Arab Journal of Urology (2014) 12, 251–255 Arab Journal of Urology (Ofﬁcial Journal of the Arab Association of Urology) www.sciencedirect.com ORIGINAL ARTICLE A short-term evaluation of the safety and the eﬃcacy of bipolar transurethral resection of the prostate in patients with a large prostate (>90 g) Mohamed M. Abdallah , Mohamed O. Badreldin Urology Department, Menouﬁya University Hospital, Menouﬁya University, Egypt Received 22 July 2014, Received in revised form 28 October 2014, Accepted 29 October 2014 KEYWORDS Abstract Objective: To evaluate the efﬁcacy and safety of bipolar transurethral resection of the prostate (TURP) in patients with a large prostate (>90 g), as a sig- Bipolar; niﬁcant recent modiﬁcation of TURP is the incorporation of bipolar technology, Transurethral which uses the same technique as monopolar TURP but with normal saline as the prostatectomy; irrigant. Large prostate Patients and methods: Forty patients with a prostate of >90 g and who were con- sidered at risk for monopolar TURP were treated by bipolar TURP. The operative ABBREVIATIONS duration, resection time, resected tissue weight, resection rate, resection ratio, Q , maximum amount of irrigation ﬂuid used, the decrease in intraoperative haemoglobin level, max urinary ﬂow rate; haematocrit and serum sodium levels, and the blood loss were recorded. The PVR, postvoid residual follow-up data were analysed. urine volume Results: The mean (SD) operative duration was 116.3 (25.52) min, the resection time was 106.5 (25.69) min, the resected volume was 78.9 (20.58) g, the decrease in haemoglobin levels was 1.67 (0.46) g/dL, the mean serum sodium decline was 2.60 (0.68) mmol/L, and the blood loss was 532 (101.2) mL. The blood loss/g of resected tissue was 6.85 (0.70) mL. The mean (SD) postoperative bladder irrigation time was 2.0 (0.32) days, the catheterisation time was 3.25 (0.55) days and the postoperative hospital stay was 3.25 (0.55) days. This journal is partially supported by Karl Storz GmbH. That support had no inﬂuence on the peer-review of this paper, which was entirely independent of Karl Storz. Corresponding author at: Faculty of Medicine, Department of Urology, Shibin Elkom, Menouﬁya, Egypt. E-mail address: firstname.lastname@example.org (M.M. Abdallah). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier http://dx.doi.org/10.1016/j.aju.2014.10.003 2090-598X ª 2014 Arab Association of Urology. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). 252 Abdallah, Badreldin Conclusion: Bipolar technology makes it possible to use TURP to treat patients with very large prostates and who are at risk when treated by the standard monopo- lar technology, with a satisfactory safety proﬁle and with favourable efﬁcacy. ª 2014 Arab Association of Urology. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/3.0/). Introduction Japan) , and thus bipolar TURP is not a homogenous technique. The efﬁcacy and the safety of each bipolar device must be evaluated separately . BPH is a disease of older men and thus comorbid con- The aim of the present study was to determine ditions are common. The complications of TURP have whether bipolar TURP adds any advantage to standard been reduced over the last two decades due to advances TURP in patients with large prostates who are at risk if in technology and mechanics. However, concerns treated by standard monopolar TURP, and if bipolar remain about complications, such as TUR syndrome, TURP is safe and effective. Thus we evaluated the efﬁ- blood loss and urethral strictures . Despite the intro- cacy and safety of bipolar TURP in patients with a large duction of alternative procedures, TURP is still the stan- prostate (>90 g). dard operation for managing BPH in small and medium-sized prostates . TURP has undergone many Patients and methods modiﬁcations over the last two decades to decrease the rate of perioperative complications . Different types of irrigant solutions have been used Forty patients with a prostate of >90 g and who were for TURP, e.g., distilled water, sorbitol, glycine, manni- considered at risk using monopolar TURP were treated tol and normal saline. Fluid absorption during TURP is using bipolar TURP by one surgeon who had extensive inevitable and carries the risk of developing TUR syn- experience (10 years) in monopolar TURP. The study drome, with serious