clinical study a prospective study of bipolar...

Clinical StudyA Prospective Study of Bipolar Transurethral Resection ofProstate Comparing the Efficiency and Safety of the Method inLarge and Small Adenomas

Nikolaos Mertziotis1 Diomidis Kozyrakis2 Christos Kyratsas1 and Andreas Konandreas1

1 Iaso General Hospital 264 Messogeion Avenue 15562 Athens Greece2General Hospital of Volos 134 Polimeri Street 38222 Volos Greece

Correspondence should be addressed to Nikolaos Mertziotis mertzholgr

Received 6 July 2015 Accepted 11 November 2015

Academic Editor Matthew Rutman

Copyright copy 2015 Nikolaos Mertziotis et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Bipolar technology offers a new perspective in the treatment of BPH Purpose To present our experience with the TURis system(Olympus Tokyo Japan) Materials and Methods From February 2011 till December 2013 in a prospective study 93 patients weretreated for BPH They were evaluated with IPSS QoL uroflow (119876max) and residual urine (RU) preoperatively as well as 6 and 9months postoperatively Based on the prostate volume the patients were divided into two groups group A (119899 = 48) with prostates ge75 cc and group B (119899 = 45) with smaller prostate glands All patients underwent bipolar TURP orand plasma vaporization ResultsThe postoperative improvement for IPSS QoL119876max and RUwas statistically significantThe operation time was longer in group Ain comparison with group B (119875 lt 0001) The former group also had higher infection and stricture formation rates however therewas no statistical difference between the two groups Conclusions Treatment with the TURis constitutes an effective technique andcan be offered to large prostates with results equivalent to those in small ones Regarding safety large adenomas treated with TURisare not at a higher risk for urethral stricture but their odds to develop urogenital infections are relatively higher compared to thesmaller adenomas

1 Introduction

Benign prostate hyperplasia (BPH) is a high prevalent dis-ease among the middle agedelderly male population Eventhough it is poorly defined it is encountered at a rate ofapproximately 50 in ages between 51 and 60 years [1]Othersreport a prevalence of 26 in males during their fifth decadeof life and up to 46 during their eighth decade [2] Medicaltreatment with a

1blockers and 5-a reductase inhibitors

offers good results to patients with mild to moderate symp-toms while for those with more severe lower urinary tractsymptoms an interventional treatment is recommended Formany years transurethral resection of the prostatic adenomawith monopolar electrocautery (M-TURP) has been the goldstandard of surgical treatment due to its effectiveness and itsdurable results over time but its safety profile is not ideal[3ndash5] Postoperative hemorrhage blood clot retention and

urethral strictures are a few of the potential complicationsThe hyponatremia and TUR syndrome are associated withthe irrigation of a nonconductive solution (eg glycine 15mannitol 5) to distend the bladder during the monopo-lar prostatectomy [6ndash8] Prolonged resection time makespatients vulnerable to electrolyte disorders [9] and for safetyreasons prostates greater than 80ndash100mL are excluded fromadequate treatment with M-TURP in one single session [1011]

Several devices and techniques have been developed toovercome these limitations ofM-TURP and the bipolar resec-tion of the prostate (B-TURP) is one of them This methoduses normal saline solution 09 as irrigation fluid whichhas the advantage to eliminate the risk of TUR syndrome [1213] This is because the absorption of the irrigation fluid bythe vascular system of the prostate is clinically insignificantThe bipolar device is also considered to have an optimal

Hindawi Publishing CorporationAdvances in UrologyVolume 2015 Article ID 251879 6 pageshttpdxdoiorg1011552015251879

2 Advances in Urology

haemostatic effect minimizing the postoperative hemorrhage[14 15]

We herein present the clinical results of a prospectivestudy composed of BPH patients treated with the bipolarresectoscope in saline and we are comparing the surgicalresults and the complications encountered in large prostateswith those in smaller adenomas

2 Material and Methods

From February 2011 till December 2013 93 consecutivepatients were treated by the same surgeon for BPH with thebipolar 26 F resectoscopeOES Pro byOlympus Tokyo Japanin saline Electric current was delivered by the electrosurgicalgenerator UES-40 SurgMaster Resection of the prostate wasperformed using the loop resectoscope combined in somecases with vaporization of the adenoma using the plasmabutton device (TURis)

