|Year : 2019 | Volume
| Issue : 6 | Page : 262-265
Comparative assessment of monopolar versus bipolar transurethral resection of prostate for the management of benign prostatic enlargement
Kshitij Raghuvanshi, Abid Raval, Devendra Kumar Jain, Ketan P Vartak, Sachin Patil, Shams Iqbal, Rajesh Dhake, Hrishikesh Deshmukh
Department of Urology, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India
|Date of Submission||03-May-2019|
|Date of Acceptance||20-Jun-2019|
|Date of Web Publication||23-Dec-2019|
Dr. Kshitij Raghuvanshi
Department of Urology, Bharati Vidyapeeth Medical College and Hospital, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
Objectives: The objective is to compare monopolar transurethral resection of the prostate (M-TURP) versus bipolar TURP (B-TURP). Methods: In this prospective comparative study, 102 patients scheduled to undergo transurethral resection of prostate were enrolled and table randomized to surgery by M-TURP or B-TURP. International Prostate Symptom Score (IPSS), uroflowmetry, ultrasonography (kidney-ureter-bladder), prevoid, postvoid and laboratory investigations (for preanesthetic fitness) were done preoperative and 3-month postsurgery. Results: Patients were divided into two groups namely M-TURP and B-TURP. The mean age of patients was comparable between both groups. There is a significantly lower mean resection time in M-TURP compared to B-TURP. IPSS, postvoid residual volume, and Qmaximproved in both groups, and it was statistically insignificant. Drop in hemoglobin levels (g/dl) in patients of M-TURP was higher compared than B-TURP. Conclusions: Both M-TURP and B-TURP are safe and effective modality. However, B-TURP will surely replace M-TURP as gold standard.
Keywords: Bipolar, benign prostatic enlargement, monopolar, pre- and post-surgery complications, transurethral resection, transurethral resection of the prostate
|How to cite this article:|
Raghuvanshi K, Raval A, Jain DK, Vartak KP, Patil S, Iqbal S, Dhake R, Deshmukh H. Comparative assessment of monopolar versus bipolar transurethral resection of prostate for the management of benign prostatic enlargement. Urol Sci 2019;30:262-5
|How to cite this URL:|
Raghuvanshi K, Raval A, Jain DK, Vartak KP, Patil S, Iqbal S, Dhake R, Deshmukh H. Comparative assessment of monopolar versus bipolar transurethral resection of prostate for the management of benign prostatic enlargement. Urol Sci [serial online] 2019 [cited 2020 Aug 6];30:262-5. Available from: http://www.e-urol-sci.com/text.asp?2019/30/6/262/273876
| Introduction|| |
Benign prostatic enlargement (BPE) is a well-known disease affecting elderly men. It is commonly associated with comorbidity. BPE causes lower urinary tract symptoms (LUTS), and the management of these patients is a major concern for urological professionals.,
Out of several treatment modalities available, surgical intervention through monopolar transurethral resection (TUR) of the prostate (M-TURP) is considered as a gold standard due to its proven safety and efficacy.,, However, systemic absorption of the electrolyte-free irrigation solutions (i.e., glycine, sorbitol, and mannitol) and high-frequency electrical current in M-TURP can result in number of complications including urethral strictures, bleeding, bladder neck contractures, or TUR syndrome.,,
Bipolar TURP (B-TURP) is a modification of conventional M-TURP procedure, and the use of isotonic irrigating fluid (normal saline or lactate ringer) reduces the risk of TUR syndrome. Although, previous studies comparing B-TURP with M-TURP revealed promising benefits, including fewer frequencies of bleeding and hyponatremia, the use of bipolar technology over conventional M-TURP has not gained the status of gold standard.
In this prospective observational study, the assessment of the feasibility of techniques of M-TURP and B-TURP in the management of patients requiring surgical intervention for BPE was done by comparing the resection time, pre- and post-surgery complications and final outcome in patients of BPE undergoing TURP using monopolar versus bipolar equipment.
| Methods|| |
The present study was a prospective interventional comparative (two surgical techniques) study, conducted between March 1, 2017, and October 1, 2018. The study patients were recruited from patients attending the urology outpatient department in Bharti Hospital, Pune, India. A total of 102 patients scheduled to undergo TURP were recruited and alternatively subjected to surgery by monopolar or bipolar technique without any bias. The study protocol was approved by the institutional ethics committee of Bharati Vidypeeth Deemed University (Reference no. BVDU/MC/09 obtained on March 1st, 2017). Written informed consent was obtained from each patient for participation in the study.
