Bipolar TURP Procedure Advantages & Complications

[Dr. Aditya Bagrodia]
...As we start talking about the relevant patient characteristics, symptom characteristics, and anatomical considerations, perhaps it would be useful, Claus, if you could give a comprehensive list of options that are available, as you see it.

[Dr. Claus Roehrborn]
...Those treatments nowadays are grouped into minimally invasive (done as an outpatient or an ambulatory surgery center) versus the surgeries that require full anesthesia (done in a hospital setting usually and require more or less an overnight stay).

...You can also group these treatments by if they remove tissue or if they do not remove tissue. I'll give you an example. A TURP classically removes tissue. It's an ablative procedure and it's invasive and it requires hospitalization at least for a day. Non-ablative would be a UroLift. You place the UroLift devices and you push the tissue to the side but no tissue is ultimately removed. So ablative versus non-ablative is another way of differentiating it.

There would be a differentiating between treatments that consist of permanent placement of items, such as a UroLift, and there's a whole slew coming down the pipe, the Zenflow device, the Butterfly device, the Medeon device, all of which are experiencing trials in the United States right now and may or may not be approved by the FDA. Versus treatments that don't use devices that are implanted permanently.

And then there's the categorization by devices that work by laser energy versus electrocautery energy versus other energies. For example the Rezum procedure uses steam, just hot water heated by radio frequency energy, and then is injected and as the steam gives off the energy it destroys the tissue. So the energy source is another question. And to add to that, there is the Aquablation treatment that doesn't use any heat per se--neither electrical generated heat nor laser generated heat nor steam--but it uses basically saline at room temperature with a very intense water pick system to destroy prostate tissue.

You can already see how complex it is, how you can group these treatments by energy source, by ablative or non-ablative, by implant versus non-implant. Then comes the question: are these treatments all suitable for all sizes and shapes? But if you look through the list, minimally invasive devices currently approved and recommended in the United States would be the UroLift device, which is an implant, and the Rezum treatment, which is a steam-based heat treatment that partially ablates tissue. Then amongst the surgical treatments there would be monopolar/bipolar TURP, the PVP, the GreenLight or KTP or 532nm laser ablation of the prostate. Then there would be a host of enucleation techniques and, as you know, enucleation now can be done with the traditional way, the holmium laser enucleation which is called HoLEP, the thulium laser which is called ThuLEP, but people do it with the green-light laser as well and it's called KTP laser enucleation, or even do it with a bipolar resectoscope device and just get into the enucleation plane.

Then we have the treatments for the very large prostates that go beyond the HoLEP or ThuLEP, the robotic or open or robotic-assisted laparoscopic enucleation of the prostate as alternatives for the very large prostates.

[Dr. Aditya Bagrodia]
Maybe I'll interrupt you for just a moment, Claus, and ask you, among all of these options, of which pretty much everything is available, how does the median lobe presence or absence affect your decision?

[Dr. Claus Roehrborn]
I think this is, fortunately, an insight that has made, finally, it's way into the guidelines, both the EAU and to some degree the AUA guidelines, the recognition that the intravesical lobe plays a major role. Starting with the least invasive. The Rezum treatment has clearly shown that if you put the needle in the median lobe, if it's present, you get a better improvement than if there's a median lobe and you don't put the needle in. So putting the needle in, injecting the steam, ablating that median lobe gets you a better improvement than if you leave it alone. So the Rezum works out okay for the median lobe. You'll likely have a longer catheterization time, but it in the end works out.

The UroLift is approved because there is a study that was done, called the MedLift study, where they took a UroLift device and sort of stapled that median lobe to the side. There's a risk in exposing that wire. There's a risk in maybe having material exposed to the urine and forming stones, and there's a risk it doesn't work if you don't do it a lot. So, I don't like to do it because I think there are other treatments available for it, but it is technically approved for it.

The KTP or GreenLight laser is a bit odd because it shoots down in a 70 degree forward motion, so if you vaporize over the median lobe, eventually you get through it and then you hit the trigone. And that's just something I don't like to do or teach the residents because when you hit the trigone you can easily hit the ureteral orifice and then you coagulate it and it's a question of do you put a stent up and how long and what are you going to do about it. So substantial median lobe, I don't like the KTP all that much, I have to admit. For substantial intravesical lobe I like preferentially to do a TURP because I can very elegantly lob that median lobe off without jeopardizing the trigone, the UOs, taking it flush off the bladder neck and I think that's the most elegant way of going about it….

So big decision point, the intravesical lobe. No medical therapy. Please don't give medical therapy for substantial intravesical lobe ever. Doesn't work and it's just a waste of time and money. Choose your weapon carefully. If you have access to not much, then use your TURP loop. It's the best tool yet.