Has Conventional Standard Monopolar TURP become Obsolete?

• 24 Mar 2020 08:14:26 AM
• |Endo Urology

Dear All,

I saw this video of Ajay Bhandarkar on ‘Modified En Bloc Bipolar Plasma Enucleation of Prostate: Our Technique for Treatment of Obstructive Benign Prostatic Hyperplasia’ published on March 13^th, 2020 in Video Endourology I am forwarding the link for those interested in watching the same.

https://www.liebertpub.com/doi/10.1089/vid.2019.0090?utm_source=sfmc&utm_medium=email&utm_campaign=END%20VID%20FP%20Mar23%202020&d=3/23/2020&mcid=23900981

(Free access is available only till April 7^th, 2020)

 I am sure many in India and some of them in our group are performing ‘Enucleation technology for BPH’ using different energies. Most would be using Laser Technologies for this. How many are using Bipolar Technology, nay Monopolar Technology, for Enucleation of Prostate. Is this technology far superior from the standard TURP that we used to perform using Monopolar? Do the experts suggest that the TURP that we all used to perform become obsolete and should relegate to history?

I am sure each of you in the will be providing your views for the benefit of our younger generation.

It is interesting that when anything new dawns; one will start punching holes in the existing technologies and outcomes the various adverse aspects making one wonder whether the earlier treatments were causing more harm than good for the patients.

With warm Regards,

Venu

Comments(8)

• 

  Ravindra Sabnis

  25 Mar 2020 11:47:11 PM

  Debate of resection Vs enucleation was going on for last 10 years & will go on for another 20 years. 

  This is because there are no definitive advantages of enucleation. Initially HOLEP came - but because of laser not available everywhere - it was never accepted as common method for BPH. However now, bipolar enucleation , vapour enucleation methods are described where no new investment is required. But still, resection remains as most popular method Even bipolar vs monopoly debate is going on, with no answer still. 

  All new methodologies will make difference in very large prostate. claimed advantages of these methods are obvious in very large prostate (>100 gm). But controversial benefits in small gland. Unfortunately of fortunately, average prostate size in India is much less & hence debate in India will continue. 

  In africa, where size is very big, there HOLEP may be method of choice in many. 

  But so far my understanding goes, monoplane TURP will not go away. 

• 

  Dr. Anil Takvani

  26 Mar 2020 11:47:42 AM

  Yes I agree with Dr. Subnis.

  In my practice average size of prostate is 60 to 70 gram. Ranges from 45 gram to 110 gram. Monopolar or bipolar resection is producing excellent outcomes with least complications.

  Monopolar is fast in my experience in compare to bipolar resection. In bipolar coagulation is slow and requires very precision. Chance of inadequate coagulation on table are high which opens up in postoperative recovery when BP comes to its original level during recovery. This is not only my experience but other friends also experiencing more bleeding and even clot evacuation with bipolar.

  Lase or bipolar Enucleation may be more effective so far so post operative flow improvement but has high incidence of incontinence or stress incontinence may take 3 to 6 months or may be more or remains permanent.
  

  Most fearful complication of prostate surgery for benign enlargement is incontinence according to majority patients. And it is almost unacceptable for them. In this circumstance I agree role of enucleation is limited to very large prostate.

  We have experts in group of enucleations and their inputs are very much desirable. 

  
  

  
  

• 

  Pankaj N Maheshwari

  28 Mar 2020 07:19:12 PM

  Interesting topic Sir

  I loved the comments by Sabnis Sir. He has sent people like me who are in love with HoLEP straight to Africa!!  

  That was in lighter vein but i have few comments on this discussion:

  1. TURP will not get obsolete. Surely not in near future. If you offer TURP to patients with less than 60-70G adenoma (depending on your resection skills and capabilities), it is perfectly justified.
  2. There is a significant increase in patients with large adenomas (>100G), here enucleation has a distinct advantage. 
  3. All modalities of enucleation have nearly similar results. 
  4. There is also a huge increase in patients on anti platelet agents. In this subset Ho laser has a distinct advantage. 
  5. Enucleation is possible by both low power and high power holmium laser
  6. Students need to learn BOTH enucleation as well as TURP. 
  7. The risk of incontinence is there all procedures. Lot of RCT's have shown risk of incontinence similar in TURP and HoLEP. 

  
  

• 

  Abhay Mahajan

  02 Apr 2020 09:32:35 PM

  I agree with Dr. Pankaj. For large glands >100 gms, laser enucleation is definitely a better procedure than resection ( mono or bipolar), in terms of improvement in IPSS & uroflow.

