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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 523-527

Role of bipolar plasma enucleation of the prostate in the treatment of benign prostatic hyperplasia


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

Date of Submission09-May-2016
Date of Decision05-Jul-2016
Date of Acceptance10-Jul-2016
Date of Web Publication27-Jun-2020

Correspondence Address:
Ahmed S Ghonaimy
Department of Urology, Faculty of Medicine, Menoufia University, Shebin El Kom, Menoufia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_249_16

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  Abstract 


Objective
The aim was to evaluate the role of bipolar plasma enucleation of the prostate as regards surgical efficacy and perioperative morbidity in the treatment of benign prostatic hyperplasia (BPH) in comparison with bipolar transurethral resection of the prostate (TURP).
Background
Bipolar plasma enucleation has been reported to be a new method for the management of BPH.
Patients and methods
A total of 30 patients with lower urinary tract symptoms associated with BPH were included in this study. Of these, 20 patients underwent bipolar TURP and 10 underwent bipolar plasma enucleation. All patients were preoperatively assessed and were evaluated at 3 months after surgery. The International Prostate Symptom Score, postvoid residual urine volume, and maximum flow rate were obtained at the follow-up. Immediate and late complications were recorded.
Results
The authors found that the differences were statistically significant regarding calculated blood loss during operation with less blood loss in the enucleation group. The resected tissue volume was more in the enucleation group but without statistically significant difference. Postoperative hemoglobin and sodium drop were less in the enucleation group. The mean postoperative bladder irrigation time, catheter time, and hospital stay were similar in both groups. Transurethral resection syndrome did not occur in any patient in this study. All patients in both groups showed marked improvement in clinical evaluation after 3 months postoperatively.
Conclusion
The authors observed that bipolar plasma enucleation of the prostate can be a promising endoscopic treatment alternative for patients with BPH, showing comparable efficacy, hospital stay, and faster recovery compared with bipolar TURP, with less incidence of intraoperative and postoperative complications.

Keywords: benign prostatic enlargement, bipolar, enucleation


How to cite this article:
El Din AG, Abd-Al Baky TM, El-Sherif EA, Ghonaimy AS. Role of bipolar plasma enucleation of the prostate in the treatment of benign prostatic hyperplasia. Menoufia Med J 2020;33:523-7

How to cite this URL:
El Din AG, Abd-Al Baky TM, El-Sherif EA, Ghonaimy AS. Role of bipolar plasma enucleation of the prostate in the treatment of benign prostatic hyperplasia. Menoufia Med J [serial online] 2020 [cited 2020 Jul 16];33:523-7. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/523/287764




  Introduction Top


Benign prostatic hyperplasia (BPH) is one of the main fields of interest for modern urology due to its remarkably high prevalence and negative impact on the patients' quality of life[1].

Currently, there are many types of therapy available for patients with BPH, ranging from conservative management to surgery, including watchful waiting, drug therapy, minimally invasive treatments, and open prostatectomy[2].

The European Association of Urology guidelines recommended that the gold standard of surgical treatment for BPH from 30 to 80 g is monopolar transurethral resection of the prostate (TURP). Open prostatectomy, which has been the standard treatment for large BPH, is now challenged by minimally invasive treatments, which avoids wound complications, reduced blood loss, and hospital stay[3].

The bipolar TURP (B-TURP) provides a new minimally invasive surgical option for the management of BPH that enables the resection of tissue under saline[4],[5]. B-TURP is safer than monopolar TURP because of lower risk for TUR syndrome, less intraoperative bleeding, and lower incidence of postoperative complications[6].

This technique has been further refined by the development of plasma-kinetic (PK) technology that allows enucleation of whole lobes of the prostate with less blood loss and less residual adenoma[7].

The bipolar plasma enucleation of the prostate (BPEP) technique represents a promising endoscopic approach in large BPH cases, characterized by good surgical efficacy, reduced morbidity, fast postoperative recovery, and satisfactory follow-up parameters[3].


  Patients and Methods Top


The study protocol was approved by the Local Ethics Committee of Menoufia University. All patients have given written informed consent before inclusion in the study. A prospective, randomized study was performed in the Urology Department of Menoufia University Hospital within the time frame of April 1, 2014 and November 1, 2015. Thirty patients with bladder outlet obstruction and prostate sizes ranged between 40 and 90 g were randomized into two groups (the first group was managed by B-TURP and the second group was managed by BPEP).

For both techniques, the used electrosurgical unit was Covidien ForceTriad energy platform, manufactured by Valleylab: a division of Tyco Healthcare Group LP (Boulder, Colorado USA).

