DOI: 10.12809/hkmj164831
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
LETTER TO THE EDITOR
Re: Early postoperative outcome of bipolar
transurethral enucleation and resection of the
prostate
Benson Yeung, FHKAM (Surgery)
Private surgeon, Hong Kong
Corresponding author: Dr Benson Yeung (dr.bensonyeung@gmail.com)
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To the Editor—I enjoyed the article by Cho et al1
titled, “Early postoperative outcome of bipolar
transurethral enucleation and resection of the
prostate,” published in the December 2015 issue of
Hong Kong Medical Journal. I noted with interest
that the authors reported no urethral stricture,
meatal stenosis, or bladder neck contracture at
3 months despite the larger prostates and more
difficult procedures (mean preoperative transrectal
ultrasonography prostate volume of 71.9 cm3 and
mean operating time of 86.1 minutes). Komura et al2
recently published the results of their randomised
trial of monopolar (abbreviated M-TURP) versus
bipolar transurethral resection of the prostate
(abbreviated TURis) in the April 2015 issue of BJU International. They reported “a significant
difference in postoperative urethral stricture rates
between groups was detected (6.6% in M-TURP
vs 19.0% in TURis; P=0.022). After stratifying
patients according to prostate volume, there was
no significant difference between the two treatment
groups with regard to urethral stricture rates in
patients with a prostate volume of ≤70 mL (3.8% in
M-TURP vs 3.8% in TURis), but in the TURis group
there was a significantly higher urethral stricture
rate compared with the M-TURP group in patients
with a prostate volume >70 mL (20% in TURis vs
2.2% in M-TURP; P = 0.012).” The difference was
also noted by Tang et al3 who suggested “the risk
factors for B-TURP (to result in more urethral
strictures) included a larger resectoscope diameter,
higher ablative energy, and longer procedure time”
in their review and meta-analysis published in the
September 2014 issue of the Journal of Endourology.
My personal experience is more in line with the
previously reported experiences in that I appear to
have less bleeding with the bipolar technique and
less worry about transurethral resection syndrome.
Hence I resect more, operate for longer, and end up
with at least 3 times more strictures after switching
from the monopolar to the bipolar technique,
despite routinely performing preoperative urethral
dilatation. I am interested to find out how the
incidence of urethral strictures will now compare
with results of monopolar TURP in Cho et al’s
ongoing series after they have operated on more
patients, and whether the authors perform routine
preoperative urethrotomy or other prophylaxis
against urethral stricture.
References
1. Cho CL, Leung CL, Chan WK, Chu RW, Law IC.
Early postoperative outcome of bipolar transurethral
enucleation and resection of the prostate. Hong Kong Med
J 2015;21:528-35. Crossref
2. Komura K, Inamoto T, Takai T, et al. Incidence of urethral
stricture after bipolar transurethral resection of the
prostate using TURis: results from a randomised trial. BJU
Int 2015;115:644-52. Crossref
3. Tang Y, Li J, Pu C, et al. Bipolar transurethral resection
versus monopolar transurethral resection for benign
prostatic hypertrophy: a systematic review and meta-analysis.
J Endourol 2014;28:1107-14. Crossref
Authors’ reply
CL Cho, FRCSEd (Urol), FHKAM (Surgery);
Clarence LH Leung, MRCSEd;
Wayne KW Chan, FRCSEd (Urol);
Ringo WH Chu, FRCSEd (Urol), FHKAM (Surgery);
IC Law, FRCSEd (Urol), FHKAM (Surgery)
Division of Urology, Department of Surgery, Kwong Wah Hospital,
Yaumatei, Hong Kong
Corresponding author: Dr CL Cho (chochaklam@yahoo.com.hk)
We appreciate Dr Yeung’s comments and specifically
respond to his concerns as follows.
Urethral stricture and bladder neck
contracture after transurethral surgery usually
occurs after 6 months postoperatively.1 Longer
follow-up is required to conclude the incidence of
urethral stricture and bladder neck contracture in
our patients. The time interval for occurrence of
meatal stenosis after transurethral surgery is less
clearly defined in the literature. In our experience,
meatal stenosis is uncommon in the first 6 months
following surgery. Our study reported the early
postoperative outcome of bipolar transurethral
enucleation and resection of the prostate (TUERP).
The incidence of urethral stricture and bladder neck
stenosis 3 months postoperatively is expected to be
low. We will continue to follow up our patients and
plan to report intermediate and long-term results in
the future.
The concern about a higher incidence of
urethral stricture after bipolar transurethral
resection of the prostate (TURP) was raised by the
recent articles by Komura et al and Tang et al.1 2 Their
technique differed to ours, however. The concern
about a higher incidence of postoperative urethral
stricture remains. There are a lack of clinical data
that address the long-term results of bipolar TURP
including the incidence of urethral stricture.3 Size
of sheath, duration of operation, and current leak
have all been suggested as possible mechanisms that
cause urethral stricture following bipolar TURP. We
perform bipolar TUERP using a 26-Fr resectoscope
which is the same as bipolar TURP. By utilising the
bipolar TUERP technique, less electrocautery is
used compared with bipolar TURP. The enucleation
procedure is performed mechanically with the
sheath. Electrocautery is used to cauterise the
denuded vessels only. The relatively avascular
subtotally enucleated adenoma facilitates an easier
resection process with less need for electrocautery.
In theory, the incidence of urethral stricture after
bipolar TUERP should be lower than that for bipolar
TURP if current leak is the major mechanism
that underlies development of urethral stricture.
Comparative studies with long-term follow-up are
required to reach a conclusion.
We do not routinely perform preoperative
urethral dilatation. A 26-Fr resectoscope can be
inserted without difficulty in most of our patients.
Unfortunately, there is no evidence to suggest that
preoperative measures, including urethrotomy, can
effectively reduce the incidence of postoperative
urethral stricture.
References
1. Komura K, Inamoto T, Takai T, et al. Incidence of urethral
stricture after bipolar transurethral resection of the
prostate using TURis: results from a randomised trial. BJU
Int 2015;115:644-52. Crossref
2. Tang Y, Li J, Pu C, et al. Bipolar transurethral resection
versus monopolar transurethral resection for benign
prostatic hypertrophy: a systematic review and meta-analysis.
J Endourol 2014;28:1107-14. Crossref
3. Mamoulakis C, Ubbink DT, de la Rosette JJ. Bipolar
versus monopolar transurethral resection of the prostate:
a systematic review and meta-analysis of randomized
controlled trials. Eur Urol 2009;56:798-809. Crossref