Transurethral Resection Syndrome Research Articles

Comparative Outcomes of Monopolar and Bipolar Transurethral Resection of the Prostate: An Institutional Perspective.

Objective This prospective comparative study aimed to highlight and compare two types of transurethral resection of the prostate (TURP), namely M-TURP (monopolar) and B-TURP (bipolar), in the endoscopic management of benign prostatic hyperplasia (BPH). Methods and materials This research was conducted between 2022 and 2023 at a tertiary care health center. Included in the investigation were 100 consenting study participants undergoing M-TURP and B-TURP at our center. All referred patients presenting with clinical, ultrasound, or uroflowmetry features of BPH and those with failed attempts at medical management were included in the study. Patients with carcinoma of the prostate were excluded from the study. Post-operatively, the endpoints for comparison included maximal urinary flow rate (Qmax), prostate volume, duration of hospital stay, duration of catheterization, drop in serum sodium concentration, and drop in hemoglobin levels. Descriptive statistics were computed to delineate the study sample. After the completion of data collection, data analysis was performed using SPSS for Windows, Version 16.0 (Released 2007; SPSS Inc., Chicago, IL, USA), and the correlations sought were achieved using the Chi-square test of significance. Results The peak incidence of BPH was seen in the sixth decade of life: the M-TURP group was 65.16 ± 7.07 years (mean ± standard deviation), while that in the B-TURP group was 62.32 ± 8.16 years (mean ± standard deviation). Nine percent of the study participants did not show any comorbidities. The most frequent symptom of BPH at presentation was a poor urinary stream (78%, n = 100), followed by nocturia (67%, n = 100). In our study, patients undergoing M-TURP had a mean serum prostate-specific antigen (PSA) level of 4.31 ± 1.03 ng/mL, while patients undergoing B-TURP had a mean serum PSA of 4.24 ± 0.99 ng/mL (p = 0.820; p > 0.05). The study found that patients undergoing M-TURP had a mean prostate size of 35.04 ± 3.57 cc, while those undergoing B-TURP had a mean prostate size of 35.72 ± 3.22 cc (p = 0.765). For the B-TURP group, the mean decrease in postoperative serum sodium concentration was 4.3 mEq/L, while for the M-TURP group, it was 6.4 mEq/L (p = 0.903). In the M-TURP group, there were three cases of transurethral resection (TUR) syndrome, while the B-TURP group had only one case. Conclusion BPH is a common problem affecting the quality of life of several male patients. Both M-TURP and B-TURP are comparable in their efficacy in treating BPH, with the exception of a higher incidence of hyponatremia and TUR syndrome in the M-TURP group.

COMPARISON OF THE OUTCOME OF MONOPOLAR VERSUS BIPOLAR DIATHERMY USE DURING TRANSURETHRAL RESECTION OF PROSTATE

Monopolar transurethral resection of the prostate (M-TURP) remains a widely used surgical modality for treating benign prostatic hyperplasia (BPH). However, bipolar TURP (B-TURP), which uses isotonic saline as an irrigant, may reduce the risk of dilutional hyponatremia and transurethral resection (TUR) syndrome associated with M-TURP. Objective: To compare the outcomes of bipolar versus monopolar diathermy during transurethral resection of the prostate. Methods: This randomized controlled trial was conducted at the Department of Urology & Renal Transplantation, Bahawal Victoria Hospital, Bahawalpur, from March 1, 2022, to May 31, 2023. The study included 100 patients, aged 55 to 85 years, scheduled for transurethral resection of the prostate due to BPH. Exclusion criteria were prostatic carcinoma, previous prostate surgery, cirrhosis, chronic renal failure, and bleeding disorders. Patients were randomized into Group A (M-TURP with 5% dextrose water as irrigant) and Group B (B-TURP with normal saline as irrigant). Outcomes, including changes in serum sodium levels, hemoglobin levels, and incidence of TUR syndrome, were assessed 12 hours postoperatively. Statistical analysis was performed using appropriate methods to compare the two groups. Results: The mean drop in hemoglobin (g/dL) was significantly more significant in the bipolar group (51.71 ± 7.28) compared to the monopolar group (47.86 ± 8.26) (p = 0.0001). The mean decrease in serum sodium levels (mEq/L) was significantly less in the monopolar group (143.57 ± 13.85) compared to the bipolar group (75.51 ± 7.98) (p = 0.0001). TUR syndrome occurred in 2 (4.0%) patients in the M-TURP group, whereas no cases were reported in the B-TURP group (p = 0.153). Conclusion: Bipolar transurethral resection of the prostate is associated with a smaller drop in hemoglobin, a lesser decrease in serum sodium levels, and a lower incidence of TUR syndrome than monopolar transurethral resection.