The used set for both techniques was composed of Karl–Storz bipolar cutting loop and vaporizing electrode, Karl–Storz (active) bipolar working element, bipolar high-frequency cord for the force triad unit compatible with Karl–Storz sheath and Karl–Storz 26-Fr continuous flow resectoscope with a rotatable inner tube.

Also, the used telescope system was composed of HOPKINS telescope 30°, diameter 4 mm, autoclavable with fiber optic light transmission incorporated, all manufactured by Karl–Storz (Endoskope, Tuttlingen town, Germany).

All patients who participated in this study were indicated for surgical treatment of BPH and fit for operation. All patients were preoperatively evaluated in detail by medical history, physical examination including digital rectal examination (DRE), laboratory investigations including preoperative serum sodium level and imaging evaluation including abdominopelvic and transrectal ultrasound. IPSS, uroflowmetry (Qmax), and postvoiding residual (PVR) urine volume were determined in all cases. Assessment of IPSS, Qmax, and PVR urine volume were omitted in men presented by urinary retention. In both groups, resection time and resected volume were analyzed. Blood loss and drop in hemoglobin and sodium values were determined. Postoperative catheter time and hospital stay were recorded. Intraoperative and postoperative complications and the need for blood transfusion were noted. The improvement of IPSS, Qmax, and PVR urine after 3 months were also recorded for all patients.

Statistical analysis

The data collected were tabulated and analyzed by the Statistical Package for the Social Sciences computer program SPSS version 20 (SPSS 20; IBM, Armonk, New York, USA). Descriptive data were put by percentage, and quantitative data as mean ± SD and median. P value is considered significant if less than 0.05. χ2 test, Fisher's exact test, and Wilcoxon signed rank test were used.


  Results Top


Regarding preoperative baseline parameters, there were no statistically significant differences between the two groups, and this validated the randomization of this study [Table 1].
Table 1: Comparing BPEP and B-TURP group's preoperative data evaluation

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We found that the operative time was less in B-TURP than in BPEP, but with no significant statistical difference [Figure 1].
Figure 1: Chart comparing bipolar plasma enucleation of the prostate and bipolar transurethral resection of the prostate groups' operative data (operation-related data).

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The differences were statistically significant regarding to calculated blood loss during operation with less blood loss during BPEP [Table 2].
Table 2: Comparing BPEP and B-TURP groups operative data (patient related)

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Regarding to resected tissue volume, it was more with BPEP technique but also without significant statistical difference. Also, postoperative Hb, Hct, and Na+ drops were less in BPEP but also with no significant statistical difference [Table 2].

The mean postoperative bladder irrigation time, postoperative catheter time, and postoperative hospital stay were similar in both groups with no significant statistical difference [Table 3].
Table 3: Comparing BPEP and B-TURP groupfs postoperative course

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In both groups, there was no need for blood transfusion neither intraoperatively nor postoperatively. Also, TUR syndrome did not occur in any patient in our study.

As regards postoperative complications, urine retention and need for reoperation occurred only in one case in the B-TURP group (5%), but it did not occur in any patient of the BPEP group. But regarding secondary hematuria after catheter removal, the same percent presented in both groups (10%) and these patients were managed successfully by conservative treatment with no need for reoperation or blood transfusion. The same percentage was present in both groups as regards postoperative urinary incontinence (only 10%). The incontinence was in the form of urge incontinence and was treated successfully by medical treatment (antimuscarinics) [Table 4].
Table 4: Comparing BPEP and B-TURP group's postoperative complications

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All patients in both groups showed marked improvement in IPSS, Qmax, and PVR after 3 months postoperatively [Table 5].
Table 5: Comparing BPEP and B-TURP groupfs follow-up data

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  Discussion Top


In the era of minimally invasive treatment, various new technologies have been developed that aim to minimize the morbidity of TURP[4].

The transurethral plasma-kinetic resection of the prostate (PKRP) provides a minimally invasive surgical option for the management of BPH that enables the resection of tissue by creating an ionized plasma corona using an axipolar electrode and normal saline as an irrigant[4],[5].

This technique has been further refined by the development of PK technology that allows enucleation of whole lobes of the prostate, as reported by Neillet al.[8].

Most of the authors focused their research on the holmium laser enucleation of the prostate, often characterized as a consecrated part of the large BPH treatment armamentarium[9]. Despite the numerous reports supporting the favorable clinical outcomes of holmium laser enucleation of the prostate, it did not yet gain an actual 'standard management' status, maybe due to challenges implied by the steep learning curve and high equipment costs[10].

One of the most recent studies, that yet has been published in January 2016, reported that transurethral bipolar enucleation of the prostate (TuBE) is an effective operation for refractory urinary tract symptoms including those who are in urinary retention[11].

In our study, 30 cases had a prostate size ranging from 40 to 90 g and they were randomized between two groups (B-TURP and BPEP groups).

