Bipolar Transurethral Resection of the Prostate Causes Deeper Coagulation Depth and Less Bleeding Than Monopolar Transurethral Prostatectomy

Evaluation of the Efficacy and Safety of Bipolar and Monopolar Transurethral Prostate Resection in Geriatric Patients

BACKGROUND

Benign prostatic hyperplasia unresponsive to medical treatment is an important problem for elderly patients. Although the gold standard surgical treatment is monopolar transurethral resection of the prostate (MTURP), postoperative complications are still a concern.

AIM

The aim of this study was to determine which transurethral prostate resection (TURP) methods are more effective and safer in elderly patients.

METHODS

Patients who underwent TURP in our clinic between 2012 and 2021 were analyzed retrospectively and divided into three groups according to their ages. Patients were treated with MTURP (n = 169) and bipolar transurethral resection of the prostate (BTURP) (n = 1152). Pre- and post-operative data for age groups were compared according to TURP methods.

RESULTS

The resection speed in the BTURP method was statistically significantly faster in groups 2 and 3 (P < 0.05). Although not statistically significant (P > 0.05), there was a numerically smaller decrease in hemoglobin (Hb) value in group 2 and a numerically greater decrease in post-voiding residual (PVR) volume in groups 1 and 3 in the BTURP method. The increase in maximum urine flow (Qmax) was significantly higher only in group 2 (P = 0.032), but it was numerically higher in all groups in the BTURP method.

CONCLUSION

The results of this study showed that BTURP was at least as effective and safe as MTURP in geriatric patients and also better in terms of Hb decrease, resection speed, Qmax increase, and PVR volume decrease.

Perioperative Dyselectrolytemia in Patients Undergoing Transurethral Resection of the Prostate Using 0.9% Normal Saline Irrigation

BACKGROUND

The choice of irrigation fluid used in transurethral resection of the prostate (TURP) has a significant impact on serum electrolyte levels. Among the many available options, 0.9% normal saline (NS) is considered to be more physiological.

MATERIAL AND METHODS

This observational study was conducted on 60 adult males aged 50-70 years, classified as American Society of Anesthesiologists grade 1 and 2, undergoing TURP with 0.9% NS irrigation under spinal anesthesia achieved with a mixture of 0.5% heavy bupivacaine. The patients' hematocrit and serum electrolyte levels were obtained after six hours and compared with preoperative values.

RESULTS

Hematocrit reduced from 40.32 ± 6.27 to 31.07 ± 5.40 (p < 0.001). Both serum sodium and potassium decreased from 136.77 ± 3.27 to 128.31 ± 5.91 and from 4.02 ± 0.26 to 3.81 ± 0.36, respectively (p < 0.001). However, serum chloride showed only a minimal increase from 101.58 ± 2.88 to 102.25 ± 1.66 (p < 0.12).

CONCLUSION

Although the changes in serum sodium and potassium were statistically significant, they did not have any physiological consequences in our study. However, this emphasizes the importance of vigilant electrolyte monitoring to identify and mitigate the risk of electrolyte disturbances during TURP surgeries.

The role of irrigation fluid in transurethral resection of the prostate outcomes and surgeon performance

INTRODUCTION

Transurethral resection of the prostate (TURP) is the gold-standard for the treatment of benign prostate enlargement (BPE) associated with lower urinary tract symptoms (LUTS), after failure of conservative therapy. At present, only resection-rate (grams of prostate resected over time) is regarded as an efficiency parameter to evaluate the skill of the operator and to assess the outcome of the procedure.

MATERIALS AND METHODS

Five surgeons performed TURP using a Gyrus-type bipolar system in 123 patients with BPE/LUTS who came to our observation from June 2016 to December 2019. The amount of irrigation fluid used during the procedure was registered and correlated to the operating time, resection-rate, prostate adenoma weight, post-operative bladder irrigation time, intraoperative bleeding and days of catheterization.

RESULTS

We found an inverse correlation between the amount of irrigation fluid used during TURP and the resection-rate recorded for all operators, according to Spearman's Correlation (r = -0.78, p = 0.002); a direct correlation was also found between the amount of irrigation fluid and the adenoma weight. Finally, we also found a direct correlation with intraoperative bleeding and the duration and amount of bladder irrigation during and after TURP.

CONCLUSIONS

The amount of irrigation fluid used is proposed as a reliable parameter to estimate the efficiency of the endoscopic procedure as well to assess the skill of the operator and shortterm results. The observed data encourage the possibility of applying this new efficiency indicator to all endoscopic maneuvers.

Necrosis zone depth after bipolar plasma vaporization and resection in the human prostate

Objectives

To compare the depth of thermal necrosis after use of bipolar resection and vaporization technique comparing intra-individually bipolar loop and bipolar button electrodes.

Methods

Transurethral resection and vaporization of the prostate was performed in 55 male patients (260 specimens in total). In a standardized procedure, a bipolar resection loop was used for resection, and a bipolar button electrode was used for vaporization. Both electrodes were applied in each patient, either in the left or in the right lateral lobe. The depth of necrotic zones in the resected or vaporized tissue of each patient was measured in a standardized way by light microscopy.