The inclusion criteria for study enrolment were patients with BPE with moderate-to-severe LUTS, history of recurrent acute urinary retention with failed catheter, recurrent urinary tract infection, gross hematuria, back pressure changes, bladder calculus, bladder diverticulitis, or failed medical therapy.
Exclusion criteria include prostate cancer, neurogenic bladder, previous prostate surgery, and urethral stricture.
All patients were evaluated as per the proforma. Documentation of detailed history and physical examination was done for each patient. All patients were subjected to laboratory investigations (pre- and post-surgery), which included hemogram, renal function tests, and urinalysis. Appropriate antibiotics were given according to sensitivity pattern preoperatively in cases where urine culture showed the evidence of infection. The antibiotic was started 1-day preoperatively and continued till 5 days postoperatively.
B-TURP and M-TURP were performed using a 26 Fr KARL STORZ resectoscope. A 20 Fr Foley catheter was inserted into all patients postoperation for 48 h, and bladder irrigation with normal saline was continued.
Storage symptoms were assessed with international prostate symptom score, maximum flow rate by uroflowmetry and postvoid residual (PVR) volume, before and 3 months after surgery.
Comparative analysis of data was carried out using either two independent sample t-test or Mann–Whitney U test (continuous data). For intragroup analysis and intergroup analysis, McNemar's test (paired data) and Chi-square test (discrete data), respectively, were used. P < 0.05 was considered statistically significant.
| Results|| |
A total of 102 patients with BPE were divided into two groups, namely M-TURP (n = 51) and B-TURP (n = 51).
The mean age of patients in both groups was comparable [Table 1]. The IPSS reduced in both the groups and was comparable. The Qmax (mL/s) improved postoperatively in both the groups, and it was comparable between the two groups. The prostate size recorded 3 months' postsurgery reduced in both groups; however, the reduction in the gland size was more in B-TURP group compared M-TURP [Table 1].
The mean resection time required for patients undergoing M-TURP was significantly low as compared to B-TURP group [Table 1]. Drop in hemoglobin (Hb) levels (g/dl) in patients of M-TURP group was significantly higher compared to patients of B-TURP group [Figure 1]a. Drop in sodium and potassium in both the groups showed insignificant difference [Figure 1]b.
|Figure 1: Comparison of (a) hemoglobin and (b) sodium levels across the study groups. B-TURP: Bipolar transurethral resection of the prostate, M-TURP: Monopolar transurethral resection of the prostate|
Click here to view
| Discussion|| |
Due to serious complications associated with the practice of conventional M-TURP, an alternative approach of B-TURP has come into limelight and has shown promising results by eliminating the risk of TUR syndrome. The present study evaluated safety and efficacy of B-TURP and M-TURP in the management of patients requiring surgical intervention for BPE.
In the present study, the patient's age (n = 102) ranged from 51 years to 88 years, with a comparable mean age of 67.68 years in the M-TURP group and 70.82 years in the B-TURP group (P = 0.07). These results are in concordance with the few previous studies,,, except one study which reported a significantly higher mean age for the monopolar group as compared to the bipolar group (P = 0.025).
A prolonged resection time (>90 min) is an important factor contributing to fluid absorption and the subsequent complications. The present study demonstrated significantly lower resection time for M-TURP group than the B-TRUP group (31.20 vs. 43.10 min) (P < 0.001), suggestive of monopolar surgery requiring less time. However, this might be due to the less acquaintance to the equipment in the early few cases due to first time availability of B-TURP in our institute. In the later cases, the time taken for surgery is comparable. The present study results contradict the observations of several other studies,,, which reported nonsignificant difference in operating time between M-TURP and B-TURP. However, results of the studies,, who have reported significantly longer operative times for bipolar group as compared to monopolar group corroborates with the present study. This observed trend of increased operative time was attributed to the use of the larger loop size of the monopolar resectoscope as compared to the bipolar resectoscope, to the considerably larger size of the gland resected using bipolar technology, to the well-trained surgeons who can use M-TURP, to the smaller diameter of the resection loop, a small-sized resectoscope 24 French in B-TURP.