Before treatment patient history was taken and clinicalexamination was performed on each patient followed byIPSS and quality of life (QoL) questionnaire transabdominalor transrectal ultrasonography of the urinary tract anduroflowmetry test with residual urine (RU) echographicassessment In a prospective follow-up all these tests wereroutinely repeated in 6ndash9 month interval after the operation

The criteria for surgical treatment were formed based onone or more of the following high prostate symptom score(IPSS ge 20) poor BPH related quality of life (score 5 or 6)failure to respond to conservative treatment or recurrence ofsymptoms after conservative treatment 119876max le 10mLsechigh postvoiding residual urine volume (ge 200mL) andurinary retention or patientrsquos preference Discontinuation ofany antiplatelet or anticoagulative treatment was mandatoryprior to surgery

Aiming to perform a comparative analysis the presurgi-cal prostate volume established the criterion based on whichpatients were classified into two groups group A was thatof large prostates (ge75mL) and group B was the one withprostates less than 75mL and represented the control groupof our study

The two groups were preoperatively examined for statisti-cal significant differences regarding the age the prostate vol-ume the IPSS the QoL the maximum flow (119876max) and theRU The surgical outcome was expressed as the postsurgicalimprovement over the baseline (preoperative) values for eachone of the IPSS QoL 119876max and RU and a comparison ofthe results between the two groups was provided Operationtime hospitalization postsurgical catheterization and com-plication rates were recorded for each group separately andthe results were statistically analyzed

The statistical analysis was performed using the StataMP 101 (StataCorp LP Texas USA) software for windowsNormality was examined using the Shapiro-Wilk test Com-parison of the two groups was performed using Wilcoxonrank-sum test and t-test for values in abnormal and normaldistribution respectively Statistical significance was definedas 119875 lt 005

Table 1 Patientsrsquo characteristics at presentation

Factor Mean value RangeAge (years) 713 46ndash92Prostate volume (mL) 6098 43ndash185IPSS 182 7ndash32QoL 337 2ndash6119876max (mLsec) 844 2ndash14Residual urine (mL) 16771 20ndash700Urinary retention 6

3 Results

The patientsrsquo characteristics are presented in Table 1 Themean age at presentation was 713 years (range 46ndash92) Themean prostate volume was 6098mL (range 43ndash185) Themean IPSS QoL 119876max and RU were 182 337 844mLsecand 16771mL For both groups the mean operation time was6326min (range 36ndash151) the mean duration of catheteriza-tion was 2806 hours (range 16ndash98) and the mean hospitalstay was 3201 hours (range 22ndash75) The percentage ofimprovement for IPSS QoL 119876max and RU was 4741minus5667 10107 and minus6597 respectively and statisticallysignificant improvement was noted (Table 2) Two patientswere unable to void after surgery One of themwas reoperatedon and the other was treatedwith intermittent catheterizationfor 6monthsThe latter subsequently had a successful voidingwithout catheterization Two nonfatal major cardiovascularcomplicationswere diagnosed onemyocardial infarction andone pulmonary embolism Urethral strictures were identifiedin 8 patients and urogenital infections in 10 Nine patientscomplained of persistent symptomatology of the lower uri-nary tract mainly storage symptoms for more than 3monthsand were treated with anticholinergic regimens An overviewof surgical complications is presented in Table 3

At the imaging of the lower urinary tract 48 out of the93 patients (52 group A) had prostates greater than 75mL(mean 9213mL range 75ndash185) while the rest 45 patients(48 group B) had smaller prostates (mean 5129mL range43ndash66) The preoperative characteristics of both groups arepresented in Table 4 When statistically examined the twogroupswere comparable in all the preoperative characteristicsexcept for the prostate size and the peak flow in uroflowmetryThe percentage of postsurgical improvement for group Awas minus5246 minus4757 15768 and minus6503 for IPSS QoL119876max and RU respectively and minus4541 minus6060 11608and minus6582 for group B respectivelyThe statistical analysisdid not reveal any significant difference in the surgicaloutcome between the two groups The operation time waslonger in large prostates but the bladder catheterization timeand hospital stay were similar (Table 5) The complicationrates are presented in Table 6 and although the urogenitalinfection rate of group A was much higher than that of groupB no statistical significance was revealed

Advances in Urology 3

Table 2 Presentation of the operation time catheterization time hospital stay and surgical results for the whole group of patients