Results

The mean depth with standard deviation of thermal injury caused by the loop electrode was 0.0495±0.0274 mm. The vaporization electrode caused a mean thermal depth with standard deviation of 0.0477±0.0276 mm. The mean difference of necrosis zone depths between the two types of electrodes (PlasmaButton-resection loop) was -0.0018 mm (p=0.691).

Conclusion

For the first time, we present directly measured values of the absolute necrosis zone depth after application of plasma in the transurethral treatment of benign prostatic hyperplasia. The measured values were lower than in all other transurethral procedures. Standardized procedures of measurement and evaluation allow a statistically significant statement that the low necrosis depth in bipolar procedures is independent of the applied electrodes.

Correlation of Postoperative Outcomes According to the Amount of Prostatic Tissue Removed in Patients Undergoing Transurethral Resection of the Prostate

OBJECTIVE

The present study assesses the effect of the proportion of tissue resected during transurethral resections of the prostate (TUR-P) on lower urinary tract symptoms (LUTS) and other parameters in patients with a benign prostatic obstruction (BPO).

MATERIALS AND METHODS

Forty-three patients who underwent TUR-P between 2018 and 2021 were assessed prospectively. The patients were divided into two groups according to the percentage of tissue removed (group 1 <30%, group 2 >30% resection). Age, prostate volume, amount of resected tissue, operative time, length of hospital stay, duration of catheterization, International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum urinary flow rate (Qmax), and serum prostate-specific antigen (PSA) (ng/dl) at preoperative and postoperative three months were recorded.

RESULTS

The percentage of tissue removed was 22.2% vs. 48.4% (p = 0.001), IPSS reduction was 77.7% vs. 83.3% (p = 0.048), QoL improvement was 77.2% vs. 84.8% (p = 0.133), Qmax increase was 171.3% vs. 193.5% (p = 0.032), and serum PSA decrease was 56.4% vs. 69.2% (p = 0.049) in groups 1 and 2, respectively. In addition, the operative time was 38.5 vs. 53.6 min (p = 0.001), the length of hospital stay was 2.0 vs. 2.4 days (p = 0.001), and the duration of catheterization average was 4.1 vs. 4.9 days (p = 0.002).

CONCLUSION

Resections of at least 30% of prostatic tissue can provide a significant improvement in the symptoms and parameters related to benign prostatic obstruction, while resections of less than 30% of prostatic tissue can effectively reduce urinary symptoms and improve the quality of life in older adult patients with comorbidities who require shorter operating times.

A prospective randomized study comparing bipolar plasmakinetic transurethral resection of the prostate and monopolar transurethral resection of the prostate for the treatment of Benign Prostatic Hyperplasia: efficacy, sexual function, Quality of Life, and complications

Objective:

To generate high-quality data comparing the clinical efficacy and safety profile between monopolar transurethral resection of the prostate (M-TURP) and bipolar plasmakinetic resection of the prostate (PK-TURP) for benign prostatic hyperplasia (BPH).

Materials and Methods:

Prospective, randomized, single-blinded study conducted in a tertiary-care public institution (Dec/2014-Aug/2016). Inclusion criteria: prostate of <80g in patients with drug-refractory lower urinary tract symptoms (LUTS), complications derived from BPH, or both. Exclusion criteria: a history of pelvic surgery/radiotherapy, neurogenic bladder dysfunction or documented/suspected prostate carcinoma. Treatment efficacy evaluated at 1, 3, 6 and 12 months. Efficacy outcomes: international prostate symptom score (IPSS), quality-of-life (QoL) score, international index of erectile function-5 (IIEF-5), maximum urinary flow rate (Qmax), postvoid residual urine (PVRU) volume, and prostate volume (PV). Complications and sequelae also assessed. Comparisons performed with parametric/non-parametric tests.

Results:

Out of the 100 hundred patients, 84 qualified for the analysis (45 M-TURP/39 PK-TURP). No significant differences found in baseline characteristics or operative data, except for a longer operative time in PK-TURP (MD:7.9min; 95%CI:0.13-15.74; p=0.04). No differences found in IPSS, Qmax or PVRU volume. QoL score at 12 months was higher in PK-TURP (MD:0,9points; 95%CI:0.18-1.64; p=0.01). No differences in sexual function, PV, complications or sequelae were found. This study is “rigorous” (Jadadscale) and has a low risk of bias (Cochrane-Handbook).

Conclusions:

Based on this controlled trial, there is not significant variation in effectiveness and safety between M-TURP and PK-TURP for the treatment of BPH. The small difference in QoL between PK-TURP and M-TURP at the one-year follow-up is not perceivable by the patients and, therefore, not clinically relevant.

Reprint - Bipolar vs. monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction: A Cochrane review

INTRODUCTION

There remains uncertainty regarding the differences in patient outcomes between monopolar transurethral resection of the prostate (MTURP) and bipolar TURP (BTURP) in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO).

METHODS

A systematic literature search was carried out up to March 19, 2019. Methods in the Cochrane Handbook were followed. Certainty of evidence (CoE) was assessed using the GRADE approach.