Outcome of Monopolar versus Bipolar Transurethral Resection of Prostate

Introduction: Transurethral resection of the prostate is the gold standard surgical treatment for benign prostatic hyperplasia with the lower urinary tract symptoms. Bipolar system is a new in technology to lower the adverse effects of monopolar system. This study was designed to find out clinic-demographic data and peri-operative outcomes of the monopolar versus bipolar transurethral resection of prostate. Methods: This prospective comparative study was conducted from June 2022 to March 2023, in the Department of Urology of Bir Hospital, National Academy of Medical Sciences, Nepal. Ethical approval of research was taken from Institutional Review Board, NAMS: Ref No. 735/2079/80. Microsoft Excel was used for descriptive analysis for clinic-demographic and outcome variable data, were presented in frequencies and percentages and their relation were analyzed by chi-square test/fisher’s exact test. A p-value of <0.05 statistically significant. Result: A total 80 patients were compared, bipolar(40 cases) and monopolar(40 cases). There were no differences in the incidence of hyponatremia, clot retention and evacuation rate, re-catheterization rate, mean hemoglobin loss, and mean length of hospital stay. The longer duration of operation time (>60 min) was observed in bipolar transurethral resection ( p=0.001). The transurethral resection syndrome was found only in M-TURP. Conclusion: Both monopolar and bipolar transurethral resection of prostate showed no statistical differences in the amount of resected prostatic tissue, the incidence of hyponatremia, length of hospital stays, blood transfusion rate, re-catheterization rate, clot retention and evacuation rate. The shorter duration of surgery and the trans-urethral resection syndrome was observed in M-TURP.

Comparison of Holmium Laser Enucleation of Prostate versus Bipolar Resection of Prostate in Patients with Benign Prostatic Hyperplasia: A Prospective Interventional Study

Introduction: Surgical treatment for Benign Prostatic Hyperplasia (BPH) has advanced significantly in recent years. Transurethral Resection of the Prostate (TURP) is a minimally invasive procedure associated with a low risk of complications and clinical limitations, including life-threatening Transurethral Resection (TUR) syndrome, as, well as higher costs due to longer hospital stays and challenges in managing large glands. Aim: To compare the safety and effectiveness of prostate enucleation using Holmium Laser Enucleation of the Prostate (HoLEP) with bipolar resection of the prostate in cases of BPH. Materials and Methods: A hospital-based prospective interventional study was conducted in the Department of Urology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India, from January 2020 to July 2022. The study included 60 patients, divided into two groups of 30 each. Males aged ≥45 years with recurrent Lower Urinary Tract Symptoms (LUTS) secondary to BPH, with or without Acute Urinary Retention (AUR) (drug-refractory) or with failed medical therapy (alpha-blockers, 5-alpha reductase inhibitors), were included in the study. In the first group, HoLEP was performed (Group I), while in the second group (Group II), patients underwent bipolar resection. Data were analysed and statistically evaluated using Statistical Package for the Social Sciences (SPSS) software version 21.0. A p-value of less than 0.05 was considered statistically significant. Results: The mean age of patients in the HoLEP group was 60.25 years, while in the Bipolar TURP (B-TURP) group, it was 59.67 years. Both groups had similar proportions of patients with moderate urinary symptoms {International Prostate Symptom Score (IPSS)} and large prostates (>80 grams). The mean amount of irrigation fluid used (40.83±9 litres vs. 21.2±5.9 litres) and the duration of surgery (106.33±14.24 min vs. 67.4±9.73 minutes) were significantly higher in the HoLEP group compared to the B-TURP group (p-value<0.001). Postoperative catheterisation time (1.003±0.23 days vs. 2.38±0.52 days) (p<0.001) and length of hospital stay (3.2±0.65 days vs. 4.67±1.32 days) (p<0.001) were significantly longer in the B-TURP group compared to the HoLEP group. Both the HoLEP and bipolar resection of the prostate groups did not experience significant intraoperative or immediate postoperative complications; however, one patient in the HoLEP group developed urethral stricture as a late complication. Conclusion: The B-TURP procedure is an equally effective and feasible method for treating BPH patients, with a smaller learning curve and lesser financial burden.

