Bipolar versus Monopolar Transurethral Resection of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials

doi:10.1016/j.eururo.2009.06.037

European Urology

Volume 56, Issue 5, November 2009, Pages 798-809

https://doi.org/10.1016/j.eururo.2009.06.037 Get rights and content

Abstract

Context

Incorporation of bipolar technology in transurethral resection (TUR) of the prostate (TURP) potentially offers advantages over monopolar TURP (M-TURP).

Objective

To evaluate the evidence by a meta-analysis, based on randomized controlled trials (RCTs) comparing bipolar TURP (B-TURP) with M-TURP for benign prostatic obstruction. Primary end points included efficacy (maximum flow rate [Q_max], International Prostate Symptom Score) and safety (adverse events). Secondary end points included operation time and duration of irrigation, catheterization, and hospitalization.

Evidence acquisition

Based on a detailed, unrestricted strategy, the literature was searched up to February 19, 2009, using Medline, Embase, Science Citation Index, and the Cochrane Library to detect all relevant RCTs. Methodological quality assessment of the trials was based on the Dutch Cochrane Collaboration checklist. Meta-analysis was performed using Review Manager 5.0.

Evidence synthesis

Sixteen RCTs (1406 patients) were included. Overall trial quality was low (eg, allocation concealment and blinding of outcome assessors were poorly reported). No clinically relevant differences in short-term (12-mo) efficacy were detected (Q_max: weighted mean difference [WMD]: 0.72 ml/s; 95% confidence interval [CI], 0.08–1.35; p = 0.03). Data on follow-up of >12 mo are scarce for B-TURP, precluding long-term efficacy evaluation. Treating 50 patients (95% CI, 33–111) and 20 patients (95% CI, 10–100) with B-TURP results in one fewer case of TUR syndrome (risk difference [RD]: 2.0%; 95% CI, 0.9–3.0%; p = 0.01) and one fewer case of clot retention (RD: 5.0%; 95% CI, 1.0–10%; p = 0.03), respectively. Operation times, transfusion rates, retention rates after catheter removal, and urethral complications did not differ significantly. Irrigation and catheterization duration was significantly longer with M-TURP (WMD: 8.75 h; 95% CI, 6.8–10.7 and WMD: 21.77 h; 95% CI, 19.22–24.32; p < 0.00001, respectively). Inferences for hospitalization duration could not be made. PlasmaKinetic TURP showed an improved safety profile. Data on TUR in saline (TURis) are not yet mature to permit safe conclusions.

Conclusions

No clinically relevant differences in short-term efficacy exist between the two techniques, but B-TURP is preferable due to a more favorable safety profile (lower TUR syndrome and clot retention rates) and shorter irrigation and catheterization duration. Well-designed multicentric/international RCTs with long-term follow-up and cost analysis are still needed.

Introduction

Benign prostatic hyperplasia (BPH) is the only tumor that inevitably affects almost every aging male, and there is consensus on its progressive nature [1]. BPH-related obstruction (ie, benign prostatic obstruction [BPO]) [2] is associated with lower urinary tract symptoms (LUTS). The incidence of LUTS/BPO is high and increases linearly with age [3]. The impact on quality of life (QoL) and health care cost justifies additional research into the use of therapeutic resources [4].

For 8 decades, transurethral resection of the prostate (TURP) has been considered the cornerstone of surgical management for BPO, due to the procedure's outstanding, well-documented, long-term treatment efficacy [5]. Similar data on durability for any other instrumental BPO treatment are lacking [5], and the evidence supports the notion that “TURP is here to stay” [6].

Although significant technical improvements during the past 15 yr have reduced intra- and postoperative adverse events, there are still concerns regarding complications, such as transurethral resection (TUR) syndrome, bleeding, and urethral strictures (USs) [7]. A prospective multicenter study on 10 654 patients with BPO treated with TURP showed that mortality has decreased (0.1%) but that morbidity, although reduced, continues to be high (11.1%) [8]. The most significant recent technical modification of TURP is the incorporation of bipolar technology. Bipolar TURP (B-TURP) addresses a fundamental flaw of monopolar TURP (M-TURP) by allowing performance in normal saline, and the technique seems to be promising [9].