RESULTS

A total of 59 randomized controlled trials (RCTs) with 8924 participants were included. BTURP probably results in little to no difference in International Prostate Symptom Score (IPSS) at 12 months (mean difference -0.24, 95% confidence internal [CI] -0.39--0.09; participants=2531; RCTs=16; moderate CoE) or health-related quality of life (HRQOL) at 12 months (mean difference -0.12, 95% CI -0.25-0.02; participants=2004, RCTs=11; moderate CoE), compared to MTURP. BTURP probably reduces TUR syndrome (relative risk [RR] 0.17, 95% CI 0.09-0.30; participants= 6,745, RCTs=44; moderate CoE) and blood transfusions (RR 0.42, 95% CI 0.30-0.59; participants=5727, RCTs=38; moderate CoE), compared to MTURP. BTURP may carry similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01-4.06; participants=751; RCTs=4; low CoE), re-TURP (RR 1.02, 95% CI 0.44-2.40; participants=652, RCTs=6, I²=0%; low CoE) and erectile dysfunction (International Index of Erectile Function [IIEF-5]) at 12 months (mean difference 0.88, 95% CI -0.56-2.32; RCTs=3; moderate CoE), compared to MTURP.

CONCLUSIONS

BTURP and MTURP probably improve urological symptoms to a similar degree. BTURP probably reduces TUR syndrome and blood transfusion slightly postoperatively. The moderate certainty of evidence available for primary outcomes suggests no need for further RCTs comparing BTURP and MTURP.

Electrocoagulation Accounts for a Significant Portion of Discrepancy Between Preoperative Ultrasonography Prostate Size Estimation and Resected Tissue Weight

Background and Objectives: Transurethral resection of the prostate (TURP) is considered to be the gold standard surgical procedure for medium-sized prostates. However, there is a drastic difference between the weight of resected tissue reported by the pathologist and the sonographic estimate of prostate weight before the operation. The present study investigates the role of electrocoagulation in tissue loss during monopolar (M-) and bipolar (B-) TURP. Methods: In this experimental in vitro study, 33 prostate glands removed from patients by open suprapubic prostatectomy were roughly divided in half and the weight of each half was recorded precisely. One half of the specimen was resected using a monopolar resectoscope and the other half was resected by bipolar resectoscope in an out-of-body simulated condition. The weight of obtained chips was measured and the amount of lost tissue was calculated. Data from prostates with final pathologic diagnosis of benign prostatic hyperplasia were included in the analysis. The mean difference of prostate weight before and after out-of-body resection and also the proportion of tissue loss between M-TURP and B-TURP were compared using t-test. Results: Data from 62 prostate halves were included in the final analysis. The mean weight of samples after M-TURP was considerably lower than before resection (38.0 ± 6.9 and 48.7 ± 9.0, respectively, p < 0.001). Similarly, the mean weight of prostate samples after B-TURP was lower than the weight before resection (36.2 ± 7.3 and 48.4 ± 9.1, respectively, p < 0.001). However, the ratio of tissue loss in B-TURP (25.3% ± 2.5%) was significantly higher than in M-TURP (21.3% ± 3.7%) (p < 0.001). Conclusion: Prostate resection using electrocoagulation leads to a significant prostate tissue loss due to heat effect. Furthermore, tissue loss in B-TURP is slightly more than M-TURP.

Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction

BACKGROUND

Transurethral resection of the prostate (TURP) is a well-established surgical method for treatment of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). This has traditionally been provided as monopolar TURP (MTURP), but morbidity associated with MTURP has led to the introduction of other surgical techniques. In bipolar TURP (BTURP), energy is confined between electrodes at the site of the resectoscope, allowing the use of physiological irrigation medium. There remains uncertainty regarding differences between these surgical methods in terms of patient outcomes.

OBJECTIVES

To compare the effects of bipolar and monopolar TURP.

SEARCH METHODS

A comprehensive systematic electronic literature search was carried out up to 19 March 2019 via CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, PubMed, and WHO ICTRP. Handsearching of abstract proceedings of major urological conferences and of reference lists of included trials, systematic reviews, and health technology assessment reports was undertaken to identify other potentially eligible studies. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared monopolar and bipolar TURP in men (> 18 years) for management of LUTS secondary to BPO.

DATA COLLECTION AND ANALYSIS

Two independent review authors screened the literature, extracted data, and assessed eligible RCTs for risk of bias. Statistical analyses were undertaken according to the statistical guidelines presented in the Cochrane Handbook for Systematic Reviews of Interventions. The quality of evidence (QoE) was rated according to the GRADE approach.

