BJU International (1999), 83, 227237

REVIEW
Is transurethral resection of the prostate still justified?
S. MADERSB ACHER and M. MARBE RGER
Department of Urology, University of Vienna, Austria

Keywords Transurethral resection of the prostate, benign prostatic hyperplasia, eBcacy, side-eCects, less invasive
therapy

Presented as the BAUS Lecture at the Annual Meeting of the BAUS, Edinburgh 1997

(WW) to holmium-laser resection (Table 1). RCTs with

Introduction
a follow-up of <6 months and with a substantial number
For decades TURP was the undisputed gold standard of of patients in urinary retention preoperatively were
therapy for patients with LUTS due to BPH; however, excluded.
within the past 10 years this role has increasingly been
challenged by the development of medical (5a reductase
The current morbidity of TURP
inhibitors, a1-receptor blockers) and less invasive inter-
ventional alternatives [18]. The main driving forces Mortality after TURP has decreased substantially during
behind this development were the high prevalence of the the past 30 years and is <0.25% in contemporary TURP
disease, an absolute indication for surgery in only 510% series [1016]. Horninger et al. reported no postoperative
of patients with symptomatic BPH, recent technical deaths in a consecutive series of 1211 patients under-
innovations and, most importantly, the apparently going TURP between 1988 and 1991 [16]. In the 29
unchanged high morbidity of TURP [916]. As a result, RCTs reviewed, no patient died within the first 6 weeks
the number of prostatectomies decreased substantially after surgery, reflecting advances in anaesthesia achieved
[17,18], e.g. in the USA the number of TURPs for BPH during the past two decades.
was 253 000 within the US Medicare Program in 1987 The major intraoperative complication of TURP
and fell to 145 000 in 1994, a reduction of 43% [17].
This trend is also demonstrable in Europe, although less
Table 1 Pertinent characteristics of the 29 RCTs analysed
pronounced in countries with very extensive public
healthcare systems [18]. Enthusiastic reports on the No. of patients* in
success of alternative treatment options in the lay and No. of
urological press seemed to herald the end of TURP as Method studies Reference(s) TURP Control
the gold standard, perhaps best reflected by Stameys
quote in 1993 that TURP is now a therapy of history Open 1 20 43 32
[19]. Prostatectomy
The objective of this review is to determine the current TUIP 6 2126 285 270
TUVP 4 2730 199 189
status of TURP with particular reference to less invasive
Holmium Laser 1 31 11 23
procedures and recent developments of transurethral VLAP 7 3238 351 416
electrosurgery. To reliably assess this issue, we reviewed ILC 2 39, 40 41 60
the recent urological literature and, specifically, all 29 TUNA 2 41, 42 107 117
randomized clinical trials (RCTs) published between TUMT 2.5 2 43, 44 61 61
1986 and 1998 comparing less-invasive treatment IRFT 1 45 25 25
options directly with TURP (Table 1) [2048]. These 29 TUMT 2.0 1 46 32 37
BDP 2 26, 47 45 46
RCTs contain clinical information for a total of 3032
WW 1 48 280 276
patients, 1480 being randomized to TURP, 1552 to less- Total 29 1480 1552
invasive treatment options, from watchful waiting
* At study entry. Three-arm study comparing TURP to TUIP and
Accepted for publication 2 September 1998 balloon dilatation of the prostate (BDP).

