotic phylaxis in high risk patients undergoing transurethral prostatectomy Br J Surg 1987;74:192–194.
pro-13 Gibbons RP, Stark RA, Correa RJ, Cummings KB, Mason JT The prophylactic use–or misuse–of antibiotics in transurethral prostatectomy J Urol 1978; 119:381–383.
14 Berry A, Barratt A Prophylactic antibiotic use in transurethral prostatic tion: a meta-analysis J Urol 2002;167:571–577.
resec-15 Blandy JP, Notley RG Transurethral Resection of the Prostate, 3rd ed, Oxford, UK: Butterworth- Heinemann, 1993, p 52–104.
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16 Richter S, Ringel A, Sluzker D Combined cystolithotomy and transurethral resection of prostate: best management of infravesical obstruction and massive
or multiple bladder stones Urology 2002;59:688–691.
17 Creevy CD Hemolytic reactions during transurethral prostatic resection J Urol 1947;58:125–131.
18 Creevy CD, Webb EA A fatal hemolytic reaction following transurethral tion of the prostate gland: a discussion of its prevention and treatment Surgery 1947;21:56–66.
resec-19 Beirne GJ, Madsen PO, Burns RO Serum electrolyte and osmolality changes following transurethral resection of the prostate J Urol 1954;93:83–86.
20 Holtgrewe H, Valk W Factors influencing the mortality and morbidity of surethral prostatectomy: a study of 2,015 cases J Urol 1962;87:450–459.
tran-21 Borboroglu PG, Prodromos G, Kane C, et al Immediate and postoperative complications of transurethral prostatectomy in the 1990s J Urol 1999; 162:1307–1310.
22 Roos NP, Wennberg JE, Malenka DJ, et al Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia.
N Engl J Med 1989;320:1120–1124.
23 Chute CG, Stephenson WP, Guess HA, Lieber M Benign prostatic hyperplasia:
a population based study Eur Urol 1991;20(suppl 1):11–17.
24 Fuglsig S, Aagaard K, Jonler M, Olesen S, Norgaard JP Survival after thral resection of the prostate: a 10-year follow-up J Urol 1994;151:637–639.
transure-25 Kearney MC, Bingham JB, Bergland R, Meade-D’Alisera P, Puchner PJ cal predictors in the use of finasteride for control of gross hematuria due to benign prostatic hyperplasia J Urol 2002;167:2489–2491.
Clini-26 Hirshberg E, Klotz L Post transurethral resection of prostate incontinence in previously radiated prostate cancer patients Can J Urol 1998;5(2):560–563.
27 Soderdahl DW, Knight RW, Hansberry KL Erectile dysfunction following surethral resection of the prostate J Urol 1996;156:1354–1356.
tran-28 Bieri S, Iselin C, Rohner S Capsular perforation localization and adenoma size
as prognostic indicators of erectile dysfunction after transurethral tomy Scand J Urol Nephrol 1997;31:545–548.
29 Perera N, Hill J Erectile and ejaculatory failure after transurethral tomy Ceylon Med J 1998;43:74–77.
prostatec-30 Wasson JH, Reda DJ, Bruskewitz RC, et al A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia The Veterans Affairs Cooperative Study Group on transurethral resection of the prostate N Engl J Med 1995;332:75–79.
31 Brookes ST, Donovan JL, Peters TJ, Abrams P, Neal DE Sexual dysfunction in men after treatment for lower urinary tract symptoms: evidence from random- ized controlled trial BMJ 2002;324:1059–1061.
32 Flanigan RC, Reda DC, Wasson JH, et al Five year outcome of surgical tion and watchful waiting for men with moderately symptomatic benign pros- tatic hyperplasia: a Department of Veterans’ Affairs cooperative study J Urol 1998;160:12–16.
resec-33 Riehmann M, Knes JM, Heisey D, Madsen PO, Bruskewitz RC Transurethral resection versus incision of the prostate: a randomized, prospective study Urology 1995;45:76–775.
34 Yang Q, Peter TJ, Donovan JL, Wilt TJ, Abrams P Transurethral incision pared with transurethral resection of the prostate for bladder outlet obstruction:
Trang 8transure-J Urol 2000;164:65–70.