MAIN RESULTS

A total of 59 RCTs with 8924 participants were included. The mean age of included participants ranged from 59.0 to 74.1 years. Mean prostate volume ranged from 39 mL to 82.6 mL. Primary outcomes BTURP probably results in little to no difference in urological symptoms, as measured by the International Prostate Symptom Score (IPSS) at 12 months on a scale of 0 to 35, with higher scores reflecting worse symptoms (mean difference (MD) -0.24, 95% confidence interval (CI) -0.39 to -0.09; participants = 2531; RCTs = 16; I² = 0%; moderate certainty of evidence (CoE), downgraded for study limitations), compared to MTURP. BTURP probably results in little to no difference in bother, as measured by health-related quality of life (HRQoL) score at 12 months on a scale of 0 to 6, with higher scores reflecting greater bother (MD -0.12, 95% CI -0.25 to 0.02; participants = 2004; RCTs = 11; I² = 53%; moderate CoE, downgraded for study limitations), compared to MTURP. BTURP probably reduces transurethral resection (TUR) syndrome events slightly (risk ratio (RR) 0.17, 95% CI 0.09 to 0.30; participants = 6745; RCTs = 44; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 20 fewer TUR syndrome events per 1000 participants (95% CI 22 fewer to 17 fewer). Secondary outcomes BTURP may carry a similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01 to 4.06; participants = 751; RCTs = 4; I² = 0%; low CoE, downgraded for study limitations and imprecision), compared to MTURP. This corresponds to four fewer events of urinary incontinence per 1000 participants (95% CI five fewer to 16 more). BTURP probably slightly reduces blood transfusions (RR 0.42, 95% CI 0.30 to 0.59; participants = 5727; RCTs = 38; I² = 0%; moderate CoE, downgraded for study limitations), compared to MTURP. This corresponds to 28 fewer events of blood transfusion per 1000 participants (95% CI 34 fewer to 20 fewer). BTURP may result in similar rates of re-TURP (RR 1.02, 95% CI 0.44 to 2.40; participants = 652; RCTs = 6; I² = 0%; low CoE, downgraded for study limitations and imprecision). This corresponds to one more re-TURP per 1000 participants (95% CI 19 fewer to 48 more). Erectile function as measured by the International Index of Erectile Function score (IIEF-5) at 12 months on a scale from 5 to 25, with higher scores reflecting better erectile function, appears to be similar (MD 0.88, 95% CI -0.56 to 2.32; RCTs = 3; I² = 68%; moderate CoE, downgraded for study limitations) for the two approaches.

AUTHORS' CONCLUSIONS

BTURP and MTURP probably improve urological symptoms, both to a similar degree. BTURP probably reduces both TUR syndrome and postoperative blood transfusion slightly compared to MTURP. The impact of both procedures on erectile function is probably similar. The moderate certainty of evidence available for the primary outcomes of this review suggests that there is no need for further RCTs comparing BTURP and MTURP.

Pyuria and Post-Operation Urinary Tract Infection after Diode Laser Vaporesection of the Prostate

Background: Monopolar transurethral resection of prostate (m-TURP) remains the gold standard for benign prostate obstruction (BPO). Recently developed laser surgical technique provides fewer peri-operative complications with equivalent outcomes. Diode laser vaporesection (DiLRP) offers better hemostasis, shorter catheterization duration, and shorter hospital stay, however, deep thermal penetration might cause prolonged prostatic urethra inflammation and subsequent complications. We conducted a retrospective study to compare the pyuria duration and post-operative urinary tract infection sequelae (POUTIs) between DiLRP and m-TURP. Methods: From July 2011 to September 2015, we retrieved medical records for patients with lower urinary tract symptoms resulting from prostate obstruction who underwent m-TURP and DiLRP. Demographic characteristics were recorded from a computerized database. The duration of pyuria after operation was compared by Kaplan-Meier analysis and risk factors were evaluated by Cox regression analysis. Results: One hundred twelve patients underwent DiLRP and 81 underwent m-TURP performed by the same surgeon during the same period. The mean age of the patients was 72 ± 7.3 years in the DiLRP group and 70 ± 7.6 years in the m-TURP group (p = 0.069). There was a higher percentage of anticoagulant used in the DiLRP group than in the m-TURP group (18.5% vs. 7.4%, p = 0.028). Operation time was longer but post-operative normal saline irrigation interval was shorter in DiLRP compared with m-TURP, respectively (62.8 ± 20.6 vs. 47.4 ± 22.1 minutes, p < 0.001; 2.1 ± 0.3 vs. 2.5 ± 0.9 days, p < 0.001). The post-operative infections were statistically significantly higher in the DiLRP group, including epididymitis (10.2% vs. 1.2%, p = 0.013) and POUTIs-related hospitalization (8.3% vs. 1.2%, p=0.031).The DiLRP resulted in longer pyuria period (16 vs. 12 weeks, p = 0.0014), with factors including operative method by DiLRP (hazard ratio [HR]: 1.828, p = 0.003) and age (HR: 0.665, p = 0.040). Conclusions: According to our study, DiLRP associated with more POUTIs is possibly caused by a longer pyuria period. Further larger prospective studies are necessary for the evaluation of the association between post-operative pyuria and POUTIs.

Comparison of Safety, Efficacy and Cost Effectiveness of Photoselective Vaporization with Bipolar Vaporization of Prostate in Benign Prostatic Hyperplasia

Objectives

To compare bipolar vaporization of prostate (BPVP) with photoselective vaporization (PVP) of prostate in the surgical management of benign prostatic hyperplasia in terms of safety, efficacy and cost effectiveness.

