AUA 2018: Bipolar Transurethral Resection of Bladder Tumor Provides Better Tissue for Histopathology but Has No Superior Efficacy and Safety

San Francisco, CA ( Bipolar TURBT technology has become increasingly used, particularly for longer procedures, in the hopes of reducing TUR syndrome – long procedures using hypotonic fluids (such as glycine or water) for monopolar TUR procedures (TURP or TURBT) puts the patient at risk of developing severe hyponatremia. Bipolar technology, which utilizes saline instead, helps reduce that risk and enables longer procedures. While very useful for TURP procedures, its utility in relatively shorter TURBT procedures has been of clinical interest.

In this abstract, the authors address, in a randomized trial, the efficacy of bipolar TURBT vs. monopolar TURBT. Specifically, they wanted to assess relative safety (obturator reflex, bladder perforation) and quality of resection (quality of histopathology). They randomized all patients undergoing TURBT over a 10 month period into either bipolar (BTURBT) or monopolar (MTURBT), in blocks of 10 patients. Both patient and physician were blinded prior to the procedure - allocation was concealed in sealed envelope and implemented by operating room technician.

With regards to settings: BTURBT was performed by using a bipolar electrocautery with a 26 Fr resectoscope. For BTURBT power settings with automatic adjustment were used delivering 160 to 200 W for cutting and 100 to 120 W for coagulation. MTURBT was performed by using a standard 26 Fr resectoscope in the power setting with energy levels of 70 to 90 W for cutting and 30 to 60 W for coagulation.

A total of 75 patients underwent BTURBT (if allocated in groups of 10, how did they end up with 75?) and 70 underwent MTURBT. Both the groups were comparable for demographic profiles including age, gender, comorbidities, ASA grade, tumor size, tumor location and resection time. No significant differences note. Urothelial histology was found on ~80-90% of both groups.

In terms of safety, the incidence of obturator reflex was not significantly higher in MTURBT group {8/70 (11%) Vs 13/75 (17%), p = 0.325}. The bladder perforation rate was also not significantly higher (4/70 Vs 1/75, p = 0.192). 

In terms of histopathology, cautery artifact was significantly higher in the MTURBT group (22/75 vs 3/70, p < 0.001). Grade 3 thermal damage was observed in significantly high proportion of patients in MTURBT group (12/70 vs 3/75, p = 0.024).

Based on this interesting study, albeit small, bipolar TURBT is as safe as monopolar TURBT, but less likely to cause grade 3 thermal damage and cautery artifact on final specimen. This would suggest that bipolar TURBT may be better from an oncologic perspective.

However, as I discussed with the presenter, they are still working on looking at the ability to accurately grade pathology (using blinded pathology review) and will follow-up with these results!  Anecdotally, I have found that the cautery on bipolar turbt is less effective than monopolar. Perhaps looking at post-operative bleeding and other complications would be important for future studies?

Presented by:  Pragatheeswarane Murugavaithianathan, Chandigarh, India
Co-Authors: Shrawan Singh, Sudheeer K Devana, Ravimohan Mavuduru, Santosh Kumar, Nandita Kakkar, Arup Kumar Mandal

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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