bipolar turp

BIPOLAR TURPBIPOLAR TURP

DEFINITIONDEFINITION

An electrode whereby two active An electrode whereby two active electrodes are attached to a single electrodes are attached to a single support and having a structure that support and having a structure that allows high frequency electric allows high frequency electric current to pass through these two current to pass through these two electrodes when electrified electrodes when electrified (International Electrotechnical (International Electrotechnical Commission 1998). Commission 1998).

what’s the needwhat’s the need

To rule out TUR syndrome risk(2%)To rule out TUR syndrome risk(2%) To overcome time limitation.To overcome time limitation. To reduce obturator jerk & To reduce obturator jerk &

assosiated injury.assosiated injury. To reduce carbonizationTo reduce carbonization

What’s differentWhat’s different

Electrosurgical resection, cutting Electrosurgical resection, cutting energy in a bipolar fashion rather energy in a bipolar fashion rather than straight monopolar current than straight monopolar current used in traditional TURP used in traditional TURP

Technique virtually identical except Technique virtually identical except for special bipolar electrical for special bipolar electrical generator and specially modified generator and specially modified loops and resectoscopes loops and resectoscopes

Discharge from whole loopDischarge from whole loop

Low resistant electrolyte mediumLow resistant electrolyte medium Resistance:Resistance:

saline - 40 ohmssaline - 40 ohms

glycine - 800 ohmsglycine - 800 ohms

water - 1600 ohmswater - 1600 ohms

tissue - 500 ohmstissue - 500 ohms

blood vessle - 125 ohmsblood vessle - 125 ohms

Special requirementsSpecial requirements In bipolar system, both active and return In bipolar system, both active and return

electrodes are contained within the electrodes are contained within the instrument, (eg, the wire loop, vaporization instrument, (eg, the wire loop, vaporization electrode). electrode).

The original bipolar wire loops used two The original bipolar wire loops used two parallel wires spaced about 2 mm apart,parallel wires spaced about 2 mm apart,

current models now use a single wire loop current models now use a single wire loop with the electrical ground return built into with the electrical ground return built into the shaft of the loop. *the shaft of the loop. *

Loop – small &thin (loop-5mm,wire Loop – small &thin (loop-5mm,wire dia-.28mm)dia-.28mm)

MECHANISMMECHANISM A plasma corona or field of ionization is A plasma corona or field of ionization is

formed between loops, disrupting the formed between loops, disrupting the molecular tissue bonds that allows molecular tissue bonds that allows resection by instantaneos vaporization of resection by instantaneos vaporization of tissue along with hemostasis tissue along with hemostasis

the bipolar technique requires an the bipolar technique requires an electrolytic medium to conduct the electrical electrolytic medium to conduct the electrical energy from the active to the return energy from the active to the return electrode.electrode.

High energy produces large amount of air High energy produces large amount of air bubble-very high resistance in bubble- high bubble-very high resistance in bubble- high potential discharge in low resistant area. potential discharge in low resistant area.

Once discharge started that can be Once discharge started that can be maintained till output <100 Wmaintained till output <100 W

Low risk of depth penetrationLow risk of depth penetration Heated sheath injury low.Heated sheath injury low. Tissue (protein) cut by >215*cTissue (protein) cut by >215*c carbonization >420*ccarbonization >420*c TURis - 300-400*c TURis - 300-400*c

Initiation of the cut was slowerInitiation of the cut was slower with all with all devices (i.e. most pronounced with devices (i.e. most pronounced with ACMI/VISTA)ACMI/VISTA)

Time lag 0.1 secTime lag 0.1 sec higher output powers bleeding was less higher output powers bleeding was less

compared to monopolar technology. compared to monopolar technology. More importantly, the coagulation depth More importantly, the coagulation depth

was significantly reduced (141 vs. 287 was significantly reduced (141 vs. 287 micron), which could be reconfirmed by micron), which could be reconfirmed by pathological studies after TURP (Rassler). pathological studies after TURP (Rassler).