The purpose of this systematic review is to critically evaluate the evidence based on randomized controlled trials (RCTs) that compare B-TURP with M-TURP in patients with BPO and, where possible, to conduct a quantitative meta-analysis in an attempt to provide, for the first time, conclusions based on level 1a evidence. We aim to substantiate the advantages and disadvantages of each technique in terms of efficacy and safety (primary outcomes). Efficacy was quantified by postoperative maximum flow rate (Q_max) and/or International Prostate Symptom Score (IPSS). Reoperation for residual tissue was also considered. Safety was estimated by the postoperative occurrence of at least one of the following parameters: (1) drop in serum sodium level, (2) TUR syndrome, (3) drop in hemoglobin (Hb) level, (4) need for transfusion, (5) clot retention, (6) acute urinary retention (AUR) after catheter removal, (7) meatal stenosis (MS), (8) bladder neck contracture (BNC), and (9) US. Secondary outcomes included operation time, duration of bladder irrigation, catheterization, and hospitalization time.

Section snippets

Evidence acquisition

Objectives, literature-search strategy, methods for determining trial selection based on strict inclusion criteria, data elements, data extraction, and trial quality assessment were defined beforehand. Each step in this protocol was completed independently by two of the authors (CM and DU). Any disagreement was resolved by discussion, and final decision was based on a consensus.

Previously published systematic reviews and meta-analyses

Although many interesting reviews have recently been published [9], [12], [13], [14], [15], [16], only two reports by the same group of investigators fulfilled the methodological standards of a systematic review [17], [18]. The first one compared the efficacy and safety of newer ablative methods (including B-TURP) against M-TURP for treating patients with BPO [17]. The second extended the attempt toward a cost-effectiveness comparison (B-TURP was not evaluated in this respect), including

Conclusions

Considering the two main limitations that may hamper our meta-analysis, namely, the low trial quality and the relatively limited follow-up, this systematic review provides the strongest available evidence, for the first time, showing that no clinically relevant differences in short-term efficacy exist between the two techniques. Furthermore, no differences were evident regarding operation time and rates of adverse events such as transfusions, retention after catheter removal, or urethral

References (50)

B. Djavan et al.
The urologist view of BPH progression: results of an international survey
Eur Urol
(2002)
P. Abrams et al.
Evaluation and treatment of lower urinary tract symptoms in older men
J Urol
(2009)
K.M.C. Verhamme et al.
Incidence and prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in primary care—the Triumph project
Eur Urol
(2002)
O. Reich et al.
Techniques and long-term results of surgical procedures for BPH
Eur Urol
(2006)
J. Rassweiler et al.
Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention
Eur Urol
(2006)
O. Reich et al.
Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients
J Urol
(2008)
J.J. de la Rosette et al.
Minimally invasive treatment of male lower urinary tract symptoms
Urol Clin North Am
(2008)
A. Tefekli et al.
A hybrid technique using bipolar energy in transurethral prostate surgery: a prospective, randomized comparison
J Urol
(2005)
M. de Sio et al.
Gyrus bipolar versus standard monopolar transurethral resection of the prostate: a randomized prospective trial
Urology
(2006)
J.M. Abascal Junquera et al.
Bipolar versus monopolar transurethral resection of the prostate: preoperative analysis of the results
Actas Urol Esp
(2006)

H.S.S. Ho et al.

A prospective randomized study comparing monopolar and bipolar transurethral resection of prostate using transurethral resection in saline (TURIS) system

Eur Urol

(2007)

D.P. Michielsen et al.

Bipolar transurethral resection in saline-an alternative surgical treatment for bladder outlet obstruction?

J Urol

(2007)

F. Iori et al.

Bipolar transurethral resection of prostate: clinical and urodynamic evaluation

Urology

(2008)

R. Autorino et al.

Four-year outcome of a prospective randomised trial comparing bipolar plasmakinetic and monopolar transurethral resection of the prostate

Eur Urol

(2009)

M.M. Issa et al.

Dilutional hyponatremia of TURP syndrome: a historical event in the 21st century

Urology

(2004)

G. Wendt-Nordahl et al.

The Vista system: a new bipolar resection device for endourological procedures: comparison with conventional resectoscope

Eur Urol

(2004)

X. Huang et al.

Bipolar versus monopolar transurethral resection of prostate: pathologic study in canines

Urology

(2007)

L. Qu et al.

Use of a novel ex-vivo model to compare the hemostatic properties of plasmakinetic resection, transurethral vaporization resection and conventional transurethral resection of the prostate

Urology

(2007)

O. Reich

Editorial comment on: a prospective randomized study comparing monopolar and bipolar transurethral resection of prostate using transurethral resection in saline (TURIS) system

Eur Urol

(2007)

J.T. Wei et al.