The mean ages of B-TURP and BPEP groups were 66 ± 6 and 66 ± 4, respectively. There was no statistically significant difference between the two groups.

Regarding preoperative data baseline parameters (prostate size, prostate specific antigen (PSA), IPSS, Qmax, PVR urine volume, hemoglobin concentration, hematocrit percentage, and serum Na + level), there were no statistically significant differences between the two groups.

In our study the operative time was shorter for the B-TURP group than the BPEP group, but with no significant statistical difference (mean ± SD; 94 ± 23 and 105 ± 16 for B-TURP and BPEP groups, respectively). This may be due to unfamiliarity with the new technique of BPEP.

In contrast to these results, Liaoet al.[12] published a study comparing plasmakinetic enucleation with bipolar plasmakinetic resection of the prostate for BPH. Their results were as follows: the mean operative time was less in the PKEP group (71 ± 15.4 min) than in the PKRP group (76 ± 13.5 min). No significant statistical differences were found between them (P = 0.09).

Regarding the resected prostatic tissue volume, we found that it was slightly more in the BPEP group than in B-TURP groups, but with no significant statistical difference (48 ± 10 and 45 ± 13, respectively).

These results were similar to those mentioned by Zhuet al.[13] in their study comparing electrosurgical enucleation vs bipolar TURP larger than 70 ml. They recorded greater resected prostate weight in the BPEP group (mean ± SD 64.2 ± 19.0 in BPEP vs 50.6 ± 20.0 g, P = 0.03 in B-TURP).

But Liao et al.[12] reported slightly more resected tissue volume in B-TURP than BPEP with a mean of 47 g in BPEP vs 51 g in B-TURP, P = 0.16 but with no significant statistical difference.

The current study showed that the irrigation fluid volume was slightly less in the BPEP group (49 ± 12 for B-TURP and 46 ± 9 for BPEP) than in the B-TURP group, but also with no significant statistical difference.

Regarding the hemoglobin drop and hematocrit drop in our study, they were less in the BPEP group than the B-TURP group (for HB drop mean ± SD was 0.3 ± 0.2 and 0.5 ± 0.3 g/dl and for both groups Hct drop mean ± SD was 2.5 ± 2 and 2.9 ± 2.2%, respectively); also there was no statistical difference between both groups.

In this study, regarding the drop in serum sodium level we have reported a mean of 2.5 ± 1.5 mmol/l for B-TURP and 1.2 ± 1.4 mmol/l for BPEP with no significant statistical difference.

Regarding the blood loss, we found that there was a significant statistical difference in favor of the BPEP group (mean ± SD; 232 ± 118 ml/min vs 142 ± 53 ml/min in B-TURP and BPEP groups, respectively; P = 0.02).

Liao et al.[12] found that the blood loss observed in the PKEP group and conventional PKRP group were 146–48.6 and 254–76.4 ml, respectively, which was statistically significant (P < 0.0001).

Also Zhu et al.[13] found less blood loss with BPEP (mean 0.87 ± 0.42 vs 1.74 ± 0.63 g in BPEP and B-TUPR, respectively, P < 0.01).

In this study, regarding intraoperative and postoperative blood transfusion rate, we found that it was the same in BPEP and B-TURP groups as no patient needed blood transfusion in both groups. Also, Liaoet al.[12] reported that none of the patients needed blood transfusion in both groups.

As regards postoperative bladder irrigation time in our study, we recorded that it was similar in both groups with mean ± SD being 1.1 ± 0.3 day and 1 day for the B-TURP group and the BPEP group, respectively, with no significant statistical difference.

As regards the postoperative catheterization time and hospital stay, no significant statistical difference was found in both groups. For catheterization time, mean ± SD was 3.5 ± 0.6 in B-TURP and 3 ± 0.5 in BPEP, but for hospital stay, mean ± SD was 3 ± 0.5 in both groups.

The previously mentioned results were in accordance with those mentioned by Liaoet al.[12] who have reported catheterization time mean 4.1 vs 3.9 days, (P = 0.13) and the total hospital stay mean 9.3 vs 8.7 days, (P = 0.11) in B-TUPR and BPEP, respectively, with no statistical difference in both techniques.

As regards TUR syndrome, it did not occur in either groups in our study. The same results were reported by Liaoet al.[12] and also by Zhuet al.[13].

Regarding secondary hematuria after catheter removal, both groups showed that the same percentage of patients developed this complication (10% in both groups).

Liao et al.[12] reported that secondary bleeding was seen in 1.4% of patients in the PKRP group and in 1.6% patients in the PKEP group after removal of the catheters.

Also, in our patients, postoperative incontinence was seen in only two (10%) patients of the B-TURP group and in one (10% also) patient of the BPEP group without significant statistical difference.

