Surgical outcomes of endoscopic enucleation of the prostate in community aging males with or without preoperative urinary retention

OBJECTIVES

This study aims to investigate the surgical outcomes of endoscopic enucleation of the prostate in older males with or without preoperative urinary retention (UR).

MATERIAL AND METHODS

We conducted a study on selected patients with symptomatic benign prostatic hyperplasia (BPH) who underwent either thulium:YAG laser (vela XL) prostate enucleation (ThuLEP) or bipolar plasma enucleation of the prostate (B-TUEP) at the geriatric urology department of our institution. The studied patients were categorized into two groups, namely the UR group and the non-UR group, on the basis of whether they experienced UR in the 1 month preceding their surgery. Their clinical outcomes following prostate endoscopic surgery were evaluated and analyzed.

RESULTS

Our results revealed comparable outcomes for operation time, length of hospital stay, percentage of tissue removed, re-catheterization rate, and urinary tract infection rate within the 1 month between the B-TUEP and ThuLEP surgery groups, regardless of UR history. However, the non-UR B-TUEP group experienced more blood loss relative to the non-UR ThuLEP group (P = .004). Notably, patients with UR exhibited significantly greater changes in IPSS total, IPSS voiding, and prostate-specific antigen values relative to those without UR.

CONCLUSIONS

Both ThuLEP and B-TUEP were effective in treating BPH-related bladder outlet obstruction. Our study identified more pronounced changes in IPSS total, IPSS voiding, and prostate-specific antigens within the UR group. Moreover, the rate of postoperative UR in this group was not higher than that observed in the non-UR group. Our study also revealed that the presumed benefits of laser surgery in reducing blood loss were less pronounced for patients with UR.

Bicentric retrospective study comparing the postoperative outcomes of patients treated surgically for bladder stones with or without concomitant surgery for BPH

PURPOSE

To compare the postoperative outcomes of male patients who underwent bladder stone (BS) removal, with or without concomitant benign prostatic hyperplasia (BPH) surgery.

PATIENTS AND METHODS

All men aged > 50 years who underwent BS removal at two French university hospitals between 2009 and 2018 were retrospectively reviewed. Four binary outcome criteria were identified during the follow-up: early postoperative complications, stone recurrence, subsequent surgery for BS or BPH, and late surgical complications. A composite score ranging from 0 to 4 was calculated by combining the four criteria.

RESULTS

A median follow-up period of 42 months was observed in 179 patients. Of these, 107 patients were in the "concomitant surgical treatment" (CST) group and 72 in the bladder "stone removal alone" (SRA) group. The CST group presented higher baseline post-void residual volume (105 vs. 30 ml, p = 0.005). Patients who underwent CST had a significantly lower rate of BS recurrence (12% vs. 39%; p = 0,001) and underwent fewer subsequent surgeries (14% vs. 44%; p < 0.001). There was no significant difference in the early (51% vs. 35%, p = 0,168) and late (26% vs. 17%, p = 0,229) complications rates between the two groups. A better composite score was observed in the CST than in the SRA, but the difference was not significant (3.07 vs. 2.72, p = 0.078).

CONCLUSION

As CST increases morbidity and decreases the risk of reoperation, each situation should be considered, taking into account patient choice and comorbidities.

Simple and Convenient Method for Assessing the Severity of Bleeding during Endoscopic Prostate Surgery and the Relationships between Its Corresponding Surgical Outcomes

Bleeding during endoscopic prostate surgery is often overlooked, and appropriate measurement techniques are rarely applied. We proposed a simple and convenient method for assessing the severity of bleeding during endoscopic prostate surgery. We determined the factors affecting bleeding severity and whether they affected the surgical results and functional outcomes. Records from March 2019 to April 2022 were obtained for selected patients who underwent endoscopic prostate enucleation through either 120-W Vela XL Thulium:YAG laser or bipolar plasma enucleation of the prostate. The bleeding index was measured using the following equation: irrigant hemoglobin (Hb) concentration (g/dL) × irrigation fluid volume (mL)/preoperative blood Hb concentration (g/dL) × enucleated tissue (g). Our research revealed that patients who underwent surgery employing the thulium laser, those aged over 80 years, and those with a preoperative maximal flow rate (Qmax) of more than 10 cc/s experienced less surgical bleeding. The patients' treatment outcomes differed depending on the severity of the bleeding. Enucleating prostate tissue was easier in the patients with less severe bleeding, who also had a lower risk of developing urinary tract infections and an improved Qmax.

Venous thromboembolism (VTE) prophylaxis following transurethral resection of the prostate (TURP): An audit of practice in Scotland

Objectives:

To establish the current practice of urologists in Scotland with regard to venous thromboembolism (VTE) prophylaxis following transurethral resection of the prostate (TURP).

Methods:

An electronic survey was distributed to all practicing urology consultants and trainees in Scotland. Participants were asked questions regarding their current practice with regard to peri-operative VTE prophylaxis and were offered free-text responses. Findings were compared with a previous UK-wide study from 2002, and with current European Association of Urology (EAU) guidelines.

Results:

56/113 (49.6%) of urologists responded to the survey. Overall, 71.4% of responding urologists prescribed pharmacological VTE prophylaxis following TURP. No urologists routinely prescribe VTE prophylaxis on discharge. 94.6% of responding urologists utilise mechanical prophylaxis in the form of thromboembolic deterrent (TED) stockings, with 35.7% of urologists discharging patients with TED stockings. No urologists reported a death from uncontrollable bleeding after TURP in the previous 10 years, whereas 10% of respondents had a patient whom had suffered a death or serious complication from a thromboembolic event following TURP in the past 10 years. A range of free-text responses were given.