An Evaluation of Monopolar and Bipolar Electrocautery in Transurethral Resection of Urinary Bladder Tumors

Background: Transurethral resection of bladder tumor (TURBT) has a role in the diagnostic evaluation and treatment of bladder cancer, which is traditionally conducted through monopolar electrocautery; however, bipolar electrocautery has gained attention these days. Cautery artifacts are known as the drawbacks of TURBT and can be seen in both monopolar and bipolar electrocautery but with varying severity. Studies comparing bipolar to monopolar TURBT have shown conflicting results. Objectives: This study was carried out to compare the occurrence of cautery artifacts and a number of important clinical outcomes between patients undergoing monopolar and bipolar electrocautery during TURBT. Methods: This prospective study included adult patients with age 18 years old or higher diagnosed with primary bladder tumors with a size ≤4 cm. The patients were randomized into monopolar and bipolar groups (34 patients per group). The occurrence of cautery artifacts, duration of surgery, the incidence of urinary bladder perforation, fall in hemoglobin, need for blood transfusion, transurethral resection syndrome, and postoperative hospital stay were compared between the two groups. Results: In our study, the incidence of cautery artifacts was significantly lower in the bipolar group than in the monopolar group (P-value < 0.0001). The two groups were comparable in terms of the duration of surgery, urinary bladder perforation, fall in hemoglobin, need for blood transfusion, transurethral resection syndrome, and postoperative hospital stay. Conclusions: Bipolar TURBT is superior to monopolar TURBT regarding a reduction in the incidence of cautery artifacts.

Combination of 180-W GreenLight XPS laser and bipolar transurethral resection of prostate for the treatment of large prostates beyond 100ml: a novel hybrid technique.

The aim of this study was to evaluate the safety and efficacy of the 180-W GreenLight laser (GL) XPS™ plus bipolar transurethral resection of the prostate (TURP) for the treatment of a prostate volume (PV) beyond 100ml. From January 2014 to December 2022, 79 patients with PV > 100ml who underwent GL-XPS plus bipolar TURP were enrolled. The median follow-up time was 13.7months. The International Prostate Symptom Score (IPSS), PV, uroflow study, post-void residual (PVR) volume, and prostate-specific antigen (PSA) before and after the operation were recorded. Subgroup analysis was performed to compare the outcomes between the patients with follow-up times of < 36months and > 36months. Statistically significant improvements in all the postoperative parameters were observed in both < 36months and > 36months groups. There was no blood transfusion or transurethral resection (TUR) syndrome in this series. Most of all, a second TURP was unnecessary during the follow-up. Only one (1.3%) Clavien-Dindo grade 3b complication was noted. The hybrid technique of 180-W XPS™ GreenLight laser plus bipolar TURP can be safely and efficiently performed on patients with a prostate volume of > 100ml.

Clinical Issues - March 2023.

Conversion to an open procedure Keywords: laparoscopic procedure, open procedure, emergent conversion, open procedure cart, preoperative briefing. Excess absorption of fluid distension media Keywords: fluid distension media, arthroscopy, transurethral resection (TUR) syndrome, fluid extravasation, fluid intravasation. Hysteroscopic fluid deficit thresholds Keywords: maximum fluid deficit, hysteroscopy, hypotonic solution, isotonic solution, distension media. Alternative insufflation gases Keywords: carbon dioxide (CO2 ), nitrous oxide (N2 O), insufflation, gas distension media, pneumoperitoneum.

1.5% Glycine vs 5% Glucose Irrigant During TURP on Serum Electrolytes &amp; TUR Syndrome” Which One is Better?

