BIPOLAR VERSUS MONOPOLAR TRANSURETHRAL RESECTION OF PROSTATE IN TREATMENT OF BENIGN PROSTATIC ENLARGEMENT

1* 2 3 3 3 Niraj Thapa , Ganesh Bhakta Acharya , Abhishek Poudel , Ananda Neupane , Sushil Mishra Received : 25 November, 2021 Accepted : 15 January, 2022 Published : 21 Februrary, 2022 Thapa N et al ISSN: 2542-2758 (Print) 2542-2804 (Online) 1647 Birat Journal of Health Sciences Vol.6/No.3/Issue 16/Sep.-Dec., 2021 Original Research Ar cle


INTRODUCTION
Benign prosta c Enlargement (BPE) is one of the most 1,2 common diseases that affect aging males. The lower urinary tract symptoms (LUTS) due to benign prosta c obstruc on (BPO) con nue to be a major concern, affec ng 3,4 about a third of men over age 50. It has been es mated that approximately 30% of male popula on in Europe and United States have a chance of undergoing to transurethral 5 resec on of prostate (TURP) during their life me. There are many modali es of treatment for BPO, which include drug therapies, endoscopic surgery like TURP among others and open prostatectomy. Monopolar Trans Urethral Resec on of 6,9 Prostate (M-TURP) is currently considered as gold standard. In M-TURP, the electrical current runs through the body from the ac ve electrode (connected to the resectoscope loop) towards the large surfaced grounding path a ached to the skin. In this electrical circuit, a non-conduc ve irriga on fluid (glycine, sorbitol, and mannitol) is mandatory to 10 prevent dispersing of the electrical current. M-TURP has dominated surgical treatment of LUTS due to BPH for > 70 11 years. Though, it has been considered to be the surgical "gold standard" for treatment of BPO, there is s ll poten al for complica ons such as intraopera ve bleeding, clot reten on, and transurethral resec on syndrome, and [12][13][14] overall morbidity rate is reported at 11.1%. In the last decade, several novel procedures have been introduced for the treatment of BPO, and one of the novelest modifica ons could be the incorpora on of bipolar technology to transurethral resec on of the prostate using normal saline (NS) irriga on. Bipolar Trans Urethral Resec on of Prostate (B-TURP) addresses the fundamental flaw of M-TURP because it can be performed in NS. Bipolar technology allows the electric current to complete without 5 passing through the pa ent. Durable efficacies of TURP using bi-polar systems has been exhibited in a number of Randomized Controlled Trials (RCTs). Bipolar TURP has 5 revealed promising results as shown by various studies. In this study, we have compared Monopolar and Bipolar TURP in terms of hospital Stay, resec on me, resected ssue volume, changes in hemoglobin and sodium, blood transfusion required, complica ons like TUR syndrome, clot reten on and hemorrhagic episodes with an objec ve to study the feasibility of bipolar TURP over M-TURP.

METHODOLOGY
An analy cal study was done in all cases who had undergone TURP in Manipal Teaching Hospital in between August 2018 to August 2020 with an objec ve to compare post-opera ve results in between M-TURP and B-TURP techniques. Various clinico-demographic profiles [age, smoking, alcohol, comorbidi es, preopera ve status like prostate size, post void residual volume (PVRU), intravesical protrusion etc.] and intra and postopera ve data [opera ve me, irriga on fluid required, resected ssue, pre and post-opera ve hemoglobin, sodium, packed cell volume (PCV), postopera ve hemoglobin drop, blood transfusion required etc.] were collected and compared in between two commonly used techniques for TURP in our hospital; M-TURP and B-TURP.
All the pa ents operated during the study dura on were included in the study. Pa ents whose data were incomplete in the records or whose records were untraceable due to various reasons were excluded from the study. A er taking clearance from the Ins tu onal Review Board (IRB) the records were collected from the departmental records and medical record department. All the con nuous data were presented in terms of mean and standard devia on and categorical data in terms of percentage. Comparison were done using student's t test for mean and chi square for percentages. The pre-opera ve and postopera ve hemoglobin and sodium changes were compared using paired t test. P value less than 0.05 was termed significant. Sta s cal analysis was done using SPSS 22.0 so ware.

RESULTS
During the study period, 86 pa ents had undergone TURP in our hospital operated by two urosurgeons. Out of these, only 73 pa ents fulfilled the inclusion criteria and rest were excluded either due to incomplete data or lost records. Out of 73 pa ents, 33 pa ents had undergone B-TURP and 40 Pa ents had undergone M-TURP. On comparing various preopera ve clinico-demographic factors like age, intake of alcohol, smoking, comorbidi es, prostate size, PVRU, intravesical protrusion of prostate and biochemical parameters in between the two groups, we found no sta s cal significant difference sugges ng similar distribu on of cases in between the study popula on (Table 1.) Table 1: Comparison of preopera ve parameters in between the study popula ons of two groups.
Total hospital stay was slightly lesser in B-TURP group although there was no sta s cal significant difference in between the two groups. The post-opera ve Hb in M-TURP group was 11.10±1.321 and in B-TURP group was 12.24± 1.225 and the difference was significant sta s cally (P<0.001). Similarly, the difference in between post-opera ve PCV was sta s cally significant and lower in M- There was no significant difference in between resec on me, post-opera ve sodium, post-opera ve hemorrhagic episodes, clot reten on and blood transfusions ( Table 2).
Table2: comparison of Various parameters in between Monopolar and Bipolar TURP Table 3 shows pre and post-opera ve changes in hemoglobin and sodium in both the groups separately. Although the drop in hemoglobin was sta s cally significant in both the groups, the hemoglobin drop was slightly lesser in B-TURP group than in M-TURP group. The hemoglobin drop (mean difference in pre and post-opera ve Hb) was 1.148 in M-TURP group and 0.181 in B-TURP Group.There were no sta s cal significant changes in pre and postopera ve sodium in both the groups (Table3).

