BackTable / Urology / Article
Bipolar TURP Procedure Advantages & Complications
Quynh-Chi Dang • Jun 5, 2021 • 4.4k hits
The bipolar transurethral resection of the prostate (TURP) procedure involves the use of a resectoscope containing a bipolar current to resect excess prostate tissue, alleviating symptoms in patients with benign prostate hyperplasia (BPH). Before choosing to embark on a bipolar TURP procedure, urologists must consider the scenarios in which a bipolar TURP is preferred, such as the presence of a substantial intravesical lobe or in prostate cancer patients, and those in which a bipolar TURP may be technically challenging, such as in large prostates or during trainee operations.
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The BackTable Urology Brief
• Different BPH surgical options can be categorized based on invasiveness, use of ablation, implantation, energy source, and anatomical approaches.
• The TURP procedure involves the use of a resectoscope carrying an electrical current to trim away excess prostate tissue in BPH patients. TURP procedures can be categorized as bipolar (where a low-frequency bipolar electrical current is used) or monopolar (where a high-frequency monopolar electrical current is used).
• Bipolar TURP is a viable surgical option for prostates over 80 g, but the risks of hypothermia, visual disorientation, and postoperative bleeding are present. Using this procedure to resect large prostates may be technically challenging for trainees.
• When a substantial intravesical lobe is present, the bipolar TURP procedure allows the surgeon to disconnect the lobe elegantly and safely. Additionally, bipolar TURP is the ideal option for prostate cancer patients, as it optimizes radiation therapy and histological analysis of prostate tissue.
Table of Contents
(1) Bipolar TURP Procedure Steps Overview
(2) Bipolar TURP Complications in Large Prostates
(3) Bipolar TURP Advantages for Substantial Intravesical Lobes
(4) Bipolar TURP Advantages for Prostate Cancer Patients
Bipolar TURP Procedure Steps Overview
There are a variety of new BPH treatments that can be categorized in a multitude of ways: minimally invasive vs. full anesthesia, ablative vs. non-ablative, permanent vs. temporary device implantation, and laser vs. other energy sources. The bipolar TURP procedure was historically considered as the “gold standard” treatment for benign prostate hyperplasia (BPH). The TURP procedure steps are as follows: sterile solution is delivered into the urethra and a transurethral cystoscopy is performed to visualize the patient’s prostate and bladder anatomy. Then, a transurethral resectoscope is inserted, allowing the urologist to trim excess prostate tissue that protrudes into the urethra. The fluid carries the prostate tissue into the bladder, and the excess tissue is eventually removed. Bipolar and monopolar TURP procedures are differentiated with regard to the energy source of the resectoscope; the recently developed bipolar TURP procedure uses a low-frequency bipolar electrical current and saline irrigation while traditional monopolar TURP procedure uses a high-frequency monopolar electrical current and electrolyte-free irrigation.
[Dr. Aditya Bagrodia]
...As we start talking about the relevant patient characteristics, symptom characteristics, and anatomical considerations, perhaps it would be useful, Claus, if you could give a comprehensive list of options that are available, as you see it.
[Dr. Claus Roehrborn]
...Those treatments nowadays are grouped into minimally invasive (done as an outpatient or an ambulatory surgery center) versus the surgeries that require full anesthesia (done in a hospital setting usually and require more or less an overnight stay).
...You can also group these treatments by if they remove tissue or if they do not remove tissue. I'll give you an example. A TURP classically removes tissue. It's an ablative procedure and it's invasive and it requires hospitalization at least for a day. Non-ablative would be a UroLift. You place the UroLift devices and you push the tissue to the side but no tissue is ultimately removed. So ablative versus non-ablative is another way of differentiating it.
There would be a differentiating between treatments that consist of permanent placement of items, such as a UroLift, and there's a whole slew coming down the pipe, the Zenflow device, the Butterfly device, the Medeon device, all of which are experiencing trials in the United States right now and may or may not be approved by the FDA. Versus treatments that don't use devices that are implanted permanently.
And then there's the categorization by devices that work by laser energy versus electrocautery energy versus other energies. For example the Rezum procedure uses steam, just hot water heated by radio frequency energy, and then is injected and as the steam gives off the energy it destroys the tissue. So the energy source is another question. And to add to that, there is the Aquablation treatment that doesn't use any heat per se--neither electrical generated heat nor laser generated heat nor steam--but it uses basically saline at room temperature with a very intense water pick system to destroy prostate tissue.