Conclusion:

Our national audit has identified a wide variation between practice and current published guidance. These results contrast dramatically with a previous UK wide audit from 2002, which found 14% of urologists utilised pharmacological prophylaxis, 50% utilised mechanical prophylaxis only and 23% used no thromboprophylaxis at all. Recent guidance from the EAU recommends against using pharmacological prophylaxis due to the increased bleeding risk. Given that current practice does not marry with published recommendations; we believe that further research is required in this area for stronger evidence-based guidelines to be developed.

Level of evidence:

4

The relationship between prostatic microvessel density and different concentrations of oestrogen/androgen in Sprague-Dawley rats

BACKGROUND

Currently, there are relatively few studies on the effects of changes in oestrogen and androgen levels on prostatic microvessel density (MVD). This article aimed to study the changes in prostatic MVD in Sprague-Dawley (SD) rats after castration under the effect of oestrogen/androgen at different concentrations.

METHODS

Male SD rats aged 3-4 months were randomly divided into a control group, a castration group, and groups with different concentrations of oestrogen/androgen treatment after castration. Dihydrotestosterone (DHT) and oestradiol (E) were administered daily by subcutaneous injection for one month. All the rats were killed by cervical dislocation after one month, and the serum DHT and E concentrations of the rats in each group were measured by ELISA. Prostate tissue specimens were immunohistochemically stained with monoclonal antibodies against CD34 and factor VIII for MVD.

RESULTS

Compared with the control group, the MVD decreased significantly in the castration group (P < 0.05). When the exogenous E concentration was constant, in general, the MVD of rats in all the groups increased with increasing exogenous DHT concentration. Compared with the castration group, the MVD increased significantly in the E0.05 + DHT0.015 mg/kg, E0.05 + DHT0.05 mg/kg, E0.05 + DHT0.15 mg/kg, E0.05 + DHT0.5 mg/kg, and E0.05 + DHT1.5 mg/kg groups (P < 0.05). In addition, when the exogenous DHT concentration was constant, the MVD increased with increasing exogenous E concentration in all the groups. Among them, compared with the control and castration groups, the MVD increased significantly in the DHT0.15 + E0.015 mg/kg, DHT0.15 + E0.15 mg/kg, and DHT0.15 + E0.5 mg/kg groups (P < 0.05).

CONCLUSIONS

Androgens play an important role in the regulation of prostatic MVD in SD rats, and a decrease in DHT concentration can induce a decrease in prostatic MVD. In contrast, prostatic MVD can be increased with increasing DHT concentration. In addition, prostatic MVD can be increased gradually with increasing oestrogen concentration.

A ten-year observational study of the use of two-way catheters post-transurethral resection of the prostate without the use of post-op irrigation

Background:

Over 15,000 transurethral resections of the prostate (TURP) are performed annually in the United Kingdom. It is therefore vital that every aspect of peri-operative care be optimised. Our centre favours the use of two-way catheters post-operatively without the use of continuous bladder irrigation (CBI).

Objectives:

To evaluate our practice of using two-way catheters without irrigation post-TURP and to determine impact on patient care compared with standard three-way catheterisation. Our primary outcome was duration of admission, but multiple secondary outcomes were also analysed. Design, setting, and participants: This was a prospective observational study. Every patient undergoing TURP at our centre from 2009 to 2019 was included. Following TURP patients were catheterised with two-way catheters. Prospective patient data were collected pertaining to peri-operative factors. These data were then compared with the data published in the literature.

Results:

687 patients underwent TURP at our centre between 2009 and 2019. The average age of patients was 71.42 (±7.89). 87.17% ( n = 598) had two-way catheters placed post-operatively. Average duration of admission was 1.61 (±1.35) days, increasing to 2.20 days if patients required three-way catheters or 2.53 days if requiring CBI. TWOC was successful in 97.71% of patients. Complication rate was 8.73% ( n = 60). When compared with other centres, our method reduced lengths of admission and transfusion rates (1.6 days versus 3.1 days and 0.87% versus 2.83%, respectively).

Conclusion:

Our method is safe and is associated with a reduced length of admission. We recommend this practice to the wider urological community.

Patient summary:

This study looked at whether there was any impact on patients if two-way catheters were used following TURP. We found that use of two-way catheters reduced length of admission and duration of catheterisation. We also found that it did not increase likelihood of peri-operative complications in comparison with other centres.

Surgical Complications in the Management of Benign Prostatic Hyperplasia Treatment

PURPOSE OF REVIEW

There are a variety of treatment options for men with symptomatic benign prostatic hyperplasia (BPH); transurethral resection of the prostate (TURP) remains the gold standard surgical treatment. The field continues to evolve with the introduction of new energy and laser technologies, increasing adoption of enucleation techniques, in addition to the advent of minimally invasive surgical technologies (MIST) that enable office-based treatments. The choice in surgical management has become very nuanced depending on a variety of patient and anatomic factors. There continues to be high success rates for surgical treatment of BPH; however, the risk profiles vary across the various surgical treatments. We sought to evaluate contemporary series and summarize the experience of complications associated with BPH treatment and management of these complications.