morbidity and mortality . Nor- was conducted at the authors’ institution between 2011 mal saline as an isotonic solution is the most and 2013, as a prospective study. The indications for physiological irrigant for TURP, but it conducts elec- TURP included moderate to severe LUTS not respond- tricity and this prohibits its use with conventional ing to medical treatment, refractory retention due to monopolar TURP . A signiﬁcant recent modiﬁcation prostatic obstruction, recurrent haematuria due to of TURP is the implementation of bipolar technology. BPH, effects on the upper urinary tract system and Bipolar TURP uses the same technique as monopolar recurrent UTIs due to prostatic enlargement. TURP but can be done using normal saline as the irri- An informed consent was obtained from all patients, gant, and thus bipolar TURP is now being widely used and all patients were assessed by a detailed medical his- . tory, physical examination, laboratory evaluation and The principles of bipolar resection using high-fre- uroﬂowmetry study. quency current have been tested experimentally and clin- We used the TURis system (ERBE VIO 300 D, ically by different manufacturers . Bipolar TURP is Gyrus), which is compatible with the Karl-Storz bipolar similar to monopolar TURP, but requires a specialised TURP system, using a cutting mode setting of 200– resectoscope and loops that can return the current 280 W and a coagulation mode setting of 80–120 W. through the loop or within the inner sheath. As it per- We used a 26-F continuous-ﬂow resectoscope with a mits cutting in a conductive saline medium, this allows rotating inner tube and separate irrigation channels, an the operation to be performed using normal physiolog- active bipolar working element from Karl-Storz, and ical saline. The cutting loop electrode can also be used bipolar cutting and vaporising loop electrodes (all to coagulate, and modiﬁcations of the electrode also Karl-Storz, Germany). The irrigant used was isotonic allow tissue vaporisation . 0.9% saline at room temperature (Figs. 1 and 2). The advantages of bipolar resection are the use of The surgical technique for bipolar TURP is similar to normal saline as an irrigant, reducing the risk of TUR that for monopolar TURP, with a few differences. The syndrome, and an improvement in haemostasis, result- resection is started at the bladder neck, followed by ing in better intraoperative visualisation, a shorter cath- resection of the lateral lobes and then the anterior lobe, eterisation time and reduced hospital stay . with the apical tissue resected last. During the ‘cutting’ There are many types of bipolar devices in the mar- resection in bipolar TURP, the ‘plasma corona’ should ket, e.g., a controlled tissue-resection system (ACMI, be developed before starting the resection. The cutting Marlborough, MA, USA), a plasmakinetic system loop should be held away from the prostate tissue by a (Gyrus ACMI, Southborough, MA, USA), and transu- few millimetres when initiating the cutting current via rethral resection in saline (TURis, Olympus, Tokyo, the foot pedal. The prostate chips are created in a way Bipolar transurethral resection of the prostate 253 of irrigant used, and the declines in intraoperative hae- moglobin level, haematocrit and serum sodium. The blood loss was estimated from the preoperative haemo- globin concentration, volume of irrigant used, and hae- moglobin concentration in the irrigation ﬂuid return obtained immediately after ﬁnishing the procedure. The irrigant return should be heparinised during the procedure by adding 1500 IU of heparin/8 L of irrigant return, then uniformly mixed to prevent coagulation of the blood contents. The blood loss was then calculated as reported previously [10,11], i.e., the preoperative hae- moglobin concentration, minus that in the irrigant return (g/dL) · volume (L) · 1000. The rate of blood loss (amount of blood loss/resection time) and the Figure 1 Cutting and vaporising bipolar loops. amount of blood lost/g of resected tissue were also cal- culated. Intraoperative complications and blood trans- fusions when indicated were recorded. The postoperative evaluation included vital signs (pulse, blood pressure, and temperature), immediate complete blood count and serum sodium levels, analge- sic requirements, the need for blood transfusion, bladder