Objective: To observe the changes in the serum electrolytes and occurence of the transurethral resection syndrome (TUR) with 1.5% glycine and 5% glucose as an irrigant fluid during TUPR Patients and methods: Between June 2008 and May 2010, 120 patients were included in a prospective comparative trial comparing 1.5% glycine with 5% glucose irrigation fluids. We measured blood loss, fluid absorption, biochemistry including serum electrolytes RBS and peri-operative symptoms. Blood samples were taken before and immediately and 24 h after TURP. Irrigating fluid absorption during TURP was measured by serum sodium level. Operative details were recorded, including the type of anaesthesia (with or with no sedation), resection time and weight of resected tissue. Peri-operative symptoms were documented prospectively. TUR syndrome was defined as a serum sodium level of £125 mmol/L with two or more associated symptoms or signs of TUR syndrome. Results: Two (1.67%) patients had TUR syndrome; all two were irrigated with glycine, although this difference was not statistically significant (P = 0.10). Of the two patients who had TUR syndrome, one had bradycardia, two had hypotension, two were drowsy, one was nauseous, two had prickling sensation, two experienced uneasiness, one had blurred vision and two were confused; none had chest pain. There was no difference between the groups in levels of sodium, potassium, urea, creatinine or peri-operative blood loss (defined as a change from before to after TURP in haemoglobin level, accounting for transfusions). Conclusions: Endoscopic transurethral resection of the prostate performed using 5% glucose as irrigating solution during surgery, when compared with 1.5% glycine are associated with lower perioperative morbidity including TUR syndrome. Except for the transient postoperative hyperglycemia, in glucose group, both irrigants are nearly equivalent &amp; safe. In other studies, glycine was reportedly toxic, and that the levels recorded were many times the upper limit of normal may have both immediate and long-term effects Bangladesh J. Urol. 2021; 24(1): 9-13

Clinical practice guideline for transurethral plasmakinetic resection of prostate for benign prostatic hyperplasia (2021 Edition)

Benign prostatic hyperplasia (BPH) is highly prevalent among older men, impacting on their quality of life, sexual function, and genitourinary health, and has become an important global burden of disease. Transurethral plasmakinetic resection of prostate (TUPKP) is one of the foremost surgical procedures for the treatment of BPH. It has become well established in clinical practice with good efficacy and safety. In 2018, we issued the guideline “2018 Standard Edition”. However much new direct evidence has now emerged and this may change some of previous recommendations. The time is ripe to develop new evidence-based guidelines, so we formed a working group of clinical experts and methodologists. The steering group members posed 31 questions relevant to the management of TUPKP for BPH covering the following areas: questions relevant to the perioperative period (preoperative, intraoperative, and postoperative) of TUPKP in the treatment of BPH, postoperative complications and the level of surgeons’ surgical skill. We searched the literature for direct evidence on the management of TUPKP for BPH, and assessed its certainty generated recommendations using the grade criteria by the European Association of Urology. Recommendations were either strong or weak, or in the form of an ungraded consensus-based statement. Finally, we issued 36 statements. Among them, 23 carried strong recommendations, and 13 carried weak recommendations for the stated procedure. They covered questions relevant to the aforementioned three areas. The preoperative period for TUPKP in the treatment of BPH included indications and contraindications for TUPKP, precautions for preoperative preparation in patients with renal impairment and urinary tract infection due to urinary retention, and preoperative prophylactic use of antibiotics. Questions relevant to the intraoperative period incorporated surgical operation techniques and prevention and management of bladder explosion. The application to different populations incorporating the efficacy and safety of TUPKP in the treatment of normal volume (< 80 ml) and large-volume (≥ 80 ml) BPH compared with transurethral urethral resection prostate, transurethral plasmakinetic enucleation of prostate and open prostatectomy; the efficacy and safety of TUPKP in high-risk populations and among people taking anticoagulant (antithrombotic) drugs. Questions relevant to the postoperative period incorporated the time and speed of flushing, the time indwelling catheters are needed, principles of postoperative therapeutic use of antibiotics, follow-up time and follow-up content. Questions related to complications incorporated types of complications and their incidence, postoperative leukocyturia, the treatment measures for the perforation and extravasation of the capsule, transurethral resection syndrome, postoperative bleeding, urinary catheter blockage, bladder spasm, overactive bladder, urinary incontinence, urethral stricture, rectal injury during surgery, postoperative erectile dysfunction and retrograde ejaculation. Final questions were related to surgeons’ skills when performing TUPKP for the treatment of BPH. We hope these recommendations can help support healthcare workers caring for patients having TUPKP for the treatment of BPH.

