2 The technology

Description of the technology

2.1 Transurethral resection in saline (TURis, Olympus Medical) is a bipolar electrosurgery system designed for use when surgical intervention is indicated for prostatic enlargement.

2.2 The TURis system consists of an Olympus generator, a resectoscope, which incorporates the TURis active working element and electrode, a telescope, an inner and outer sheath, a light guide cable, and a saline cable. The active and return electrode are contained within the resectoscope at the site of the operation, eliminating the need for a patient return electrode because TURis uses saline irrigation fluid to conduct electrical current within the resectoscope. The surgeon uses an endoscopic image to guide the electrode assembly through the urethra to the prostate. The electrode is then used to cut and coagulate prostate tissue and saline is used to flush the bladder free of resected prostate tissue and blood. Electrodes are available in different sizes and shapes (described as loop, button and roller) for cutting or coagulation and to take into account surgeon choice. Generally a loop is used to repeatedly cut out small chippings to create a wide channel through the prostate and a roller or button may be used to achieve haemostasis. The prostatic chippings are flushed out before inserting a urethral urinary catheter at the end of the procedure.

2.3 The components of the TURis system are covered by individual CE marks. The most recent of these was issued in 2013 for the TURis working element.

2.4 The list prices for the components of the TURis system for transurethral resection of the prostate (excluding VAT) are:

  • £8905 for the resectoscope assembly (which includes the active working element, telescope, inner and outer sheath, light guide cable and saline cable).

  • £14,681 for an ESG‑400 Olympus generator.

  • Single‑use roller and loop electrodes are £156.67 and £126.67 respectively. Each TURis procedure uses 1 loop electrode and some procedures, typically 1 in 5, use an additional roller electrode.

    The ESG‑400 Olympus generator is usually provided at no cost as part of contractual arrangements with Olympus to purchase electrodes at list price.

2.5 The claimed benefits of the TURis system for transurethral resection of the prostate presented by the company were:

  • Reduced risk of transurethral resection syndrome through the use of saline irrigation fluid.

  • Reduced risk of postoperative blood transfusion because of intraoperative bleeding.

  • A shorter length of stay in hospital due to a shorter surgical procedure and fewer intra‑ and postoperative complications.

  • Earlier catheter removal time for improved patient comfort.

  • A quicker procedure compared with monopolar transurethral resection of the prostate (TURP) so more men can be treated.

  • Fewer complications during and after surgery resulting in lower readmission rates.

  • Reduced costs (associated with postoperative blood transfusion, healthcare‑associated infection, length of hospital stay, postoperative irrigation and a patient return electrode).

  • The use of saline irrigation fluid is cheaper and more readily available than glycine.

Current management

2.6 The NICE guideline on lower urinary tract symptoms defines benign prostate enlargement as an increase in the size of the prostate gland because of benign prostatic hyperplasia, and states that about 50% of men with benign prostatic hyperplasia will develop benign prostatic enlargement. It recommends that surgery is offered only if voiding lower urinary tract symptoms are severe or if drug treatment and conservative management options have been unsuccessful or are not appropriate.

2.7 For surgical treatment of benign prostatic enlargement, the NICE guideline on lower urinary tract symptoms recommends the use of monopolar or bipolar TURP, monopolar transurethral vaporisation of the prostate or holmium laser enucleation of the prostate.

2.8 The NICE guideline on lower urinary tract symptoms also recommends some alternative options:

  • Transurethral incision of the prostate (TUIP) can be offered as an alternative to other types of surgery to men with a prostate estimated to be smaller than 30 g.

  • Open prostatectomy should only be offered as an alternative to other types of surgery to men with prostates estimated to be larger than 80 g.

  • Other alternatives such as laser vaporisation techniques, bipolar transurethral vaporisation of the prostate or monopolar or bipolar transurethral vaporisation resection of the prostate should only be considered as part of a randomised controlled trial that compares these techniques with TURP.

  • National Institute for Health and Care Excellence (NICE)