1999 BJU International 227

228 S. MADERSB AC HER and M. MARB ERGER
remains haemorrhage requiring blood transfusion. In
the series by Mebust et al. on 3885 patients treated in
197887, the transfusion rate was 2.5% [13]; Horninger
et al. reported a transfusion rate of 4.2% [16]. The
transfusion rate after TURP in the 29 RCTs reviewed
was slightly higher, with a mean (sem, range, sd, 95%
CI) of 8.6% (5.2, 035, 9.7, 3.9-13.4). If the series with
an excessively high transfusion rate of 35% is excluded
[23], the mean transfusion rate decreases to 7.2% (95%
CI 3.410.5).
TUR syndrome (i.e. fluid intoxication, serum
Na+<130 mmol/L) has largely disappeared through
the use of modern irrigation fluids, improved surgical
technique and instrumentation. In the series by Mebust
et al. [13] the TUR syndrome occurred in 2.0%; others
have reported 2.8% [1012,15,16]. In the 29 RCTs
reviewed, the TUR syndrome was reported only in three
studies, at 3.4%, 4.7% and 6.7%. TURP morbidity in the
last study was substantially higher than usually reported,
as shown by a transfusion rate of 35% [23]. A potential
explanation for this incidence of transfusion and TUR
syndrome might be the long operative duration (mean
59 min) considering the small prostates treated (mean
prostatic weight 15.6 g) reflecting obvious surgical
problems.
The most frequent early complications after TURP
(within the first 46 weeks) are prolonged urinary
retention, postoperative bleeding with clot retention and
urinary tract infection. In the RCTs reviewed, major
postoperative bleeding with subsequent clot retention
was reported in 5.5% of cases. However, the predominant
cause for prolonged urinary retention after TURP is
primary detrusor failure, which cannot be attributed to
an insuBcient TURP. Although there is a correlation
between peak flow rate (Q ), prostate volume and post-
max
void residual volume (PVR) to urodynamically proven
BOO, a low Q does not necessarily indicate BOO
max
[4951]. We evaluated whether failure after TURP can
be predicted in patients with acute urinary retention and
found that those with prolonged retention after TURP
were older (mean 83.5 years, sd 7 vs 70.1, sd 8), had
larger preoperative retention volumes (1780 vs
1080 mL) and a significantly lower maximum detrusor
pressure (24.4 vs 73.5 cmH2O) at the preoperative
urodynamic evaluation [52]. These data indicate that
proper patient selection substantially reduces morbidity
after TURP by avoiding surgery in patients that will not
benefit from the procedure [52].
The major two late postoperative complications
(>46 weeks) after TURP are urethral strictures (mean
3.8%, sd 2.0, range 011.6, sd 3.9, 95% CI 1.75.8)
and bladder neck contractures (4.7, 4.2, 031, 8.1,
0.39.2); these were calculated from the 29 RCTs
reviewed. Improvements in surgical technique, lubri-
cants, resectoscopes and electrical power generators have
contributed to the substantially lower incidence of
urethral strictures than reported in previous series
[1016,2048].
The long-standing controversy on erectile dysfunction
after TURP was clarified by the VA Cooperative Study
Group comparing TURP with WW [48]. At a mean
follow-up of 2.8 years, the proportion of patients
reporting a deterioration of their sexual performance
was identical in both study arms, i.e. 19% after TURP
and 21% in the WW group; 3% in each group reported
an improvement of sexual function during the study
[48]. The mean (sem, sd, 95% CI) proportion of patients
reporting erectile dysfunction after TURP was 6.5 (5.4,
8.1, 0.212.7) from the 29 RCTs reviewed [2048].
This discrepancy, as well as the wide range of erectile
dysfunction given in these RCTs, probably arises
because no consistent, standardized questionnaire was
used.
The incidence of retrograde ejaculation after TURP
depends on the degree of bladder neck resection. If
preservation of antegrade ejaculation is an issue, the
bladder neck should be preserved. in the 29 RCTs
reviewed, retrograde ejaculation was seen in a mean
(sem, sd, range 95% CI) of 65.4 (10.8, 17.9, 36100,
53.477.5) of patients [2048].
In conclusion, the morbidity of contemporary TURP
is lower than previously reported. The major compli-
cation of TURP remains bleeding requiring blood
transfusion.
The morbidity of less-invasive interventional
therapy
Undoubtedly the major attraction of all minimally invas-
ive procedures is a lower intraoperative morbidity than
with TURP. The risk of bleeding requiring transfusion is
minimal and it is the rare exception that patients receive
blood during or after the procedure (Table 2). In parallel,
there were no reports of TUR syndrome in the respective
minimally invasive treatment arms in the 29 RCTs
reviewed. However, at least theoretically, TUR syndrome
could occur during more ablative less-invasive pro-
cedures, e.g. holmium laser prostatectomy, if a large
venous sinus is opened or the prostatic capsule perfor-
ated. The decisive issue regarding intraoperative mor-
bidity of less-invasive procedures is the degree of
anaesthesia needed. Only low- and high-energy transur-
ethral microwave thermotherapy (TUMT) can reliably
be performed under topical anaesthesia [53].
Transurethral needle ablation (TUNA) and interstitial
laser coagulation (ILC) require topical anaesthesia and
intravenous application of sedoanalgesics in a substantial
number of patients. All the other less-invasive
1999 BJU International 83, 227237
 IS TUR P STIL L JUST IFIED? 229