Overall, the energy input during bipolar Overall, the energy input during bipolar was higher compared to monopolar. was higher compared to monopolar.

Time lag due to time taken for air Time lag due to time taken for air bubble formation all over loopbubble formation all over loop

Overcome by initiating loop in saline Overcome by initiating loop in saline (low resistant) itself.(low resistant) itself.

Increase perfusate temperature Increase perfusate temperature Can be accustomedCan be accustomed

Fluid is either warmed in a warming Fluid is either warmed in a warming cabinet or run through a fluid warmerA cabinet or run through a fluid warmerA

Not only because it increases patient Not only because it increases patient safety by preventing hypothermia, which safety by preventing hypothermia, which can occur with longer procedures,can occur with longer procedures,

Because warmed saline for irrigation Because warmed saline for irrigation decreases the lag time and allows for decreases the lag time and allows for faster cutting .faster cutting .

Also by decrease flowAlso by decrease flow

Collateral and penetrative tissue damage Collateral and penetrative tissue damage is reduced compared to standard is reduced compared to standard monopolar TURP surgery& less monopolar TURP surgery& less granulation tissue is formed granulation tissue is formed

less tissue charring occurs, which helps in less tissue charring occurs, which helps in identifying the surgical capsule and other identifying the surgical capsule and other landmarks. landmarks.

negates the need for diathermy padnegates the need for diathermy pad unwanted stimulation of the obturator unwanted stimulation of the obturator

nerves and cardiac devicesnerves and cardiac devices..

Performing TURP with saline Performing TURP with saline eliminates the possibility of TUR eliminates the possibility of TUR syndrome, so limitations in gland syndrome, so limitations in gland size and procedure time also are size and procedure time also are eliminated eliminated

The resected prostate chips are The resected prostate chips are cleaner and have less coagulation or cleaner and have less coagulation or desiccation defects, which simplifies desiccation defects, which simplifies pathological examination.pathological examination.

Overall hemostasis is possibly Overall hemostasis is possibly slightly improved with the bipolar slightly improved with the bipolar instrument, although rapid sweeping instrument, although rapid sweeping with the loop using coagulating with the loop using coagulating current is less effective than with a current is less effective than with a monopolar system.monopolar system.

Direct pressure on a bleeding site is Direct pressure on a bleeding site is the recommended technique (pin the recommended technique (pin point coagulation)point coagulation)

CriteriaCriteriaTURP TURP

monopolarmonopolarOlympusOlympus

Gyrus Gyrus plasmakinetiplasmakineti

cc

StorzStorzbipolarbipolar

Size (F) ofSize (F) ofresectoscoperesectoscope

24-2624-26 24-2624-26 2626 24-2624-26

Active LoopActive Loop Normal sizeNormal size Smaller Smaller Two sizesTwo sizes SmallerSmaller

Neutral Neutral ElectrodeElectrode

At skinAt skinResection Resection sheathsheath

Proximal to Proximal to looploop

Opposite to Opposite to looploop

Life-time of Life-time of looploop

Resterilisable Resterilisable (100-200g)(100-200g)


Disposable Disposable (one case)(one case)


View during View during resectionresection

++++++ ++++++ ++++++ ++++++

AuthorsAuthorsNN BleedingBleeding

Rate (%) Rate (%)

TUR-synTUR-syndrome (%)drome (%)

CatheterCatheter time (d) time (d)

UrethralUrethralstricture (%)stricture (%)

Singh 2005 Singh 2005 6060

- TURP - TURP 3030 0.00.03.33.3

3.43.4 0.00.0

- bipolar (Vista) - bipolar (Vista) 3030 0.00.0 0.00.0 2.52.5 1.31.3

Tefekli 2005 Tefekli 2005 9696

- TURP - TURP 4747 2.12.1 0.00.0 3.83.8 2.12.1

- bipolar (Gyrus) - bipolar (Gyrus) 4949 2.02.0 0.00.0 2.32.3 2.12.1

de Sio 2006 de Sio 2006 7070

- TURP - TURP 3535 11.411.4 0.00.0 4.14.1 2.82.8

- bipolar - bipolar (Gyrus) (Gyrus)

3535 5.75.7 0.00.0 3.03.0 2.8 2.8

Patankar 2006 Patankar 2006 104104

- TURP - TURP 5151 3.93.9 3.93.9 1.81.8 n.a.n.a.

