EUROPEAN UROLOGY 56 (2009) 796–797
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Editorial
Referring to the article published on pp. 798–809 of this issue
Bipolar Transurethral Resection of the Prostate: What Did We
Learn, and Where Do We Go from Here?
Oliver Reich *
Ludwig-Maximilians-University Munich, Campus Grosshadern, 81377 Munich, Germany
Even though bipolar transurethral resection of the prostate
(B-TURP) was introduced several years ago, the true merits of
this modification of conventional monopolar TURP (M-TURP)
remain unclear to many urologists. Several reasons may exist
for this ambiguity within the urologic community.
Considering the minor quality and heterogeneity of most
existing trials, the level of evidence in the literature is rather
low. Randomized controlled trials (RCTs) are scarce, and
many trials lack institutional review board approval or even
informed consent.
Bipolar TURP (B-TURP) does not represent a homogenous
technique. The different manufacturers rely on distinctively
different electrophysical principles. Thus, the efficacy and,
even more important, the safety profile must be judged
carefully and separately for each of these devices. Even for the
same manufacturers, the techniques (electrode design as well
as high-frequency generators) have advanced in recent years
in many instances and thus need to be reevaluated [1–3].
In a powerful effort to overcome this lack of information,
Mamoulakis et al report on B-TURP versus M-TURP in a
systematic review and meta-analysis of RCTs [4]. An
extensive literature search was performed to detect all
RCTs available that compare the two techniques. The
authors were able to include 16 RCTs with 1406 patients
in their thorough analysis. No clinically relevant differences
in short-term efficacy were detected. The authors found
that treating 50 and 20 patients with B-TURP will result in
one less transurethral resection (TUR) syndrome and one
less clot retention, respectively.
Generally, the authors have to be congratulated for their
effort to shed some light on this complex issue of the
intrinsic value of B-TURP; however, even a profound meta-
analysis can only be as valid as the trials investigated.
DOI of original article: 10.1016/j.eururo.2009.06.037
* Tel.: +49 89 7095 3524.
E-mail addresses: Oliver.Reich@med.uni-muenchen.de, OMReich@aol.com.
0302-2838/$ – see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Correctly, the authors conclude that their findings must be
regarded as the ‘‘strongest available evidence.’’
So what are the merits of using B-TURP instead of
M-TURP currently when performing an otherwise identical
procedure?
Functioning in a conductive medium instead of in the
conventional nonconductive irrigation fluid is a prerequisite
of bipolar technology. This advantage is the most evident
because all factors related to hypotonic/hypo-osmolar fluid
irrigation (dilutional hyponatremia, TUR syndrome) should
be eliminated. Therefore, bipolar technology is expected to
provide more time to perform longer resection as well as
coagulation without compromising safety. The number
needed to harm of 50 regarding the TUR syndrome reported
by Mamoulakis et al might not seem too impressive at first
glance but still confirms this important clinical advantage [4].
As a surgeon, one must be fully aware of the fact that
isotonic irrigation fluids will eliminate the electrolyte
disturbances of systemic uptake but will not be able to
prevent severe cardiac and/or pulmonary failure in cases of
large volume uptake.
The other significant findings concern hemostasis.
Mamoulakis et al report that they found a lower rate of
clot retention and shorter irrigation and catheterization
duration for B-TURP [4]. The rationale for these findings is
indistinct. In my personal experience with multiple bipolar
devices, I was not able to confirm superior hemostasis. This
position is supported by most of my colleagues. However,
now having this elaborate state-of the-art review at hand,
one must think about the clinical implications and
consequences. Is the evidence so strong that B-TURP should
be declared the new standard of care? Why not, considering
the fact that no disadvantages are associated with this novel
doi:10.1016/j.eururo.2009.07.029
 EUROPEAN UROLOGY 56 (2009) 796–797
modification? What role do economic factors play?
Mamoulakis et al did not touch this issue, which is a
difficult one due to the diverse costs of the different devices
and the wide variation among the different countries’
health care systems. Will we have new insights regarding
the pros (and maybe cons) of B-TURP once we are able to
review long-term data?
One specifically important finding, in my view, concerns
urethral strictures after B-TURP: It is very comforting to see
that, in the present meta-analysis, the alarming rate of
urethral strictures reported by Tefekli et al [5] was not
substantiated.
To conclude, despite growing evidence, I believe that B-
TURP has not evolved to a new standard in TURP yet. We
first must obtain sound data regarding long-term results as
well as economic issues. With this review at hand, however,
one can not disagree with the authors declaration of B-TURP
as ‘‘preferable.’’
Conflicts of interest: O. Reich received speaker honoraria from American
Medical Systems and Olympus.
797
References
[1] Ho HSS, Yip SKH, Lim KB, Fook S, Foo KT, Cheng CWS. A prospective
randomized study comparing monopolar and bipolar transurethral
resection of prostate using transurethral resection in saline (TURIS)
system. Eur Urol 2007;52:517–24.
[2] Reich O. Editorial comment on: a prospective randomized study
comparing monopolar and bipolar transurethral resection of pros-
tate using transurethral resection in saline (TURIS) system. Eur Urol
2007;52:523–4.
[3] Faul P, Schlenker B, Gratzke C, Stief CG, Reich O, Hahn RG. Clinical
and technical aspects of bipolar transurethral prostate resection.
Scand J Urol Nephrol 2008;42:318–23.
[4] Mamoulakis C, Ubbink DT, de la Rosette JJMCH. Bipolar versus
monopolar transurethral resection of the prostate: a systematic
review and meta-analysis of randomized controlled trials. Eur Urol
2009;56:798–809.
[5] Tefekli A, Muslumanoglu AY, Baykal M, Binbay M, Tas A, Altunrende
F. A hybrid technique using bipolar energy in transurethral prostate
surgery: a prospective, randomized comparison. J Urol 2005;174:
1339–43.