RECENT FINDINGS

A comprehensive literature review was performed, and identified 79 manuscripts, published between 2005 and 2021 characterizing the diagnosis and management of complications following BPH surgery. Commonly cited issues included bleeding, ureteral orifice injury, bladder neck injury, rectal injury, TURP syndrome, bladder neck contractures, urethral stricture disease, refractory OAB symptoms, and complications unique to new modalities of treatment. The practicing urologist has multiple surgical options to choose from in treating patients with symptomatic BPH. The surgical management of BPH is generally well tolerated with high objective success rates that allow for significant improvement in urinary quality of life. It is critical to understand the potential complications associated with these various treatment options, which will enable trainees and practicing urologists to better counsel patients and manage these potential complications.

A clinical trial comparing BiVap (Richard Wolf®) saline vaporization of the prostate vs. TwisterTM Diode Laser System in the treatment of benign prostatic obstruction between prostate volume 90 to 150 ml

INTRODUCTION

To evaluate the efficacy, safety and postoperative outcomes of the BiVap and Twister systems with benign prostatic obstruction (BPO) in prostate volüm between 90-150 ml.

METHODS

In total, we included 131 patients treated with BiVap system (n = 68) and Twister system (n = 63). Postoperative complications including urinary tract infection, transient hematuria, severe dysuria and fever >38° C, urinary incontinence and urethral stricture were also noted. All patients were evaluated at the postoperative 1st, 3rd, 6th and 12th month and preoperative and postoperative values of IPSS score, QoL score, total PSA, IIEF 15, PVR, Qmax and Qave were compared.

RESULTS

Preoperative demographic characteristics were similar in the 2 groups. There was observed significant improvement for IPSS, Qmax, Qave, PVR, and QoL score by the postoperative first month compared to the preoperative values in both groups. Maximum improvement in the IPSS, Qmax, Qave, QoL score and PVR were achieved at postoperative 6, 3, 12, 3 and 12th months respectively in group 1. In group 2 maximum improvement in the same parameters were achieved at postoperative 6, 3, 6, 6 and 12th months, respectively.

CONCLUSIONS

BiVap and Twister systems are safe, effective, and useful technique, which can be used in the surgical treatment of BPO between 90-150 ml.

Automated Classification of Blood Loss from Transurethral Resection of the Prostate Surgery Videos Using Deep Learning Technique

Transurethral resection of the prostate (TURP) is a surgical removal of obstructing prostate tissue. The total bleeding area is used to determine the performance of the TURP surgery. Although the traditional method for the detection of bleeding areas provides accurate results, it cannot detect them in time for surgery diagnosis. Moreover, it is easily disturbed to judge bleeding areas for experienced physicians because a red light pattern arising from the surgical cutting loop often appears on the images. Recently, the automatic computer-aided technique and artificial intelligence deep learning are broadly used in medical image recognition, which can effectively extract the desired features to reduce the burden of physicians and increase the accuracy of diagnosis. In this study, we integrated two state-of-the-art deep learning techniques for recognizing and extracting the red light areas arising from the cutting loop in the TURP surgery. First, the ResNet-50 model was used to recognize the red light pattern appearing in the chipped frames of the surgery videos. Then, the proposed Res-Unet model was used to segment the areas with the red light pattern and remove these areas. Finally, the hue, saturation, and value color space were used to classify the four levels of the blood loss under the circumstances of non-red light pattern images. The experiments have shown that the proposed Res-Unet model achieves higher accuracy than other segmentation algorithms in classifying the images with the red and non-red lights, and is able to extract the red light patterns and effectively remove them in the TURP surgery images. The proposed approaches presented here are capable of obtaining the level classifications of blood loss, which are helpful for physicians in diagnosis.

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.

Bipolar vaporization of the prostate may cause higher complication rates compared to bipolar loop resection: a randomized prospective trial

INTRODUCTION

Transurethral resection of the prostate (TURP) by resection loop or vaporization button is becoming a standard of care due to its better safety profile (less bleeding and less incidence of TUR syndrome). However, there are published data showing bipolar vaporization may be associated with increased late complications. In this study, we compared results of bipolar TURP using the resection loop versus vaporization button for treatment of benign prostatic hyperplasia (BPH) to determine the relative safety profile.

PATIENTS AND METHODS

Between January 2013 and March 2014, 89 patients with BPH were randomized to surgical intervention either by Olympus (Gyrus) Bipolar loop TURP or Olympus (Gyrus) Bipolar button vaporization. Inclusion criteria were; BPH with Q-max < 10 ml/s, IPSS  > 18 and prostate volume > 40 g. All patients were evaluated preoperatively and at 1, 3 and 9 months. Evaluation included IPSS, uroflowmetry, prostate volume by ultrasound. Clavien complications and operative time were recorded. Statistical analysis was done using Statistical Package of Social Science (SPSS) version 17 software.

RESULTS

44 patients were included in bipolar TURP and 45 patients in vaporization arm. Preoperative mean prostate volume (59 g versus 58 g, p = 0.52) and mean IPSS (19 versus 20, p = 0.38) were equivalent in both groups. Vaporization was associated with a significant increase in operative time (mean of 81 ± 15 min range 40-110 versus 55 ± 10 min range 30-70 min, p < 0.001), less blood loss (0.8% versus 2.0% drop in hemoglobin, p < 0.001) but increased postoperative urinary frequency (80% versus 50%, p < 0.001), hematuria with clots up to 4 weeks post surgery (20% versus 2%, p < 0.001) and postoperative urethral stricture (11% versus 0%, p < 0.001). Both techniques improved urine flow with Q-max (17 ml/s versus 18 ml/s p = 0.22). Prostate volume (32 g versus 31 g, p = 0.31) and IPSS (6 versus 5, p = 0.22), were comparable in both treatment arms.