Urologic Diseases in America project: benign prostatic hyperplasia

J Urol

(2008)

J.J. de la Rosette

Tailoring treatment in benign prostatic hyperplasia management

Curr Opin Urol

(2009)

C. Mamoulakis et al.

Bipolar transurethral resection of the prostate: the “golden standard” reclaims its leading position

Curr Opin Urol

(2009)

Higgins JPT, Altman DG, eds; Cochrane Statistical Methods Group and the Cochrane Bias Methods Group. Chapter 8:...

J.P. Higgins et al.

Measuring inconsistency in meta-analyses

BMJ

(2003)

J. Rassweiler et al.

Bipolar transurethral resection of the prostate-technical modifications and early clinical experience

Minim Invasive Ther Allied Technol

(2007)

Cited by (216)

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms
2023, European Urology
Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.
To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.
A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.
The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient’s characteristics, expectations, and preferences; surgeon’s expertise; and availability of modalities.
The guidelines provide an evidence-based approach for the management of male LUTS.
A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient’s expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.
Emerging Technologies for the Surgical Management of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Obstruction. A Systematic Review
2023, European Urology Focus
Surgical management of lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) aims at ablating prostate adenoma by resection, enucleation, or vaporisation. Apart from established ablation modes according to the European Association of Urology guidelines, various technologies have emerged as safe/effective alternatives but remain under investigation.
To explore short-term benefits/harms of emerging technologies for surgical management of LUTS/BPO.
A systematic literature search was conducted using MEDLINE, EMBASE, and CENTRAL via Ovid up to June 18, 2022. We included randomised controlled trials (RCTs) exploring aquablation, prostatic arterial embolisation (PAE), Rezum, prostatic urethral lift (PUL), and temporary implantable nitinol device (iTIND) versus sham/transurethral resection of the prostate (TURP).
We included ten RCTs (1108 men). Aquablation versus TURP: insignificant change in International Prostate Symptoms Score (IPSS; mean difference [MD] 0.0, 95% confidence interval [CI] –2.44 to 2.44), quality of life (QoL; MD 0.30, 95% CI –0.81 to 0.21), maximum urinary flow rate (Qmax; MD –0.30, 95% CI –3.71 to 3.11), retreatment (risk ratio [RR] 0.18, 95% CI 0.02–1.66), and urinary incontinence (UI; RR 0.71, 95% CI 0.26–1.95). PAE versus monopolar TURP (M-TURP): insignificant change in IPSS (MD 3.33, 95% CI –28.39 to 35.05), QoL (MD 0.12, 95% CI –0.30 to 0.54), International Index of Erectile Function (IIEF-5; MD 3.07, 95% CI –1.78 to 7.92), and UI (RR 0.15, 95% CI 0.01–2.86), and significant change in Qmax (MD –9.52, 95% CI –14.04 to –5.0), favouring M-TURP. PAE versus bipolar TURP: insignificant change in IPSS (MD –2.80, 95% CI –6.61 to 1.01), QoL (MD –0.69, 95% CI –1.46 to 0.08), Qmax (MD –3.51, 95% CI –8.08 to 1.06), UI (RR 0.14, 95% CI 0.01–2.51), and retreatment (RR 1.91, 95% CI 0.19–19.63). PUL versus TURP: insignificant change in QoL (MD 0.40, 95% CI –0.29 to 1.09), UI (RR 0.13, 95% CI 0.02–1.05), and retreatment (RR 0.48, 95% CI 0.12–1.86), and significant change in IPSS (MD 3.40, 95% CI 0.22–6.58), and IIEF-5 (MD 3.00, 95% CI 0.41–5.59) and Qmax (MD –9.60, 95% CI –13.44 to –5.76), favouring PUL and TURP, respectively. Rezum and iTIND have not been evaluated in RCTs against TURP to date.
Supporting evidence for clinical use of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits/harms should be investigated further in high-quality RCTs.
This review summarises the evidence for the clinical use of aquablation, prostatic arterial embolisation (PAE), prostatic urethral lift (PUL), Rezum, and temporary implantable nitinol device (iTIND) to manage lower urinary tract symptoms secondary to benign prostatic obstruction. The supporting evidence for the clinical usage of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits and harms should be investigated further in high-quality randomised controlled trials.
Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association
2021, Progres en Urologie
