BIPOLAR TURP

DEFINITION
An electrode whereby two active electrodes are
attached to a single support and having a
structure that allows high frequency electric
current to pass through these two electrodes
when electrified (International Electrotechnical
Commission 1998).
whats the need
To rule out TUR syndrome risk(2%)
To overcome time limitation.
To reduce obturator jerk & assosiated injury.
To reduce carbonization
Whats different
Electrosurgical resection, cutting energy in a
bipolar fashion rather than straight monopolar
current used in traditional TURP
Technique virtually identical except for special
bipolar electrical generator and specially
modified loops and resectoscopes
Discharge from whole loop
Low resistant electrolyte medium
Resistance:
saline - 40 ohms
glycine - 800 ohms
water - 1600 ohms
tissue - 500 ohms
blood vessle - 125 ohms
Special requirements
In bipolar system, both active and return
electrodes are contained within the instrument,
(eg, the wire loop, vaporization electrode).
The original bipolar wire loops used two parallel
wires spaced about 2 mm apart,
current models now use a single wire loop with
the electrical ground return built into the shaft
of the loop. *
Loop small &thin (loop-5mm,wire dia-.28mm)
MECHANISM
A plasma corona or field of ionization is formed
between loops, disrupting the molecular tissue bonds
that allows resection by instantaneos vaporization of
tissue along with hemostasis
the bipolar technique requires an electrolytic medium to
conduct the electrical energy from the active to the
return electrode.
High energy produces large amount of air bubble-very
high resistance in bubble- high potential discharge in
low resistant area.
Once discharge started that can be maintained
till output <100 W
Low risk of depth penetration
Heated sheath injury low.
Tissue (protein) cut by >215*c
carbonization >420*c
TURis - 300-400*c
Initiation of the cut was slower with all devices (i.e.
most pronounced with ACMI/VISTA)
Time lag 0.1 sec
higher output powers bleeding was less compared to
monopolar technology.
More importantly, the coagulation depth was
significantly reduced (141 vs. 287 micron), which could
be reconfirmed by pathological studies after TURP
(Rassler).
Overall, the energy input during bipolar was higher
compared to monopolar.
Time lag due to time taken for air bubble
formation all over loop
Overcome by initiating loop in saline (low
resistant) itself.
Increase perfusate temperature
Can be accustomed
Fluid is either warmed in a warming cabinet or
run through a fluid warmerA
Not only because it increases patient safety by
preventing hypothermia, which can occur with
longer procedures,
Because warmed saline for irrigation decreases
the lag time and allows for faster cutting .
Also by decrease flow

Collateral and penetrative tissue damage is reduced
compared to standard monopolar TURP surgery& less
granulation tissue is formed
less tissue charring occurs, which helps in identifying
the surgical capsule and other landmarks.
negates the need for diathermy pad
unwanted stimulation of the obturator nerves and
cardiac devices.

Performing TURP with saline eliminates the
possibility of TUR syndrome, so limitations in
gland size and procedure time also are
eliminated
The resected prostate chips are cleaner and have
less coagulation or desiccation defects, which
simplifies pathological examination.

Overall hemostasis is possibly slightly improved
with the bipolar instrument, although rapid
sweeping with the loop using coagulating
current is less effective than with a monopolar
system.
Direct pressure on a bleeding site is the
recommended technique (pin point coagulation)
Criteria
TURP
monopolar
Olympus
Gyrus
plasmakineti
c
Storz
bipolar
Size (F) of
resectoscope
24-26 24-26 26 24-26
Active Loop Normal size Smaller Two sizes Smaller
Neutral
Electrode
At skin
Resection
sheath
Proximal to
loop
Opposite to
loop
Life-time of
loop
Resterilisable
(100-200g)
Resterilisable
(100-200g)
Disposable
(one case)
Resterilisable
(60-80g)
View during
resection
+++ +++ +++ +++
Authors
N

Bleeding
Rate (%)
TUR-syn
drome (%)

Catheter
time (d)
Urethral
stricture (%)

Singh 2005 60
- TURP 30 0.0
3.3

3.4 0.0
- bipolar (Vista) 30 0.0 0.0 2.5 1.3
Tefekli 2005 96
- TURP 47 2.1 0.0 3.8 2.1
- bipolar (Gyrus) 49 2.0 0.0 2.3 2.1
de Sio 2006 70
- TURP 35 11.4 0.0 4.1 2.8
- bipolar
(Gyrus)
35 5.7 0.0 3.0 2.8
Patankar 2006 104
- TURP 51 3.9 3.9 1.8
n.a.
- bipolar (Gyrus) 53 0.0 0.0 0.8
n.a.
Ho 2006 100
- TURP 52 3.8 3.8 n.a 6.3
- bipolar
(Olympus)
48 6.3 0.0 2.0 1.9
Advantages of bipolar technology
Less conductive trauma (i.e. resulting to a lower rate
of bladder neck stenosis or urethral strictures)
Elimination of TUR-syndrome (i.e. hyponatremia)
Lower risk of capsular lesion (i.e. decreased
stimulation of pelvic floor)
Better visual orientation (i.e. reduced coagulation
depth)
Self-cleaning of the loop (i.e. by high energy level at
plasma ignition)
Potential disadvantages of bipolar
technology
Higher risk of conductive trauma if current
is deviated (i.e. via sheath) due to higher
energy levels for ignition of plasma (i.e.
insufficient lubrication).
Small loop - more time
Risk of recurrent bleeding due to smaller
coagulation zone.
Fluid absorption still possible, but serum
natrium cannot be used as early indicator.
Inferior quality of loops (fine resection,
durability).

Effects assosiated with circulating volume
Hyperchloremic acodosis-git,renal,cns.



future
New coagulating intermittent cutting (CIC) device uses a
constant voltage pulse current with controlled pulse intervals to
help reduce bleeding
Serum natrium cannot be used as indicator, if sodium chloride
represents the irrigant. It was emphasised, that fluid overload
with sodium chloride (i.e. following capsular perforation) may
have deleterious consequences.
Interestingly in animal studies, Ringer`s lactate proved to be
superior over sodium chloride as high conductive solution.
For detection of fluid absorption still include the injection of
ethanol, but also of nitrid oxide (NO) in the irrigation fluid.



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