CONCLUSIONS

Bipolar vaporization of the prostate, despite being a technically robust, speedy and with less intraoperative bleeding, appears to be associated with increased postoperative irritative symptoms, increased late-onset postoperative bleeding and high urethral stricture rates.

Comparison of Bipolar Plasma Vaporization versus Standard Holmium Laser Enucleation of the Prostate: Surgical Procedures and Clinical Outcomes for Small Prostate Volumes

Bipolar plasma vaporization of the prostate (BPVP) is an attractive alternative to resection. There are numerous studies comparing transurethral resection of prostate or photoselective vaporization of the prostate with BPVP; however, there is a lack of data comparing holmium laser enucleation of the prostate (HoLEP) with BPVP. We aimed to compare HoLEP and BPVP with a focus on functional outcomes, safety, and complications. Methods: From January 2017 to June 2018, patients who underwent HoLEP or BPVP for benign prostatic hypertrophy were enrolled in this study. Inclusion criteria were a prostate volume <40 mL measured by transrectal ultrasound, international prostate symptom score (IPSS) >7, maximum urinary flow rate (Qmax) <15 mL/s, and postvoiding residual volume (PVR) >100 mL. Perioperative and postoperative parameters including IPSS, Qmax, quality of life, PVR, and complications were compared between groups. Results: Sixty-three patients were enrolled in this study. There were small differences in perioperative parameters. Hospital stays and catheterization periods were significantly shorter in the BPVP group. The postoperative complications were comparable between groups. PVR was comparable in both groups except for 1 month postoperatively. The incontinence rate was higher in the HoLEP group, but without statistical significance. Conclusion: In terms of surgical safety and efficacy as well as patient comfort, BPVP is comparable with HoLEP for small prostate volumes. BPVP can be a viable alternative technique in small BPH surgical treatment.

The morbidity associated with a TURP procedure in routine clinical practice, as graded by the modified Clavien-Dindo system

Background: Transurethral resection of the prostate (TURP) is considered the reference surgical method of treating benign prostatic enlargement (BPE) causing obstruction. The procedure still carries a significant risk of perioperative morbidity according to previous reports. The aim of the present study was to disclose complications after TURP undertaken in routine clinical practice at a non-academic center.Methods: All patients with BPE submitted to TURP from January 2010 to December 2012 were evaluated for complications occurring during hospital stay, after discharge up to the end of the third post-operative month and finally for any late endourological re-interventions undertaken up to five years after TURP. All complications were graded according to the Clavien-Dindo system.Results: In total, 354 men underwent a TURP during the study period. In total, 47% had pre-operative urinary retention. Significant co-morbidity was seen in 17% of men (ASA III-IV). Spinal anaesthesia was applied to 312 men (88%). During hospital stay, major complications, graded as Clavien-Dindo ≥ III, was seen in only eight men (2.3%). Minor complications occurred in 91 men (26%). Between hospital discharge and follow-up visit major complications were noted in 12 men (3.4%). Minor complications occurred in 79 men (22%). The only factor that was associated with an increased risk of a major complication was general anaesthesia. Late complications, requiring an endourological re-intervention, occurred in 30 men (9.7%).Conclusion: TUR-P in routine clinical practice was associated with a low incidence of severe complications. TUR syndrome was very rare. Within five years a small proportion of men require the transurethral intervention to be redone.

Can bipolar energy serve as an alternative to monopolar energy in the management of large bladder tumours >3 cm? A prospective randomised study

Objectives: To assess the safety and the effectiveness of bipolar energy in the transurethral resection of primary large bladder tumours (TURBT) and compare it to conventional monopolar energy. Patients and methods: From November 2015 to June 2017, 80 patients underwent endoscopic resection primarily for large bladder cancer tumours of >3 cm. They were randomly assigned into two groups: 40 patients underwent a TURBT with conventional monopolar current (M-TURBT) and 40 were treated with bipolar current (B-TURBT). Results: There were no statistically significant differences between the two groups for the patients' demographic and tumour characteristics. There was a significant difference between M-TURBT and B-TURBT for resection time, obturator reflex, hospital stay, and catheterisation time, which were all higher in the M-TURBT group; the mean (SD) resection time was 26.45 (5.73) vs 22.85 (7.52) min (P = 0.048), the obturator reflex was 25% vs 5% (P = 0.025), the median hospital stay and catheterisation times were 2 vs 1 day (P = 0.012 and P = 0.023, respectively). No statistically significant difference was found between the groups for bladder perforation, TUR syndrome, drop in haemoglobin level, and blood transfusion rate. However, there was statically significant difference in the postoperative haematuria rate, which was higher in the M-TURBT group, at 24 patients vs eight in the B-TURBT group (60% vs 20%; P = 0.01). After 1-year follow-up, there was no significant difference in the recurrence rate between the groups. Conclusion: B-TURBT is a safe and effective alternative procedure to M-TURBT for the management of primary large bladder tumours of >3 cm. Abbreviations: CONSORT: consolidated standards of reporting Trials; Hb: haemoglobin; NMIBC: non-muscle-invasive bladder cancer; TUR: transurethral resection; (B-)(M-)TURBT: (bipolar) (monopolar) transurethral resection of bladder tumour.