Table 2 Intra- and postoperative

complications (%) of TURP and less No. of Blood Urethral Retrograde 2ry
invasive procedures given in the 29 RCTs Method studies transfusion stricture ejaculation intervention

TURP 29 8.6 3.8 65.4 2.6

TUIP* 6 0.4 4.1 18.2 15.9
TUVP 4 0 3.4 85 0
Ho laser 1 0 0 0 4.3
VLAP 7 0 0 ND 12.9
TUNA 2 0 ND 0 2
TUMT 2.5 2 0 0 22 3.2
IRFT 1 0 ND ND 5
TUMT 2.0 1 0 0 0 11
BDP* 2 0 0 ND 15
WW 1 0 0 ND 23

* Three-arm study comparing TURP to TUIP and BDP. ND, no data.

procedures (transurethral vaporization of the prostate,
TUVP, holmium laser resection, visual and contact laser
ablation of the prostate, VLAP) require general/spinal
anaesthesia, as does TURP.
In procedures with no immediate removal of necrotic
tissue, such as high-energy TUMT, VLAP or transrectal
high-intensity focused ultrasound (HIFU) therapy, the
early postoperative phase is characterized by prolonged
postoperative urinary retention [68,54,55]. After
VLAP, the mean duration of catheter drainage reported
in the RCTs ranged from 4.7 days [34] to 14.7 days
[32] and 19 days [36]. After high-energy TUMT, reten-
tion periods of 1014 days are documented [8].
In a prospective, unrandomized study, we compared
the early postoperative morbidity of TURP to TUNA,
TUVP, VLAP and transrectal HIFU [56]. The mean (sd)
duration of catheter drainage was 3.7 (1.2) days after
TURP, 6.8 (1.7) days after HIFU, 7.8 (1.5) days after
VLAP, 2.0 (0.4) days after TUNA and 3.3 (0.8) days
after TUVP [56]. In that series, no patient required a
blood transfusion [56]. The overall rate of complications
requiring therapy in the first 6 weeks was identical for
all techniques [56]. Clearly, the need for necrotic tissue
to be sloughed urethrally adds to morbidity, although
this is not always stated [56]. A detailed daily question-
naire revealed that the frequency and loss of urine was
comparable for all five procedures within the first 6
weeks after treatment, but dysuria was considerably
higher after VLAP and TUVP [56]. After VLAP patients
still had to void an average of four times every night
after 6 weeks, while the remaining four procedures
yielded a significant and comparable decrease [56].
Responses to the global quality-of-life question showed
that the patients were generally more worried after
VLAP and TUNA than after TURP, TUVP and HIFU
[56].
Because the follow-up in most studies evaluating less-
invasive procedures is limited, data on long-term compli-
cations are scarce, but seem to indicate a slightly lower
rate (except the rate of secondary intervention; see
below) than TURP. The proportion of urethral strictures
after less-invasive procedures in the 29 RCTs was 1.4%
[2048].
In conclusion, the morbidity of less-invasive pro-
cedures is higher than previously assumed and is charac-
terized by a shift from the intraoperative to the early
postoperative phase. There appears to be a close corre-
lation between clinical eBcacy and morbidity.
The eYcacy of TURP compared with less-
invasive interventional therapy
The assessment of clinical eBcacy of any treatment to
relieve BOO caused by BPH is hampered by a profound
placebo eCect [5759]. This was highlighted in a recent
study by Nawrocki et al. analysing low-energy TUMT
[59]. In contrast with previously published sham TUMT
studies, the authors randomized patients to active treat-
ment, sophisticated sham treatment (with both patient
and doctor unaware) and an untreated group. The Q
max
did not change significantly in any of the three study
arms [59] but the AUA symptom score decreased almost
identically in the standard and simulated TUMT arm,
and was unchanged in the untreated group. Reasons for
this apparent contradiction to previously published
sham-controlled TUMT studies could be the elaborate
study design and the fact that only patients with urodyn-
amically proven BOO were treated [8,59]. Obviously,
more invasive procedures and elaborate study designs
with frequent follow-up visits induce a more pronounced
placebo eCect. This placebo eCect underlines the need for
RCTs and is also stressed by the fact that results in
phase-II trials are usually better than those of RCTs
[57].

