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10 1 1 599 6528
10 1 1 599 6528
10 1 1 599 6528
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Editorial
Referring to the article published on pp. 798–809 of this issue
Oliver Reich *
Ludwig-Maximilians-University Munich, Campus Grosshadern, 81377 Munich, Germany
Even though bipolar transurethral resection of the prostate Correctly, the authors conclude that their findings must be
(B-TURP) was introduced several years ago, the true merits of regarded as the ‘‘strongest available evidence.’’
this modification of conventional monopolar TURP (M-TURP) So what are the merits of using B-TURP instead of
remain unclear to many urologists. Several reasons may exist M-TURP currently when performing an otherwise identical
for this ambiguity within the urologic community. procedure?
Considering the minor quality and heterogeneity of most Functioning in a conductive medium instead of in the
existing trials, the level of evidence in the literature is rather conventional nonconductive irrigation fluid is a prerequisite
low. Randomized controlled trials (RCTs) are scarce, and of bipolar technology. This advantage is the most evident
many trials lack institutional review board approval or even because all factors related to hypotonic/hypo-osmolar fluid
informed consent. irrigation (dilutional hyponatremia, TUR syndrome) should
Bipolar TURP (B-TURP) does not represent a homogenous be eliminated. Therefore, bipolar technology is expected to
technique. The different manufacturers rely on distinctively provide more time to perform longer resection as well as
different electrophysical principles. Thus, the efficacy and, coagulation without compromising safety. The number
even more important, the safety profile must be judged needed to harm of 50 regarding the TUR syndrome reported
carefully and separately for each of these devices. Even for the by Mamoulakis et al might not seem too impressive at first
same manufacturers, the techniques (electrode design as well glance but still confirms this important clinical advantage [4].
as high-frequency generators) have advanced in recent years As a surgeon, one must be fully aware of the fact that
in many instances and thus need to be reevaluated [1–3]. isotonic irrigation fluids will eliminate the electrolyte
In a powerful effort to overcome this lack of information, disturbances of systemic uptake but will not be able to
Mamoulakis et al report on B-TURP versus M-TURP in a prevent severe cardiac and/or pulmonary failure in cases of
systematic review and meta-analysis of RCTs [4]. An large volume uptake.
extensive literature search was performed to detect all The other significant findings concern hemostasis.
RCTs available that compare the two techniques. The Mamoulakis et al report that they found a lower rate of
authors were able to include 16 RCTs with 1406 patients clot retention and shorter irrigation and catheterization
in their thorough analysis. No clinically relevant differences duration for B-TURP [4]. The rationale for these findings is
in short-term efficacy were detected. The authors found indistinct. In my personal experience with multiple bipolar
that treating 50 and 20 patients with B-TURP will result in devices, I was not able to confirm superior hemostasis. This
one less transurethral resection (TUR) syndrome and one position is supported by most of my colleagues. However,
less clot retention, respectively. now having this elaborate state-of the-art review at hand,
Generally, the authors have to be congratulated for their one must think about the clinical implications and
effort to shed some light on this complex issue of the consequences. Is the evidence so strong that B-TURP should
intrinsic value of B-TURP; however, even a profound meta- be declared the new standard of care? Why not, considering
analysis can only be as valid as the trials investigated. the fact that no disadvantages are associated with this novel