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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 225-232

Safety and efficacy of bipolar TURP in management of benign prostatic hyperplasia


Department of Urology, Faculty of Medicine, Menoufia University, Menufia, Egypt

Date of Submission13-Mar-2014
Date of Acceptance30-Apr-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Mohamed Nabil El-Helbawy
Department of Urology, Faculty of Medicine, Menoufia University, Menufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155999

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  Abstract 

Objectives
The aim of this study was to evaluate the safety and clinical efficacy of bipolar transurethral resection of the prostate (TURP) in the treatment of symptomatic benign prostatic hyperplasia as compared with standard monopolar TURP.
Background
Monopolar TURP, which was considered the gold standard surgical therapy for men with lower urinary tract symptoms due to benign prostatic hyperplasia, was recently challenged by bipolar TURP, which uses bipolar energy for transurethral prostate resection in saline media, thus avoiding the need for glycine irrigation and its associated complications.
Materials and methods
From October 2011 to October 2013, 70 consecutive patients with symptomatic benign prostate hyperplasia were randomized into a prospective study comparing the two modalities. Resection time, resected volume, resection speed, and ratio were analyzed in both groups. Blood loss and volume of decline of hemoglobin and sodium values were determined. Postoperative catheter time and hospital stay were also recorded. Intraoperative and postoperative complications and the need for blood transfusion were noted. The improvements in International prostate symptoms score, Qmax , and postvoid residual urine after 1 and 3 months were also recorded for all patients.
Results
Comparative data on International prostate symptoms score, maximum flow rate (Qmax ), and postvoid residual urine volume showed a significant improvement with respect to baseline values in both groups, but the differences between the two groups were insignificant except for Qmax at 3 months' follow-up. Resection speed and ratio, intraoperative blood loss, serum sodium loss, postoperative catheterization time, hospital stay, and complication rate were significantly better in the bipolar group.
Conclusion
Bipolar TURP is safer than monopolar TURP because of lower risk for TUR syndrome, less intraoperative bleeding, and lower incidence of postoperative complications.

Keywords: Benign prostatic hyperplasia, bipolar, monopolar, prostate, transurethral resection of prostate


How to cite this article:
El-Helbawy MN, Abd-allah MM, Abd-Elbaky TM, Elserafy FA. Safety and efficacy of bipolar TURP in management of benign prostatic hyperplasia. Menoufia Med J 2015;28:225-32

How to cite this URL:
El-Helbawy MN, Abd-allah MM, Abd-Elbaky TM, Elserafy FA. Safety and efficacy of bipolar TURP in management of benign prostatic hyperplasia. Menoufia Med J [serial online] 2015 [cited 2019 Sep 20];28:225-32. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/225/155999


  Introduction Top


Symptomatic bladder outlet obstruction and lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH) are among the most significant problems affecting men. The application of electrosurgical current in urology began in the 19th century, and the modern electrosurgical transurethral resection of the prostate (TURP) was first described by Stern in 1926 and modified by McCarthy in 1931 [1].

Although TURP is still regarded as an effective surgical technique and has been established as the golden standard with excellent functional short-term and long-term results with a mortality rate approaching zero within the last decade, it is still associated with significant morbidity; [2] therefore, it has undergone technical improvements aiming to reduce the incidence of intraoperative and postoperative complications [3].

Irrigants used during TURP ranged from distilled water to a variety of nonhemolytic solutions such as glycine, sorbitol, and mannitol. Absorption of such hypo-osmolar solutions may result in TUR syndrome with serious morbidity and mortality [4]. As an isotonic electrolyte medium, normal saline is the most physiologic irrigant for TURP, but its electrical conducting properties prohibit its use with conventional monopolar cautery. The development of bipolar resection systems now permits the use of normal saline as irrigant [5].

Modifications, such as incorporation of bipolar technology allowing the performance of TURP in normal saline, have been made to minimize the complications of TURP and increase the volume of gland that can be safely tackled; the technique seems to be promising [6].