The effect of a mixture of 2.7% sorbitol-0.54% mannitol solution on blood coagulation: an invitro, observational healthyvolunteer study using rotational thromboelastometry (ROTEM)

Background

We investigated the effect of irrigation fluid on coagulation according to the hemodilution level using rotational thromboelastometry (ROTEM).

Methods

Venous blood was taken from 12 healthy volunteers and divided into four specimen tubes that were diluted to various levels (0%, 10%, 20%, and 40%) using an irrigation fluid composed of 2.7% sorbitol and 0.54% mannitol.

Results

Significant prolongation of clotting time was observed in the 40% diluted sample using both INTEM (P = 0.009) and EXTEM (P = 0.001) assays. However, the clot formation time was prolonged significantly in the 10%, 20%, and 40% diluted samples using both INTEM (P < 0.001) and EXTEM (P = 0.002, P < 0.001, and P < 0.001, respectively) assays. A significant decrease of α-angle of INTEM and EXTEM were observed in the 10% (P < 0.001), 20% (P < 0.001 and P = 0.001, respectively), and 40% (P < 0.001) groups compared with the 0% dilution group. The maximum clot firmness (MCF) of INTEM decreased significantly in the 20% (P < 0.001) and 40% (P < 0.001) diluted samples. In the MCF of EXTEM and FIBTEM assays, 10% (P = 0.009 and P = 0.015, respectively), 20% (P = 0.001), and 40% (P < 0.001) samples showed a significant decrease compared with the 0% sample. Nevertheless, most of the ROTEM values were within the reference range, except the 40% sample.

Conclusions

Blood became hypocoagulable when it was diluted in vitro with a fluid composed of 2.7% sorbitol and 0.54% mannitol.

Transurethral procedures in the treatment of benign prostatic hyperplasia: A systematic review and meta-analysis of effectiveness and complications

BACKGROUND

With the progress of surgical techniques and instruments, various minimally invasive surgical therapies were developed to treat benign prostatic hyperplasisa (BPH). However, the efficacy and safety of different transurethral procedures for the treatment of BPH are still undefined.

METHOD

A systematic search was performed for all randomized controlled trials (RCTs), which compared the transurethral procedures for BPH from 1995 to 2016. The clinical baseline characteristics, International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual (PVR), maximum flow rate (Qmax), short-term and long-term complications were analyzed using RevMan and ADDIS software.

RESULT

Eighty-eight randomly controlled trials and fifteen procedures were included in the network meta-analysis. HoLEP greatly inproved PVR. TmLRP had the best efficacy in improving QoL score. Diode laser vaporization of prostate was superior in improving IPSS and Qmax. Diode laser through vaporization required the shortest time in catheterization, while Nd:YAG was the longest procedure. For the hospitalization time, TUR was the longest and HoLEP was the shortest. TmLRP was related to the lowest postoperative hemoglobin decrease. TmLEP had the least rates of occurrence of hematuria, reoperation and erectile dysfunction. HoLEP was the best choice to reduce the incidence of recatheterization, urinary retention, urinary tract infection, stress urinary incontinence and retrograde ejaculation. The complications such as blood transfusion, urethral stricture, bladder neck contracture were relatively rare in the patients who underwent diode laser vaporization of prostate.

CONCLUSION

Compared with other transurethral procedures, thulium, holmium and diode lasers were associated with better efficacy and fewer complications.

[Safety and efficacy of intravenous tranexamic acid in endoscopic transurethral resections in urology: Prospective randomized trial]

BACKGROUND

Endoscopic urological procedures (transurethral resection of the prostate TURP/transurethral resection of bladder tumor TURBT) are not without risk of significant bleeding. This risk is due to the vascular nature of the tissues and their high levels of fibrinolytic enzymes in the tissues and urine. This study was conducted to evaluate the safety and efficacy of the antifibrinolytic agent tranexamic acid (TXA) in reducing blood loss in patients undergoing TURP/TURBT and transfusion requirement.

METHODS

This study was a prospective, randomized, double-blind, placebo controlled clinical trial. One hundred and thirty-one patients of ASA physical status I or II, undergoing TURP (60 patients) or TURBT (71 patients) were randomly allocated to receive IV TXA: bolus of 10mg/kg at the induction of anesthesia followed by infusion of 1mg/kg/h intraoperatively and for 24h postoperatively or an equal volume of saline (control group). Blood loss was evaluated in terms of reduction in the serum hemoglobin level (delta Hb=Hb H24-Hb H0).

RESULTS

There was no difference between two groups in terms of transfusion requirements and episodes of retention. TXA did not significantly reduce mean blood loss compared with placebo during TURP (1.37±0.69 vs. 1.72±1.23g/dL respectively, P=0.256) or TURBT (1.15±0.95 vs. 1.07±0.88g/dL; P=0.532). No thrombotic complications were noted in any patient.

CONCLUSION

Tranexamic acid did not reduce transfusion requirements or perioperative blood loss in transurethral resection of the prostate or bladder tumor.

LEVEL OF EVIDENCE

4.