Factor Mean value (range) Percentage of change 119875 valueOperation time (minutes) 6326 (36ndash151)Catheterization time (hours) 2806 (16ndash98)Hospital stay (hours) 3201 (22ndash75)IPSSDagger prepost 182957 minus4741 0001QoLDagger prepost 337146 minus5667 0001119876maxdagger prepost 8441697 10107 0001

Residual urineDagger prepost 167715708 minus6597 0001DaggerAbnormal distribution the comparison was made with the Wilcoxon matched pairs signed ranks testdaggerNormal distribution the comparison was made with the 119905-test (matched pairs)

Table 3 Overview of surgical complications for both groups ofpatients

Complication Number of patients (119899 = 93) Percentage ()Urethral stricture 8 86Urinary retention 2 21Blood transfusion 1 10Urogenital infection 10 107Prolonged LUTS 9 96Prolonged hematuria 2 21Cardiovascular events 2 21

Table 4 Comparison of the preoperative characteristics of the twogroups of patients

Variant Group Α Group Β119875 value

(119899 = 48) (119899 = 45)Agedagger (yrs) 723 (718) 710 (1056) 0631119881prostDagger (cm3) 921 [75ndash185] 512 [43ndash66] lt0001

IPSSdagger 196 (626) 177 (539) 0221Qoldagger 37 (098) 325 (093) 0093119876maxdagger (mLsec) 66 (287) 90 (312) 0011

RUDagger (mL) 1625 [150ndash240] 150 [100ndash200] 0386DaggerAbnormal distribution the median and IQR values are shown and thecomparison is based on the Wilcoxon rank-sum testdaggerNormal distribution the mean and SD values are shown and the compari-son is based on the 119905-test

4 Discussion

Historically Gyrus (ACMI SouthboroughMAUSA)was thefirst manufacturer that incorporated bipolar technology intothe resectoscope device known as the PlasmaKinetic System(PKS)Theprostatectomywas performed using normal saline09 as the irrigant fluid instead of a nonconductive solutionoffering the advantage of minimal absorption by the openvessels and eliminating the risk of electrolytic disordersparticularly the serum sodium level drop [12 16] Lateron another bipolar resectoscope manufactured by Olympus(SurgMaster device TURis) was released into the markethaving similar advantages to those of PKS [17] The use oftwo interchangeable electrodes the resection loop and themushroom shaped plasmabutton allows a fast complete andprecise resection of the adenomas [18]

Table 5 Comparison of the surgical outcome operation timecatheterization time and hospital stay between the two groups ofpatients (OK)


(119899 = 48) (119899 = 45)IPSSDagger minus5246 minus4541 0934QoLdagger minus4757 minus6060 0603119876maxdagger (mLsec) 15768 11608 0384

RUDagger (mL) minus6503 minus6582 0655Mean operation time (minutes)Dagger 8876 5423 lt0001Mean catheterization time (hours)Dagger 2941 2758 0356Mean hospital stay (hours)Dagger 3406 3129 0211DaggerAbnormal distribution the comparison is based on theWilcoxon rank-sumtestdaggerNormal distribution the comparison is based on the 119905-test

Nowadays bipolar technology is a safe and effectivemethod to perform the transurethral prostatectomy An earlymeta-analysis published in 2009 showed that the bipolarmethod had the same efficacy as the monopolar one butthe safety of the former technique was more favorable Inparticular the clot retention rate and the TUR syndromerisk were lower in the bipolar arm Moreover the irriga-tion and catheterization time were significantly shorter [19]Another meta-analysis published 4 years later despite themethodological limitations of the RCT incorporated in thestudy and the short follow-up period came to similar conclu-sions emphasizing once more the better safety profile (non-TUR syndrome less clot retention and blood transfusion)encountered in the bipolar arm [13] Aiming to overcome anymethodological flaws a well-designed multicenter double-blind randomized trial that fulfilled the COCHRANE criteriafor high quality trials was performed comparing the bipolarAutoZone II 400 ESU with the M-TURP Although thedilutional hyponatremia was diagnosed more frequently inthe monopolar group the TUR syndrome risk was similar inboth arms (monopolar 07 versus bipolar 0)The authorsconcluded that the improved safety profile of the B-TURPwasonly theoretical bearing minimal clinical significance whenthe operation was performed by experienced surgeons [20]