Methods

Data was analyzed retrospectively for patients who underwent either PVP or BPVP between August 2012 to July 2014 for prostate size ≤ 80 ml. Preoperative and postoperative period values along with details like operative time, blood loss, hospitalization days, catheter removal time, blood transfusion and etc., were noted down. International prostatic symptom score, quality of life scores, post void residue, and maximum flow rate were recorded preoperatively and postoperatively at each follow-up visit. Follow-up was performed at 1, 3, 6, 12 and 18 months.

Results

Similar preoperative characteristics were observed in all the study arms. Hemoglobin drop, transfusion rate, catheter time and hospital days were similar in both the groups. The follow-up data indicates sustainable significant improvement in international prostatic symptom score, quality of life, post void residue and maximum flow rate in both the groups. As expected the cost of the procedure was significantly more in PVP group as compared to BPVP group (p < 0.01). Neither group had severe perioperative complications and no blood transfusion was required in both the groups.

Conclusion

Both PVP and BPVP were safe and effective alternatives in men requiring surgery for benign prostatic hyperplasia including patients who were on anticoagulants. Additionally, BPVP has the advantage of being significantly cheaper and therefore it can be more useful in developing countries.

Urethral strictures after bipolar transurethral resection of prostate may be linked to slow resection rate

PURPOSE

This study aimed to determine the urethral stricture (US) rate and identify clinical and surgical risk factors associated with US occurrence after transurethral resection of the prostate using the bipolar Gyrus PlasmaKinetic Tissue Management System (PK-TURP).

MATERIALS AND METHODS

This was an age-matched case-control study of US occurrence after PK-TURP. Retrospective data were collected from the hospital records of patients who had a minimum of 36 months of follow-up information. Among the data collected for analysis were prostate-specific antigen level, estimated prostate weight, the amount of prostate resected, operative time, history of urinary tract infection, previous transurethral resection of the prostate, and whether the PK-TURP was combined with other endourological procedures. The resection rate was calculated from the collected data. Univariate and multivariate analyses were performed to identify clinical and surgical risk factors related to US formation.

RESULTS

A total of 373 patients underwent PK-TURP between 2003 and 2009. There were 13 cases of US (3.5%), and most of them (10 of 13, 76.9%) presented within 24 months of surgery. Most of the US cases (11 of 13, 84.6%) occurred at the bulbar urethra. Multivariable logistic regression analyses identified slow resection rate as the only risk factor significantly associated with US occurrence.

CONCLUSIONS

The US rate of 3.5% after PK-TURP in this study is comparable to contemporary series. A slow resection rate seems to be related to US occurrence. This should be confirmed by further studies; meanwhile, we must be mindful of this possibility when operating with the PK-TURP system.

Transurethral plasmakinetic resection of the prostate is a reliable minimal invasive technique for benign prostate hyperplasia: a meta-analysis of randomized controlled trials

To evaluate the efficacy and safety of plasmakinetic resection of the prostate (PKRP) versus transurethral resection of the prostate (TURP) for the treatment of patients with benign prostate hyperplasia (BPH), a meta-analysis of randomized controlled trials was carried out. We searched PubMed, Embase, Web of Science and the Cochrane Library. The pooled estimates of maximum flow rate, International Prostate Symptom Score, operation time, catheterization time, irrigated volume, hospital stay, transurethral resection syndrome, transfusion, clot retention, urinary retention and urinary stricture were assessed. There was no notable difference in International Prostate Symptom Score between TURP and PKRP groups during the 1-month, 3 months, 6 months and 12 months follow-up period, while the pooled Q max at 1-month favored PKRP group. PKRP group was related to a lower risk rate of transurethral resection syndrome, transfusion and clot retention, and the catheterization time and operation time were also shorter than that of TURP. The irrigated volume, length of hospital stay, urinary retention and urinary stricture rate were similar between groups. In conclusion, our study suggests that the PKRP is a reliable minimal invasive technique and may anticipatorily prove to be an alternative electrosurgical procedure for the treatment of BPH.

A Prospective Study of Bipolar Transurethral Resection of Prostate Comparing the Efficiency and Safety of the Method in Large and Small Adenomas

Bipolar technology offers a new perspective in the treatment of BPH. Purpose. To present our experience with the TURis system (Olympus, Tokyo, Japan). Materials and Methods. From February 2011 till December 2013 in a prospective study, 93 patients were treated for BPH. They were evaluated with IPSS, QoL, uroflow (Q_max), and residual urine (RU), preoperatively as well as 6 and 9 months postoperatively. Based on the prostate volume, the patients were divided into two groups: group A (n = 48) with prostates ≥ 75 cc and group B (n = 45) with smaller prostate glands. All patients underwent bipolar TURP or/and plasma vaporization. Results. The postoperative improvement for IPSS, QoL, Q_max, and RU was statistically significant. The operation time was longer in group A in comparison with group B (P < 0.001). The former group also had higher infection and stricture formation rates; however, there was no statistical difference between the two groups. Conclusions. Treatment with the TURis constitutes an effective technique and can be offered to large prostates with results equivalent to those in small ones. Regarding safety, large adenomas treated with TURis are not at a higher risk for urethral stricture but their odds to develop urogenital infections are relatively higher compared to the smaller adenomas.