irrigation time, catheterisation time, hospital stay, and complications, if present. All patients were followed for P1 year using the IPSS, uroﬂowmetry and measure- ments of maximum urinary ﬂow rate (Q ) and the max postvoid residual urine volume (PVR). The results were assessed statistically by a univari- ate analysis of the pre and post-operative IPSS, PVR and Q (at 1 month and 1 year) using the Wilcoxon test. max Figure 2 26-F continuous-ﬂow resectoscope, working element, Results cutting and vaporising loop electrodes, and bipolar cord. similar to those in monopolar TURP and are displaced The mean (SD) age of the patients was 67.7 (3.96) years. into the bladder by the inﬂow of the saline solution. The Twelve (30%) presented in acute urinary retention, 28 chips are then removed from the bladder. If there is a (70%) had moderate to severe LUTS, and 26 (65%) delay between operating the cutting switch and initia- had associated comorbidities in the form of diabetes tion of the plasma corona there is probably charred tis- mellitus, hypertension, cardiac diseases, and renal sue on the surface of the loop. When that occurs the impairment. The mean baseline data and values immedi- loop should be placed away from tissues and this allows ately after TURP are summarised in Table 1. the plasma to be formed for a few seconds, which cleans Complications during the ﬁrst month after TURP the loop. During coagulation, no plasma is formed, and were classiﬁed according to the modiﬁed Clavien system instead a whitish area around the coagulated point is . The grade I complications included haematuria visible. Bipolar TURP has the advantage of vaporising with or without blood clot retention in three patients, the adenoma in areas that are difﬁcult to be resected and they were managed by bedside bladder irrigation. Another three patients developed a UTI and they were by the cutting loop. Importantly, there should be no dilutional hypona- managed by antibiotics. The grade II complications traemia with bipolar TURP, but volume overload is a included one patient who developed hypertension and potential risk, so the regular administration of a loop signs of volume overload; he had a history of ischaemic diuretic (furosemide 40 mg) after an hour of surgery is heart disease, and this complication was managed by the recommended. anaesthesiologist using furosemide diuretics (0.1 mg/kg) The operative data recorded were the type of anaes- as an initial bolus dose, followed by 0.1 mg/kg/h. The thesia, operative duration, resection time (the time from dose could be doubled every 2 h to a maximum of starting the resection until the insertion of the three-way 0.4 mg/kg/h, guided by central venous pressure. urethral catheter), resected tissue weight, resection rate Another two patients required blood transfusion after (resected tissue weight/resection time), resection ratio TURP when the haemoglobin level was <10 g/dL, (resected tissue volume/total prostate volume), amount and one unit of blood was transfused to each patient. 254 Abdallah, Badreldin Discussion Table 1 Baseline data and values immediately after TURP. Variable Mean (SD, range) There are other studies of bipolar TURP in patients Baseline with large prostate glands, and Table 3 summarises the Prostate size (g) 124.4 (34.5, 95–220) data of the present and other studies [13–16]. Kan IPSS 27.0 (3.78, 22–33) Q (mL/s) 6.20 (2.07, 3.5–9.2) et al.  reported a mean (SD) operative duration of max PVR (mL) 195.7 (119.2, 50–350) 87.0 (34.3) min, a resected volume of 45.7 (18.2) g, and PSA (ng/dL) 4.66 (2.27, 0.7–8.8) mean declines in haemoglobin of 1.1 (1.0) g/dL, and a Haemoglobin (g/dL) 14.20 (0.64, 13.2–15.8 serum sodium level of 0.5 (3.2) mmol/L, and with only Haematocrit (%) 41.59 (2.15, 39.1–46.9 one case of intraoperative bleeding in the bipolar TURP Serum Na+ (mmol/L) 139.05 (3.36, 134–145) group. Their results are comparable to those in the pres- Immediately after TURP ent study, and the differences were due to the smaller Haemoglobin (g/dL) 12.53 (0.72, 11.1–14.2) baseline prostate size they selected. Haematocrit (%) 36.91 (2.04, 34.2–41.4) Serum Na+ (mmol/L) 136.45 (3.63, 131–143) Kwon et al.  also reported similar results in their Decline in: bipolar TURP group, with a mean operative duration of haemoglobin (g/dL) 1.67 (0.46, 1.2–2.8) 132.9 (49.8) min, a