Comparative Analysis between Monopolar and Bipolar TURP - A Single Institute Prospective Controlled Study

Background: The ‘gold standard’ surgical treatment of clinically obstructive BPH is TURP, but life-threatening complications such as transurethral resection syndrome are occasionally observed. This has traditionally been provided as monopolar TURP, but morbidity associated with MTURP has led to the introduction of other surgical techniques. Objectives: To compare the effects of bipolar and monopolar TURP. Methods: In this prospective comparative study, 50 patients of each group undergo transurethral resection of prostate were enrolled and randomized to surgery by M‑TURP or B-TURP. International Prostate Symptom Score (IPSS), uroflowmetry, ultrasonography, prevoid, postvoid and international prostate symptom score (IPSS), maximum urinary flow rate (Qmax), postvoid residual urine (PVRU) volume, and prostate volume (PV). Complications and sequelae also assessed. Comparisons performed. Results:No significant differences found in baseline characteristics or operative data, No differences found in IPSS, Qmax or PVRU volume. Conclusions:Based on this controlled trial, there is not significant variation in effectiveness and safety between M-TURP and Bipolar -TURP for the treatment of BPH. Accordingly, M-TURP continues to be a valid option for the treatment of BPE. Keywords: Transurethral resection of prostate, Monopolar, Bipolar.

Research on Applications of Transurethral Plasmakinetic Enucleation of the Prostate in Elderly Patients Aged ≥80 Years.

Objective: To evaluate the safety and efficacy of transurethral plasmakinetic enucleation of the prostate (PKERP) vs. transurethral resection of the prostate (TURP) in elderly patients aged ≥80 years with benign prostate hyperplasia.Materials and Methods: We conducted a retrospective analysis of the PKERP (n = 123) and TURP (n = 143) in patients aged ≥80 years at urology department of The Third Xiangya Hospital of Central South University from January 2016 to October 2019. Then the preoperative, intraoperative, and postoperative data of different indicators were compared between the two groups. The follow-up was done at 3 months, 1 year after surgical treatment.Results: No significant differences were observed between the two groups for the baseline characteristics, including age, prostate volume, prostate-specific antigen (PSA) level, concurrent disease, maximum urinary flow rate (MFR), international prostate symptoms score (IPSS), and quality of life (QoL) score. The operative time, hemoglobin decrease, and postoperative flushing time were significantly lower in the PKERP group compared with the TURP group. However, no significant differences were observed between both groups for postoperative hospital stay, incidence of transurethral resection syndrome (TURS), prostatic capsular perforation, and genuine urinary incontinence. The follow-up results showed that the MFR of the PKERP group was significantly higher than the TURP group at 1 year after surgery.Conclusion: Compared with TURP, PKERP is a safe and efficacious method for treating patients aged ≥80 years with benign prostate hyperplasia, and it may improve long-term urination symptoms.

A prospective comparative study on the operative outcomes between monopolar versus bipolar transurethral resection of prostate for benign prostatic hyperplasia: An institutional experience