1999 BJU International 83, 227237

230 S. MADERSB AC HER and M. MARB ERGER
Symptoms
Comparing the subjective improvement reported in
diCerent studies is impeded by the use of diCerent scoring
systems (e.g. IPSS, AUA-7, Boyarski, DAN-PSS).
Therefore, to correlate symptomatic improvement after
TURP to less-invasive treatment alternatives, we calcu-
lated the respective proportions of symptomatic improve-
ment. The mean (SEM, SD, 95% CI) decrease in symptom
score after TURP in the 29 RCTs analysed was 70.6%
(4.6, 10.9, 66.475.5) (Fig. 1) [2048]. In all studies
the symptom score more than halved and in 58% this
decrease exceeded 70%. This subjective improvement
after TURP was compared with the respective less-
invasive treatment arm(s) in the 29 RCTs (Fig. 2a); all
less-invasive procedures (even WW) resulted in a sub-
stantial decrease in urinary symptoms [2048]. The
respective proportions range from 38% (interstitial radio-
frequency therapy) to 80% for TUVP and only techniques
resulting in tissue ablation gave results comparable
with TURP.
Uroflowmetry and PVR
The most frequently used objective variables to assess
clinical eBcacy are the Q and PVR. The mean increase
max
in Qmax after TURP in the 29 RCTs reviewed was 125%,
with an absolute mean (SEM, SD, range 95% CI)
improvement of 9.7 mL/s (1.2, 3.3, 2.820.8, 8.611.2;
Fig. 1) [2048]. Figure 2b compares improvements in
Q for the 29 TURP arms with that from the less-
max
invasive procedures; the improvement in Q after TURP
max
was superior to that after transurethral incision of the
300
250
Improvement (%)
200
150
100
50
0
Symptom score Qmax (mL/s) Residual volume
(mL)
Fig. 1. Improvement of symptoms, Qmax and PVR after contempor-
ary TURP. Data from 29 RCT TURP arms containing information
on 1480 patients were included. Each dot represents a single RCT.
The horizontal bars indicate the 10th and 90th percentiles, the
centre of the box the 50th percentile, and the lower and upper
end of the box the 25th and 75th percentiles. The median
improvement in urinary symptoms, Qmax and PVR after contem-
porary TURP is 72%, 120% and 70%; the respective mean values
are given in the text.
prostate (TUIP), VLAP, ILC, TUNA, low- and high-energy
TUMT, interstitial radiofrequency therapy (IRFT), balloon
dilatation of the prostate (BDP) and WW. In this analysis
(Fig. 2) the improvement in Q after TUVP and hol-
max
mium-laser resection (one study only) slightly exceeded
that after TURP, although the diCerence was never
statistically significant [2048]. The improvement
(mean, SEM, 95% CI) in Q after TURP (114%, 30,
max
76153) was superior to that after TUIP (70%, 34,
27112) in six RCTs comparing both methods, but was
not statistically significant (P=0.08). However, the
mean increase in Q after VLAP (83%, 33, 43122)
max
was significantly less pronounced (P=0.038) than after
TURP (119%, 20, 88137) in the seven RCTs. The
improvement in Q after TURP (146%, 12, 126165)
max
and TUVP (155%, 17, 128182) was comparable in the
four RCTs published to date. The number of RCTs for
the other less-invasive procedures reviewed here (hol-
mium laser, ILC, TUNA, TUMT 2.5, IRFT, TUMT 2.0,
BDP and WW) was too low (i.e. fewer than three) for a
comparable analysis.
It is generally accepted that a Q after therapy of
max
>15 mL/s suggests that the treatment resulted in a
highly eBcient decrease of BOO [4951]. In fact, most
patients with a Q of >15 mL/s are urodynamically
max
unobstructed. For the TURP studies analysed, this was
the case in 27 of 29 (93%) [2048]; this proportion is
substantially higher than after TUNA (one of two stud-
ies), ILC (none of two), IRFT (none of one), VLAP (four
of seven), high-energy TUMT (one of two) and low-
energy TUMT (none of one).
Data on PVR are in agreement with those of Q ,
max
indicating that TURP is still the gold standard; PVR
decreased by a mean (SEM, SD, 95% CI) of 60.5% (10,
23, 4871) after TURP, compared with 66% (23, 20,
15.4116) after TUVP and 52% (14, 16, 3172) after
VLAP. The decrease in PVR was less pronounced after
TUNA (43%), TUMT (18%), IRFT (9%) and BDP (2%)
[2048].
Urodynamics
The definitive urodynamic impact of procedures designed
to relieve BOO can only be assessed by pressure-flow
studies (pQS) [4951]. In an extensive review, Bosch
summarized the urodynamic eCects of various treatment
modalities for BPH [60]. The rank order of urodynamic
eBcacy as determined in this meta-analysis revealed that
the most eBcient therapy in relieving BOO was open
prostatectomy, followed by TURP, VLAP/TUVP/TUIP,
TUMT/TUNA/HIFU, medical therapy (a1-receptor block-
ers, 5a-reductase inhibitors) and WW regimens [6064].
In the 29 RCTs reviewed, only a few contained data for
pQS. The data of these RCTs confirm the conclusions of
1999 BJU International 83, 227237
 IS TUR P STIL L JUST IFIED? 231