36 Gujral S, Abrams P, Donovan JL, et al A prospective randomized trial ing transurethral resection of the prostate and laser therapy in men with chronic urinary retention: the CLasP study J Urol 2000;164:59–64.
compar-37 Chacko KN, Donovan JL, Abrams P, et al Transurethral prostatic resection or laser therapy for men with acute urinary retention: the ClasP randomized trial.
J Urol 2000;164:166–170.
Trang 10Chapter 12 / TVRP 195
195
From: Management of Benign Prostatic Hypertrophy
Edited by: K T McVary © Humana Press Inc., Totowa, NJ
to the use of the thick-loop electrode and adds resection to the tion, desiccation, and coagulation accomplished with other electrodes.Otherwise the equipment is identical to that used for transurethral resec-tion of the prostate (TURP) The generator must be capable of pro-
vaporiza-ducing 25–45% higher wattage (2,4) The indications for TUVP are
the same as those for TURP This chapter will demonstrate that thismodality is a modification of TURP
Trang 11196 Littlejohn, Kang, and Kaplan
There are numerous transurethral modalities available for the ment of benign prostatic hyperplasia (BPH) The final common path-way of each of these methods is heat The differences occur in whetherone uses microwave, radio frequency, laser, or high-intensity focusedultrasound, and how the energy form of choice is converted to heat,which yields the desired effect in the prostatic tissue Vaporization is theeffect of a specific range of temperature exerted on tissue, resulting incellular lysis and evaporation of the intracellular fluid This technology
treat-is a modification of TURP; however, vaporization treat-is quite dtreat-istinct fromstandard electrosurgical resection This distinction can be easily over-looked when working with familiar equipment and using a familiartechnique; however, there are subtle but critical technical nuances.The efficacy of transurethral vaporization and vapor resection iscomparable to that of TURP However, there are differences in opera-tive time, length of catheterization, blood loss, and fluid absorption.TUVP using the roller electrodes and TUVRP using the thick loop arenot assumed to be equivalent, and outcome data from each will be pre-sented separately
HISTORIC BACKGROUND
TURP has been the gold standard for the surgical treatment of BPHfor prostates <80 g This established technique is based on the use ofhigh-frequency electrical current to cut and fulgurate tissue and obtainhemostasis Furthermore, standard TURP uses a thin-wire resectoscopeloop and removes prostatic tissue by resection of chips, with minimaltissue vaporization and no desiccation
However, well-recognized morbidities associated with TURP ing, hospital stay, electrolyte disturbances, and anesthetic requirement)have led many urologists to seek other alternatives One of the earliestmodifications of TURP was transurethral electrovaporization of theprostate (TUVP, TVP, TUEVP, EVAP), which entered mainstream
(bleed-urology in 1995 after successful pilot studies in 1994 and 1995 (1–3).
Transurethral electrovaporization stems from the concept of ablatingthe tissue by means of simultaneous vaporization and desiccation,allowing for better visualization and minimal blood loss TUVP requiresthe use of a slower loop resection speed; a lack of tissue specimens; use
of new, more powerful generators; and use of an electrode with agrooved, fluted, or rollerbar design The procedure was well received byurologists because of its technical similarities to TURP
Technological advancements have resulted in modification of the izing electrode, creating an electrode that enables simultaneous vaporiza-
Trang 12vapor-Chapter 12 / TVRP 197
tion and resection Various names have been given to this new technique,including vaporizing-resection, transurethral vaporization-resection ofthe prostate (TVRP, TUVRP), vapor-cut, electrovaporization-resection,and thick-loop TURP This electrode features a thin leading edge to aid
in resection and a thick trailing edge for vaporization and desiccation
INDICATION/CONTRAINDICATIONS
Indications for TUVP are same as those for TURP Primarily, theyinclude moderate-to-severe symptoms on the International ProstateSymptom Score (I-PSS) or the American Urologic Association Symp-tom Index (AUA SI), and/or prostatism refractory to medical therapy.Other absolute indications for surgery are acute refractory urinary reten-tion, recurrent infection, recurrent hematuria, cystolithiasis, andpostrenal azotemia
There are no absolute size requirements The literature generallyrecommends TUIP for prostatic glands <30 g without a median lobebecause of reported low morbidity For the same reason, an open pros-tatectomy is recommended for glands >80 g The median lobe is not acontraindication for TUVP, unlike for some of the other new minimallyinvasive procedures
Contraindications for the procedure are same as for any other surgeryand include active infection and coagulopathy Preoperative laboratorytesting is routinely done to identify these contraindications Of note,patients with pacemakers will need careful monitoring during theperioperative period
Although studies have shown mixed outcome results for post-TURPinfection rates, the administration of prophylactic first-generationcephalosporin (unless other antibiotics are indicated) is used (e.g., mitral
valve prolapse) (5).