Background: Benign prostatic hyperplasia (BPH) is a common disease in elderly men. Monopolar transurethral resection of prostate (M-TURP) is considered the gold standard for the treatment of bladder outlet obstruction due to BPH. Its modification, bipolar TURP (B-TURP), promises to overcome its most prominent drawbacks, such as bleeding and dilutional hyponatremia. Aims and Objectives: This study aims to study the feasibility, effectiveness, and safety of B-TURP over M-TURP. Materials and Methods: A total of 110 patients with BPH were prospectively randomly assigned to undergo B-TURP (55) or M-TURP (55). Patient characteristics of the two groups were similar. Hemoglobin was measured preoperatively and postoperatively. IPSS, maximal flow rate, and post-void residual urine volume were assessed preoperatively. Duration of surgery, mean weight of resected tissue, mean irrigation fluid used, mean drop in hemoglobin, mean change in sodium, and mean post-operative irrigation used were also compared. Results: Duration of resection time was significantly shorter in M-TURP (P=0.0034). The mean change in sodium and mean post-operative irrigation used were significantly lower in bipolar group with P&lt;0.05 and 0.0024, respectively. The mean drop in post-operative hemoglobin concentration (P=0.0916) was statistically insignificant. There was one instance of the transurethral resection (TUR) syndrome in the M-TURP group whereas no TUR syndrome occurred in the B-TURP group. Conclusion: B-TURP and M-TURP are effective and safe techniques for the surgical treatment of BPH. B-TURP definitely reduces the incidence of dilutional hyponatremia and post-operative irrigation use making it a competitor to replace M-TURP as the new gold standard.

Outcome of bipolar transurethral resection in benign enlargement of prostate: A retrospective analysis.

Introduction: Lower urinary tract symptoms (LUTS) secondary to benign enlargement of prostate (BEP) is one of the common urological problem in men. Bipolar transurethral resection of prostate (B-TURP) is a standard surgical intervention for BEP. In this study we aim to analyze the perioperative outcome and complications of B-TURP for BEP.&#x0D; Method: This retrospective study analyzed the perioperative outcome &amp; complications of B-TURP in patients with BEP from August 2017 to July 2020at Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal. Data was collected from the operating room register and from inpatients files from the record section. SPSS version 16 was used to analyze the data. Study variables included age, ASA grade with known concomitant co-morbidities, prostate volume, total prostate specific antigen (TPSA), operative time, decreased hemoglobin level, postoperative bladder irrigation duration, hospital stay, transurethral resection syndrome (TURS), hyponatremia, blood transfusion, postoperative hematuria requiring intervention, postoperative acute urinary retention, urinary tract infection (UTI) and urine incontinence.&#x0D; Result: A total of 72 patients underwent B-TURP. Data was analyzed on 46 patients. Those with incomplete data and those files which were unable to retrieve were not analyzed. Perioperative outcomes were: median operative time was 81.73 minutes, median hospital stay was 3.4 days, median decreased hemoglobin was 3.0 g/dl and median postoperative bladder irrigation duration was 22.50 hours. Perioperative complications were: hyponatremia in 1 (2.1%), postoperative urinary retention in 2 (4.3%), blood transfusion in 4 (8.6%), postoperative hematuria requiring intervention in 3(6.5%), urinary incontinence in 8(17.3%) &amp; urethral stricture in 6 (13.0%). There were no TURS &amp; mortalities.&#x0D; Conclusion: Our study shows B-TURP is safe procedure with minimal morbidity for the treatment of benign enlargement of prostate.&#x0D; Keywords: Benign enlargement of prostate (BEP), bipolar transurethral resection of prostate (B-TURP), lower urinary tract symptoms (LUTS)&#x0D;

English

BACKGROUND In this study we wanted to compare the clinical outcomes in terms of symptom improvement and perioperative results of monopolar and bipolar trans urethral resection of prostrate (TURP) for benign prostatic hyperplasia (BPH) and evaluate the advantages of bipolar transurethral resection over the monopolar resection. METHODS A total of 150 patients who underwent trans urethral resection of prostate (TURP) surgical procedure, (n = 75 for monopolar TURP) and (n = 75 for bipolar TURP) for BPH enrolled between December 2018 to November 2020 at the Department of Urology in VSSIMSAR, Burla, Odisha. RESULTS Significant differences were found in operating time in minutes (45.11 ± 4.029 vs 41.99 ± 5.020, P &lt; 0.025) between monopolar and bipolar TURP. The mean sodium falls in post-operative period in bipolar and monopolar TURP was 7 Meq and 3 Meq respectively which was statistically significant (P - value less than 0.05). Bipolar TURP is equally effective as monopolar in reducing the international prostate symptom score (IPSS), improvement in quality of life, maximum urinary flow rate. Trans urethral resection (TUR) syndrome was reported in two patients who had undergone monopolar resection without any incidence in bipolar group. 3 patients in monopolar group developed clot retention compared to 1 in bipolar group in post-operative period. Fall in haemoglobin (Hb) and packed cell volume (PCV) was more with monopolar group but insignificant. CONCLUSIONS Bipolar TURP is safe and equally effective as monopolar TURP with advantage of shorter operative time and absence of dilutional hyponatremia and TUR syndrome, but needs large randomized trials with long follow up to confirm its efficacy and safety. KEYWORDS Monopolar TURP; Bipolar TURP; Benign Prostate Hyperplasia

