2019 American Urological Association assessment of BPH surgical procedures

As a satisfied TURP recipient, I did not need to read much. I did find the discussion on monopolar vs bipolar TURP pretty interesting and am pasting it here for anyone who might be considering a TURP.

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A large body of literature has been published in recent years regarding certain modifications of the standard TURP using monopolar energy, most notably the use of bipolar energy transmission.

Contrary to monopolar TURP, the energy does not travel through the body to reach a skin pad in bipolar TURP systems. The energy is confined between an active (resection loop) and a passive pole situated on the resectoscope tip. While monopolar TURP requires the use of either iso-osmolar solutions of sorbitol, mannitol, or glycine, bipolar TURP may be performed in 0.9% NaCl solution. This reduces (if not eliminates) the risk for acute dilutional hyponatremia during prolonged resection, which may lead to the so-called TUR syndrome.

Regarding the comparative efficacy, effectiveness, and safety of monopolar versus bipolar TURP, there are five systematic reviews and meta-analyses published between 2009 and 2015 that compared bipolar TURP to monopolar TURP.34-38 None of the authors found significant differences in terms of I-PSS improvement at 12 months or improvements in peak urinary flow rates, the main efficacy parameters of interest.

However, there were differences regarding safety parameters. Time to catheter removal or catheterization time was evaluated in four pooled analyses. All four favored bipolar TURP; however, the differences in the effect estimate were highly variable as was the degree of heterogeneity. Length of stay and dilution hyponatremia both favored bipolar TURP; however, there was close to 98% heterogeneity in each of the meta-analyses that evaluated these outcomes. Pooled data from Mamoulakis (2009), Burke (2010), Tang (2014), and Omar (2014) all supported that TUR syndrome occurred less frequently in the group that received bipolar TURP.35-38

Risk reduction for clot retention favored bipolar TURP in general. Bleeding and drops in hemoglobin seem to favor bipolar TURP but with a relatively high degree of heterogeneity in both meta-analyses. Need for blood transfusion post-operatively seems to favor bipolar TURP, although two out of six meta-analyses revealed no statistical significance.

The findings of the meta-analyses and systematic reviews allow the following conclusions:

Since there are no differences in efficacy, it is reasonable to compare surgical interventions in this guideline document with either monopolar or bipolar TURP series regarding efficacy measures.

Since the main difference between monopolar and bipolar TURP is regarding TUR syndrome, which is unique to TURP and no other treatment, safety parameters other than TUR syndrome can also be compared between surgical interventions and monopolar and bipolar TURP.

The reduced risk of hyponatremia and TUR syndrome allows for longer resection times; therefore, bipolar TURP may be used in larger glands compared to monopolar TURP.

Since not all hospitals have bipolar TURP equipment available, it is left to the surgeon's discretion and level of experience as to which type of TURP energy she/he may use.

For the remainder of this document the reader should assume that all efficacy comparisons between surgical interventions and TURP make no difference as to what type of energy was used for the TURP comparator arm(s).