NEW YORK (Reuters Health) – For benign prostatic hyperplasia (BPH), monopolar transurethral resection of the prostate (TURP) is being increasingly challenged as the gold standard.
Two randomized controlled trials, published online on May 12 and 28 in the British Journal of Urology International, now show that bipolar transurethral resection in saline and saline plasma vaporization, respectively, may be superior alternatives.
“Truth is that bipolar TURP is the new standard of care vs monopolar TURP,” said urologist Dr. Richard A. Santucci, specialist-in-chief at Detroit Medical Center, who was not involved in the studies.
“It involves FAR less bleeding and no risk of the so called “TUR syndrome” which happens with monopolar but not bipolar TURP,” he told Reuters Health via e-mail. In the TUR syndrome, absorption of large volumes of bladder irrigation fluid results in hyponatremia.
In one study, Dr. Qi Chen, of Fudan University in Shanghai, China, and colleagues followed 100 men for two years after either monopolar TURP or bipolar transurethral resection in saline (TURIS). For irrigation, they used saline tagged with 1% ethanol for TURIS and a 4% ethanol-tagged mannitol solution for TURP – because ethanol levels in exhaled breath correlate with fluid absorption.
Intraoperative breathalyzer measurement of end-tidal breath ethanol showed that TURIS patients absorbed significantly less fluid on average than TURP patients (208 vs. 512 mL, p<0.001). Mean serum sodium decreases were also smaller (3.5 vs. 6.3 mmol/L, p<0.001), as were mean decreases in hemoglobin (1.1 vs. 1.6 g/dL, p=0.008).
No patients developed TUR syndrome.
Two patients in the TURP group needed recatheterization, but during the two year follow-up, there was no difference in reoperation rate, maximum urinary flow rate, or International Prostate Symptoms Scores.
“The present study shows that the bipolar system is a promising technique to challenge the ‘gold standard’ surgical therapy for benign prostatic hyperplasia,” Dr. Chen and colleagues conclude.
Dr. Michael J. Lynch, a urologist formerly with Colchester General Hospital in Essex, U.K., who was not involved in the study, agreed.
“It will certainly challenge traditional TURP,” he told Reuters Health by e-mail, adding that bipolar TURIS was as easy to learn as traditional monopolar TURP.
In another study, electro-vaporization in bipolar TURIS was more effective and safer than TURP. Researchers from “Saint John” Emergency Clinical Hospital in Bucharest, Romania, enrolled 155 patients with benign prostatic enlargement. Inclusion criteria included a maximum urinary flow rate of less than 10 mL/s, a prostate volume of 30 to 80 mL, and an International Prostate Symptoms Score of more than 19.
Compared with TURP patients, those who had the TURIS with plasma vaporization (TURis-PVP) had less capsular perforation and bleeding (p=0.037 and p=0.013, respectively). Surgery also took less time with TURis-PVP, and hospital stays were half as long. At 6 months, International Prostate Symptoms Scores were 5 for TURP vs. 9.1 for TURis-PVP (p<0.05) and maximum urinary flow rates were 21.8 mL/s and 19.3 mL/s.
“In conclusion,” said lead author Dr. Bogdan Geavlete and colleagues, “TURis-PVP represents a promising endoscopic treatment alternative for patients with benign prostatic enlargement, with good efficacy, reduced morbidity, fast recovery and satisfactory follow-up.”
However, both Dr. Santucci and Dr. Lynch noted that at this point, some doctors have started using the more advanced — but also more difficult — holmium laser enucleation of the prostate.
“We have all but abandoned even the bipolar TURP in favor of the much better Laser TURP (which involves practically no bleeding and often can be done without placing a urinary catheter afterwards, which is a great relief to the patient),” Dr. Santucci said.
Dr. Lynch chimed in: “I know which one I would want!”
References:
http://www3.interscience.wiley.com/journal/123437517/abstract
http://www3.interscience.wiley.com/journal/123479584/abstract
BJU Int 2010.