Nevertheless the number of publications that focused onthe surgical outcome in large volume prostates is limited


Table 6 Comparison of surgical complications between the two groups

Complication Group Α Group Β119875 value

(119899 = 48) number of patients () (119899 = 45) number of patients ()Urethral stricture 6 (125) 2 (44) 0163Urinary retention 1 (21) 1 (22) 0974Blood transfusion 1 (21) 0 (0) 0328Urogenital infection 7 (146) 3 (66) 0219Prolonged LUTSincontinence 6 (125) 3 (66) 0185Prolonged hematuria 2 (42) 0 (0) 0166Cardiovascular events 2 (42) 0 (0) 0166

In a case series of 4 patients with excessive prostate volumes(gt160mL) prostatectomy was performed with the Gyrus PKsystem Despite the prolonged operation time the percentageof complications was favorable regarding the hemoglobinlevel and serum sodium level drop The hospitalization timewas short (mean 12 hours) and the catheterwas removed afteran average of 76 hours [21]

In a prospective randomized studywith adenomas greaterthan 60 gr the PK system was compared with the conven-tionalM-TURPThe short term surgical outcome (IPSS119876maxand RU) was similar between the two groups but the bipolarsystem had a clear advantage in blood loss in hyponatremiaevents and in catheter stayThe authors stressed the inherentpotential of the new technique to become the new goldstandard of the minimal invasive prostatectomy [22]

Similar to the PK system several authors focused onthe advantage of the Olympus TURis over the monopolarsystem in terms of complication rates In prostates gt50mLthe hemoglobin level drop was minimal the immediate post-operative complications were fewer and the hospitalizationand catheter stay were shorter [23] Others underscore thelimited postoperative drop in sodium level minimizing therisk of TUR syndrome [24] All the aforementioned papershave a short follow-up period therefore the issue of latecomplications and durable results over time remains to beanswered

In a study of 136 patients with a follow-up of 3 yearsthe authors compared the TURis with the M-TURP [25]In the subgroup of patients with small adenomas bothtechniques yield similar results regarding the postoperativecomplications but in prostates gt70mL the urethral stricturerate was as high as 20 in the TURis arm and only 22 inthe monopolar one (119875 = 0012) Likewise Rassweiler et alreported on high stricture formation rates among patientstreated either with the PKS or the TURis device [18] Thesealarming results were not confirmed in the meta-analysispublished by Omar and colleagues in which the percentageof urethral strictures was not higher than 33 [13]

In our series 86 of the patients developed urethralstenosis The prolonged surgical time and perhaps the largecaliber of the resectoscope sheath (26 F) might constitutethe explanation for this complication It could be assumedthat for some urethras the resectoscope sheath may belarge enough as to cause ischemia and urethral trauma

In addition the power settings of 310W and 170W that weused for resection and coagulation may have produced athermal damage to the sensitive periurethral tissue and thusstricture formation [14 26] By adjusting the working settingsto a lower power level we hope that we will be able to reducethe frequency of this complication

The UTI rate was as high as 146 among large prostatesand approximately 66 in smaller adenomas It shouldbe stated that we registered not only patients with febrileurogenital infection but those with asymptomatic orminimalbothersome positive urinary culture as well Except forpatients with an indwelling urethral catheter we performeda preoperative urinary culture and we proceeded to theoperation only when the results of the urine culture werenegative for bacteria or sterile We routinely administered acephalosporin II or an ampicillinsulbactam regimen intra-venously 301015840ndash601015840 before and 5-6 hours after the operation Insome cases with a history of catheterization or an estimatedhigh risk for infection particularly in large adenomas wecontinued the treatment for 5ndash7 days orally Apart fromthe hypothesis that large prostates may host a plethora ofbacterial populations or more aggressive strains that arereleased into the circulation during prostatectomy and thelonger operation time no clear explanation for the highinfection rate could be given

In our opinion the disadvantages of the TURis includingthe cost of surgical loop and plasma button electrode arecounterbalanced by the short time of postoperative fluidirrigation catheter stay and hospitalization Considering thatthe majority of patients were discharged after less than 36hours of hospital stay it is safe to assume that the benefitfor the health care system is major Although we have notperformed an official technoeconomic study one day less ofhospital stay is translated into approximately gt400C of costsavings The brief postoperative recovery time and the earlyreturn to work also have a profound positive effect on theindividualrsquos psychological and economic status