- bipolar (Gyrus) - bipolar (Gyrus) 5353 0.00.0 0.00.0 0.80.8 n.a.n.a.

Ho 2006 Ho 2006 100100

- TURP - TURP 5252 3.83.8 3.83.8 n.an.a 6.36.3

- bipolar - bipolar (Olympus) (Olympus)

4848 6.36.3 0.00.0 2.02.0 1.91.9

Advantages of bipolar Advantages of bipolar technologytechnology

� � Less conductive trauma (i.e. resulting Less conductive trauma (i.e. resulting to a lower rate of bladder neck stenosis or to a lower rate of bladder neck stenosis or urethral strictures)urethral strictures)� Elimination of TUR-syndrome (i.e. � Elimination of TUR-syndrome (i.e. hyponatremia) hyponatremia) � Lower risk of capsular lesion (i.e. � Lower risk of capsular lesion (i.e. decreased stimulation of pelvic floor)decreased stimulation of pelvic floor)� Better visual orientation (i.e. reduced � Better visual orientation (i.e. reduced coagulation depth)coagulation depth)� Self-cleaning of the loop (i.e. by high � Self-cleaning of the loop (i.e. by high energy level at plasma ignition)energy level at plasma ignition)

Potential disadvantages of Potential disadvantages of bipolar technologybipolar technology

Higher risk of conductive trauma if Higher risk of conductive trauma if current is deviated (i.e. via sheath) current is deviated (i.e. via sheath) due to higher energy levels for due to higher energy levels for ignition of plasma (i.e. insufficient ignition of plasma (i.e. insufficient lubrication). lubrication).

Small loop - more timeSmall loop - more time Risk of recurrent bleeding due to Risk of recurrent bleeding due to

smaller coagulation zone.smaller coagulation zone.

Fluid absorption still possible, but Fluid absorption still possible, but serum natrium cannot be used as serum natrium cannot be used as early indicator. Inferior quality of early indicator. Inferior quality of loops (fine resection, durability).loops (fine resection, durability).

Effects assosiated with circulating Effects assosiated with circulating volumevolume

Hyperchloremic acodosis-Hyperchloremic acodosis-git,renal,cns.git,renal,cns.

futurefuture New coagulating intermittent cutting (CIC) New coagulating intermittent cutting (CIC)

device uses a constant voltage pulse current with device uses a constant voltage pulse current with controlled pulse intervals to help reduce controlled pulse intervals to help reduce bleeding bleeding

Serum natrium cannot be used as indicator, if Serum natrium cannot be used as indicator, if sodium chloride represents the irrigant. It was sodium chloride represents the irrigant. It was emphasised, that fluid overload with sodium emphasised, that fluid overload with sodium chloride (i.e. following capsular perforation) may chloride (i.e. following capsular perforation) may have deleterious consequences.have deleterious consequences.

Interestingly in animal studies, Ringer`s lactate Interestingly in animal studies, Ringer`s lactate proved to be superior over sodium chloride as proved to be superior over sodium chloride as high conductive solution. high conductive solution.

For detection of fluid absorption still include the For detection of fluid absorption still include the injection of ethanol, but also of nitrid oxide (NO) injection of ethanol, but also of nitrid oxide (NO) in the irrigation fluid. in the irrigation fluid.

THANK YOUTHANK YOU