Bipolar electrocautery offers the advantage of active and return electrodes being placed on the same axis on resectoscopes using high current locally but with limited negative effects at a distance, which provides an advantage over the monopolar system in which the current passes through the patient's body, from the active electrode, placed on the resectoscope, toward the return plate placed on the patient's leg, with several disadvantages such as heating of deeper tissue, nerve or muscle stimulation, and possible malfunction of the cardiac pacemaker [7].

The benefits of bipolar, high-frequency current has been realized by different manufacturers on the basis of the improvements in high-frequency generators, and the standard monopolar TURP is now being challenged by bipolar resection [8].

Since its introduction, bipolar TURP has gained much popularity and has become available worldwide and, currently, challenges monopolar TURP as being the gold standard in treating BPH. The proposed advantages of bipolar resection are improved hemostasis, better intraoperative visualization, and the use of saline as an irrigant, which reduces the risk for TUR syndrome [9]. Some studies also reported shorter catheterization time and reduced hospital stay [10].


  Materials and methods Top


This study was performed in the urology department of Menofeya university hospital from October 2011 to October 2013 after being approved by the ethics committee. Seventy patients with bladder outlet obstruction due to BPH and prostate size between 40 and 90 g were randomized into two groups (the first managed by standard monopolar TURP and the second managed by bipolar TURP).

Exclusion criteria included the following: prostatic size less than 40 g or more than 90 g; proven prostate cancer; voiding disorders not related to BPH (e.g. neurogenic bladder, stricture urethra); International prostate symptoms score (IPSS) score less than 12 or Qmax greater than 12 ml/s; irreversible bleeding diathesis; bladder tumors; large bladder diverticulum or bladder stones; and patient refusing or being unsuitable for surgery.

Informed consent was taken from all patients who fulfilled the inclusion and exclusion criteria and all patients were preoperatively evaluated in detail by means of medical history taking, physical examination including DRE, laboratory investigations including serum sodium level and complete blood count, and imaging evaluation including abdominopelvic and transrectal ultrasonography to evaluate the urinary tract for associated pathology, to measure postvoid residual (PVR) urine volume, and to estimate the preoperative prostate size. IPSS was determined in all cases. Patients were further assessed by uroflowmetry (Qmax ). Assessment of IPSS, Qmax , and PVR urine volume was omitted in men presenting with urinary retention.

Monopolar TURP was performed with a 26 Fr continuous flow Karl-Storz resectoscope, an active Karl-Storz monopolar single-stem working element, and a standard thin-loop electrode. Several electrosurgical units were utilized, including Martin, EMED ES 400, and ERBE VIO 300 D electrosurgical generators, with a coagulation current of 80 W and a cutting current of 120 W. Glycine 1.5% was used for irrigation. Bipolar surgery was performed with a 26 Fr continuous flow Karl-Storz resectoscope, an active Karl-Storz bipolar double-stem working element, and a Karl-Storz bipolar cutting loop electrode. An ERBE VIO 300 D electrosurgical generator with cutting mode set on 300 W was utilized. Normal saline 0.9% was used for irrigation.

Surgical procedures were carried out under spinal or general anesthesia. Urinary tract infection (UTI) was treated before the operation, and all patients were given third-generation cephalosporin preoperatively for prophylactic purpose. At the end of the procedure a 22 For three-way Foley catheter was inserted and continuous irrigation was commenced with saline at a rate sufficient to maintain a light pink return. Irrigation was stopped as soon as the color of the returning fluid became clear. The catheter was removed 24 h after cessation of irrigation and no later than 3 postoperative days, and the patient was discharged after assurance of successful voiding.

