Treatment for an enlarged prostate depends on the severity of symptoms, with various treatments available. In rare cases, however, surgery is needed to reduce the size of an enlarged prostate by cutting away sections of the gland, known as a ‘Transurethral Resection of the Prostate’.
A team of researchers at the Cedar Healthcare Technology Research Centre in Wales, UK, present updates on a treatment known as the PLASMA system, an innovative approach which differs to traditional forms of treatment and reduces hospital stay for patients, thereby effectively cutting treatment time and costs.
Read the original article: NICE.org
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In this episode we look at a review carried out by the Cedar Healthcare Technology Research Centre in Wales in the UK.
Staffed by experienced researchers, Cedar is part of the National Health Service and has close links to Cardiff University. The centre works on a variety of projects, including carrying out independent evidence reviews to inform medical guidance published by the National Institute for Health and Care Excellence or ‘NICE’.
NICE recommends which medical treatments and drugs should be available to people through the NHS. The aim is to balance best practice in health and social care with value for money, in order to improve outcomes for everyone.
NICE updates its guidance for medical technologies every five years. One of the latest – guidance MTG53 – reviews an electrosurgical system used to treat lower urinary tract symptoms associated with an enlarged prostate in men. The condition is known as Benign Prostatic Hyperplasia or ‘BPH’.
The PLASMA system, formerly known as TURis and manufactured by Olympus Medical, was the subject of earlier guidance published in 2015. The new guidance updates and replaces the earlier guidance, recommending that the PLASMA system should be used for the treatment of BPH when surgical intervention is needed. Not only does the evidence suggest that PLASMA can reduce complications associated with treatment, it can also reduce the length of hospital stay and number of catheterisations that patients require, thereby reducing associated costs.
Let’s take a more detailed look at BPH and how it is treated.
An enlarged prostate is a common condition in men over the age of 50. An enlarged prostate places pressure on the bladder and urethra – the tube that drains urine from the bladder – and leads to problems such as a frequent need to pass urine, or difficulty in beginning to urinate.
Treatment depends on the severity of the symptoms, and can include changes in lifestyle, as well as a variety of medicines. In rare cases, surgery is needed to reduce the size of an enlarged prostate by cutting away sections of the gland.
The medical term for this procedure is ‘Transurethral Resection of the Prostate’ or ‘TURP’. Performed under anaesthetic, it involves a device called a resectoscope which the surgeon guides remotely while viewing a monitor. This small, tube-like instrument is inserted through the tip of the penis and along the urethra to the prostate. Containing a light and camera, it also incorporates a cutting tool. When sufficient tissue has been trimmed form the prostate, the resectoscope is removed and a catheter is inserted to pump fluid into the bladder and flush out the waste. The catheter is usually in place for a few days after the treatment.
NICE’s updated guidance on the use of the PLASMA system to perform TURP procedures first reviews the clinical evidence that Cedar gathered for its research.
The previous guidance was based on a review of 10 randomised studies involving 1,870 people, and one meta-analysis provided by the manufacturer. Still relevant to the updated advice, the studies all showed that PLASMA’s bipolar technology was as clinically effective as monopolar devices. Two studies reported that the PLASMA system reduced the length of hospital stay, and no studies reported any difficulties with TUR syndrome. In addition, in three studies that looked at bleeding, fewer people were reported to require a blood transfusion using the bipolar PLASMA system than when using a monopolar procedure.
The researchers looked at two additional studies from more recent publications, including one randomised controlled trial. These reported that hospitalisation time was on average 2.5 days for the PLASMA procedure, compared with 3.4 days for monopolar TURP. On the negative side, one study reported that patients using the PLASMA system reported a higher rate of urethral stricture or narrowing in the months following the procedure.
The new guidance also looks at the cost evidence for recommending the PLASMA system. This is based on information provided by three professional experts, as well as PLASMA’s manufacturer, Olympus Medical.
Independent researchers at Cedar investigated and modelled different cost scenarios. These included: the length of hospital stay and catheterisation time required by patients treated using the PLASMA system compared with monopolar TURP; whether hospitals already had Olympus equipment on site; and whether additional equipment such as an additional electrode was required.
The professional experts provided other insights into the use and development of TURP procedures within the NHS.
Compared with the previous guidance, the experts said that in their professional opinion blood transfusion rates associated with TURP may now be lower than when reviewed for the earlier guidance note. In addition, compared with monopolar systems, the PLASMA system is associated with better haemostasis – an improved ability to stem bleeding.
The experts reported that bipolar electrosurgery is now thought by many to be the ‘gold standard’ for surgical treatment of symptoms associated with enlarged prostate. It is not yet standard across the NHS, and uptake is variable across the UK, but the number of hospitals using PLASMA technology is growing. According to Olympus Medical, 100 NHS centres were using the PLASMA system in 2019, compared with 61 in 2015.
Cedar’s update on the use of the PLASMA system to treat lower urinary tract symptoms associated with an enlarged prostate in men was reviewed by an evidence advisory committee at NICE.
It found that evidence gathered for the earlier guidance note on Olympus Medical’s bipolar TURP technology is still relevant, now that the system’s name has changed from TURis to PLASMA. Although one study raised concerns about urethral stricture, this was not the professionals’ experience. As a result, the committee agreed that the PLASMA procedure is clinically effective. The committee also noted that the evidence showed that, compared with monopolar technology, the PLASMA system reduces the risk of TUR syndrome and reduces the need for blood transfusion.
Regarding cost, the committee agreed that the main reason for recommending PLASMA was the reduced length of time that patients have to remain in hospital. Although the PLASMA system is more expensive than when the original guidance was published, the committee still found it cost-effective, as it requires a day less in hospital compared with monopolar devices. Cost savings are even greater when treatment is carried out as a day-case, for example in low-risk patients. In addition to its recommendation of PLASMA, the committee agreed that purchase costs can in some cases be reduced, as it may be used with existing compatible equipment.
Dr Knight highlights “The main benefits of the PLASMA system compared to surgery using monopolar devices was the reduction in catheterization and hospitalization time. This is a big benefit to the patients but would also reduce costs associated with the procedure”
“Even if the recommendations end up being similar, it is of course very important to update the guidance so that clinicians can be assured the latest evidence has been taken into account”.
The new guidance represents NICE’s recommendations, after careful consideration of the evidence available. Healthcare professionals are expected to take the guidance into account when making clinical decisions, but they must also consider individual patients’ circumstances.
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