Five-Year Follow-Up Study of Transurethral Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia

PURPOSE

To explore the long-term clinical efficacy and safety of transurethral plasmakinetic resection of the prostate (PKRP) for benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A total of 550 patients with BPH who had undergone PKRP from October 2006 to September 2009 were enrolled in this study. All patients were evaluated at baseline and follow-up (3, 12, 24, 36, 48, 60 months postoperatively) by peak flow rate (Qmax), postvoid residual (PVR), quality of life (QoL), International Prostate Symptom Score (IPSS), and Overactive Bladder Symptom Score (OABSS). Operative details and postoperative complications regarded as safety outcomes were documented.

RESULTS

A total of 467 patients completed the 5-year follow-up. The mean duration of surgery was 36.43 minutes, mean catheterization time was 48.81 hours, mean hospital stay was 4.21 days. At 60 months postoperatively, the mean Qmax increased from 6.94 mL/s at baseline to 19.28 mL/s, the mean PVR decreased from 126.33 mL to 10.45 mL, the mean IPSS score decreased from 15.79 to 7.51, the mean QoL score decreased from 4.36 to 1.91, and the mean OABSS score decreased from 6.39 to 3.65 (P < 0.001), respectively. In perioperative complications, the blood transfusion rate was 2.7%, urinary tract infection rate was 3.6%; no transurethral resection syndrome (TUR syndrome) occurred. In late complications, urethral stricture rate was 5.4%, recurrent bladder outlet obstruction rate was 2.1%, and the reoperation rate was 4.5%.

CONCLUSIONS

PKRP is based on conventional monopolar transurethral resection of the prostate (TURP) and uses a bipolar plasmakinetic system. Our results indicate that the long-term clinical efficacy and safety of PKRP for BPH are remarkable. In particular, the incidence of urethral stricture, recurrent bladder outlet obstruction, and reoperation is low. We suggest that PKRP is a reliable minimally invasive technique that may be the preferred procedure for the treatment of patients with BPH.

Plasmakinetic resection technology for the treatment of benign prostatic hyperplasia: evidence from a systematic review and meta-analysis

The aim of this study was to compare plasmakinetic resection of the prostate (PKRP) with transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) in terms of efficacy and safety. Published RCTs were searched from PubMed, Embase, Science Citation Index, and Cochrane Library up to April 10, 2014. After methodological quality assessment and data extraction, meta-analysis was performed using the STATA 12.0 software. 18 reports of 16 RCTs were included in this analysis. Meta-analyses showed that PKRP significantly improved Qmax at 12 months, but no significant difference was found for other efficacy outcomes. In terms of safety, treatment of PKRP was associated with reduced drop in serum sodium, lower TUR syndrome, reduced need of blood transfusion, clot retention, and shorter catheterization time and hospital stay; in contrast, there were no significant differences in the analysis of operative time, postoperative fever, and long-term postoperative complications. In summary, current evidence suggests that, although PKRP and TURP are both effective for BPH, PKRP is associated with additional potential benefits in efficacy and more favorable safety profile. It may be possible that PKRP may replace the TURP in the future and become a new standard surgical procedure.

Heat Damage Zones Created by Different Energy Sources Used in the Treatment of Benign Prostatic Hyperplasia in a Pig Liver Model

INTRODUCTION

There are different types of transurethral prostatic surgeries and the complication profiles are different. This study aims to compare the heat damage zones (HDZ) created by five different technologies in a pig liver model.

MATERIALS AND METHODS

Monopolar resection, bipolar resection, electrovaporization, and Greenlight™ lasers of 120 and 180 W were used to remove fresh pig liver tissue in a simulated model. Each procedure was repeated in five specimens. Two blocks were selected from each specimen to measure the three deepest HDZ.

RESULTS

The mean of HDZ was 295, 234, 192, 673, and 567 μm, respectively, for monopolar resection, bipolar resection, electrovaporization, Greenlight laser 120 W, and Greenlight laser 180 W, respectively. The Greenlight laser produced one to three times deeper HDZ than the other energy sources (p=0.000).

CONCLUSION

Both 120 and 180 W Greenlight lasers produced deeper HDZ than the other energy sources. Urologists need to be aware of HDZ that cause tissue damage outside the operative field.

Incidence of urethral stricture after bipolar transurethral resection of the prostate using TURis: results from a randomised trial

OBJECTIVES

To assess whether bipolar transurethral resection of the prostate (B-TURP) using the TURis system has a similar level of efficacy and safety to that of the traditional monopolar transurethral resection of the prostate (M-TURP), and to evaluate the impact of the TURis system on postoperative urethral stricture rates over a 36-month follow-up period.

PATIENTS AND METHODS

A total of 136 patients with benign prostatic obstruction were randomised to undergo either B-TURP using the TURis system or conventional M-TURP, and were regularly followed for 36 months after surgery. The primary endpoint was safety, which included the long-term complication rates of postoperative urethral stricture. The secondary endpoint was the follow-up measurement of efficacy.