All procedures were evaluated for operative time, resection time, resected tissue weight, resection rate (resected weight/resection time), resection ratio (resected weight/total prostate volume), and amount of irrigation fluid used. All patients were evaluated for intraoperative blood loss, blood loss rate (blood loss per minute), blood loss per each gram of resected tissue, intraoperative complication, and for the need for blood transfusion. Immediate postoperative measurement of hemoglobin, hematocrit, and serum sodium was obtained to estimate the intraoperative loss of those values. Intraoperative blood loss was estimated by measuring the patient's preoperative hemoglobin concentration, volume of irrigation fluid used, and hemoglobin concentration in irrigation return obtained immediately after finishing the procedure. The irrigation fluid return should be heparinized during the procedure by adding 1500 IU of heparin/8 l of fluid, which is uniformly mixed to prevent clotting of its blood contents. Blood loss is calculated using the following equation [11]:



Postoperative irrigation time, catheter time, and hospital stay were recorded in all patients. IPSS, uroflowmetry (Qmax ), and measurements of PVR urine were evaluated at 1 and 3 months postoperatively. Patients were also evaluated for development of postoperative complications and for reoperation for at least 6 months.


  Results Top


Of 70 patients, 35 were randomized to each monopolar and bipolar TURP group. The patient population and their preoperative characteristics are shown in [Table 1]. There was no statistically significant difference in any parameter and that validated the randomization of the study between the two groups.

The difference between the two groups was statistically insignificant regarding operative time, resection time, resected tissue weight, and volume of irrigation fluid used. The mean operative time was 69.54 ± 14.92 versus 72.71 ± 17.95 min and the mean resection time was 57.17 ± 14.64 versus 61.6 ± 17.33 min for the bipolar group and monopolar group, respectively. The mean resected prostatic tissue volume was larger in the bipolar group (42.03 ± 10.43 g) than in the monopolar group (37.68 ± 10.46 g) but the difference was statistically insignificant. The amount of irrigation fluid used during bipolar TURP was 17.57 ± 4.57 versus 19.26 ± 4.69 l during monopolar TURP. However, regarding the resection rate and ratio there were highly significant differences in favor of the bipolar group; the mean resection rate was 0.74 ± 0.05 g/min for bipolar TURP and 0.61 ± 0.05 g/min for monopolar TURP, with a mean resection ratio of 65.83 ± 4.70% in the bipolar group and 60.23 ± 4.30% in the monopolar group.

Perioperative blood loss was significantly less in the bipolar group than in the monopolar group. The mean blood loss during bipolar TURP was 280.37 ± 91.81 ml, whereas during monopolar TURP it was 350.94 ± 138.87 ml (P < 0.05); however, these differences became highly significant when corrected for resection time and resected tissue volume (P < 0.001), as during bipolar TURP the mean blood loss rate was 4.84 ± 0.65 versus 5.62 ± 0.79 ml/min during monopolar TURP, and the mean volume of blood lost for each gram of resected tissue was 6.57 ± 0.91 ml/g during bipolar TURP and 9.21 ± 1.54 ml/g during monopolar TURP.
Table 1: Comparing preoperative data in monopolar and bipolar TURP groups

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Serum Na+ loss was less in the bipolar group (1.63 ± 0.84 mmol/l) than in the monopolar group (5.04 ± 2.35 mmol/l) and the difference was highly significant. Hemoglobin loss also was less after bipolar TURP (0.77 ± 0.33 g/dl) than after monopolar TURP (0.95 ± 0.46 g/dl) but the difference between the two groups was insignificant; however, there were two cases (5.7%) of blood transfusion in the monopolar group and none in the bipolar group. Perioperative evaluation has been summarized in [Table 2] and [Table 3].
Table 2: Comparing operative data in monopolar and bipolar TURP groups (operation-related data)

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Table 3: Comparing operative data in monopolar and bipolar TURP groups (patients-related data)

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The mean postoperative irrigation time was less in the bipolar group (1.61 ± 0.45 days) than in the monopolar group (2.14 ± 0.59 days) and the difference was highly significant. The differences were also significant regarding catheter time and hospital stay; the mean catheter time was 3 ± 0.0 days for the bipolar group and 3.20 ± 0.53 days for the monopolar group, and the mean hospital stay was 3 ± 0.34 versus 3.26 ± 0.61 days for the bipolar group and the monopolar group, respectively.