DISCUSSION
B-TURP uses saline irriga on instead of glycine and hence protects against TUR syndrome which is one of the poten al and dreaded complica on of TURP. TUR syndrome is closely associated with capsule perfora on during surgery and increased absorp on of fluid during prolonged opera ons. In our series, TUR syndrome was seen in 6 (8.2%) cases in M-TURP cases whereas there were no incidences of TUR syndrome in B-TURP cases (p=0.029). Tang Y et al in their systema c review and meta-analysis found that out of 24 studies which had inves gated TURP for TUR syndrome, none of the individual trials showed any significant difference between the bipolar and monopolar methods. However, a pooled analysis showed a significant difference (risk difference 0.02, 95% CI 0.01-0.03; p=0.0004) which suggest incidences of TUR syndrome can be seen in B-TURP 15 but in lesser propor on than M-TURP. Coagula on is always be er and precise with minimal thermal 16 injury to the surrounding ssue with a bipolar technique. Many studies have reported greater amount of blood loss with M-TURP. Bleeding and transfusion rates have greatly decreased over me. In our Study, the post-opera ve hemoglobin was significantly lesser in M-TURP group than in B-TURP (11.10±1.321 vs 12.24±1.225; P<0.001). Similarly, the difference in between post-opera ve PCV was sta s cally significant and lower in M-TURP group (33.22±4.002 Vs 36.25±3.751, p=0.001). Although there were no significant difference in between post-opera ve hemorrhagic episodes, the incidences were nil in B-TURP group and 5.5% (4 cases) in M-TURP group. None of the cases in B-TURPgroup required blood transfusion in comparison to four (5.5%) cases of M-TURP group, although the difference was not significant sta s cally. The post-opera ve drop in hemoglobin (difference between mean preopera ve and post-opera ve hemoglobin) was sta s cally significant in both monopolar and B-TURP groups. However, the hemoglobin drop was slightly lesser in B-TURP group than in M-TURP group. The hemoglobin drop (mean difference in pre and postopera ve Hb) was 1.148 in M-TURP group and 0.181 in B-TURP Group. Fagerstrom et al had found that the transfusion rates were significantly higher in M-TURP group than in B- 16 TURP group (11% vs 4%, p=0.01). Akman et al in their study noted that the decrease in mean hemoglobin concentra on was greater in M-TURP group than in B-TURP group, though 17 the difference was not sta s cally significant. Ho et al also noted a significant decrement in mean hemoglobin concentra on (1.8 mg/dL) in monopolar group and no significant decrease in mean hemoglobin concentra on in B- 18 TURP group (1.2 mg/dL). 19 The incidences of clot reten on in overall TURP is around 2-5%. In our Series, clot reten on was also seen in 5 cases of M-TURP group (6.8%) in comparison to single case (1.4%) of B-TURP group. Tang Y et al in their systema c review and metaanalysis found that out of 13 studies which had inves gated clot reten on in M-TURP and B-TURP cases, a pooled analysis showed that clot reten on was significantly higher in M- 15 TURP. (risk difference 0.04; 95% CI, 0.02-0.06; P < 0.0001). Total hospital stay in our study was slightly lesser in B-TURP group (4.30±1.531 days) than in M-TURP group (4.87±1.713 days) though the difference was not sta s cally significant (p=0.141). Studies have shown lesser mean dura on of 20 hospital stay in B-TURP than in M-TURP as in our study. In M-TURP, the thermal energy is directed towards the prosta c ssue which creates a lot of resistance leading to severe increase in temperature. However, in cases of Bipolar-TURP, the current passes from ac ve electrode to the adjacent return electrode via the target ssue, the ssue temperature is reduced. Furthermore, the saline irriga on medium in B-TURP is converted into a plasma field of ionized par cles by energy which disrupts organic molecular bond  21 of ssues. This can be the reason of minimal thermal injury and resul ng inflammatory processes in B-TURP which leads to quick symptoma c recovery and less hospital stay. Chen et al. reported decreases in mean postopera ve serum sodium levels for the bipolar and M-TURP groups of 22 3.2 and 10.7 mmol/L, respec vely (P < 0.01). Akman et al also reported a significant decrease was detected in the mean sodium concentra on of the monopolar group when compared to that of the bipolar group (-2.82±5.8 vs 17 1.30±3.8, p=0.03). In our study, there were no sta s cal significant mean changes in pre and post-opera ve sodium in both M-TURP and B-TURP groups (-1.05 vs 0.21). The mean resec on me in M-TURP group was 60.63± 16.467 minutes and in Bipolar-TURP was 60.06±17.963 minutes in our study without any sta s cal significant difference (p=0.889). While most of the studies have reported similar opera ng me in between the two groups as in our study, fewer studies have also shown longer 16,23,24 opera ng me in Bipolar-TURP.

LIMITATION OF THE STUDY
Since it is a retrospec ve study compara ve study the power of study will be less than in prospec ve randomized study. Moreover, in our study, surgery was performed by two different urologists and the difference in technique amongst the surgeons could affected the outcomes in turn decreasing the power of study.