A main drawback of our study is the limited number ofpatients and the lack of a control group for a direct compari-son of the bipolar technique against the monopolar one Dueto the short follow-up period the long term effectiveness andthe late complications of TURis are impossible to be definedin this series


5 Conclusions

Treatment of BPHwith the bipolar resectoscope is an effectivesurgical technique and seems to offer patients with largeprostates surgical results equivalent to those encountered insmaller prostate volumes Concerning the safety profile inour series large prostates treated with TURis are not at ahigher risk for urethral stricture but their odds to developurogenital infections are higher compared with the smalleradenomas counterparts Generally speaking the percentageof postoperative strictures and infections could be consid-ered suboptimal and should be subjected to investigationin future prospective trials Candidates for TURis prosta-tectomy irrespective of their prostatic volume should beproperly informed about the aforementioned complicationsbefore giving their consent for surgery

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] S J Berry D S Coffey P C Walsh and L L Ewing ldquoThedevelopment of human benign prostatic hyperplasia with agerdquoJournal of Urology vol 132 no 3 pp 474ndash479 1984

[2] C G Chute L A Panser C J Girman et al ldquoThe prevalenceof prostatism a population-based survey of urinary symptomsrdquoThe Journal of Urology vol 150 no 1 pp 85ndash89 1993

[3] W K Mebust H L Holtgrewe A T K Cockett and P CPeters ldquoTransurethral prostatectomy immediate and postop-erative complications A cooperative study of 13 participatinginstitutions evaluating 3885 patientsrdquo Journal of Urology vol141 no 2 pp 243ndash247 1989

[4] O Reich C Gratzke andC G Stief ldquoTechniques and long termresults of surgical procedures for BPHrdquo European Urology vol49 no 6 pp 970ndash978 2006

[5] J Rassweiler D Teber R Kuntz and R Hofmann ldquoCompli-cations of transurethral resection of the prostate (TURP)mdashincidence management and preventionrdquo European Urologyvol 50 no 5 pp 969ndash980 2006

[6] R G Hahn ldquoTransurethral resection syndrome from extravas-cular absorption of irrigating fluidrdquo Scandinavian Journal ofUrology and Nephrology vol 27 no 3 pp 387ndash394 1993

[7] D P Michielsen T Debacker V De Boe et al ldquoBipolartransurethral resection in salinemdashan alternative surgical treat-ment for bladder outlet obstructionrdquo The Journal of Urologyvol 178 no 5 pp 2035ndash2039 2007

[8] H SinghM R Desai P Shrivastav andK Vani ldquoBipolar versusmonopolar transurethral resection of prostate randomizedcontrolled studyrdquo Journal of Endourology vol 19 no 3 pp 333ndash338 2005

[9] A A Yousef G A Suliman O M Elashry M D Elsharabyand A E-N K Elgamasy ldquoA randomized comparison betweenthree types of irrigating fluids during transurethral resectionin benign prostatic hyperplasiardquo BMC Anesthesiology vol 10article 7 2010

[10] S Gravas A Bachmann A Descazeaud et al EAU 2014Guidelines on the Management of Male Lower Urinary

Tract Symptoms (LUTS) incl Benign Prostatic Obstruction(BPO) 2014 httpuroweborgguidelinetreatment-of-non-neurogenic-male-luts

[11] O Reich C Gratzke A Bachmann et al ldquoMorbidity mortalityand early outcome of transurethral resection of the prostatea prospective multicenter evaluation of 10654 patientsrdquo TheJournal of Urology vol 180 no 1 pp 246ndash249 2008

[12] H Botto T Lebret P Barre J-L Orsoni J-M Herve and P-M Lugagne ldquoElectrovaporization of the prostatewith theGyrusdevicerdquo Journal of Endourology vol 15 no 3 pp 313ndash316 2001

[13] M I Omar T B Lam C E Alexander et al ldquoSystematic reviewand meta-analysis of the clinical effectiveness of bipolar com-pared with monopolar transurethral resection of the prostate(TURP)rdquo BJU International vol 113 no 1 pp 24ndash35 2014

[14] L Qu X Wang X Huang Y Q Zhang and X Zeng ldquoThehemostatic properties of transurethral plasmakinetic resectionof the prostate comparison with conventional resectoscope inan ex vivo studyrdquoUrologia Internationalis vol 80 no 3 pp 292ndash295 2008