In the present study, baseline prostate size recorded by ultrasonography was significantly higher in the B-TURP group as compared to the M-TURP group (57.49 vs. 44.48 cc) (P < 0.001). Similar to our study, Madduri et al. also reported a larger baseline prostate size in the bipolar group. However, in contrast to the present study, few studies, reported insignificant differences between the baseline prostate size in patients of both groups. Further, the present study showed that the prostate size recorded 3 months' postsurgery was significantly reduced in both the modalities; however, the reduction in the gland size was more in the B-TURP group compared to M-TURP group (P < 0.001). A study by Kumar et al. reported a reduction in gland size: 27 cc in the monopolar group and 25.48 cc in the bipolar group, but the difference in reduction between the two groups was not significant.
Further, IPSS and Qmax scores showed significant postoperative improvements among both groups (P < 0.001). Parallel to our results, Al-Rawashdah et al. demonstrated the significant postoperative improvements in PVR, IPSS, and Qmax among both groups, but no statistically significant difference was reported between the two groups. In contrast to our study, Singhania et al. reported a significant increase in Qmax postoperatively in the bipolar group as compared to monopolar group.
Perioperative bleeding is one of the main complications in TURP, leading to clot retention and anemia. Venous bleeding occurs through open sinuses during TURP operations, and the capsule perforation increases the bleeding. Bipolar technique provides better hemostasis and visualization and minimizes blood loss., The present study demonstrated that the drop-in Hb level was significantly lower in B-TURP when compared with M-TURP group. A recent study by Al-Rawashdah et al. also demonstrated similar results suggesting a valuable benefit from B-TURP with regard to bleeding complications. A meta-analysis of 20 studies that compared monopolar and bipolar methods reported significantly lower incidences of blood transfusion and clot retention in the bipolar group. However, the present study did not report any major bleeding episode in either group that needed blood transfusion.
In the present study, Na+ and K+ levels did not change much in both the groups postsurgery, and the difference was insignificant. Parallel to these results, Karadeniz et al. reported no statistically significant difference in levels K+ between and within the groups. They also showed significant changes in pre- and postoperative Na+ levels in the monopolar group, while Na+ levels remained unchanged with the bipolar technique. Contradictory to the present study, a large number of studies,,, have reported a significant reduction of serum Na+ levels postoperatively in the monopolar group as compared to the bipolar group. These results may depict that B-TURP eliminates the risk of dilutional hyponatremia, which is significantly increased with M-TURP leading to TUR syndrome. Further, hyperkalemia cardiotoxicity is increased by hyponatremia and acidosis. Therefore, cardiovascular changes in TUR syndrome can be caused by both hyponatremia and hyperkalemia.
The limitations of this study were small sample size and small duration of the study with lack of longer follow-up period. Hence, a well-designed randomized trial study with large sample size, long duration of the study, and extended follow-up is necessary to establish more concrete views on the use of B-TURP in the management of patients with BPE.
| Conclusions|| |
The observations of this prospective study suggest that the B-TURP and M-TURP are both safe and effective surgical interventions for the treatment of BPE. However, the feasibility of B-TURP is beneficial with regard to bleeding complications, improvement in Qmax, and reduced rate of urine infection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Verhamme KM, Dieleman JP, Bleumink GS, van der Lei J, Sturkenboom MC, Artibani W, et al.
Incidence and prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in primary care – The triumph project. Eur Urol 2002;42:323-8.
Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, et al.
EAU guidelines on the assessment of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2015;67:1099-109.
Sugihara T, Yasunaga H, Horiguchi H, Nakamura M, Nishimatsu H, Kume H, et al.
In-hospital outcomes and cost assessment between bipolar versus monopolar transurethral resection of the prostate. J Endourol 2012;26:1053-8.
Reich O, Gratzke C, Stief CG. Techniques and long-term results of surgical procedures for BPH. Eur Urol 2006;49:970-8.
Burke N, Whelan JP, Goeree L, Hopkins RB, Campbell K, Goeree R, et al.
Systematic review and meta-analysis of transurethral resection of the prostate versus minimally invasive procedures for the treatment of benign prostatic obstruction. Urology 2010;75:1015-22.
Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP) – Incidence, management, and prevention. Eur Urol 2006;50:969-79.
Tao H, Jiang YY, Jun Q, Ding X, Jian DL, Jie D, et al.
Analysis of risk factors leading to postoperative urethral stricture and bladder neck contracture following transurethral resection of prostate. Int Braz J Urol 2016;42:302-11.
Reich O, Gratzke C, Bachmann A, Seitz M, Schlenker B, Hermanek P, et al.
Morbidity, mortality and early outcome of transurethral resection of the prostate: A prospective multicenter evaluation of 10,654 patients. J Urol 2008;180:246-9.
Mamoulakis C, Skolarikos A, Schulze M, Scoffone CM, Rassweiler JJ, Alivizatos G, et al.
Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs. monopolar transurethral resection of the prostate. BJU Int 2012;109:240-8.
Madduri VK, Bera MK, Pal DK. Monopolar versus bipolar transurethral resection of prostate for benign prostatic hyperplasia: Operative outcomes and surgeon preferences, a real-world scenario. Urol Ann 2016;8:291-6.
] [Full text]
Hafez M, Hamid M, Raouf S, Soaida S, Marie M. Bipolar versus monopolar transurethral prostate resection: Comparision of hemodynamic and biochemical changes. Egypt J Anaesth 2014;30:47-52.
Engeler DS, Schwab C, Neyer M, Grün T, Reissigl A, Schmid HP. Bipolar versus monopolar TURP: A prospective controlled study at two urology centers. Prostate Cancer Prostatic Dis 2010;13:285-91.
Karadeniz MS, Bayazit E, Aksoy O, Salviz EA, Tefik T, Sanli O, et al.
Bipolar versus monopolar resection of benign prostate hyperplasia: A comparison of plasma electrolytes, hemoglobin and TUR syndrome. Springerplus 2016;5:1739.
Yang EJ, Li H, Sun XB, Huang L, Wang L, Gong XX, et al.
Bipolar versus monopolar transurethral resection of the prostate for benign prostatic hyperplasia: Safe in patients with high surgical risk. Sci Rep 2016;6:21494.
Chen Q, Zhang L, Fan QL, Zhou J, Peng YB, Wang Z. Bipolar transurethral resection in saline vs. traditional monopolar resection of the prostate: Results of a randomized trial with a 2-year follow-up. BJU Int 2010;106:1339-43.
Kumar A, Vasudeva P, Kumar N, Nanda B, Jha SK, Mohanty N. A prospective randomized comparative study of monopolar and bipolar transurethral resection of the prostate and photoselective vaporization of the prostate in patients who present with benign prostatic obstruction: A single center experience. J Endourol 2013;27:1245-53.
Michielsen DP, Debacker T, De Boe V, Van Lersberghe C, Kaufman L, Braeckman JG, et al.
Bipolar transurethral resection in saline – An alternative surgical treatment for bladder outlet obstruction? J Urol 2007;178:2035-9.
Al-Rawashdah SF, Pastore AL, Salhi YA, Fuschi A, Petrozza V, Maurizi A, et al.
Prospective randomized study comparing monopolar with bipolar transurethral resection of prostate in benign prostatic obstruction: 36-month outcomes. World J Urol 2017;35:1595-601.
Singhania P, Nandini D, Sarita F, Hemant P, Hemalata I. Transurethral resection of prostate: A comparison of standard monopolar versus bipolar saline resection. Int Braz J Urol 2010;36:183-9.
Tang Y, Li J, Pu C, Bai Y, Yuan H, Wei Q, et al.
Bipolar transurethral resection versus monopolar transurethral resection for benign prostatic hypertrophy: A systematic review and meta-analysis. J Endourol 2014;28:1107-14.
Yousef AA, Suliman GA, Elashry OM, Elsharaby MD, Elgamasy Ael-N. A randomized comparison between three types of irrigating fluids during transurethral resection in benign prostatic hyperplasia. BMC Anesthesiol 2010;10:7.
Omar MI, Lam TB, Alexander CE, Graham J, Mamoulakis C, Imamura M. Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP). BJU Int 2014;113:24-35.
Krishnamoothy H, Philip S. Serum electrolytes in TURP syndrome- is the role of potassium under-estimated? Indian J Anaesth 2002;46:441-4.