a
100

80

Symtomatic improvement (%)

60

40

20

0
P

I/P

er

FT

W
2.

2.
R/

V/

BD
IL

N
as

W
TU

IR
VL

TU
TU

TU

T
-L

M
m

TU

TU
ol
H
b
300

250
Improvement of Qmax (%)

200

150

Fig. 2. (a) Symptomatic improvements and

100
(b) Qmax of TURP and less invasive
treatment modalities. Clinical data are from
29 RCTs containing clinical information on 50
3032 patients, 1480 being randomized to
TURP and 1552 to less-invasive treatment
options. The green circles indicate each 0
single study included, the red circles with
P

I/P

FT

W
e

2.

2.
R/

V/

BD
IL

N
as

W
TU

IR

the horizontal bars show the mean (SEM) of

VL

TU
TU

TU

T
-L

M
m

the pooled data from the respective

TU

TU
ol
H

techniques.

the earlier review [60]. Dahlstrand et al. [46] compared
the urodynamic eBcacy of low-energy TUMT with TURP.
Six months after therapy, the detrusor pressure at Q
max
did not change after low-energy TUMT, but declined
substantially after TURP. Ahmed et al. [43] compared
the impact of high-energy TUMT and TURP on BOO; on
the Abrams-GriBth nomogram, 27 of 30 (90%) patients
undergoing TURP were classified as unobstructed after
surgery, yet all patients remained urodynamically
obstructed after high-energy TUMT. For VLAP, Kabalin
et al. [34] reported an identical urodynamic eBcacy to
TURP, while Jung et al. [36] observed a substantially
reduced urodynamic eCect compared with TURP.
Durability
The rate of secondary intervention needed is the essential
variable for evaluating the long-term eBcacy of pro-
cedures aimed at relieving BOO. The incidence of second-
ary intervention after TURP is well documented
[14,16,6567]. Jensen et al. [65] calculated a repeat
TURP rate of 1.8% per year after TURP in 79 patients