Compared with baseline there was a highly significant improvement in IPSS, Qmax , and PVR urine volume in each group at 1 and 3 months postoperatively (P < 0.001), but the difference between the two groups was statistically insignificant except for Qmax evaluation at 3 months postoperatively. There was a statistically significant difference in favor of the bipolar group.

The mean IPSS after 1 and 3 months postoperatively decreased to 7.86 ± 1.85 and 5.34 ± 1.64, respectively, in the bipolar group, and in the monopolar group it decreased to 7.51 ± 2.25 and 5.46 ± 2.82. The mean Qmax values increased postoperatively in the bipolar group to 17.92 ± 2.01 and 19.21 ± 2.26 ml/s and in the monopolar group to 17.18 ± 1.88 and 18.05 ± 2.26 ml/s after 1 and 3 months, respectively; the mean PVR urine volume in the bipolar group decreased to 47.71 ± 31.82 ml after 1 month and to 25.43 ± 18.68 ml after 3 months, and in the monopolar group it decreased postoperatively to 51.71 ± 34.17 and 33.43 ± 35.97 ml after 1 and 3 months, respectively. Follow-up data are summarized in [Table 4] and [Figure 1],[Figure 2] and [Figure 3].
Table 4: Comparing follow-up data in monopolar and bipolar TURP groups

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Figure 1: Comparing the follow-up (IPSS) in monopolar and bipolar TURP groups. IPSS, International prostate symptoms score; TURP, transur ethral resection of the prostate.

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Figure 2: Comparing the follow-up (Qmax) in monopolar and bipolar TURP groups. TURP, transur ethral resection of the prostate.

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Figure 3: Comparing the follow-up (PVR urine volume) in monopolar and bipolar TURP groups. PVR, postvoid residual; TURP, transur ethral resection of the prostate.

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There were no cases of perioperative complications during bipolar TURP, but during monopolar TURP there were two cases (5.7%); in the first case the patient had significant bleeding and developed sepsis. Bleeding was controlled and 2 U of blood were transfused. Sepsis was managed in the ICU and the patient was discharged after 5 days. In the second case the patient developed symptomatic hyponatremia (TUR syndrome), and the serum Na+ level was 120 mmol/l. The patient was managed with diuretics, hyperosmolar saline, and close monitoring until the condition improved.

Regarding postoperative complications there were two cases (5.7%) in the bipolar group (one case of bulbar urethral stricture managed endoscopically and one case of delayed hematuria and clot retention) and five cases (14.3%) in the monopolar group (two cases of delayed hematuria and clot retention, two cases of bulbar uretheral stricture managed endoscopically - one of them had recurrent attacks of UTI and orchitis - and one case of residual obstructive prostatic tissue that necessitated reoperation). Intraoperative and postoperative complications are listed in [Table 5].
Table 5: Comparing perioperative and postoperative complications in monopolar and bipolar TURP groups

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  Discussion Top


BPH is a chronic age-related condition, affecting ~50% of men older than 50 years, 75% of men older than 70 years, and 90% of men older than 80 years [12]. For many years open prostatectomy had been the primary treatment option in patients with BPH until it was gradually replaced by TURP. Although TURP is still regarded the gold standard in patients with BPH, it is still associated with significant morbidity rates; [13] therefore, it has undergone several technical modifications during the last decade aiming to reduce the incidence of intraoperative and postoperative complications [3]. One of those technical modifications was incorporation of bipolar technology (B-TURP) allowing performance of TURP in normal saline to minimize the complications of TURP and increase the volume of gland that can be safely tackled; this technique seems to be promising [6]. Bipolar TURP has theoretical advantages that have to be further evaluated; in this study we further explore the potential benefits of bipolar TURP.