RESULTS

In peri-operative findings, no patient in either treatment group presented with transurethral resection syndrome, and the decline in levels of haemoglobin and hematocrit were similar. The mean operation time was significantly extended in the TURis treatment group compared with the M-TURP group (79.5 vs 68.6 min; P = 0.032) and postoperative clot retention was more likely to be seen after M-TURP (P = 0.044). Similar efficacy findings were maintained throughout 36 months, but a significant difference in postoperative urethral stricture rates between groups was detected (6.6% in M-TURP vs 19.0% in TURis; P = 0.022). After stratifying patients according to prostate volume, there was no significant difference between the two treatment groups with regard to urethral stricture rates in patients with a prostate volume ≤ 70 mL (3.8% in M-TURP vs 3.8% in TURis), but in the TURis group there was a significantly higher urethral stricture rate compared with the M-TURP group in patients with a prostate volume >70 mL (20% in TURis vs 2.2% in M-TURP; P = 0.012). Furthermore, the mean operation time for TURis was significantly longer than for M-TURP for the subgroup of patients with a prostate volume > 70 mL (99.6 vs 77.2 min; P = 0.011), but not for the subgroup of patients with a prostate volume ≤ 70 mL.

CONCLUSION

The TURis system seems to be as efficacious and safe as conventional M-TURP except that there was a higher incidence of urethral stricture in patients with larger preoperative prostate volumes.

Plasmakinetic vaporization versus plasmakinetic resection to treat benign prostatic hyperplasia: A prospective randomized trial with 1 year follow-up

INTRODUCTION

We evaluate the efficacy and outcomes of plasma-kinetic vaporization (PKVP) and plasmakinetic resection (PKR) to treat benign prostatic hyperplasia (BPH).

METHODS

A total of 183 patients with BPH underwent plasma-kinetic prostatic surgery between 2008 and 2012 at Kars State Hospital and Kafkas University Faculty of Medicine, Turkey. After clinical and preoperative evaluation, the patients were randomized to PKRP or PKVP groups sequentially by using computer-generated numbers. Group 1 included 96 patients treated with PKR. Group 2 included 87 patients treated with PKVP. Patients in both groups were compared in terms of hemoglobin drop, operation time, catheter duration, reobstruction, incontinence and recatheterization.

RESULTS

When we compared the maximum flow rates (Qmax values) at the 12th month, there was no statistical difference between 2 groups. Group 1 had a mean Qmax value of 17.92 ± 3.819 and Group 2 had a 18.15 ± 3.832 value (p > 0.05). There was a statistical difference between the groups in terms of hemoglobin drop, catheter duration and operation time. The mean catheter duration in Group 1 was 3.74 ± 1.049 days, and in Group 2 it was 2.64 ± 0.849 days (p < 0.05). Operation time was statistically longer in Group 2 (PKVP) and hemoglobin drop was statistically higher in Group 1 (PKR).

CONCLUSION

PKVP for BPH is safe and effective. When compared with PKRP, it provides a significantly shorter catheter duration and less bleeding due to hemostasis control with similar IPSS and Qmax improvements after 1 year.

A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update

CONTEXT

A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO).

OBJECTIVE

To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO.

EVIDENCE ACQUISITION

A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software.

EVIDENCE SYNTHESIS

A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes.

CONCLUSIONS

This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques.

PATIENT SUMMARY

Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.

Bipolar transurethral resection versus monopolar transurethral resection for benign prostatic hypertrophy: a systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of monopolar (M-TURP) and bipolar (B-TURP) transurethral resection of the prostate in benign prostatic hypertrophy (BPH) patients.

MATERIALS AND METHODS

Eligible randomized controlled trials (RCTs) were identified from electronic databases without language restrictions. Database search, quality assessment, and data extraction were independently performed. The primary postoperative outcomes of topical M-TURP and B-TURP were maximum flow rate (Qmax) and/or International Prostate Symptom Score (IPSS). Safety was estimated by TUR syndrome; need for transfusion; clot retention; bladder neck contracture (BNC); urethral stricture (US); and catheter removal time. Efficacy and safety were investigated using the Review Manager.

RESULTS

Thirty-one trials met the inclusion criteria. Pooled analysis revealed significant difference in efficacy between the M-TURP and B-TURP groups. Safety analysis revealed significant improvement in the TUR syndrome with B-TURP than with M-TURP. Pooled analysis revealed that clot retention was significantly higher in M-TURP than in B-TURP. Moreover, pooled analysis revealed no significant difference between both groups in the blood transfusion frequency or late complications (urethral strictures) and bladder neck constriction.

CONCLUSIONS

This systematic review indicates that B-TURP was significantly better in the result of Qmax and for decreasing the incidence of TUR syndrome and clot retention. No significant differences were observed in the nature of adverse events such as transfusions, retention after catheter removal, and urethral complications between both groups. Thus, B-TURP is the next generation "gold standard" for benign prostatic obstruction (BPO) because it is associated with a lower rate of clinically relevant complications such as TUR syndrome and clot retention.

[Bipolar versus monopolar transurethral resection of the prostate: a prospective randomized study]

PURPOSE

To compare bipolar with standard monopolar transurethral resection of the prostate (TURP).