1999 BJU International 83, 227237

232 S. MADERSB AC HER and M. MARB ERGER
who were followed for a mean of 8 years. In a large-
scale, multicentre study of patients undergoing TURP in
Denmark (n=27 911), England (n=2171) and Canada
(n=8995) the rate of re-intervention after TURP
increased from 2.3% to 4.3% within a year after surgery,
to 8.99.7% after 5 years and to 12.015.5% 8 years
after surgery [14]. In the RCTs reviewed here, the mean
(SEM, SD, 95% CI) rate of secondary intervention after
TURP was 2.6% (2.0, 4.7, 0.54.7) with a mean follow-
up of 16 months, thus confirming previously published
long-term follow-up studies [2048].
The need for secondary intervention is substantially
higher for minimally invasive treatment techniques
(Table 2). Indeed, many of these procedures reach the
8-year re-intervention rate after TURP (1015%) within
the first year. No data for this crucial issue, based on
RCTs, are available for TUNA, ILC, TUVP and holmium-
laser resection, but data from unrandomized long-term
follow-up studies indicate an even higher rate of second-
ary intervention. Three years after low-energy TUMT,
treatment failure rates were 2952%; 2 years after
transrectal HIFU therapy, 20% of patients required a
TURP [68,69]. Hallin and Berlin [70] reported on the
4-year outcome after low-energy TUMT; only 23% of
the initially treated group were satisfied with the result
and two-thirds had received supplementary BPH treat-
ment [70]. For high-energy TUMT, the respective per-
centages given are 415% within a year after therapy
[8]. After TUNA, Rosario et al. [62] reported that 31%
of patients had to undergo prostatectomy within a year
of therapy; in the series by Steele and Sleep this pro-
portion was 12.7% [63]. In conclusion, TURP remains
unsurpassed in terms of treatment eBcacy, particularly
in the durability of results.
Improvements in transurethral electrosurgery
Limited resection
The entire transition zone need not be removed to relieve
obstruction; particularly in patients with small prostates
(<30 mL) TUIP, with incision of the obstructing muscle
fibres at the bladder neck down to the prostate capsule,
has proved to be an eCective treatment option. To date,
six RCTs comparing TURP to TUIP with follow-up periods
of >6 months have been reported [2126]. These RCTs
have convincingly shown the eBcacy of TUIP as compar-
able or only slightly inferior to conventional TURP
(Fig. 2), but the mean (sem, sd, 95% CI) morbidity from
bleeding requiring transfusion (TUIP 0.4%, 0.8, 0.8,
01.6%; TURP 8.6%, 5.2, 9.7, 3.913.4) and clot
retention was lower (Table 2) [2126]. Retrograde ejacu-
lation occurred in only 18.2% (range 035) of patients,
substantially lower than after conventional TURP
(65.4%). Consequently, TUIP is an ideal therapeutic
option for younger, sexually active men with small
prostates, i.e. <2030 mL [2126].
Another unsolved issue is the role of radical TURP,
with resection down to the surgical capsule, although
TURP does not always have to be radical [71]. Aagaard
et al. [72] reported on the long-term outcome (10 years
of follow-up) of patients treated by either total (i.e.
radical) or minimal (English Channel) TURP. A total
of 167 patients treated between 1979 and 1980 were
assessed; after 10 years, 62 patients were available for
detailed examination. The decrease in urinary symptoms
and improvements in Q and PVR were comparable in
max
both groups. However, the treatment failure rate within
10 years was higher in the minimal (23%) than in the
total-TURP arm (7%) [72]. Nevertheless, these long-term
data show that minimal and total TURP lead to similar
long-term results, indicating that radical TURP is
unnecessary in all patients. For postoperative compli-
cations, minimal TURP was advantageous, as only one
patient (3%) of the minimal but 14% of the total-TURP
group developed urethral strictures requiring dilatation
[72]. Intraoperative complications (e.g. bleeding) and
the rate of retrograde ejaculation were not given [72].
Obviously, more tissue removal does not necessarily
represent a better TURP; the decisive factor is the
removal of the obstructive elements. The indication for
minimal TURP has not been established to date.
However, based on the clinical experience with TUVP
(which provides only minimal tissue removal) and TUIP,
it can be assumed that prostate volume is a decisive
factor and that minimal (English Channel) TURP is best
suited for patients with prostates of <30 mL.
Electrovaporization
Prostatic tissue can only be cut electrosurgically if the
voltage at the cutting electrode is >200 V and creates
an electric arc. This focuses high-frequency (HF) current
stochastically onto the tissue, leading to a very rapid
rise in temperature and immediate tissue vaporization
[73,74]. Conventional TURP is performed with thin-wire
loop electrodes, of #0.3 mm diameter. The predominant
eCect of these wire loops is cutting, while tissue vaporiz-
ation plays only a minor role. To create simultaneous
coagulation during the cutting electroresection, deeper
heat penetration is required than that provided by the
standard TURP cutting electrode [73]. By combining the
two electrosurgical eCects, desiccation (vaporization of
intra/extracellular water) and coagulation of cellular
elements into one motion, prostatic tissue removal with
minimal bleeding can be feasible by using broad roller-
ball-like loops [5,8,73,74], i.e. TUVP. Several phase-II
clinical trials and four RCTs comparing TUVP to TURP
1999 BJU International 83, 227237
 IS TUR P STIL L JUST IFIED? 233