In this study there were no statistically significant differences between the two groups with respect to the preoperative data baseline parameters (prostate size, PSA, IPSS, Qmax , PVR urine volume, hemoglobin concentration, hematocrit percentage, and serum Na+ level), and this also validated the randomization of this study.

In our study the difference between the two groups was insignificant regarding operative time, resection time, resected tissue weight, and irrigation fluid volume. However, regarding the resection rate and resection ratio there was a highly significant difference in favor of the bipolar group: the mean resection rate was 0.74 ± 0.05 g/min for bipolar TURP versus 0.61 ± 0.05 g/min for monopolar TURP with a mean resection ratio of 65.83 ± 4.70% in the bipolar group and 60.23 ± 4.30% in the monopolar group.

Our results were in accordance with those reported by Giulianelli et al. [14] and Tefekli et al. [15]. In contrast, Michielsen et al. [16] found that bipolar TURP required significantly more time than monopolar TURP (56 ± 25 vs. 44 ± 20 min). He attributed it to the learning curve and the use of a small-sized resectoscope 24 Fr in bipolar TURP due to the loop design, and he stated that the availability of larger resection loops could resolve this technical limitation. Poh et al. [17], also in contrast to our results, found that bipolar TURP has a significantly slower resection rate than monopolar TURP (0.45 ± 0.19 vs. 0.56 ± 0.25 g/min). The reason may again be due to the smaller size of the resectoscope used for bipolar TURP 24 Fr. Fagerström et al. [18] found that the difference in the resection ratio was insignificant between the two groups (48.8 ± 21.0 and 45.3 ± 15.9% for bipolar and monopolar TURP, respectively).

We found that blood loss was significantly less in the bipolar group than in the monopolar group (280.37 ± 91.81 vs. 350.94 ± 138.87 ml; P < 0.05), which may be due to the locally limited energy field between the two electrodes in which high power levels are achieved. This high-energy field effectively coagulates bleeding vessels at the surface of the resected tissue with as less energy wasted to deeper tissue layers and less negative effect on them, also perhaps due to better visualization due to the use of normal saline as irrigant. Furthermore, the differences between the two groups became highly significant for bleeding when corrected for resection time and weight of the resected tissue (P < 0.001).

Similar results were reported by Bhansali et al. [19] (195.97 vs. 361.51 ml; P < 0.001), Fagerström et al. [18](235 vs. 350 ml; P < 0.001), and Patankar et al. [20] (140.6 ± 75.96 vs. 282.67 ± 136.1 ml, respectively). Fagerström et al. [18] also corrected the blood loss with resection time and resected tissue weight and he reported nearly similar blood loss rates (3.79 vs. 5.71 ml/min) and blood loss/g of resected tissue (11.43 vs. 14.48 ml/g) in the bipolar and monopolar groups, respectively.

In our study serum Na+ loss was significantly lower in the bipolar group (1.63 ± 0.84 mmol/l) than in the monopolar group (5.04 ± 2.35 mmol/l) because of the use of normal saline as an irrigant, the result being comparable to that of Singhania et al. [21] who reported a greater decline in serum sodium in the monopolar group (4.12 vs. 1.3 mmol/l). In another study Michielsen et al. [16] also reported less intraoperative serum Na+ loss in the bipolar group (1.44 vs. 2.23 mmol/l).

In our study we have reported a highly significantly shorter postoperative irrigation time (1.61 ± 0.45 vs. 2.14 ± 0.59 days) and a significantly shorter catheter time (3 ± 0.0 vs. 3.20 ± 0.53 days) and hospital stay (3 ± 0.34 vs. 3.26 ± 0.61 days) in the bipolar group, which was comparable to the results reported by Giulianelli et al. [14] (1 ± 0.5 vs. 2 ± 2 days for catheter time and 2 ± 0.25 vs. 3 ± 2 days for hospital stay). Patankar et al. [20] also reported a significantly shorter catheter time in the bipolar group (18.44 ± 2.7 vs. 42.4 ± 15.2 h), and Tefekli et al. [15] have mentioned a significantly shorter hospital stay after bipolar TURP (2.3 ± 0.7 vs. 3.8 ± 0.7 days; P < 0.05).