You can already see how complex it is, how you can group these treatments by energy source, by ablative or non-ablative, by implant versus non-implant. Then comes the question: are these treatments all suitable for all sizes and shapes? But if you look through the list, minimally invasive devices currently approved and recommended in the United States would be the UroLift device, which is an implant, and the Rezum treatment, which is a steam-based heat treatment that partially ablates tissue. Then amongst the surgical treatments there would be monopolar/bipolar TURP, the PVP, the GreenLight or KTP or 532nm laser ablation of the prostate. Then there would be a host of enucleation techniques and, as you know, enucleation now can be done with the traditional way, the holmium laser enucleation which is called HoLEP, the thulium laser which is called ThuLEP, but people do it with the green-light laser as well and it's called KTP laser enucleation, or even do it with a bipolar resectoscope device and just get into the enucleation plane.
Then we have the treatments for the very large prostates that go beyond the HoLEP or ThuLEP, the robotic or open or robotic-assisted laparoscopic enucleation of the prostate as alternatives for the very large prostates.
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Bipolar TURP Complications in Large Prostates
When discussing bipolar TURP complications for large prostates, it is subjective because of varying surgical skill levels. However, Dr. Roehrborn personally defines large prostates as those greater than 80 g. Although bipolar TURP is a viable surgical option for large prostates, it carries an increased risk of hypothermia due to the temperature of the saline solution, trainee visual disorientation due to increased surface area during resection, and postoperative bleeding due to multiple coagulation sites. Instead, he prefers to perform a transvesical robotic assisted laparoscopic enucleation and encourages urologists to assess their own skill level and those of their trainees before choosing to perform a bipolar TURP on large prostates.
[Dr. Claus Roehrborn]
That was a heavy debate amongst the BPH guideline committee members: what is large? And some people, even the peer reviewers of the guidelines said, "Give us guidance. Give us numbers." And we refuse. Because some people can resect a 60 g prostate, some can resect an 80 g prostate, some can resect 100g prostate and we don't restrict that. So what is large is a little bit in the eye of the beholder. We suggest that large for most doctors starts at 8 0g. Because I really doubt that many of our current trainees can resect 40 or 50 g of tissue safely. Why would I say 40, 50? Because that's the transition zone tissue you want to resect if you're faced with an 80 or 90 g prostate. That's how much you want to resect. And most of them can't. So to me, large starts at 80. Anything above 80, either I want to sit there for 4 hours and do a KTP laser, which is still incomplete, or I do a bipolar TURP and I'll do it all myself with no trainee involved to do it quickly, or I just go to the category large prostates, which starts at 80 and goes to the 100 g or 200 g and 300 g.
And in that category, the best choices right now are no longer the open prostatectomy either retropubic, the old Millin approach, or suprapubic, but the best choices are either a robotic assisted laparoscopic enucleation, which 90% is done transvesical...
[Dr. Aditya Bagrodia]
Yeah, I think that's really helpful to help start the discussion. I'll ask you to comment on two things as it pertains to bipolar TURP. Why exactly is there a size cutoff if you're not going to be contending with the same fluid disturbances, post-TUR syndrome, when it comes to a bipolar TURP?
[Dr. Claus Roehrborn]
I suppose, theoretically, there is none. Now, that depends a little bit on how your setup is. In the 1980s studies were done on body temperature changes with irrigation. If you commit yourself to use body temperature saline irrigation for a bipolar TURP, I suppose you can keep on going. If you don't do that, then eventually the core temperature decreases, the longer you resect with room temperature normal saline, and eventually this becomes an issue. The patient becomes hypothermic and, as you know, coagulation parameters change and the patient doesn't do as well. But if you go with the warming, I presume you can keep going.
An argument against that is as follows: If you follow basic geometry and you calculate the inside surface area of a bowl or of a ball, the prostate ultimately becomes like a bowl, right? The opening is towards the bladder neck and the rest of it is this bowl-shaped configured prostatic capsule. The more you resect the larger the surface of that bowl gets. It's just the inside surface of what a ball would be on the outside. And it becomes harder and harder to stay oriented and to be good about your hemostasis. Particularly for trainees. They pretty soon get lost if the prostate is 60, 80, 90, 100 g in size and it's just harder and harder to execute this fully.
Secondly, if you have a very large prostate and you resect that, you have to do a lot of coagulation at the end. And you do all this coagulation and the patients oftentimes, 10 days, 14 days later, they shed this surface scab tissue and they start coming to the emergency room with fresh bleeding. So I must say that there are practical reasons, teaching reasons, training reasons, and also health reasons that I wouldn't do it. If I can do a robotic assisted enucleation in 90 minutes time, then I don't want to be there for three hours of general anesthesia time and approximate that effect with a bipolar TURP.