30

20

Qmax (mL/s)
R (TUR)

10

Fig. 3. The clinical eBcacy of TUVP (TUR) R (TUR)

decreases in patients with larger prostates; it (TUR)
R
is closely correlated with prostate volume
and is substantially decreased in patients 0 R R R RR R R R
with prostate volumes of >50 mL. Green, 0 20 40 60 80 100
pre-operative. Red, post-operative. R,
retention [76]. Prostate volume (mL)

have confirmed the clinical eBcacy of TUVP, which is

more eCective than many other minimally invasive
treatments (HIFU, low-energy TUMT, high-energy TUMT a
100
and TUNA), but clearly more invasive (Fig. 2) [8,2730].
Ekengren and Hahn [75] showed that severe compli- 80
Total energy (kW s)

cations (blood loss >800 mL, fluid absorption of

>500 mL or haemodynamic instability) were less fre- 60
quent after TUVP (P=0.012). Data for sexual function
after TUVP vary significantly; the incidence of retrograde 40
ejaculation given in RCTs ranged from 72 to 100%
(mean 85%), apparently mainly depending on the 20
amount of tissue ablated at the bladder neck; impotence
rates of 015% were reported [2730]. Most patients 0
0 2 4 6 8 10 12 14 16
suCer from irritative voiding symptoms for 46 weeks,
Operating time (min)
which seem to be more bothersome than after TURP
[2730,56]. Thermal damage to surrounding structures, b
100
even at the 300 W power setting, does not seem to be a
major problem, as shown by interstitial thermometry 80
Total energy (kW s)

and clinical experience. Only the urine inside the bladder

is heated to >45C unless continuous irrigation is 60
performed.
The major disadvantage of TUVP is that the clinical 40
eBcacy of the electrode rapidly decreases as the tissue
desiccates, i.e. with larger prostates [76,77] (Fig. 3). 20
Using an ex vivo model, Michel et al. [77] showed a loss
of eBcacy in tissue ablation of 70% between the first 0
0 2 4 6 8 10 12 14 16 18 20 22 24
and fifth movement of the roller-ball. To vaporize a gram
Operating time (min)
of water, #2500 W are necessary. As it can be assumed
that both cellular water and irrigation fluid are vaporized Fig. 4. The total energy (kW s) during TURP (a) and TUVP (b).
equally, the energy necessary to vaporize a gram of The ordinate shows the total amount of energy used and the
abscissa the operative duration. Despite a comparable total
prostatic tissue can be up to 5000 W. The total energy
operative duration, the amount of energy used during TUVP was
used during TUVP is 810-fold higher than that of seven times higher than TURP. Green, Energy used during
conventional TURP (Fig. 4) [74,77,78]. Furthermore, coagulation. Light red, Energy used during cutting. Dark red,
the electrode must be activated for substantially longer Energy used during vaporization. Data courtesy of G. Farin, ERBE
than during TURP [76]. Elektromedizin GmbH, Tubingen, Germany.