[15] X Huang L Wang X-H Wang H-B Shi X-J Zhang andZ-Y Yu ldquoBipolar transurethral resection of the prostate causesdeeper coagulation depth and less bleeding than monopolartransurethral prostatectomyrdquo Urology vol 80 no 5 pp 1116ndash1120 2012

[16] W D Dunsmuir J P McFarlane A Tan et al ldquoGyrus bipolarelectrovaporization vs transurethral resection of the prostate arandomized prospective single-blind trial with 1 y follow-uprdquoProstate Cancer and Prostatic Diseases vol 6 no 2 pp 182ndash1862003

[17] M Miki H Shiozawa T Matsumoto and T AizawaldquoTransurethral resection in saline (TURis) a newly developedTUR system preventing obturator nerve reflexrdquo NihonHinyokika Gakkai Zasshi vol 94 no 7 pp 671ndash677 2003(Japanese)

[18] J Rassweiler M Schulze C Stock D Teber and J De LaRosette ldquoBipolar transurethral resection of the prostatemdashtechnical modifications and early clinical experiencerdquo Mini-mally InvasiveTherapy and Allied Technologies vol 16 no 1 pp11ndash21 2007

[19] C Mamoulakis D T Ubbink and J J M C H de laRosette ldquoBipolar versus monopolar transurethral resection ofthe prostate a systematic review and metaanalysis of random-ized controlled trialsrdquo European Urology vol 56 no 5 pp 798ndash809 2009

[20] C Mamoulakis A Skolarikos M Schulze et al ldquoResultsfrom an international multicentre double-blind randomizedcontrolled trial on the perioperative efficacy and safety ofbipolar vs monopolar transurethral resection of the prostaterdquoBJU International vol 109 no 2 pp 240ndash248 2012

[21] D S Finley S Beck and R J Szabo ldquoBipolar saline TURP forlarge prostate glandsrdquo The Scientific World Journal vol 7 pp1558ndash1562 2007

[22] M Bhansali S Patankar S Dobhada and S Khaladkar ldquoMan-agement of large (gt60 g) prostate gland PlasmaKinetic Super-pulse (bipolar) versus conventional (monopolar) transurethralresection of the prostaterdquo Journal of Endourology vol 23 no 1pp 141ndash145 2009

[23] Q Chen L Zhang Y J Liu J D Lu and G M Wang ldquoBipo-lar transurethral resection in saline system versus traditionalmonopolar resection system in treating large-volume benignprostatic hyperplasiardquoUrologia Internationalis vol 83 no 1 pp55ndash59 2009


[24] D P J Michielsen D Coomans I Peeters and J G BraeckmanldquoConventional monopolar resection or bipolar resection insaline for the management of large (gt60 g) benign prostatichyperplasia an evaluation of morbidityrdquo Minimally InvasiveTherapy amp Allied Technologies vol 19 no 4 pp 207ndash213 2010

[25] K Komura T Inamoto T Takai et al ldquoCould transurethralresection of the prostate using the TURis system take over con-ventional monopolar transurethral resection of the prostate Arandomized controlled trial and midterm resultsrdquo Urology vol84 no 2 pp 405ndash411 2014

[26] GWendt-Nordahl A Hacker K Fastenmeer et al ldquoNew bipo-lar resection device for transurethral resection of the prostatefirst ex-vivo and in-vivo evaluationrdquo Journal of Endourology vol19 no 10 pp 1203ndash1209 2005

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Disease Markers


BioMed Research International

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Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

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Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


haemostatic effect minimizing the postoperative hemorrhage[14 15]

We herein present the clinical results of a prospectivestudy composed of BPH patients treated with the bipolarresectoscope in saline and we are comparing the surgicalresults and the complications encountered in large prostateswith those in smaller adenomas

2 Material and Methods

From February 2011 till December 2013 93 consecutivepatients were treated by the same surgeon for BPH with thebipolar 26 F resectoscopeOES Pro byOlympus Tokyo Japanin saline Electric current was delivered by the electrosurgicalgenerator UES-40 SurgMaster Resection of the prostate wasperformed using the loop resectoscope combined in somecases with vaporization of the adenoma using the plasmabutton device (TURis)

