Monopolar Versus Bipolar Trans-Urethral Resection of Bladder Tumours (TURBT): A single centre, parallel arm randomized controlled trial

INTRODUCTION: Cancer of the urinary bladder is among the commonest malignancies in the world and has a high mortality rate. The initial management in all cases consists of a complete trans-urethral resection of the bladder tumour (TURBT), with a histopathological analysis on which further treatment decisions are based. Trans-urethral resection was introduced early in the 20th century and has since remained the mainstay of surgical management. Technical modifications have enabled the safer and more efficient performance of the procedure, however complications remain. Bipolar resection allows electric current to return to the machine via an electrode in the resectoscope itself. Hence no current passes through the patient, and no separate earthing electrode is required. It has been established in the last decade as an excellent alternative for trans-urethral resection of the prostate (TURP). It offers the option of resection in normal saline (a physiological solution), thereby reducing fluid and electrolyte abnormalities, and allowing prolongation of the procedure with a more complete resection. The hemostatic properties of this system have been claimed to be superior to the traditional monopolar cautery. In TURBT, the bipolar system also offers the possibility of reduction of obturator jerks, which can otherwise lead to bladder perforation. Numerous randomized controlled trials (RCT’s) exist for TURP and have proven the equivalence and safety of the bipolar system. While the above advantages have been claimed in the performance of TURBT, no high-level evidence exists in this area. With this in mind we decided to conduct a randomized control trial comparing the bipolar system with the traditional monopolar cautery for TURBT. AIMS AND OBJECTIVES: The role of bipolar cautery in the performance of TURP has become well-defined; however, its place in TURBT remains unclear. This is due to the paucity of good randomized studies in this area. The aim of our study was to perform a randomized controlled trial to compare the safety and efficacy of bipolar resection of bladder tumours with the current standard of monopolar resection. The safety of the procedure was assessed by comparing the mean blood loss, need for blood transfusion, drop in hematocrit (PCV), incidence of TUR syndrome, obturator jerk and bladder perforation between both arms. The primary end-point used to assess the safety of resection was the incidence of obturator jerk among both groups, and this was the parameter used to calculate the required sample size for the study. The others were considered secondary endpoints. The effectiveness of the resection was addressed using standard parameters that are used to assess the ‘quality’ of a TURBT. These are mainly pathological and include presence of gross residual tumour, presence of deep muscle in the biopsy sample and degree of cautery artifact in the specimen. MATERIAL AND METHODS: Design and duration of study: A single-centre parallel arm randomized controlled trial was designed and carried out at our institution from May 2011 to August 2012. The allocation ratio used was 1:1 to ensure an equal distribution among both monopolar and bipolar arms. The approval of the Institutional Review Board and Ethics Committee was obtained. The trial was registered with the Clinical Trial Registry of India (CTRI number: CTRI/2011/06/001785). Consolidated Standards of Reporting Trials (CONSORT) guidelines have been used to report all aspects of the trial. (52) Inclusion criteria: All patients undergoing TURBT for suspected bladder tumours were eligible for inclusion. Exclusion criteria: •Restaging TURBT’s for high-grade bladder cancer were excluded. •Patients refusing to participate. •Patients unfit for spinal anesthesia. •Patients who required simultaneous procedures (for example transurethral resection of the prostate, ureteroscopy, etc.). Spinal anesthesia was used for all cases, and patients had to be passed fit for the same by an anesthesiologist. No obturator block was used. The department of Anesthesiology was informed prior to starting the study and had no objections to the performance of the study. An information sheet was provided to all patients and those who consented to take part were included for randomization. Bipolar resection was carried using the Gyrus-AMCI TM Plasma-kinetic Superpulse generator. The settings used were 100W for cutting and 80W for coagulation. Resection was carried out using a thin Plasmakinetic Superloop. Normal saline was used as irrigant. Monopolar resection was performed with a Storz Vaporcut (4mm) resection loop 1.5% Glycine was used as the irrigant for all these resections. RESULTS: A total of 257 TURBT’s were performed during the duration of the study. Restaging TURBT’s excluded were 57 in number. Thirty patients refused to participate in the trial. Of the remaining 170 patients, 23 were deemed unfit for regional anesthesia and were excluded. The remaining 147 cases were randomized into the monopolar or bipolar arms. Of these cases, 6 patients in the monopolar arm and 4 in the bipolar arm were excluded from intention-to-treat analysis as they underwent a breach of protocol. This took the form of a simultaneous additional procedure like TURP or ureteroscopy; or being inadvertently given general anesthetic by the anesthesiologist. As a result 69 cases in the monopolar arm and 68 in the bipolar arm were eligible for per-protocol statistical analysis. The initial distribution of 75 in the monopolar arm and 72 in the bipolar arm underwent intention to treat analysis. The mean age of patients was 55.13 years and only 9 cases were female. As expected, the majority of the cohort was smokers. Diabetes and hypertension were the most common associated comorbid illnesses, being seen in over 43% of the patients. CONCLUSION: Our study demonstrates that bipolar resection appears to be equivalent to monopolar resection in the performance of TURBT. The only benefit clearly demonstrated in our study is significant reduction in severe cautery artifact obtained with bipolar resection. This may allow better interpretation of the pathological sample. There was no instance of TUR syndrome in the bipolar arm, and this may be beneficial in allowing complete resection in high-risk patients without the fear of precipitating fluid-electrolyte disturbances. However, our study was underpowered to detect the statistical significance of this outcome. Other purported advantages like better hemostasis and a reduced incidence of obturator jerk and bladder perforation were not observed in our study. Further well-conducted randomized studies are required to determine the exact role of bipolar TURBT in the urologists’ armamentarium

Urovision 2020: The future of urology

Urology, as a specialty, has always been at the forefront of innovation and research. Newer technologies have been rapidly embraced and, in many cases, improved upon in order to achieve better patient outcomes. This review addresses the possible future directions that technological advances in urology may take. The role of further miniaturization of urolithiasis treatment, robotic surgery and other minimally invasive techniques is addressed. The potential for enhanced imaging and diagnostic techniques like magnetic resonance imaging and ultrasonography modifications, as well as the potential applications of nanotechnology and tissue engineering, are reviewed. This article is based on the Dr. Sitharaman Best Essay award of the Urological Society of India for 2013

Surgery for Bladder and Upper Tract Urothelial Cancer

The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy