Yasunori Hiraoka

Transurethral Enucleation of Benign Prostatic Hyperplasia

AbstractA prostatic detaching blade for a new endoscopic method has been devised for transurethral resection of the prostate along the cleavage plane at the surgical capsule. After partial resection of the adenoma with the loop the remaining adenoma, except for a portion at the bladder neck, is detached from the surgical capsule under direct vision with the detaching blade. The remaining adenoma then is removed by the electric loop down to the detached surgical capsule. This method of resection has been performed in 200 patients with improvement of symptoms in all. Detachment of the adenoma along the surgical capsule always is possible, thereby defining the depth of resection and minimizing the risk of capsular perforation compared to standard transurethral prostatectomy (J. Urol., 142: 1247-1250, 1989)

Trial of Complete Detachment of the Whole Prostate Lobes in Benign Prostate Hyperplasia by Transurethral Enucleation of the Prostate

Introduction: We tried a complete detachment of the whole prostate lobes for benign prostate hyperplasia (BPH) by transurethral enucleation of the prostate (TUE). The feasibility of a new modified TUE technique (transurethral detaching prostatectomy = TUDP) was assessed by retrospective analysis. Materials and Methods: For 46 BPH cases the whole prostate lobes were detached from the surgical capsule completely by a prostate-detaching blade and resectoscope beak, and dropped into the bladder. The detached prostate lobes were removed by a soft tissue morcellator. The preoperative total prostate and adenoma volume by transabdominal ultrasound measurement (TAUS) were 47.75 ± 25.63 and 27.8 ± 17.33 ml. Results: In all 46 BPH cases, the whole prostate lobes could be detached completely without a perforation. Transurethral resection (TUR) syndrome and blood transfusion were not seen. Operation time was 54.28 min. The mean of removed tissue weight, that of hemoglobin loss and that of decrease of serum sodium was 37.11 g, 1.65 mg/dl and 1.56 mEq/l, respectively. Postoperative prostate volume and PSA were decreased to 9.56 ml and 0.8 ng/ml with complete removal of an adenoma. Conclusions: TUDP could achieve complete removal of even a large adenoma without perforation, transurethral resection syndromes and blood transfusion safety.

Measurement of Residual Adenoma after Transurethral Resection of the Prostate by Transurethral Enucleation Technique

Objective: Transurethral resection of the prostate (TURP) leaves a lot of residual adenoma and has a high recurrence rate, but the residual adenoma weight has not been measured surgically. Using surgery we tried to measure the residual adenoma after TURP. Material and Methods: Total adenoma resection was performed via standard TURP in 64 cases with benign prostatic hyperplasia and the weight of the residual adenoma was measured by transurethral enucleation (TUE) of the prostate. Results: Prostate volume averaged 37.4 ml and adenoma volume averaged 20.6 ml by TRUS. The average weight of the prostate removed by TURP was 9.8 g. After TURP residual adenoma was confirmed in all cases by TUE, and the average weight of the residual adenoma was 10.2 g. The total average prostate volume removed by TURP and TUE was 20.1 g. The average residual rate of the adenoma removed by TURP was 54.5%. Conclusion: TURP leaves about half of the adenoma. Therefore, TURP might be very difficult for complete resection of an adenoma.

Prostate-Specific Antigen Levels and Density in the Internal and External Glands of the Prostate in Benign Prostatic Hyperplasia Patients with Normal or Gray-Zone PSA Levels

Objective: In patients with benign prostatic hyperplasia (BPH) showing normal prostate-specific antigen (PSA) levels (normal PSA group) and those with BPH showing gray-zone PSA levels (gray-zone PSA group), we assessed PSA levels secreted from the internal and external glands. Materials and Methods: We performed transurethral enucleation of the prostate (TUE) in 102 BPH patients with normal PSA and 59 BPH patients with gray-zone PSA at our department from 1999 to 2001. Preoperatively and approximately 6 months postoperatively, we measured serum PSA levels and determined prostatic volumes via transrectal ultrasonography (TRUS) to calculate PSA levels secreted from the internal and external glands as well as various PSA density (PSAD) values. Results: The total PSA level was 1.8 and 6.1 ng/ml in the normal and gray-zone PSA groups, respectively. The PSA level of the external gland was 0.6 and 0.8 ng/ml and the PSAD of the external gland was 0.07 and 0.08 ng/ml/cm3 in the normal and gray-zone PSA groups, respectively. The internal gland PSA was 1.3 and 5.4 ng/ml and the internal gland PSAD value was 0.11 and 0.30 ng/ml/cm3 in the normal and gray-zone PSA groups, respectively. Conclusions: Our results demonstrated that increased PSA levels in BPH cases with gray-zone PSA were attributable to increased PSA secreted from the internal gland rather than from the external gland. In our opinion, the determination of PSA and PSAD of the internal and external gland may be clinically significant in the future.