L’objectif du Comité des Troubles Mictionnels de l’Homme (CTMH) de l’Association Française d’Urologie (AFU) était de mettre à jour les recommandations françaises parues en 2012 et celles de l’EAU parues en 2019 concernant la prise en charge chirurgicale et interventionnelle de l’obstruction sous-vésicale (OSV) liée à une hyperplasie bénigne de prostate (HBP).
Une revue systématique de la littérature (PubMed®), concernant l’OSV liée à l'HBP, a été conduite entre 2018 et 2020 afin de compléter celle prise en compte par les recommandations précédentes. Ce travail a comporté une stratégie bibliographique prédéfinie puis une analyse critique de la littérature avec attribution de niveaux de preuve et rédaction de conclusions et de recommandations permettant de répondre aux questions cliniques posées.
Proposer une incision cervicoprostatique (ICP) pour traiter chirurgicalement les patients ayant des symptômes du bas appareil urinaire (SBAU) modérés à sévères avec un volume prostatique < 30 cm³, sans lobe médian. Proposer une résection transurétrale de prostate (RTUP) mono- ou bipolaire pour traiter chirurgicalement les patients ayant des SBAU modérés à sévères avec un volume prostatique entre 30 et 80 cm³. La vaporisation par laser Greenlight™ ou bipolaire peuvent être proposées en alternative à la RTUP. Proposer une vaporisation laser Greenlight™ aux patients à risque hémorragique. Proposer une énucléation endoscopique de prostate pour traiter chirurgicalement les patients ayant des SBAU modérés à sévères en alternative à la RTUP et à l’adénomectomie voie haute (AVH). L’adénomectomie mini-invasive est une alternative à l’AVH pour les centres ne disposant pas de technique endoscopique adaptée. L’embolisation des artères prostatiques peut être proposée en cas de contre-indication ou de refus d’une intervention chirurgicale pour des prostates de volume > 80 cm³. Les implants intra-prostatiques sont une alternative pour traiter les SBAU chez les patients souhaitant conserver leur fonction éjaculatoire et ayant un volume prostatique < 70 cm³ sans lobe médian. L’Aquablation et le Rezum™ ne peuvent être recommandées en pratique courante en raison d’un recul clinique insuffisant et de l’absence de comparaison aux techniques de référence.
Les évolutions notables des techniques de prise en charge chirurgicales de l’OSV liée à l’HBP s’orientent vers une diminution de la morbidité des gestes et une amélioration de la qualité de vie au-delà du simple traitement des SBAU.
The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).
All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.
Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume < 30 cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80 cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume > 80 cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume < 70 cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.
Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.
From BPH to male LUTS: a 20-year journey of the EAU guidelines
2024, Prostate Cancer and Prostatic Diseases
Long-Term Outcomes Following Bipolar Transurethral Plasma Enucleation of the Prostate: 10-Year Follow-Up
2023, Journal of Endourology
Surgical Outcomes for Elderly Patients Undergoing Transurethral Resection of the Prostate for Chronic Urinary Retention and Proposal of a Management Algorithm
2023, Journal of Endourology

View all citing articles on Scopus

View full text

Review – Benign Prostatic HyperplasiaBipolar versus Monopolar Transurethral Resection of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Introduction

Section snippets

Evidence acquisition

Previously published systematic reviews and meta-analyses

Conclusions

Eur Urol

J Urol

Eur Urol

Eur Urol

Eur Urol

J Urol

Urol Clin North Am

J Urol

Urology

Actas Urol Esp

Eur Urol

J Urol

Urology

Eur Urol

Urology

Eur Urol

Urology

Urology

Eur Urol

Urologic Diseases in America project: benign prostatic hyperplasia

J Urol

Tailoring treatment in benign prostatic hyperplasia management

Curr Opin Urol

Bipolar transurethral resection of the prostate: the “golden standard” reclaims its leading position

Curr Opin Urol

Measuring inconsistency in meta-analyses

BMJ

Bipolar transurethral resection of the prostate-technical modifications and early clinical experience

Minim Invasive Ther Allied Technol

Review – Benign Prostatic Hyperplasia
Bipolar versus Monopolar Transurethral Resection of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials