Incorporation of bipolar technology in transurethral resection (TUR) of the prostate (TURP) potentially offers advantages over monopolar TURP (M-TURP).
To evaluate the evidence by a meta-analysis, based on randomized controlled trials (RCTs) comparing bipolar TURP (B-TURP) with M-TURP for benign prostatic obstruction. Primary end points included efficacy (maximum flow rate [Qmax], International Prostate Symptom Score) and safety (adverse events). Secondary end points included operation time and duration of irrigation, catheterization, and hospitalization.
Based on a detailed, unrestricted strategy, the literature was searched up to February 19, 2009, using Medline, Embase, Science Citation Index, and the Cochrane Library to detect all relevant RCTs. Methodological quality assessment of the trials was based on the Dutch Cochrane Collaboration checklist. Meta-analysis was performed using Review Manager 5.0.
Sixteen RCTs (1406 patients) were included. Overall trial quality was low (eg, allocation concealment and blinding of outcome assessors were poorly reported). No clinically relevant differences in short-term (12-mo) efficacy were detected (Qmax: weighted mean difference [WMD]: 0.72
No clinically relevant differences in short-term efficacy exist between the two techniques, but B-TURP is preferable due to a more favorable safety profile (lower TUR syndrome and clot retention rates) and shorter irrigation and catheterization duration. Well-designed multicentric/international RCTs with long-term follow-up and cost analysis are still needed.
Keywords: Benign prostatic hyperplasia, Bipolar, Electrosurgery, Meta-analysis, PlasmaKinetic, Prostate, Randomized controlled trial, Review, Saline, Transurethral resection of prostate.
Benign prostatic hyperplasia (BPH) is the only tumor that inevitably affects almost every aging male, and there is consensus on its progressive nature . BPH-related obstruction (ie, benign prostatic obstruction [BPO])  is associated with lower urinary tract symptoms (LUTS). The incidence of LUTS/BPO is high and increases linearly with age . The impact on quality of life (QoL) and health care cost justifies additional research into the use of therapeutic resources .
For 8 decades, transurethral resection of the prostate (TURP) has been considered the cornerstone of surgical management for BPO, due to the procedure's outstanding, well-documented, long-term treatment efficacy . Similar data on durability for any other instrumental BPO treatment are lacking , and the evidence supports the notion that “TURP is here to stay”.
Although significant technical improvements during the past 15 yr have reduced intra- and postoperative adverse events, there are still concerns regarding complications, such as transurethral resection (TUR) syndrome, bleeding, and urethral strictures (USs) . A prospective multicenter study on 10
The purpose of this systematic review is to critically evaluate the evidence based on randomized controlled trials (RCTs) that compare B-TURP with M-TURP in patients with BPO and, where possible, to conduct a quantitative meta-analysis in an attempt to provide, for the first time, conclusions based on level 1a evidence. We aim to substantiate the advantages and disadvantages of each technique in terms of efficacy and safety (primary outcomes). Efficacy was quantified by postoperative maximum flow rate (Qmax) and/or International Prostate Symptom Score (IPSS). Reoperation for residual tissue was also considered. Safety was estimated by the postoperative occurrence of at least one of the following parameters: (1) drop in serum sodium level, (2) TUR syndrome, (3) drop in hemoglobin (Hb) level, (4) need for transfusion, (5) clot retention, (6) acute urinary retention (AUR) after catheter removal, (7) meatal stenosis (MS), (8) bladder neck contracture (BNC), and (9) US. Secondary outcomes included operation time, duration of bladder irrigation, catheterization, and hospitalization time.
2. Evidence acquisition
Objectives, literature-search strategy, methods for determining trial selection based on strict inclusion criteria, data elements, data extraction, and trial quality assessment were defined beforehand. Each step in this protocol was completed independently by two of the authors (CM and DU). Any disagreement was resolved by discussion, and final decision was based on a consensus.
2.1. Literature-search strategy
The literature was systematically searched with the assistance of a clinical librarian to detect all RCTs comparing B-TURP with M-TURP in patients with BPO. The search was conducted up to February 19, 2009, using the following electronic databases: Medline, Embase, Science Citation Index, and the Cochrane Library up to issue 1 of 2009. No temporal, regional, publication status, or language restrictions were set. The search strategy is summarized in Appendix A. The official Web sites of the manufacturers of all currently commercially available B-TURP systems were also checked. The reference lists of all selected papers were further reviewed for potentially relevant trials.
Eligible trials were full papers reporting on at least one of the two primary outcomes of interest: efficacy and safety. If necessary, official translations into English or Dutch were obtained through the independent Dutch Interpretation and Translation Center (www.tvcn.nl). Citations in abstract form, trials that studied different interventions (eg, transurethral vaporization of the prostate [TUVP] or transurethral vaporization-resection of the prostate [TUVRP], laser technology), and non-RCTs were excluded.
2.2. Quality assessment, data extraction and analysis
The methodological quality assessment of selected trials was based on the Dutch Cochrane Collaboration checklist, which is in accordance with Table 8.5.a of the Cochrane Handbook for Systematic Reviews of Interventions.
Data of the included trials were extracted and summarized. Unreported complications were considered to be not recorded unless specifically stated as not occurring. Meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK).
Statistical heterogeneity was assessed using the I2 statistic. In the absence of heterogeneity (I2: <30%), a fixed effects model was used. A random effects model was used for mild heterogeneity (I2: 30–60%). For I2 >60% we refrained from doing a meta-analysis. If data could be pooled, depending on heterogeneity , summary estimates of treatment effect with 95% confidence intervals (CIs) were calculated for every comparison and the p-value for the overall treatment effect was added. For continuous variables, the weighted mean difference (WMD) was calculated. For dichotomous outcomes, the absolute risk reduction or risk difference (RD) was used, which is an absolute effect measure of the difference between experimental and control event rates, allowing calculation of the numbers needed to harm (NNH). The presence of publication bias, if any, was evaluated using funnel plots. In the case of clinical or statistical heterogeneity, sensitivity analyses were attempted to facilitate the meta-analysis by omitting trials with an apparent reason for heterogeneity. Subgroup analysis of the different bipolar systems was planned beforehand.
3. Evidence synthesis
3.1. Previously published systematic reviews and meta-analyses
Although many interesting reviews have recently been published , , , , , and , only two reports by the same group of investigators fulfilled the methodological standards of a systematic review  and . The first one compared the efficacy and safety of newer ablative methods (including B-TURP) against M-TURP for treating patients with BPO . The second extended the attempt toward a cost-effectiveness comparison (B-TURP was not evaluated in this respect), including nonablative, minimally invasive techniques . Based on a systematic literature search through September 2006, both reports considered the same RCTs, only six in total (386 patients) , , , , , and .
IPSS was the primary outcome; others included Qmax, duration of operation, length of hospital stay, reoperation, and adverse events  and . The authors concluded that data were too few to provide precise estimates and that statistically significant differences could not be detected. Duration of the operation was the only exception, favoring B-TURP, which bore a significant heterogeneity and was of doubtful clinical or economic importance .
3.2. Trial inclusion
A total of 573 citations were retrieved from databases and a manufacturer's Web site (Fig. 1). Finally, 17 reports on 16 RCTs matched the inclusion criteria , , , , , , , , , , , , , , , , and .
Eligibility was not obvious from the titles and abstracts alone in four cases , , , and , and the final decision was based on a review of the full manuscript after requesting official translation in two cases, one from Korean  and one from Chinese . In this way, three studies were excluded (no evidence of randomization  and  or retrospective study design ). Furthermore, one trial was excluded because the intervention arm received a combination of B-TUVP and B-TURP (hybrid technique) instead of B-TURP alone .
Two of the 17 trials described the same set of patients and reported identical information at 12-mo follow-up  and . Only extra data on longer-term (48 mo) follow-up were extracted from the most recent publication . Among the remaining trials, there was no evidence of duplicate populations. In two trials from the same group of investigators, it was obvious that results were reported on different patients because the trial periods did not overlap  and .
Compared to the previously published systematic reviews  and , we report on a much greater trial and patient population. The previous authors provided no evidence other than the period of the literature search to justify the exclusion of any trial that was included in the present review, and they analyzed only 31% of the trials we included (5 of 16) , , , , and  as well as the sole RCT that we excluded .
3.3. Description of included trials
Trial sizes ranged from 40 to 240 patients, totaling 1406 patients randomized into B-TURP and M-TURP arms. There was no evidence of significant clinical heterogeneity regarding patient inclusion criteria, preoperative patient characteristics, and performance of treatments. Only one trial included patients with markedly larger prostates compared to the others . The main trial and baseline patient characteristics are summarized in Table 1.
|Reference||Country of origin||Trial size‡||Resectoscope, F‡||Bipolar technology||Follow-up, mo||Age, yr‡||Prostate volume, ml‡||Hemoglobin, g/dl‡||Sodium, mmol/l‡||Qmax, ml/s‡||IPSS‡||QoL score‡||PVR, ml‡|
|Yang et al, 2004 ||Taiwan||59/58||na/na||PK||3||na/na||48.9/45.8||13.7/13.5||138.8/140.8||10.9/10.4||21.6/20.9||4.0/3.7||150/99|
|Singh et al, 2005 ||India||30/30||25.5/25.6||Vista CTR||3||67.9/68.9||na||13.2/12.8||139.2/139.3||5.1/5.8||21.6/20.5||4.4/4.6||136/124|
|De Sio et al, 2006 ||Italy||35/35||26/26||PK||12||61.0/59.0||47.5/51.6||na||na||6.3/7.1||24.3/24.2||3.9/4.2||75/80|
|Autorino et al, 2009 ||48|
|Nuhoglu et al, 2006 ||Turkey||30/27||25/27||PK||12||65.2/64.6||49.0/47.0||14.6/14.1||141.1/141.4||7.3/6.9||17.3/17.6||na||88/96|
|Seckiner et al, 2006 ||Turkey||24/24||26/27||PK||12||63.9/61.2||41.4/49.4||14.3/14.1||147.1/148.0||8.3/8.5||23.2/24.1||4.7/4.4||138/88|
|Patankar et al, 2006 ||India||51/53||24/na||PK||0.7||62.0/64.0||52.3/51.3||na||na||6.4/5.9||23.7/23.3||na||na|
|Kim et al, 2006 ||Korea||25/25||24/27||PK||6||70.6/68.1||51.7/53.2||na||na||na||na||na||na|
|Abascal Junquera et al, 2006 ||Spain||21/24||26/26||TURis||na||67.3/69.5||42.5/39.5||na||na||7.2/7.7||na||na||na|
|Ackayoz et al, 2006 ||Turkey||21/21||26/27||PK||na||66.0/67.0||47.0/40.0||na||141.0/140.0||na||na||na||na|
|Lin et al, 2006 ||Taiwan||18/22||26/26||Vista CTR||12||69./69.0||na||na||na||6.0/7.0||29.5/29.5||na||na|
|Erturhan et al, 2007 ||Turkey||120/120||26/27||PK||12||67.4/68.5||42.0/43.0||na||na||9.2/10.9*||24.0/23.0||3.0/2.0||135/114*|
|Ho et al, 2007 ||Singapore||52/48||26/26||TURis||12||66.5/66.6||54.8/56.5||14.8/14.0*||141.0/139.5||6.5/6.8||24.6/22.6||na||na|
|Rose et al, 2007 ||Germany||34/38||na/na||TURis||na||na/na||na||na||na||na||na||na||na|
|Michielsen et al, 2007 ||Belgium||120/118||26/24||TURis||na||73.1/73.8||na||14.1/13.4||142.0/142.2||na||na||na||na|
|Iori et al, 2008 ||Italy||27/26||26/24||PK||12||63.0/65.0||48.0/49.0||na||141/140||8.7/7.0*||20.0/21.0||3.6/3.0||96/99|
|Bhansali et al, 2009 ||India||35/35||26/26||PK||12||na/na||82.6/82.4||na||na||4.2/4.4||na||na||na|
‡ The data for the monopolar/bipolar techniques are given, respectively.
* Significant difference between monopolar and bipolar transurethral resection arms.
3.4. Methodological quality
Overall trial quality was low. True (computer-aided) randomization was used in only two trials  and . Half did not report the randomization method , , , , , and . Consequently, allocation concealment could not be guaranteed in at least 50% of the trials. Withdrawals, if any, were rarely mentioned. Blinding of patients and outcome assessors for the treatment received were stated clearly in only two trials  and  and five trials , , , , and , respectively, while the nature of the intervention made blinding of the performing physicians impossible. In two trials, it was clearly stated that at least some patients were treated differently apart from the intervention  and . Specifically, three patients in the M-TURP arm received furosemide because serum sodium levels approached the lower normal limits versus none in the B-TURP arm , while patients in the M-TURP arm but not in the B-TURP arm were routinely treated with furosemide if resection time was >60
|Yang et al, 2004 ||Yes||?||Yes||No||Yes||No||?||No||?||?||?||Yes||?||?||?||No|
|Singh et al, 2005 ||Yes||Yes||Yes||No||Yes||No||?||No||Yes||?||Yes||Yes||?||?||?||No|
|De Sio et al, 2006 ||Yes||Yes||Yes||Yes||Yes||No||?||No||Yes||Yes||No||Yes||Yes||Yes||No||Yes|
|Autorino et al, 2009 |
|Nuhoglu et al, 2006 ||Yes||?||Yes||Yes||Yes||No||?||No||?||Yes||Yes||Yes||Yes||Yes||?||No|
|Seckiner et al, 2006 ||Yes||?||Yes||No||Yes||No||?||No||?||Yes||Yes||Yes||?||?||?||No|
|Patankar et al, 2006 ||Yes||Yes||Yes||Yes||Yes||No||Yes||No||Yes||Yes||Yes||Yes||Yes||?||?||No|
|Kim et al, 2006 ||Yes||?||Yes||No||Yes||No||?||No||?||?||Yes||Yes||?||?||?||No|
|Abascal Junquera et al, 2006 ||Yes||?||Yes||No||Yes||No||?||No||Yes||Yes||Yes||Yes||?||?||?||No|
|Ackayoz et al, 2006 ||Yes||?||Yes||No||Yes||No||?||No||?||Yes||Yes||Yes||?||?||?||No|
|Lin et al, 2006 ||Yes||Yes||Yes||Yes||Yes||No||?||No||?||Yes||No||Yes||Yes||?||?||No|
|Erturhan et al, 2007 ||Yes||?||Yes||Yes||Yes||No||?||No||?||Yes||Yes||Yes||?||?||?||No|
|Ho et al, 2007 ||Yes||Yes||Yes||Yes||Yes||No||?||No||?||Yes||Yes||Yes||Yes||Yes||?||No|
|Rose et al, 2007 ||Yes||?||?||No||Yes||No||?||No||?||Yes||Yes||Yes||Yes||?||?||No|
|Michielsen et al, 2007 ||Yes||Yes||Yes||No||Yes||No||?||No||?||?||Yes||Yes||Yes||Yes||?||No|
|Iori et al, 2008 ||Yes||Yes||Yes||No||Yes||No||?||No||?||?||Yes||Yes||?||?||?||No|
|Bhansali et al, 2009 ||Yes||Yes||Yes||No||Yes||No||Yes||No||Yes||Yes||Yes||Yes||Yes||?||?||Yes|
3.5. Primary end points
Data on efficacy measured by the impact of each technique on Qmax and IPSS , , , , , , , , , , , and  as well as QoL score , , , , , , and , compared to baseline, was provided at follow-up periods ranging from 1 to 48 mo in 12 trials. All trials but one  concluded that both techniques were equally effective. Pooling five trials reporting on Qmax at 12 mo (Fig. 2) showed a small but significant (p
Although a significant decrease in TUR syndrome incidence has been reported during the past decades, it still represents a serious perioperative complication . Function in a conductive medium instead of the conventional nonconductive irrigation fluid is a prerequisite of bipolar technology. This advantage is the most important because all issues relating to hypotonic/hypo-osmolar fluid irrigation (dilutional hyponatremia, TUR syndrome) are expected to be eliminated . Therefore, bipolar technology is expected to provide more time to perform larger resection, coagulation, and training without compromising safety  and .
Most trials reporting on the postoperative drop in serum sodium level showed a significantly higher drop after M-TURP , , , , , , and , but data were extremely heterogeneous to be pooled (I2: 99%). Because the absolute serum sodium levels at baseline did not differ significantly between arms (Table 1), postoperative levels (at 2
All trials but one  reported on TUR syndrome occurrence, describing a total of 13 cases versus none after M-TURP and B-TURP, respectively. No significant difference was reported in individual trials. Pooled analysis (Fig. 3) detected an overall significant difference (RD: 2%; 95% CI, 0–3%; p
One of the major complications of M-TURP is intra- or perioperative bleeding, which is clinically significant mainly if it causes clot retention or necessitates blood transfusion or reoperation. Although transfusion rates in M-TURP series have been significantly reduced over time, clot retention incidence ranges between 2% and 5% and bleeding still remains a concern . The hemostatic capacity of bipolar current has been reported to be superior in a number of ex vivo studies, possibly attributed to deeper coagulation depths , , , , , and , as well as to the “cut-and-seal” effect of plasma created by bipolar energy  and .
Data on the postoperative change in Hb level were available from nine trials , , , , , , , , and , all reporting a nonsignificant drop between arms. Due to lack of standard deviations and large heterogeneity , , , and , they could not be pooled. Although all individual trials but one  reported a nonsignificant difference in clot retention between arms, pooled analysis (Fig. 4) showed a significantly higher frequency in the M-TURP arm (RD: 5%; 95% CI, 1–10%; p
Pooling of the eight trials , , , , , , , and  reporting on AUR showed no differences between arms (RD: 1%; 95% CI, −2% to 3%; p
The major late complications of M-TURP include strictures (US and MS: 2.2–9.8%) and BNCs (0.3–9.2%), and the incidence has not changed significantly over time, despite improvements in surgical techniques, lubricants, instruments, and electrical technology . Theoretically, bipolar technology minimizes the risk of USs, but the different electrode arrangements of the various systems should be considered separately .
Higher incidences of urethral complications (immediate urethral injury during entrance, MS , USs  and ) with bipolar systems have been suggested occasionally. Larger resectoscope diameter (27F) (PlasmaKinetic [PK]; Gyrus ACMI, Southborough, MA, USA) , , , and , higher ablative energy used , and longer procedures  have been proposed as risk factors. USs specifically associated with the TUR in saline (TURis) system (Olympus, Tokyo, Japan) have been attributed to electric current return (leakage) via the resectoscope sheath , but this concern has not been verified .
Alarming results were provided by Tefekli et al , raising serious concerns about bipolar technology in the urological community . The authors reported significantly more and severe USs in the PK arm (PK vs M-TURP: 3 of 49 vs 1 of 47; Fisher exact test, p
|Reference||Mean follow-up, mo||Monopolar TURP||Bipolar TURP||p value|
|N||Strictures, n (%)a||Stricture location||Detection, mo||Intervention||N||Device||Strictures, n (%)a||Stricture location||Detection, mo||Intervention|
|Singh et al, 2005 ||3||30||0 (0.0)||U||–||–||30||Vista CTR||1 (3.3)||U||na||na||1.000|
|1 (3.3)||BN||na||na||0 (0.0)||–||–||–||1.000|
|Lin et al, 2006 ||12||18||1 (5.6)||BN||9||Incision||22||Vista CTR||0 (0.0)||–||–||–||0.450|
|Total US (Vista CTR)||48||0 (0.0)||52||1 (1.9)||1.000|
|Yang et al, 2004 ||3||59||2 (3.4)||U||na||Urethrotomy||58||Gyrus||1 (1.7)||U||na||Urethrotomy||1.000|
|De Sio et al, 2006 ||12||35||1 (2.9)||BN||6||Reoperation||35||Gyrus||1 (2.9)||BN||6||Reoperation||1.000|
|Autorino et al, 2009 ||48||31||2 (6.5)||BU||na||Urethrotomy||32||Gyrus||1 (3.1)||BU||na||Urethrotomy||0.613|
|1 (3.2)||BN||6||Incision||1 (3.2)||BN||6||Incision||1.000|
|Nuhoglu et al, 2006 ||12||26||0 (0.0)||–||–||–||24||Gyrus||1 (4.2)||UM||3||Dilatation||0.480|
|Seckiner et al, 2006 ||12||24||1 (4.2)||BU||–||Urethrotomy||24||Gyrus||1 (4.2)||BU||–||Urethrotomy||1.000|
|0 (0.0)||–||–||–||1 (4.2)||MU||–||1.000|
|Kim et al, 2006 ||6||25||2 (8.0)||U||na||na||25||Gyrus||1 (4.0)||U||na||na||1.000|
|Erturhan et al, 2007 ||12||120||0 (0.0)||–||–||–||120||Gyrus||3 (2.5)||UIb||At entrance||–c||0.247|
|2 (1.7)||UM||na||na||3 (2.5)||UM||na||na||1.000|
|2 (1.7)||U||na||Reoperationd||2 (1.7)||U||na||na||1.000|
|1 (0.8)||BN||na||Reoperation||0 (0.0)||BN||–||–||1.000|
|Iori et al, 2008 ||12||26||1 (3.8)||BN||4||Urethrotomy||27||Gyrus||1 (3.7)||BN||4||Urethrotomy||1.000|
|Bhansali et al, 2009 ||9e||33||4 (12.1)||U||na||Urethrotomy||34||Gyrus||5 (14.7)||U||na||Urethrotomy||1.000|
|0 (0.0)||BN||na||–||1 (2.9)||BN||na||Incision||1.000|
|Total US (Gyrus) f||344||11 (0.3)||344||11 (0.3)||1.000|
|Ho et al, 2007 ||12||52||1 (1.9)||BU||2||Dilatation||48||TURis||3 (6.3)||BU||2||Dilatation||0.348|
|Michielsen et al, 2007 ||na||120||0 (0.0)||–||–||–||118||TURis||0 (0.0)||–||–||–||1.000|
|Total US (TURis)||172||1 (0.6)||166||3 (1.8)||0.364|
|Grand Total US||564||12 (2.1)||562||15 (2.7)||0.553|
a Cumulative incidence rate at the end of follow-up.
b Partial rupture of bulbo-membranous urethra.
c Catheterization over guidewire and postponement of operation for 7–10 d.
d One patient required reoperation.
e A minimum follow-up of 12 mo (mean: 13.5) is reported, but it is stated that “long term complications such as US and BN contracture were the same at the end of 9 months in both groups.”.
3.6. Secondary end points
All trials recorded the duration of either the resection or the whole procedure. Mean operation times varied from 35 to 81
Six trials reported on the duration of irrigation , , , , , and . In all trials but one , duration was longer in the M-TURP arm, and in three trials , , and , the result was statistically significant. Pooled analysis , , and  verified this result (WMD: 8.75
3.7. Sensitivity, subgroup, and publication bias analyses
3.7.1. Sensitivity analyses
In an attempt to reduce a possible source of clinical heterogeneity among trials reporting on operation time, we performed a sensitivity analysis by selecting only trials in which all operations were performed by a single surgeon , , , , , , , and . Meta-analysis of five trials that reported on this outcome and could be pooled , , , , and  showed no significant difference in operation time (WMD: 2.4
The decision for irrigation duration but mainly catheter removal and hospital discharge is multifactorial, with prior knowledge of the treatment offered potentially resulting in bias . Therefore, studies emphasizing these outcomes should be blinded for the outcome assessors. Only five RCTs clearly fulfilled this criterion (Table 2). Catheterization time appeared statistically shorter for the Vista Coblation/controlled tissue resection (CTR) system (ACMI, Southborough, MA, USA)  and for PK , , and  but not for TURis . Pooled analysis including only these trials in an attempt to exclude possible bias (Fig. 7) showed that the difference was significant in favor of B-TURP (WMD: 21.77
3.7.2. Subgroup analyses
The various bipolar systems represent distinct technological advancements based on different electrophysiological principles regarding current flow. Consequently, efficacy and, principally, safety concerns should be cautiously and separately evaluated for each system  and .
We performed subgroup analyses to check for differences among the three systems evaluated in trials. First, we omitted trials using the Vista CTR system  and  because it is now removed from the market  and . This did not change the results. Additionally, we analyzed possible differences between the PK and TURis systems. Data on TURis were too few and heterogeneous to permit any safe conclusions. Generally, we did not observe any major effects on the meta-analyses of baseline and postoperative parameters.
In the trials that used the PK device, the number of patients requiring postoperative blood transfusions was slightly but significantly lower with B-TURP than with M-TURP (RD: 3%; 95% CI, 1–6%; NNH: 33; 95% CI, 17–100; p
3.7.3. Publication bias analyses
We analyzed possible publication bias by generating funnel plots of the trials used for all of the evaluated comparisons of outcomes. No clear bias was apparent. As an example, we present the funnel plot of TUR syndrome occurrence showing no obvious asymmetry (Fig. 8).
Considering the two main limitations that may hamper our meta-analysis, namely, the low trial quality and the relatively limited follow-up, this systematic review provides the strongest available evidence, for the first time, showing that no clinically relevant differences in short-term efficacy exist between the two techniques. Furthermore, no differences were evident regarding operation time and rates of adverse events such as transfusions, retention after catheter removal, or urethral complications. B-TURP, however, is preferable, due to its more favorable profile, defined by the clinically relevant differences detected regarding complications such as TUR syndrome and clot retention. Additionally, irrigation and catheterization duration were significantly shorter with B-TURP, although it is not clear yet whether these differences can be translated into shorter hospital-stay duration. Between the two bipolar systems, PK has been submitted to a far more extended evaluation in RCTs, showing an improved safety profile. Data on TURis are not yet mature enough to permit safe conclusions. Data from well-designed multicentric/international RCTs with long-term follow-up (>12 mo) are welcomed, and a cost-analysis is still needed.
Study concept and design: Mamoulakis.
Acquisition of data: Mamoulakis, Ubbink.
Analysis and interpretation of data: Mamoulakis, Ubbink, de la Rosette.
Drafting of the manuscript: Mamoulakis.
Critical revision of the manuscript for important intellectual content: Ubbink, de la Rosette.
Statistical analysis: Ubbink, Mamoulakis.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: de la Rosette.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
Acknowledgment statement: The authors acknowledge Hanny Vriends (clinical librarian, Academic Medical Center, Amsterdam, The Netherlands), who provided assistance with the study search. Mrs. Vriends did not receive compensation for her contribution.
Dr. Charalampos Mamoulakis thanks the Alexander S. Onassis Public Benefit Foundation for a grant offered to attend a clinical fellowship program at the Academic Medical Center, Department of Urology, Amsterdam, The Netherlands.
Appendix A. Search strategy protocols used for each electronic database
- (1) Medline: (ablative OR minimally invasive[tw] OR plasmakinetic* OR plasmasect* OR PKRP OR turis OR vista OR gyrus OR wolf[tiab] OR storz[tiab] OR bipolar) AND (TURP[tw] OR Transurethral prostatectom*[tw] OR Transurethral prostate resection*[tw] OR “Transurethral Resection of Prostate”[Mesh] OR transurethral resection of the prostate[tw]) AND (((((((((((((((((((((volunteer*[tw]) OR ((prospectiv*[tw]))) OR ((control*[tw]))) OR ((prospective studies[mh]))) OR ((follow-up studies[mh]))) OR ((evaluation studies[pt]))) OR ((comparative study[pt]))) OR ((research design[mh:noexp]))) OR ((random*[tw]))) OR (((singl* OR doubl* OR trebl* OR tripl*) AND (blind* OR mask*)))) OR ((clinical trial[tw]))) OR ((clinical trials[mh]))) OR ((clinical trial[pt]))) OR ((single-blind method[mh]))) OR ((double blind method[mh]))) OR ((random allocation[mh]))) OR ((randomized clinical trials[mh]))) OR ((controlled clinical trial[pt]))) OR ((randomized controlled trial[pt]))) (the latter part is the Cochrane sensitive trials filter)
- (2) Embase: ablative.mp. OR minimally invasive.mp. OR plasmakinetic$ OR plasmasect$ OR pkrp OR turis OR vista OR gyros.mp. OR wolf.ti. OR wolf.ab. OR storz.ti. OR storz.ab. OR bipolar AND transurethral resection/ OR transurethral resection of the prostate.mp. OR transurethral prostate resection.mp. OR TURP OR transurethral prostatectom$.mp. AND Clinical Trial/ OR exp controlled clinical trial/ OR random$.mp. OR trial*.mp. (no search filter for Emabse at www.cochrane.nl)(mp.=multiple parts=all fields, .ti.=title, .ab.=abstract))
- (3) Science Citation Index: Topic=(ablative OR minimally invasive OR plasmakinetic* OR plasmasect* OR PKRP OR turis OR vista OR gyrus OR wolf OR storz OR bipolar) AND Topic=TURP OR Transurethral prostatectom* OR Transurethral prostate resection OR Transurethral Resection of Prostate OR transurethral resection of the prostate AND topic=Trial or trials
- (4) Cochrane Library: (ablative OR minimally invasive OR plasmakinetic* OR plasmasect* OR PKRP OR turis OR vista OR gyrus OR wolf OR storz OR bipolar):ti,ab,kw AND (TURP OR Transurethral prostatectom* OR Transurethral prostate resection* OR “Transurethral Resection of Prostate”[Mesh] OR transurethral resection of the prostate):ti,ab,kw
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M. Bhansali, S. Patankar, S. Dobhada, S. Khaladkar. Management of large (>60
g) prostate gland: PlasmaKinetic Superpulse (bipolar) versus conventional (monopolar) transurethral resection of the prostate. J Endourol. 2009;23:141-146 Crossref.
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-  J.S. Starkman, R.A. Santucci. Comparison of bipolar transurethral resection of the prostate with standard transurethral prostatectomy: shorter stay, earlier catheter removal and fewer complications. BJU Int. 2005;95:69-71 Crossref.
-  G. Wendt-Nordahl, A. Häcker, O. Reich, B. Djavan, P. Alken, M.S. Michel. The Vista system: a new bipolar resection device for endourological procedures: comparison with conventional resectoscope. Eur Urol. 2004;46:586-590 Crossref.
-  G. Wendt-Nordahl, A. Häcker, K. Fastenmeier, et al. New bipolar resection device for transurethral resection of the prostate: first ex-vivo and in-vivo evaluation. J Endourol. 2005;19:1203-1209 Crossref.
-  X. Huang, X.H. Wang, L.J. Qu, X.Y. Pu, X. Zeng. Bipolar versus monopolar transurethral resection of prostate: pathologic study in canines. Urology. 2007;70:180-184 Crossref.
-  L. Qu, X. Wang, X. Huang, Y. Zhang, X. Zeng. Use of a novel ex-vivo model to compare the hemostatic properties of plasmakinetic resection, transurethral vaporization resection and conventional transurethral resection of the prostate. Urology. 2007;70:1034-1038 Crossref.
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a Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
b Department of Quality Assurance and Process Innovation and Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
© 2009 European Association of Urology, Published by Elsevier B.V.