Before treatment patient history was taken and clinicalexamination was performed on each patient followed byIPSS and quality of life (QoL) questionnaire transabdominalor transrectal ultrasonography of the urinary tract anduroflowmetry test with residual urine (RU) echographicassessment In a prospective follow-up all these tests wereroutinely repeated in 6ndash9 month interval after the operation

The criteria for surgical treatment were formed based onone or more of the following high prostate symptom score(IPSS ge 20) poor BPH related quality of life (score 5 or 6)failure to respond to conservative treatment or recurrence ofsymptoms after conservative treatment 119876max le 10mLsechigh postvoiding residual urine volume (ge 200mL) andurinary retention or patientrsquos preference Discontinuation ofany antiplatelet or anticoagulative treatment was mandatoryprior to surgery

Aiming to perform a comparative analysis the presurgi-cal prostate volume established the criterion based on whichpatients were classified into two groups group A was thatof large prostates (ge75mL) and group B was the one withprostates less than 75mL and represented the control groupof our study

The two groups were preoperatively examined for statisti-cal significant differences regarding the age the prostate vol-ume the IPSS the QoL the maximum flow (119876max) and theRU The surgical outcome was expressed as the postsurgicalimprovement over the baseline (preoperative) values for eachone of the IPSS QoL 119876max and RU and a comparison ofthe results between the two groups was provided Operationtime hospitalization postsurgical catheterization and com-plication rates were recorded for each group separately andthe results were statistically analyzed

The statistical analysis was performed using the StataMP 101 (StataCorp LP Texas USA) software for windowsNormality was examined using the Shapiro-Wilk test Com-parison of the two groups was performed using Wilcoxonrank-sum test and t-test for values in abnormal and normaldistribution respectively Statistical significance was definedas 119875 lt 005

Table 1 Patientsrsquo characteristics at presentation

Factor Mean value RangeAge (years) 713 46ndash92Prostate volume (mL) 6098 43ndash185IPSS 182 7ndash32QoL 337 2ndash6119876max (mLsec) 844 2ndash14Residual urine (mL) 16771 20ndash700Urinary retention 6

3 Results

The patientsrsquo characteristics are presented in Table 1 Themean age at presentation was 713 years (range 46ndash92) Themean prostate volume was 6098mL (range 43ndash185) Themean IPSS QoL 119876max and RU were 182 337 844mLsecand 16771mL For both groups the mean operation time was6326min (range 36ndash151) the mean duration of catheteriza-tion was 2806 hours (range 16ndash98) and the mean hospitalstay was 3201 hours (range 22ndash75) The percentage ofimprovement for IPSS QoL 119876max and RU was 4741minus5667 10107 and minus6597 respectively and statisticallysignificant improvement was noted (Table 2) Two patientswere unable to void after surgery One of themwas reoperatedon and the other was treatedwith intermittent catheterizationfor 6monthsThe latter subsequently had a successful voidingwithout catheterization Two nonfatal major cardiovascularcomplicationswere diagnosed onemyocardial infarction andone pulmonary embolism Urethral strictures were identifiedin 8 patients and urogenital infections in 10 Nine patientscomplained of persistent symptomatology of the lower uri-nary tract mainly storage symptoms for more than 3monthsand were treated with anticholinergic regimens An overviewof surgical complications is presented in Table 3

At the imaging of the lower urinary tract 48 out of the93 patients (52 group A) had prostates greater than 75mL(mean 9213mL range 75ndash185) while the rest 45 patients(48 group B) had smaller prostates (mean 5129mL range43ndash66) The preoperative characteristics of both groups arepresented in Table 4 When statistically examined the twogroupswere comparable in all the preoperative characteristicsexcept for the prostate size and the peak flow in uroflowmetryThe percentage of postsurgical improvement for group Awas minus5246 minus4757 15768 and minus6503 for IPSS QoL119876max and RU respectively and minus4541 minus6060 11608and minus6582 for group B respectivelyThe statistical analysisdid not reveal any significant difference in the surgicaloutcome between the two groups The operation time waslonger in large prostates but the bladder catheterization timeand hospital stay were similar (Table 5) The complicationrates are presented in Table 6 and although the urogenitalinfection rate of group A was much higher than that of groupB no statistical significance was revealed












4 Discussion






















5 Conclusions




References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



























4 Discussion






















5 Conclusions




References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of






























5 Conclusions




References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















clinical study a prospective study of bipolar...

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