The previously mentioned results were in accordance with those mentioned by Liaoet al.[12] who said that a total of 23 (16.1%) patients in the PKRP group and 12 (7.5%) patients in the PKEP group complained of some degree of urinary incontinence.

In our study, we have reported significant improvements in the IPSS from the baseline for both B-TURP and BPEP groups after 3 months postoperatively, but the differences between the two groups were statistically insignificant. The follow-up IPSS scores in the B-TURP group was mean ± SD; 2 ± 2 points and in the BPEP mean ± SD it was 1 ± 1 points.

We have noticed that in our study, and in most of the previously mentioned studies there were improvement in IPSS, Q max, and PVR urine volume after 3 months. We expect that further improvement will occur due the gradual improvement of the bladder urodynamics that may take several months after elimination of the infravesical obstruction, and also may be due to the improvement of some irritative symptoms that may result from the electrothermal effect of such techniques.

Zhuet al.[13] stated that the postoperative improvement in International Prostate Symptom Score, quality of life, maximal flow rate, and postvoid residual urine volume was similar in the two groups at 1, 6, 12, and 24 months but significantly better in the enucleation group at 36, 48, and 60 months. During the 5-year follow-up, no patient in the enucleation group but two in the resection group experienced recurrence.


  Conclusion Top


We found that BPEP can be an alternative promising endoscopic treatment for patients with BPH, showing comparable efficacy, hospital stay, and faster recovery compared with B-TURP, with less incidence of intraoperative and postoperative complications, and with a satisfactory safety profile.

But due to the small size of this study and the short follow-up period, we think that our results need to be validated in a larger scale study with a more extended follow-up period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Li M, Qiu J, Hou Q, Wang D, Huang W, Hu C, et al. Endoscopic enucleation vs open prostatectomy for treating large benign prostatic hyperplasia: a meta-analysis of randomized controlled trials. PLoS One 2015; 10 :e0121265.  Back to cited text no. 1
    
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Madersbacher S, Lackner J, Brössner C, Röhlich M, Stancik I, Willinger M, Schatzl G, and P.S.G.o.t.A.S.o. Urology. Reoperation, myocardial infarction and mortality after transurethral and open prostatectomy: a nation-wide, long-term analysis of 23,123 cases. Eur Urol 2005; 47 :499–504.  Back to cited text no. 2
    
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Geavlete B, Stanescu F, Iacoboaie C, Geavlete P. Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia cases–a medium term, prospective, randomized comparison. BJU Int 2013; 111 :793–803.  Back to cited text no. 3
    
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Alschibaja M, May F, Treiber U, Paul R, Hartung R. Recent improvements in transurethral high-frequency electrosurgery of the prostate. BJU Int 2006; 97 :243–246.  Back to cited text no. 4
    
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Bhansali M, Patankar S, Dobhada S, Khaladkar S. Management of large (>60 g) prostate gland: PlasmaKinetic Superpulse (bipolar) vs conventional (monopolar) transurethral resection of the prostate. J Endourol 2009; 23 :141–146.  Back to cited text no. 5
    
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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.  Back to cited text no. 6
    
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Tan A, Gilling P, Kennett K, Frampton C, Westenberg A, Fraundorfer M. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 2003; 170 :1270–1274.  Back to cited text no. 7
    
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Neill MG, Gilling PJ, Kennett KM, Frampton CM, Westenberg AM, Fraundorfer MR, Wilson LC. Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Urology 2006; 68 :1020–1024.  Back to cited text no. 8
    
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Zhang Y, Du C, Xu G, Chen J, Jing X. Transurethral holmium laser enucleation for prostate adenoma greater than 100 g. Nat J Androl 2007; 13 :1091–1093.  Back to cited text no. 9
    
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Kim, M, Lee H-E, Oh S-J. Technical aspects of holmium laser enucleation of the prostate for benign prostatic hyperplasia. Korean J Urol 2013; 54 :570–579.  Back to cited text no. 10
    
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Tracey JM, Warner JN. Transurethral bipolar enucleation of the prostate is an effective treatment option for men with urinary retention. Urology 2015; 87 :166–171.  Back to cited text no. 11
    
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Liao N, Yu J. A study comparing plasmakinetic enucleation with bipolar plasmakinetic resection of the prostate for benign prostatic hyperplasia. J Endourol 2012; 26 :884–888.  Back to cited text no. 12
    
13.
Zhu L, Chen S, Yang S, Wu M, Ge R, Wu W, et al. Electrosurgical enucleation vs bipolar transurethral resection for prostates larger than 70 ml: a prospective, randomized trial with 5-year followup. J Urol 2013; 189 :1427–1431.  Back to cited text no. 13
    


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    Tables

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