Irrigation fluid absorption during transurethral bipolar and laser prostate surgery: a systematic review.

Transurethral endoscopic procedures using bipolar current, or laser energy are nowadays widely accepted and have replaced the traditional monopolar resection. A major advantage of these techniques is the utilization of isotonic saline as irrigation solution, which minimizes side effects such as symptoms associated to classical transurethral resection syndrome (TUR-syndrome). Nonetheless, clinically significant IFA also occurs with saline and is determined by pressure gradients, systemic resistance and by the amount of irrigation fluid. We aimed to investigate the extend of IFA and symptoms due to volume overload during bipolar transurethral resection (bTUR) and laser procedures of the prostate. We performed a systematic literature search using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Search terms were TUR, transurethral, laser, HoLEP, ThuLEP, greenlight, enucleation, fluid absorption, fluid uptake, and TUR-syndrome. Mean and maximum IFA during bTURP ranges between 133 and 915ml and 1019ml and 2166ml, respectively. Absorption during laser procedures can be significant with maximum values up to 4579ml and mainly occurs during prostate vaporization techniques. Incidence of moderate to severe symptoms from iso-osmolar volume overload reaches 9%. Irrigation fluid absorption during bTUR and laser surgery of the prostate is not negligible. Iso-osmolar overhydration with development of non-classical TUR-syndrome should be identified peri- and postoperatively and surgical teams should be aware of complications. Breath ethanol, venous pH, serum chloride, and bicarbonate could be markers for detecting dangerous events of IFA with saline.

Fluid overload syndrome: A potentially life-threatening complication of Thulium Laser Enucleation of the Prostate.

Systemic fluid absorption frequently occurs during endoscopic surgery. When large volumes are absorbed, fluid overload is the result. The introduction of lasers allowed the use of normal saline (0.9% sodium chloride) in endoscopic prostatic surgery. This led to the disappearance of the transurethral resection syndrome; however, the fluid overload of normal saline can cause the onset of several catastrophic effects. The present study aimed to evaluate the incidence, sign and symptoms severity of fluid overload in a large series of men who underwent Thulium Laser Enucleation of the Prostate. Between December 2014 and February 2020, 633 men underwent the procedure. Seven patients (1.1%) had symptomatic fluid overload. Two patients developed severe pulmonary oedema, which required oral intubation and admission to the intensive care unit. Two patients required delayed morcellation. The analysis of our series highlighted that old age, large prostate volume, prolonged operative time and prostatic capsular perforation influenced the onset of fluid overload syndrome. Urologists should be aware that fluid overload might be a potentially life-threatening condition and should be early recognised. Surgery should be interrupted as soon as it occurs to avoid severe pulmonary oedema.

Relevance of intravesical pressures during transurethral procedures

Endourology has undergone fundamental changes over the last 2decades. Maintaining low intrarenal pressure (IRP) during upper urinary tract procedures is an established concept. However, researchers have not yet studied the concept of reduced intravesical pressures (IVPs) during transurethral (TUR) surgery as thoroughly. Low IVP is supposed to decrease complications as fluid retention, TUR syndrome, and incidence of fever. The study aims to give an overview of the contemporarily existing concepts and specify the term of low IVP to avoid TUR-related complications and optimize TUR-related results. A literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were transurethral resection, transurethral enucleation, transurethral vaporization, pressure, fluid absorption, and TUR syndrome. Analyzed mean IVPs during TUR vary between 11 and 35 cmH2O but are mostly kept below 30 cmH2O. Mean maximum IVPs during TUR range from 20 to 55 cmH2O. Maximum IVPs seem to be lower when surgeons utilize continuous flow resection, and irrigation pressures are kept low. The results demonstrate a strong correlation between IVP levels and fluid absorption. IVP increase remains a neglected predictor of transurethral procedure complications, and endourologists should consider its intraoperative monitoring. Further research is necessary to quantify generated pressures and introduce means of controlling them.