Functional outcomes and complications following B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia: a review of the literature and Meta-analysis

OBJECTIVE

To conduct a systematic review and Meta-analysis of the literature on the efficacy and safety of B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia (BPH) in terms of demographic and clinical baseline characteristics, peri-operative variables, and postoperative outcomes and complications.

METHODS

Trials comparing B-TURP and HoLEP were identified systematically using Pubmed, Embase, CNKI, Web of Science and the Cochrane Library. Primary outcomes were the peak urinary flow rate (Q_max), post-void residual volume (PVR) and international prostate symptom score (IPSS). Secondary outcomes were operation time, irrigation duration, catheterization duration, resected tissue and complications.

RESULTS

Four trials assessing B-TURP and HoLEP were considered eligible for Meta-analysis, including three randomized controlled trials (RCTs) and one retrospective study. There was no statistically significant difference between B-TURP and HoLEP in terms of Q_max, IPSS, PVR at 3-6 months follow-up, operation duration, catheterization duration, resected tissue and complications (p > 0.05). HoLEP was associated with a significantly shorter irrigation time as compared with B-TURP (p < 0.05).

CONCLUSION

Both B-TURP and HoLEP are safe and minimally invasive techniques that are similar in terms of symptomatic relief, although these findings need further validation in larger RCTs involving larger numbers of patients and over a longer follow-up duration for B-TURP or HoLEP before a new gold standard procedure emerges for surgical treatment of BPH.

An update on transurethral surgery for benign prostatic obstruction

Clinical benign prostatic hyperplasia (BPH) is one of the most common cause of lower urinary tract symptoms and transurethral resection of prostate (TURP) has been the gold standard technique for surgical treatment of benign prostate obstruction (BPO) over the last 2 decades. Although monopolar TURP is considered a safe and effective option for surgical management of BPO, there are some disadvantages, namely bleeding, transurethral resection syndrome, incompleteness of treatment. This review aims to highlight these problems, and describe the advances in technology and techniques that have evolved to minimise such complications. With the advent of lasers and bipolar technology, as well as enucleative techniques to remove the prostatic adenoma/adenomata, the problems of bleeding, transurethral resection syndrome and incomplete treatment are significantly minimised. Monopolar TURP will likely be replaced by such technology and techniques in the near future such that transurethral surgery of the prostate remain a safe and effective option in alleviating the harmful effects of BPO.

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

The TURis System for Transurethral Resection of the Prostate: A NICE Medical Technology Guidance

The transurethral resection in saline (TURis) system was notified by the company Olympus Medical to the National Institute of Health and Care Excellence's (NICE's) Medical Technologies Evaluation Programme. Following selection for medical technologies guidance, the company developed a submission of clinical and economic evidence for evaluation. TURis is a bipolar surgical system for treating men with lower urinary tract symptoms due to benign prostatic enlargement. The comparator is any monopolar transurethral resection of the prostate (mTURP) system. Cedar, a collaboration between Cardiff and Vale University Health Board, Cardiff University and Swansea University in the UK, acted as an External Assessment Centre (EAC) for NICE to independently critique the company's submission of evidence. Eight randomised trials provided evidence for TURis, demonstrating efficacy equivalent to that of mTURP for improvement of symptoms. The company presented meta-analyses of key outcome measures, and the EAC made methodological modifications in response to the heterogeneity of the trial data. The EAC analysis found that TURis substantially reduced the relative risks of transurethral resection syndrome (relative risk 0.18 [95 % confidence interval 0.05-0.62]) and blood transfusion (relative risk 0.35 [95 % confidence interval 0.19-0.65]). The company provided a de novo economic model comparing TURis with mTURP. The EAC critiqued the model methodology and made modifications. This found TURis to be cost saving at £70.55 per case for existing Olympus customers and cost incurring at £19.80 per case for non-Olympus customers. When an additional scenario based on the only available data on readmission (due to any cause) from a single trial was modelled, the estimated cost saving per case was £375.02 for existing users of Olympus electrosurgery equipment and £284.66 per case when new Olympus equipment would need to be purchased. Meta-analysis of eight randomised trials showed that TURis is associated with a statistically significantly reduced risk of transurethral resection syndrome and a reduced need for blood transfusion-two factors that may drive cost saving for the National Health Service. The clinical data are equivocal as to whether TURis shortens the hospital stay. Limited data from a single study suggest that TURis may reduce the rate of readmission after surgery. The NICE guidance supports adoption of the TURis technology for performing transurethral resection of the prostate in men with lower urinary tract symptoms due to benign prostatic enlargement.

Economic Value of the Transurethral Resection in Saline System for Treatment of Benign Prostatic Hyperplasia in England and Wales: Systematic Review, Meta-analysis, and Cost-Consequence Model

CONTEXT

Monopolar transurethral resection of the prostate (M-TURP) is the current UK surgical standard of care for benign prostatic hyperplasia, a condition estimated to affect >2 million men in the United Kingdom. Although M-TURP efficacy in prostate resection is established, potential perioperative complications and associated costs remain a concern.

OBJECTIVE

To present up-to-date and robust evidence in support of bipolar transurethral resection in saline (TURis) as an alternative surgical option to M-TURP.