Radical Perineal Prostatectomy: Development of a New Surgical Technique That Divides the Dorsal Vein Complex

Standard radical perineal prostatectomy (RPP) was observed by laparoscope through a small suprapubic incision. To increase radicalness, we designed and investigated a new technique of RPP that decreased bleeding and shortened the operation time. Subjects and Methods: Standard RPP was observed by laparoscope through a small suprapubic incision after lymph node dissection in 1 case. In 17 patients with localized prostatic cancer, the dorsal vein complex including the puboprostatic ligament was ligated and divided. The modified RPP was then performed, in which the prostate covered with the prostatic fascia in the anterior region was transected at the bladder neck. Results: The results of the laparoscopic observation in standard RPP confirmed that the prostatic fascia in the prostatic anterior region had been left and the endopelvic fascia could be broken easily and safely by a clamp or finger from the perineum. With modified RPP the dorsal vein complex was easily ligated and divided without bleeding. The prostate could be transected at the bladder neck with the prostatic fascia attached to the anterior prostate as in RRP. The operation time was 140–190 min (mean 160 ± 20.1) and the volume of bleeding was 150–512 ml (mean 224 ± 60.4). Conclusion: This modified technique of RPP that transects the dorsal vein complex may replace the current technique of RPP.

Transurethral endoscopic enucleation of the prostate (EEP)

is transurethral dull enucleation of the prostate along the false capsule of the prostate as well as open prostatectomy, the so called “anatomical” enucleation, which can achieve complete removal of the adenoma. Another one is transurethral enucleation of the prostate along the surgical capsule of the prostate as well as TURP. The removal rate of adenoma (removal weight ÷ transition zone(TI) volume × 100), total prostate volume and prostate-specific antigen (PSA) at six months after surgery are useful for evaluation of radicalness [3–5]. The removal rate of the adenoma cannot be used for evaluation now, because the reports of TI volume are very rare. The removal rate of adenoma in TUE was 104% [3, 4]. The volume of the remaining surgical capsule can be calculated by total prostate volume before surgery and removed prostate weight, which is useful for the evaluation of radicalness. The average volume of the remaining surgical capsule was 31.2 ml for holmium laser enucleation of the prostate (HoLEP) [8, 10, 12–14], 34.66 ml for TURP [8–10] 13.97 ml for TUE [3, 4], 17.8 ml for open prostatectomy [11, 12, 15] and 15.75 ml for laparoscopic prostatectomy [16, 17]. Moreover, the average of total prostate volume at 6 months after surgery was useful, which was 28 ml for HoLEP, 33.3 ml for photoselective vaporization of the prostate (PVP), 30.53 ml for TURP and 9.71 ml for TUE [5]. In both of the volume of the remaining surgical capsule and the average of total prostate volume at 6 months after surgery HoLEP, TURP and PVP were bigger than TUE, open prostatectomy and laparoscopic adenomectomy of anatomical enucleation. Comparing with the transurethral enucleation of the prostate along the false capsule of the prostate and the surgical capsule of the prostate, the recurrence rate of adenoma may be different in long-term follow-up. Barnes stated that the false capsule cannot be exposed by the sharp resection of TURP [18]. The surgical capsule is never the

Evaluation of multidisciplinary treatment of bladder cancer, especially in chemoimmunotherapy (ADM and OK-432) as a consolidation therapy

SummaryThe relapse rate of bladder cancer (transitional cell Ca) is said to be about 45%–80% even after tumor resection. Multidisciplinary treatment was designed and studied to prevent such recurrence. This treatment was designed to have three steps: induction, consolidation, and maintenance therapy. Following surgical tumor removal, OK-432 and Adriamycin (ADM) were administered as consolidation therapy, followed by administration of PSK and carboquone (CQ) in small amounts as maintenance therapy continuously for about 3 years, and the course was observed.In both consolidation and maintenance groups various non-specific immunoparameters were superior in groups receiving combined immunotherapeutic agents. Thus, the use of immunotherapeutic agents in combination with chemotherapeutic agents was considered to be effective. The 3-year recurrence rate was only 8% in the multidisciplinary treatment group, while that in the non-multidisciplinary treatment group was 61%. This approach, especially with chemoimmunotherapy (ADM and OK-432) as a consolidation therapeutic mode, is therefore considered to be useful for the prevention of recurrence.