Although there have been reports of performing transurethral surgery
of prostate with the patient under local anesthesia, we generally mend using a general or spinal anesthesia There are no differences inblood loss, postoperative morbidity, or mortality between using a spinal
recom-anesthesia and a general recom-anesthesia, according to the literature (5).
EQUIPMENT/POWER SETTINGS
To perform TUVP or TURVP, minor additional equipment is neededbeyond the standard TURP set This includes different resectoscopeelectrodes and impedance-free electrosurgical generators This sectionwill cover various power generators and their respective effective powersettings and electrode designs in depth
Trang 13198 Littlejohn, Kang, and Kaplan
Electrosurgical Generators
Generator power plays a crucial role in vaporization Intuitively, aninsufficiently powered generator will not provide adequate power forvaporization Although many generators may provide sufficient powerwattage at low impedance levels, some of the older generators arenot efficient at delivering the same power at increased resistances
In electrovaporization, prostatic tissue is desiccated after the initialswipe The desiccated, vaporized tissue raises the tissue impedance.Thus, the next swipe is going to meet higher resistance and requiregreater power to achieve the same desired current or effect
For example, conventional TURP power generators, including theValley-Labs Force 2 and Force 4 (Valley-Labs, Boulder, CO) are not asefficient in delivering consistent power over a wide range of imped-
ances as Force 40 (6,7) Power/resistance curves should be available for
every generator Moreover, newer generators, such as the Valley-LabsForce 300, FX, or ERBE ICC 350 (Erbe, Tubingen, Germany) contain
microprocessors that adjust for changing tissue impedance (6) Hence,
for maximal vaporization to occur, an impedance independent surgical unit should be used If inadequate power current is used, exces-sive fulguration will result in coagulation necrosis and subsequentirritative voiding symptoms
electro-Electrovaporization is best performed with a cutting current set at
25–75 % higher power than standard TURP (6) Van Swol et al reported
that minimum power of 150 watts to tissue is needed to achieve
vapor-ization (7) For a Force 40 unit, a power setting of 240–250 watts (pure
cut) is recommended; for a Force 300, 150 watts is required For a Force
FX or ERBE units, 130–150 watts is suggested (6).
For vaporizing-resection, different investigators have used variouspower settings Kaplan used an ERBE ICC 350 unit set at 200 watts(pure cut), whereas Perlmutter used 120–150 watts (pure cut) with the
same unit for vaporization-resection (6) Kupeli et al used a Valley-Lab
Force 40 unit set at 250–300 watts (pure cut), whereas Talic et al used
an Eschmann TD411-RS unit set at 250 watts (8,9) Additionally, the
different technique used for resection and the unique electrode must betaken into account when considering power settings during vaporizing-resection
Electrodes
Electrode design is also important in achieving desired electrosurgicaleffects on tissue An electrode with a broad surface area of contact andmultiple ridges or grooves produces more vaporization than a smooth
Trang 14Figure 2 shows the Vaporcut electrode, which is comparable to theVaporTome (Circon), which consists of a thick loop with grooves, a thinleading edge for vaporization, and a thick trailing edge for coagulationand desiccation The Wedge by Microvasive (Natick, MA) is anothervaporizing-resection electrode that uses the differential loop thicknessconcept The Wing EVAP electrode (Richard Wolf) is a semicirculardesigned, gold-plated wire loop that is wider and thicker than a standardTURP loop.
Bipolar electrovaporization technology (Gyrus PlasmakineticElectrosurgical System, Buckinghamshire, UK) is the latest technologythat has entered the electrovaporization market This system allows foruse of isotonic saline as the irrigating solution, which essentially elimi-
Fig 1 Roller electrode for TUVP (Karl Storz, Tuttlingen, Germany).