resected volume of 41.4 (11.9) g, a haematocrit (%) 4.68 (1.15, 3.3–7.5) resection rate of 0.34 (0.11) g/min and an intraoperative serum Na+ (mmol/L) 2.60 (0.68, 2–4) decline in haemoglobin of 1.2 (1.0) g/dL and a sodium Calculated blood loss (mL) 532.0 (101.2, 417–777) Blood loss rate (mL/min) 5.06 (0.59, 4.1–6.3) level of 1.1 (2.2) mmol/L, with no severe intraoperative Blood loss/g resected tissue (mL/g) 6.85 (0.70, 5.24–8.04) bleeding that required a blood transfusion, and no sig- Bladder irrigation time (days) 2.0 (0.32) niﬁcant intraoperative complications. Catheterisation time (days) 3.25 (0.55) The present results are also similar to those of Finley Hospital stay (days) 3.25 (0.55) et al. , who reported a mean resection time of 163 min and a mean resected tissue weight of 80.8 g. A mean of 6.1 L of saline was used, with a mean decline in haemoglobin of 2.1 g/dL and in serum sodium of Table 2 Univariate analysis comparing variables before, and 3.3 mmol/L, with no patient requiring a blood transfu- at 1 month and 1 year after TURP, using the Wilcoxon test. sion. Bhansali et al.  reported that bipolar TURP Time IPSS PVR (mL) Q (mL/s) max might be advantageous for reducing the blood loss in Before 27.0 (3.78) 6.2 (2.07) 195.7 (119.2) men with a large prostate, as they reported signiﬁcantly 1 month 8.2 (1.6) 41.5 (23.0) 18 (1.6) less blood loss in the bipolar TURP group (196 mL) P <0.001 <0.001 <0.001 1 year 6.3 (1.4) 31 (18) 19 (1.9) than with conventional TURP (361.5 mL). P <0.001 <0.001 <0.001 In the present study two patients required blood transfusion and there were only three with complica- tions (one with haematuria and clot retention, and two with recurrent attacks of UTI and urethral stricture). All patients were followed up by assessing the IPSS, These results are comparable to those of Kwon et al. Q and PVR, with results after 1 month for 38 and max , who reported no complications in the bipolar at 1 year for 31 patients (Table 2). TURP group. The hospital stay was 6.3 (1.3) days in At 9 and 11 months respectively, two patients com- their bipolar group, which was signiﬁcantly shorter than plained of lower urinary tract obstructive symptoms, that of the monopolar TURP and open prostatectomy with recurrent attacks of UTI, and investigations groups, and there was no need for a blood transfusion showed a bulbar urethral stricture that was managed in the bipolar group. They reported two cases of TUR endoscopically by visual internal urethrotomy. Table 3 A comparison of the results before and after TURP in the present study and other similar studies. Variable Present     No. of patients 40 4 35 17 86 Preoperative Prostate size (g) 124.4 (34.5) 207.4 82.4 (18.0) 117.9 (18.6) 115.2 IPSS 27.0 (3.78) 31 – 22.5 (5.9) 21.8 Q (mL/s) 6.20 (2.07) – 4.37 (1.18) 5.6 (4.9) 7.1 max PVR (mL) 195.7 (119.2) 505 – – 161.2 Postoperative IPSS 8.2 (1.6) 2.75 6.5 8.9 (4.9) 11.6 Q (mL/s) 18.1 (1.64) – 19.9 (3.9) 15.9 (4.7) 15.1 max Bipolar transurethral resection of the prostate 255 syndrome and three patients (16%) required blood Source of Funding transfusions in the monopolar TURP group. Finley et al.  reported a mean catheterisation time None. of 76 h and a mean hospital stay of 12 h, the shorter hospital stay being due to the postoperative protocol, References as patients were discharged with a urethral catheter in situ as soon as their urine became clear. They also  Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP) – incidence, reported that no patient required blood transfusion management, and prevention. Eur Urol 2006;50:969–79. and there were no complications during or after TURP.  Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton Kan et al.  reported a mean hospital stay of 4.8 JJ, de la Rosette JJ. EAU 2004 guidelines on assessment, therapy (2.5) days; six patients (7%) received blood transfusions and follow-up of men with lower urinary tract symptoms and 11 (13%) developed complications in the form of suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol 2004;46:547–54. retention of urine, readmission for haematuria, and  Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth re-operations for prostatic enlargement and urethral 2006;96:8–20. stricture.  