[Dr. Aditya Bagrodia]
Yeah, I wholeheartedly agree. Certainly in the bladder cancer world, I would say that a properly done transurethral resection of a bladder tumor is a case that requires a technical skill set and all TURBTs are not the same and similarly all TURPs are not the same and I appreciate you highlighting that….
Bipolar TURP Advantages for Substantial Intravesical Lobes
The presence of a substantial intravesical (median) lobe of the prostate can complicate BPH surgery. Although Dr. Roehrborn acknowledges that TURP alternatives (i.e.- UroLift, Rezum, KTP laser, Aquablation, etc.) are still available, they may be more technically challenging and introduce greater risks (urinary stones, collateral damage) than the bipolar TURP. He notes that the bipolar TURP procedure allows the surgeon to disconnect the intravesical lobe elegantly and safely.
[Dr. Aditya Bagrodia]
Maybe I'll interrupt you for just a moment, Claus, and ask you, among all of these options, of which pretty much everything is available, how does the median lobe presence or absence affect your decision?
[Dr. Claus Roehrborn]
I think this is, fortunately, an insight that has made, finally, it's way into the guidelines, both the EAU and to some degree the AUA guidelines, the recognition that the intravesical lobe plays a major role. Starting with the least invasive. The Rezum treatment has clearly shown that if you put the needle in the median lobe, if it's present, you get a better improvement than if there's a median lobe and you don't put the needle in. So putting the needle in, injecting the steam, ablating that median lobe gets you a better improvement than if you leave it alone. So the Rezum works out okay for the median lobe. You'll likely have a longer catheterization time, but it in the end works out.
The UroLift is approved because there is a study that was done, called the MedLift study, where they took a UroLift device and sort of stapled that median lobe to the side. There's a risk in exposing that wire. There's a risk in maybe having material exposed to the urine and forming stones, and there's a risk it doesn't work if you don't do it a lot. So, I don't like to do it because I think there are other treatments available for it, but it is technically approved for it.
The KTP or GreenLight laser is a bit odd because it shoots down in a 70 degree forward motion, so if you vaporize over the median lobe, eventually you get through it and then you hit the trigone. And that's just something I don't like to do or teach the residents because when you hit the trigone you can easily hit the ureteral orifice and then you coagulate it and it's a question of do you put a stent up and how long and what are you going to do about it. So substantial median lobe, I don't like the KTP all that much, I have to admit. For substantial intravesical lobe I like preferentially to do a TURP because I can very elegantly lob that median lobe off without jeopardizing the trigone, the UOs, taking it flush off the bladder neck and I think that's the most elegant way of going about it….
So big decision point, the intravesical lobe. No medical therapy. Please don't give medical therapy for substantial intravesical lobe ever. Doesn't work and it's just a waste of time and money. Choose your weapon carefully. If you have access to not much, then use your TURP loop. It's the best tool yet.
Bipolar TURP Advantages for Prostate Cancer Patients
Bipolar TURP can also be used to resect enlarged prostates due to cancer. Dr. Roehrborn recommends this procedure in prostate cancer patients because it leaves behind a clean, symmetrical surface that is optimized for radiation therapy. Additionally, through this method, prostate tissue can be salvaged for further histological analysis.
[Dr. Aditya Bagrodia]
Again, there's so many things that we could talk about. One clinical scenario that I think we encounter not infrequently that's of particular interest to me as an oncologist, are patients with fairly significant lower urinary tract symptoms requiring or requesting an outlet procedure who are ultimately going to receive radiation for prostate cancer. Any specific considerations in that type of patient?
[Dr. Claus Roehrborn]
If that's the case and if that's the clinical scenario, I would say that in that patient I would do not a KTP laser, I would do the cleanest TURP or a HoLEP because what I want to achieve is a clean surface that heals and epithelializes well and creates a symmetrical, nice, biconcave cavity so that the radiation physicist can do a proper planning and that the radiation is less likely to induce damage. If you give the radiation in a poorly healing field of necrotic, partially coagulated tissue, you probably induce a lot more symptoms than otherwise. So my number one goal is to go with the treatment that I know I can create a nice, symmetrical cavity. B, I leave behind the best chance for an epithelialization healing in the shortest period of time. And I guess another consideration is I wouldn't use Aquablation or KTP because I honestly feel like, since the patient has cancer, it gives an opportunity to analyze the tissue.
Dr. Claus Roehrborn
Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 23). Ep. 6 – Contemporary Surgical Management of BPH [Audio podcast]. Retrieved from https://www.backtable.com
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