1999 BJU International 83, 227237

234 S. MADERSB AC HER and M. MARB ERGER

larger oval TURP loops can be used without increasing

Band loops
the overall instrument diameter (Fig. 5). This technical
As a logical consequence, the ideal transurethral electros- modification increases the eCectiveness of the resection
urgical principle would combine eCective tissue removal loop by up to 30%, permitting faster tissue removal and
(and not only coagulation) comparable with TURP, paral- smoother planes of resection, thus facilitating wound
leled by improved tissue coagulation, reducing intraoper- healing, reducing inflammatory reaction and postopera-
ative bleeding. Physical data and clinical experience with tive dysuria. In conclusion, ongoing technical develop-
standard TURP loops and TUVP resulted in the develop- ments improve eBcacy and reduce the morbidity of
ment of band loops [73,79]. These have the same diam- TURP.
eter at the cutting edge as standard TURP loops (0.3 mm)
but are four times wider. Consequently, with an identical
Conclusions
speed of resection, the current directed laterally to the
tissue is four times greater [73,79]. As haemostasis is also For clinical eBcacy, TURP remains the gold standard,
a function of conduction time, band-loop resection results as improvements in uroflowmetry, PVR and BOO are
in a more eBcient coagulation of bleeding vessels than better than after alternative treatment strategies
does standard TURP. Electrophysical studies showed that
the amount of energy delivered into the tissue is highly
correlated with the thickness of the band loop. For the
standard TURP loop (0.3 mm) and a resection time of
2.5 s, 195 W are delivered, while 270 W is used by using
the band loop (1.2 mm). Furthermore, the increased mass
of the band loops allows the device to be used at a higher
energy [73,79]. Thermometry at the surface of band loops
at 300 W showed temperatures of 300315C, whereas
the standard TURP loops at 160 W obtained peak tempera-
tures of 130C. In parallel to TUVP, the use of higher
energies has been a cause of concern for patient safety.
However, tissue thermometry studies have shown that
beyond 4 mm from the band loop, temperatures increase
by no more than 4C. Pathological evaluation revealed no a
adjacent organ or nerve damage. The coagulation depth
with the band loop is greater, which presumably is the
factor responsible for improved haemostasis [73,79].
To date, no RCTs comparing standard to band-loop
prostatectomy are available, but results of phase-II trials
are encouraging. Faul et al. [79] reported their experience
with a band-loop TURP in 182 patients in an unran-
domized phase-II study, with results comparable to stan-
dard TURP. Serum haemoglobin decreased only slightly,
from 155 g/L before surgery to 142 g/L after 24 h, and
no patient required a blood transfusion. The mean duration
of catheter drainage was 48 h. Histological evaluation of
the tissue chips after band-loop TURP was not impaired.
The mean (range) resected weight in this series was 27
(10.5103) g and the mean resection time 26 (775) min
[79]. The incidence of postoperative urethral strictures
seems to be comparable with that after TURP.

Oval TURP loops
The incidence of urethral strictures increases substan-
tially if the diameter of the resectoscope exceeds 25 F,
indicating that anatomical limits hinder the application
of larger instruments. By using oval-section instruments,
b
Fig. 5. Resection loop (a) and tissue-resection pattern (b) using an
oval resection loop. The oval TURP loop enhances tissue removal
by #30% and allows a smoother resection area. (b) shows the
comparison of the tissue resection pattern of a standard (top) and
an oval (bottom) TURP-loop.

1999 BJU International 83, 227237


[2048]. The durability of the clinical response after
TURP is unsurpassed, underlined by a consistently higher
failure rate requiring re-intervention (usually TURP)
after less invasive therapies (Table 2). The major intra-
operative complication of TURP is bleeding requiring
a blood transfusion, and future technical developments
should be directed at improving intraoperative haemo-
stasis. Finally, the current morbidity of TURP is lower
than previously reported and is expected to decrease
further by (i) advances in technology, (ii) improved
surgical technique and (iii) better patient selection.
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Authors
S. Madersbacher, MD, StaC Member.
M. Marberger, MD, Professor and Chairman.
Correspondence: Dr M. Marberger, Department of Urology,
University of Vienna, Wahringer Gurtel 1820, A-1090
Vienna, Austria.