EVIDENCE ACQUISITION

A systematic review (SR) of electronic databases (up to 2015) for randomised controlled trials (RCTs) comparing TURis with M-TURP was conducted, followed by evidence synthesis in the form of a meta-analysis of hospital stay, catheterisation time and procedure duration, transurethral resection (TUR) syndrome, blood transfusion, clot retention, and urethral strictures. An economic analysis was subsequently undertaken from the UK National Health Service hospital perspective with costs and resource use data from published sources.

EVIDENCE SYNTHESIS

The SR identified 15 good-quality RCTs, of which 11 were used to inform the meta-analysis. TURis was associated with improved safety versus M-TURP, eliminating the risk of TUR syndrome and reducing the risk of blood transfusion and clot retention (relative risks: 0.34 and 0.43, respectively; p<0.05). TURis also reduced hospital stay (mean difference: 0.56 d; p<0.0001). The economic analysis indicated potential cost savings with TURis versus M-TURP of up to £204 per patient, with incremental equipment costs offset by savings from reduced hospital stay and fewer complications.

CONCLUSIONS

The TURis system is associated with significant improvements in perioperative safety compared with M-TURP while ensuring equivalent clinical outcomes of prostate resection. The safety benefits identified may translate into cost savings for UK health services.

PATIENT SUMMARY

Our review of bipolar transurethral resection in saline, the new prostate resection technique, indicates that it offers equal efficacy while reducing complications and length of hospital stay.

Post-Transurethral Resection of the Prostate Inflation of Pressure-Controlled Endorectal Balloon-Impact on Postoperative Bleeding: A Preliminary Experimental Pilot Study

OBJECTIVE

To evaluate the impact of rectal balloon (RB) inflation on post-transurethral resection of the prostate (TURP) bleeding in patients with symptomatic benign prostatic hyperplasia.

METHODS

After institutional review board approval, patients who were eligible for TURP were randomized into two equal groups, depending on whether they received postoperative endorectal balloon (RB) (GII) or not (GI). The tip of three-way Foley catheter was fixed to a balloon by a blaster strip to prepare air-tight RB. Postoperatively, the RB was inflated for 15 minutes by a pressure-controlled sphygmomanometer. Perioperative data were compared between both groups, including hemoglobin (Hb) deficit 24-hour postoperatively and at time of discharge. Functional outcomes, anorectal complaints, and adverse events were assessed perioperatively and after 1 and 3 months.

RESULTS

Fifty patients were enrolled, including 13 (26%) patients who presented with indwelling urethral catheters. Baseline data and mean resected tissue weight were comparable between both groups, including preoperative Hb (p = 0.17). Immediate postoperative Hb deficit was, comparable between GI and GII patients (0.58 ± 0.18 vs 0.60 ± 0.2, p = 0.56) before RB inflation, respectively. However, compared to GI patients, mean Hb deficit significantly decreased in GII patients 24-hour postoperatively (0.2 ± 0.2 vs 0.7 ± 0.3 g, p = 0.002) and at time of discharge (0.8 ± 0.2 vs 1.3 ± 0.4 g, p = 0.003). GII patients needed significantly less postoperative irrigation (2.1 ± 1.6 vs 8.3 ± 1.8 L, p < 0.001), shorter catheterization time (2.3 ± 0.8 vs 3.8 ± 1.3 days, p < 0.001), and shorter hospital stay (2.6 ± 0.5 vs 4.3 ± 1.0 days, p < 0.001). Both groups were comparable in all functional outcomes at the most recent follow-up. Blood transfusion was needed in only one patient (4%) in GI. No patient needed recystoscopy for hematuria or clot retention in either group, while there were no anorectal complaints reported by GII patients.

CONCLUSIONS

Post-TURP endorectal balloon inflation seems to be simple, safe, and an efficient procedure to reduce postoperative bleeding and irrigation volume. It is significantly associated with shorter catheterization time and hospital stay.

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.

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.

Comparison of plasmakinetic transurethral resection of the prostate with monopolar transurethral resection of the prostate in terms of urethral stricture rates in patients with comorbidities

Purpose

To compare urethral stricture rates in comorbid patients undergoing plasmakinetic transurethral resection of the prostate (PK-TURP) and monopolar transurethral resection of the prostate (M-TURP) for benign prostatic hyperplasia.

Methods

The data of 317 patients with comorbidities undergoing either PK-TURP or M-TURP from September 2008 to December 2012 were retrospectively evaluated. Preoperative and postoperative 12-month International Prostate Symptom Score, maximal flow rate, postoperative International Index of Erectile Function scores, and urethral stricture rates were evaluated.

Results

A total of 154 patients underwent M-TURP and 163 patients underwent PK-TURP. Urethral stricture rates were 6/154 in the M-TURP treatment arm and 17/163 in the PK-TURP treatment arm (P=0.000). In the presence of hypertension and/or coronary artery disease and/or diabetes mellitus, the risk of urethral stricture complication was significantly higher in the PK-TURP group than in the M-TURP group (P=0.000).

Conclusions

The risk of urethral stricture increases with PK-TURP in elderly patients with a large prostate and concomitant hypertension and/or coronary artery disease and/or diabetes mellitus. Therefore, PK-TURP should be performed cautiously in this group of benign prostatic hyperplasia patients.

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.

Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP)

To compare monopolar and bipolar transurethral resection of the prostate (TURP) for clinical effectiveness and adverse events. We conducted an electronic search of MEDLINE, Embase, CENTRAL, Science Citation Index, and also searched reference lists of articles and abstracts from conference proceedings for randomised controlled trials (RCTs) comparing monopolar and bipolar TURP. Two reviewers independently undertook data extraction and assessed the risk of bias in the included trials using the tool recommended by the Cochrane Collaboration. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. From the 949 abstracts that were identified, 94 full texts were assessed for eligibility and a total of 24 trials were included in the review. No statistically significant differences were found in terms of International Prostate Symptom Score (IPSS) or health-related quality of life (HRQL) score. Results for maximum urinary flow rate were significant at 3, 6 and 12 months (all P < 0.001), but no clinically significant differences were found and the meta-analysis showed evidence of heterogeneity Bipolar TURP was associated with fewer adverse events including transurethral resection syndrome (risk ratio [RR] 0.12, 95% confidence interval [CI] 0.05-0.31, P < 0.001), clot retention (RR 0.48, 95% CI 0.30-0.77, P = 0.002) and blood transfusion (RR 0.53, 95% CI 0.35-0.82, P = 0.004) Several major methodological limitations were identified in the included trials; 22/24 trials had a short follow-up of ≤1 year, there was no evidence of a sample size calculation in 20/24 trials and the application of GRADE showed the evidence for most of the assessed outcomes to be of moderate quality, including all those in which statistical differences were found. Whilst there is no overall difference between monopolar and bipolar TURP for clinical effectiveness, bipolar TURP is associated with fewer adverse events and therefore has a superior safety profile. Various methodological limitations were highlighted in the included trials and as such the results of this review should be interpreted with caution. There is a need for further well-conducted, multicentre RCTs with long-term follow-up data.

[Transurethral resection of the prostate and current modifications (bipolar, electrovaporization)]

Transurethral resection of the prostate (TURP) is the surgical standard which is truly minimally invasive by using a natural orifice and is also of durable efficacy. The use of TURP removes tissue from benign prostatic hyperplasia (BPH) and leads to clinically relevant improvement in symptoms and quality of life as well as in micturition parameters and obstruction. Tissue is removed by high frequency (HF) current with synchronous hemostasis. Many modifications of TURP, such as the use of video, have become generally accepted and improved the standard. Other modifications were developed because the balance between cutting and hemostasis needed improvement in favor of hemostasis. Several modifications of TURP, such as modulation of HF pulses, band loops and bipolar resection and new procedures, such as vaporization and enucleation showed improved hemostasis. These modifications and procedures, however, have not yet replaced standard TURP but have become established as additional options.

Plasmakinetic bipolar versus monopolar transurethral resection of non-muscle invasive bladder cancer: a single center randomized controlled trial

OBJECTIVES

To compare the safety and the efficacy of plasmakinetic bipolar resectoscope versus conventional monopolar in the transurethral resection of primary non-muscle invasive bladder cancer.

METHODS

From January 2007 to December 2009, 132 patients underwent endoscopic resection for primary non-muscle invasive bladder cancer. They were randomly assigned to two groups: 67 patients underwent a transurethral resection of the bladder with bipolar plasmakinetic energy transurethral resection of the bladder and 65 were treated with conventional monopolar transurethral resection.

RESULTS

The mean operative time was 27 min for bipolar plasmakinetic energy transurethral resection of the bladder and 31 min for monopolar transurethral resection of the bladder. No significant differences in the mean change of hemoglobin and serum sodium level were observed. Mean catheterization time was 1.3 days and 2.3 days for bipolar plasmakinetic energy transurethral resection of the bladder and monopolar transurethral resection of the bladder, respectively. The mean hospital stay was shorter in the bipolar plasmakinetic energy transurethral resection of the bladder. Bladder perforation was reported in two cases for the monopolar transurethral resection of the bladder group and obturator nerve reflex occurred in a single case for both procedures. None of the patients experienced transurethral resection syndrome. The median time of bladder tumor recurrence after initial transurethral resection of the bladder was 12.4 months and 11.9 months for bipolar plasmakinetic energy transurethral resection of the bladder and monopolar transurethral resection of the bladder, respectively. No significant differences in the overall recurrence-free survival rate were observed comparing the two procedures.

CONCLUSIONS

Plasmakinetic bipolar transurethral resection represents a safe and effective procedure in the management of non-muscle invasive bladder cancer.

Recent advances in the surgical treatment of benign prostatic hyperplasia

TURP for many years has been considered the gold standard for surgical treatment of BPH. Symptoms relief, improvement in Maximum flow rate and reduction of post void residual urine have been reported in several experiences. Notwithstanding a satisfactory efficacy, concerns have been reported in terms of safety outcomes:intracapsular perforation, TUR syndrome, bleeding with a higher risk of transfusion particularly in larger prostates have been extensivelyreported in the literature.IN THE RECENT YEARS THE USE OF NEW FORMS OF ENERGY AND DEVICES SUCHAS BIPOLAR RESECTOR, HO: YAG and potassium-titanyl-phosphate laserare challenging the role of traditional TURP for BPH surgical treatment.In 1999 TURP represented the 81% of surgical treatment for BPHversus 39% of 2005. Is this a marketing driven change or is there areal advantage in new technologies?We analyzed guidelines and higher evidence studies to evaluate therole of the most relevant new surgical approaches compared to TURPfor the treatment of BPH.In case of prostates of very large size the challenge is ongoing, withminimally invasive laparoscopic approach and most recently roboticapproach. We will evaluate the most recent literature on thisemerging field.