According to our results there was a highly significant improvement in IPSS, Qmax , and PVR urine volume in each group at 1 and 3 months postoperatively compared with baseline values, but the difference between the two groups was statistically insignificant except for Qmax after 3 months postoperatively, which reflects a comparable efficacy between bipolar TURP and the standard monopolar TURP.

We noticed that there was better improvement after 3 months than after 1 month postoperatively, which may be due to the gradual improvement in bladder urodynamics, which may take several months after elimination of the infravesical obstruction, and also due to the gradual improvement in some irritative symptoms resulting from the electrothermal effect of such techniques.

Our results were similar to those mentioned by Tefekli et al. [15], Singhania et al. [21], and Giulianelli et al. [14]. All of them concluded that, although there was a highly significant improvement in each group compared with baseline with respect to IPSS, Qmax , and PVR urine volume after 1 and 3 months postoperatively, the differences between the two groups were statistically insignificant; they also reported better improvements after 3 months than after 1 month, and in some studies further improvement was seen after 6 months.

In our study in the bipolar group we reported no cases of perioperative complications and two cases of postoperative complications (one case of uretheral stricture and one case of delayed hematuria with clot retention) with an overall complication rate of 5.7%, whereas in the monopolar group we reported two cases of perioperative complications (one case of symptomatic hyponatremia and one case of significant bleeding with sepsis) and five cases of postoperative complications (two cases of delayed hematuria and clot retention, two cases of uretheral stricture - one of which had recurrent UTI and orchitis - and one case necessitating reoperation) with an overall complication rate of 20%; we also reported two cases that needed blood transfusion in the monopolar group; none of the patients in the bipolar group needed blood transfusion.

Our results were similar to those mentioned by Giulianelli et al. [14] in whose study nine patients in the monopolar group and none in the bipolar group were unable to void after catheter removal, six patients in the monopolar group and one in the bipolar group developed delayed hematuria and clot retention, two patients in the monopolar group and none in the bipolar group developed UTI, and 10 patients in the monopolar group and two in the bipolar group developed bladder neck contracture. They concluded that bipolar TURP had a significantly lower postoperative complication rate compared with monopolar TURP. Starkman and Santucci [9] reported an acute complication rate of 33% in the monopolar group and 16% in the bipolar group, and a long-term complication rate of 11% after monopolar TURP and 8% after bipolar TURP.

In contrast to our results, Méndez-Probst et al. [22] reported 11 cases of postoperative complications in the bipolar group and nine cases in the monopolar group, but complications requiring intervention were not significantly different.

From our point of view we believe that the lower incidence of intraoperative and postoperative complications in the bipolar group may be due to several factors:

  1. Better hemostatic effect of the bipolar system allowed less intraoperative and postoperative bleeding;
  2. The clearer vision obtained during bipolar TURP due to the use of normal saline as an irrigant and due to better intraoperative hemostasis helped the bipolar procedure;
  3. The higher resection speed during bipolar TURP allows shorter resection time and higher resection ratio, which in turn decreased the reoperation rate;
  4. The use of normal saline as an irrigant has eliminated the risk of dilutional hyponatremia and minimized the time limit risk factor and hence allowed more comfortable and precise resection of most of the adenoma, reducing the risk of leaving residual adenoma, which in turn reduced the reoperation rate.


But we also see that these results have to be validated in a larger-scale study with a longer follow-up period for more precise evaluation of late complications.


  Conclusion Top


Bipolar TURP represents a promising endoscopic treatment alternative for patients with BPH, with comparable efficacy, shorter hospital stay, and faster recovery compared with the standard monopolar TURP, with less incidence of TUR syndrome, intraoperative bleeding, and postoperative complications. However, because of the small size of this study and the limited follow-up period our results need to be validated in a larger-scale study with a longer follow-period.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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