• 

  Venugopal P

  04 Apr 2020 09:41:18 AM

  Dear All,

  I, being an old timer, still love performing ‘Open Simple Prostatectomy’ for these ‘Large Prostates’. Even today this is mentioned in our ‘Cook Books’ – AUA and EAU Guidelines. I do agree that all technologies have a place including Open Simple Prostatectomy. We seldom consider open Simple prostatectomy as an option because most of the younger Generation is not trained in the art of performing this (the present masters probably included in this). A well performed open simple Prostatectomy has lasting relief and redo as often required with even TURP (whichever way). Today we are engulfed with various technologies like Laser, Bipolar and Monopolar enucleation and many who have considerable experience are getting fairly good results. But I doubt whether they have stood the test of time as with Open simple Prostatectomy. Many may say that most of these procedures are performed in the elderly with a short life span and hence long term follow-up are not really needed. Till such time one lives after a procedure for BPO, he should have high quality of life devoid of revisits.

  At present, there are centres who advice Lap or Robotic Simple prostatectomy, claiming excellent outcomes, especially in large prostates. One should be aware that the techniques of Open Simple Prostatectomy are reproduced in these techniques. Hence it is mandatory that a good knowledge of the ‘Do’s and Don’ts’ of Open Simple Prostatectomy are needed for performing such technologies. How will the younger generation learn these technologies if not sure of how to perform an Open Simple Prostatectomy?

  I am not against anyone practicing any technology for alleviation of Problems with BPO. As rightly put by Ravi, may be TURP will never become obsolete even with all newer technologies, it should be realised that training for performing Open Simple Prostatectomy should also be imparted while in training.

  I know many will consider this as Gibberish and consider not worth accepting. I have no qualms at it.

  With warm regards,

  Venu

    

• 

  Abhay Mahajan

  05 Apr 2020 09:28:03 AM

  Dear Sir,

  I completely agree with you that OPEN PROSTATECTOMY ESPECIALLY MILLIN'S is an excellent procedure with minimum morbidity. In our unit, we demonstrate at least 2-3 open prostatectomy to residents for large glands. The reason is some residents are practising in a remote area, they cannot acquire laser machines in the early phase of practice and acquiring enucleation skills may take time. 

  But in today's era, every patient wants some endoscopic procedure. Hence, one day we will have to be well versed with the latest enucleation procedures.

• 

  Ajay Bhandarkar

  07 Apr 2020 10:57:59 PM

  Dear Sir,

  Thanks for quoting my article for discussion. Personally it is an honour for me to get appreciation from you. 

  I only partly agree with your and Dr. Sabnis’s views and thoughts for enucleation procedures. I feel that science should keep evolving always. Even TURP as a procedure took long time to get established. There are wide variations in end results or acceptance of completeness of procedure in TURP also. 

   Recently I read an article on outcomes of various surgical procedures for BPH, > 95000 patients in Germany ( based on their insurance data records).

  
  

  Gilfrich C. et al.Morbidity and mortality after surgery for lower urinary tract symptoms: a study of 95 577 cases from a nationwide German health insurance database.Prostate Cancer Prostatic Dis. 2016; 19: 406-411

  
  

  They  compared, Open Prostatectomy, Laser and other enucleation procedures , TURP and vaporisation procedures. Conclusions of their study was OP gave best long term outcome( least reintervention rates) but, significantly higher morbidity. TURP and enucleation were similar in morbidity, enucleation being significantly(4.5 to 7%) better in need for reintervention. Need for Reintervention was 12 to 18% in TURP. Vaporisation procedures has least morbidity but very poor long term efficacy.

  So, enucleation definitely has some advantage over conventional resection. Only hassle is to overcome the learning curve. I feel residents who are under training or even junior consultants, must try their best to adapt enucleation techniques. Senior consultant who is an expert resectionist, will definitely be least motivated to overcome this learning curve.

  I don’t think that, by learning enucleation technique, you want to do away with conventional resection. It is just a matter of strengthening your armamentarium and skills to tackle very common ailment like obstructive BPH. 

  
  

  Ajay Bhandarkar

• 

  Tanuj Paul Bhatia

  17 Apr 2020 11:09:21 PM

  Sir by all endocscopic enucleations we are trying to achieve results equivalent to open prostatectomy which was also an enucleation technique. The flow rates are better with all enucleation techniques. 

  Regards.