MATERIAL AND METHODS

A prospectively randomized study was conducted between January 2010 and September 2011. Primary end points studied were efficacy (maximum flow rate [Qmax], International Prostate Symptom Score) and safety (adverse events, decline in postoperative serum sodium [Na+] and haemoglobin [Hb] levels). Secondary end points were operation time and duration of irrigation, catheterization, and hospitalization.

RESULTS

Sixty consecutive patients were randomized and completed the study, with 29 patients in the monopolar TURP group and 31 in the TURIS group. At baseline, the two groups were comparable in age, prostate volume, mean prostate-specific antigen value, International Prostate Symptom Score, and they had at least 12 months of follow-up. Declines in the mean postoperative serum Na+ for bipolar and monopolar TURP groups were 1.2 and 8.7 mmol/L, respectively. However, there was no statistical difference in the decline in postoperative Hb between the two groups. The mean catheterization time was 26.6 and 52 hours in the bipolar and standard groups, respectively. This difference was statistically significant as was the difference in the time to hospital discharge. The IPSS and Qmax improvements were comparable between the two groups at 12 months of follow-up.

CONCLUSION

No clinically relevant differences in short-term efficacy are existed between the two techniques, but bipolar TURP is preferable due to a more favorable safety profile and shorter catheterization duration.

Early outcomes of thulium laser versus transurethral resection of the prostate for managing benign prostatic hyperplasia: a systematic review and meta-analysis of comparative studies

PURPOSE

To assess the efficacy and safety of thulium laser resection of the prostate (TmLRP) vs transurethral resection of the prostate (TURP) for treating patients with benign prostatic hyperplasia (BPH).

METHODS

A systematic search of the electronic databases, including Medline, Scopus, China National Knowledge Infrastructure, and the Cochrane Library was performed up to May 1, 2013. The pooled outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, perioperative variables, complications, and postoperative efficacy including maximum flow rate (Qmax), postvoid residual (PVR), quality of life (QoL) and International Prostate Symptom Score (IPSS).

RESULTS

Nine trials assessing TmLRP vs. TURP were considered suitable for meta-analysis including three randomized controlled trials (RCTs), two prospective, and four retrospective studies. Compared with TURP, although TmLRP needed a longer operative time (weighted mean difference [WMD]: 9.00 min; 95% confidence interval [CI], 2.53-15.47; P=0.006), patients having TmLRP might benefit from significantly less serum sodium decreased (-3.58 mmol/L; 95% CI, -4.04 to -3.12; P<0.001), less serum hemoglobin decreased (WMD: -0.94 mmol/L; 95% CI, -1.44 to -0.44; P<0.001), shorter time of catheterization (WMD: -2.07 days; 95% CI, -2.66 to -1.49; P<0.001), shorter length of hospital stay (WMD: -1.87 days; 95% CI, -2.41 to -1.33; P<0.001), and fewer total complications (odds ratio [OR]: 0.29; 95% CI, 0.20-0.41; P<0.001). During the 1, 3, 6, and 12 months of postoperative follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QoL.

CONCLUSIONS

Our data suggest that as a promising minimally invasive technique, TmLRP appears to be a safe, feasible, and efficient alternative to TURP for treating patients with BPH with reliable perioperative safety, fewer complications, and comparable efficacy in relation to Qmax, PVR, QoL, and IPSS. Because of the inherent limitations of the included studies, further large sample prospective, multicentric, long-term follow-up studies and RCTs should be undertaken to confirm our findings.

Risk of acute myocardial infarction after transurethral resection of prostate in elderly

Background

Benign prostatic hyperplasia is a frequent disease among elderly, and is responsible for considerable disability. Benign prostatic hyperplasia can be clinically significant due to lower urinary tract symptoms that take place because the gland is enlarged and obstructs urine flow. Transurethral resection of the prostate remains the gold standard treatment for patients with moderate or severe symptoms who need active treatment or who either fail or do not want medical therapy. Moreover, perioperative and postoperative surgery complications as cardiovascular ones still occur. The incidence of acute myocardial infarction in patients undergoing transurethral resection of the prostate is controversial. The first studies showed an increase in mortality and relative risk of death from myocardial infarction in transurethral resection of the prostate group vs open prostatectomy but these results are in contrast with more recent data.

Discussion

Given the conflicting evidence of the studies in the literature, in this review we are going to discuss the factors that may influence the risk of myocardial infarction in elderly patients undergoing prostate surgery. We analyzed the possible common factors that lead to the development of myocardial infarction and benign prostatic hyperplasia (cardiovascular and metabolic), the stressor factors related to prostatectomy (surgical and haemodynamic) and the risk factors specific of the elderly population (comorbidity and therapies).

Summary

Although transurethral resection of the prostate is considered at low risk for severe complications, there are several reports indicating that cardiovascular events in elderly patients undergoing this surgical operation are more common than in the general population. Several cardio-metabolic, surgical and aging-related factors may help explain this observation but results in literature are not concord, especially due to the fact that most data derive from retrospective studies in which selection bias cannot be excluded. Subsequently, further studies are necessary to clarify the incidence of acute myocardial infarction in old people.