Singh H, Desai MR, Shrivastav P, Vani K. Bipolar versus Bhansali et al.  reported transfusion rates of 6% monopolar transurethral resection of prostate: randomized con- and 21% in their bipolar and monopolar TURP groups, trolled study. J Endourol 2005;19:333–8.  Mamoulakis C, Trompetter M, de la Rosette J. Bipolar transu- respectively, and the catheterisation time was 19.5 h in rethral resection of the prostate: the ‘golden standard’ reclaims its the bipolar group, vs. 39.3 h in the monopolar group, leading position. Curr Opin Urol 2009;19:26–32. which was statistically signiﬁcant. The hospital stay  Botto H, Lebret T, Barre P, Orsoni JL, Herve JM, Lugagne PM. was shorter in the bipolar than in the monopolar group Electrovaporization of the prostate with the Gyrus device. J (1.4 vs. 2.6 days). Endourol 2001;15:313–6.  Issa MM. Technological advances in transurethral resection of In the present study there were signiﬁcant improve- the prostate: bipolar versus monopolar TURP. J Endourol ments (P < 0.001) in all the follow-up variables com- 2008;22:1587–95. pared to the baseline values (Table 2). Kwon et al.   Starkman JS, Santucci RA. Comparison of bipolar transurethral also reported a highly signiﬁcant improvement in the resection of the prostate with standard transurethral prostatecto- IPSS and Q from baseline values after bipolar TURP my: shorter stay, earlier catheter removal and fewer complica- max tions. BJU Int 2005;95:69–71. in large prostates (>100 g) at 3 months after TURP  Faul P, Schlenker B, Gratzke C, Stief CG, Reich O, Hahn RG. (Table 3). This was also in accord with the results of Clinical and technical aspects of bipolar transurethral prostate Kan et al. , who reported a signiﬁcant improvement resection. Scand J Urol Nephrol 2008;42:318–23. in the IPSS and Q from baseline values after bipolar max  Ekengren J, Hahn RG. Blood loss during transurethral resection TURP in large prostates of >100 g (Table 3). Finley of the prostate as measured by the HemoCue photometer. Scand J Urol Nephrol 1993;27:501–7. et al.  reported that the mean IPSS and PVR  Hahn RG, Fagerstrom T, Tammela TL, Van Vierssen Trip O, reﬂected a signiﬁcant improvement from baseline values Beisland HO, Duggan A, et al. Blood loss and postoperative after bipolar TURP for such large prostates. This was complications associated with transurethral resection of the comparable to the results of Bhansali et al.  who also prostate after pretreatment with dutasteride. BJU Int reported a highly signiﬁcant improvement in IPSS and 2007;99:587–94.  Mamoulakis C, Efthimiou I, Kazoulis S, Christoulakis I, Sofras Q from baseline after bipolar TURP in large pros- max F. The modiﬁed Clavien classiﬁcation system. A standardized tates (>70 g) at a mean of 3 months of follow-up platform for reporting complications in transurethral resection of (Table 3). the prostate. World J Urol 2011;29:205–10. In conclusion, despite the relatively few patients and  Finley DS, Beck S, Szabo RJ. Bipolar saline TURP for large short follow-up in the present study, bipolar technology prostate glands. Scientiﬁc World J 2007;7:1558–62.  Bhansali M, Patankar S, Dobhada S, Khaladkar S. Management allowed TURP in patients with very large prostates and of large (>60 g) prostate gland: PlasmaKinetic Superpulse who were at risk if treated by standard monopolar (bipolar) versus conventional (monopolar) transurethral resection TURP, with a satisfactory safety proﬁle and with of the prostate. J Endourol 2009;23:141–5. favourable efﬁcacy. The higher resection speed due to  Kwon JS, Lee JW, Lee SW, Choi HY, Moon HS. Comparison of better vision and better haemostasis, in combination effectiveness of monopolar and bipolar transurethral resection of the prostate and open prostatectomy in large benign prostatic with absence of time-limiting risk factors, enabled the hyperplasia. Korean J Urol 2011;52:269–73. surgeon to resect as much prostatic tissue as possible.  Kan CF, Tsu HL, Chiu Y, To HC, Sze B, Chan SW. A prospective study comparing bipolar endoscopic enucleation of Conﬂict of interest prostate with bipolar transurethral resection in saline for management of symptomatic benign prostate enlargement larger than 70 g in a matched cohort. Int Urol Nephrol 2014;46:511–7. None.
Arab Journal of Urology
– Taylor & Francis
Published: Dec 1, 2014
Keywords: Bipolar; Transurethral prostatectomy; Large prostate; Q max , maximum urinary flow rate; PVR, postvoid residual urine volume