Comparison between a transurethral prostate split and transurethral prostate resection for benign prostatic hyperplasia treatment in a small prostate volume: a prospective controlled study.

BackgroundTransurethral resection of the prostate (TURP) was considered the golden standard to treat benign prostatic hyperplasia (BPH) for decades. However, TURP was associated with low efficiency to alleviate the lower urinary tract symptoms (LUTS) and a significantly higher risk of bladder neck contracture (BNC) for patients with small-volume BPH. Our study aims to compare the therapeutic effect of a transurethral split of the prostate (TUSP) with TURP for patients with small-volume BPH (<30 mL).MethodsIn this study, 101 small-volume BPH patients were randomly divided into two groups (TUSP and TURP group). The patient’s baseline characteristics and perioperative outcomes were recorded. The follow-up was done at six months, one year and two years after surgical treatment.ResultsNo significant differences were observed between the two groups for the baseline characteristics, including age, prostate volume, prostate-specific antigen (PSA) level, concurrent disease, post-void residual (PVR), maximum urinary flow rate (Qmax), international prostate symptoms score (IPSS), and quality of life (QoL) score. The operative time and hemoglobin decrease were significantly lower in the TUSP group compared to the TURP group. However, no significant differences were observed between both groups for catheterization time, postoperative hospital stay, and incidence of transurethral resection syndrome (TURS). However, of the late complications, the incidence of BNC in the TUSP group was significantly lower than the TURP group. No significant differences were found between both groups for other complications, including postoperative bleeding, micturition urgency, micturition frequency, micturition pain, urinary tract infection, recatheterization, transient incontinence, and continuous incontinence. Follow-up results showed that the IPSS of the TUSP group was significantly lower than the TURP group, while the Qmax of the TUSP group was significantly higher than the TURP group.ConclusionsThis study shows that TUSP may be an efficient and safe treatment for small-volume BPH (<30 mL) with a lower incidence of postoperative BNC and better longtime clinical outcomes than TURP. It suggested that TUSP could be an ideal treatment choice for small-volume BPH.

Transurethral prostate resection syndrome: skeleton in the closet is still lurking!

Transurethral prostate resection syndrome: skeleton in the closet is still lurking!

Efficacy of Goreisan in Preventing Transurethral Resection Syndrome in Transurethral Resection of the Prostate: A Randomized-Controlled Study.

Objectives: Nonconductive irrigation fluids used during transurethral resection (TUR) of the prostate can cause fluid overload and dilutional hyponatremia. TUR syndrome is generally defined as serum sodium at or below 125 mmol/L with cardiovascular and neurologic symptoms. The aim of this study was to evaluate the effects of Goreisan, a traditional Japanese Kampo medicine, on serum sodium levels and the occurrence of TUR syndrome in patients undergoing TUR of the prostate. Design: This was a randomized-controlled trial. Settings/Location: This trial was conducted at the Osaka Medical College Hospital and Keneikai Sanko Hospital. Subjects: Fifty patients scheduled for TUR of the prostate were included. Interventions: Patients in the Goreisan group (n = 23) received 2.5 g Goreisan orally on the night before surgery and on the morning of surgery. The control group (n = 27) did not receive Goreisan. Surgical procedures, perioperative management, and patient monitoring were otherwise the same in both groups. Outcome Measures: The primary outcome was occurrence of TUR syndrome. The secondary outcome was serum sodium level. Results: Serum sodium remained above 125 mmol/L in all patients, so none of the patients met the criteria for TUR syndrome. However, the Goreisan group had significantly higher intraoperative sodium levels (p < 0.001) and significantly higher intraoperative (p = 0.008) and postoperative (p = 0.02) hemoglobin levels than the control group. Conclusions: These findings indicate that preoperative Goreisan administration can help maintain serum sodium levels in patients undergoing TUR of the prostate.