==inizio objective==

Trans Urethral Resection of Prostate (TURP) remains still the gold standard and it is strongly recommended for the treatment of patient with moderate-to-severe LUTS (Lower Urinary Tract Symptoms) with prostate size of 30-80 mL (1). Patients with oversized prostates > 80-100 mL undergo to traditional open prostatectomy or to a laser enucleation. Aim of our study is to analyze the surgical outcomes and the safety of bipolar plasma TURP extended to oversized prostate.

==fine objective==

==inizio methodsresults==

Since November 2018 to December 2022 we treated with bipolar plasma TURP 29 patients with a prostate volume larger than 100 mL and up to 260 mL. The average age was 69.3 years (range 51-84); the average prostate size, measured before the procedure by ultrasound, was 133.90 mL (range 100-260); at the moment of the procedure 13 patients had a bladder catheter, 23 had history of acute urinary retention, 5 had also bladder stones, and 6 had severe LUTS and Qmax between 5 and 10 ml/s at the uroflowmetry; all of them previously received pharmacological treatment for LUTS (2 only 5α-reductase inhibitor, 7 only α-blocker, and 20 combined therapy with α-blocker and 5α-reductase inhibitor).
The TURP was performed using the bipolar plasma edge technology by Lamidey Noury Medical, saline solution as medium, instrument for resection with continuous irrigation system, and High Definition video camera and 16:9 High Definition monitor. The approach for those oversized prostate was modified, mainly it was a posterior approach to remove first the large medium lobe and then the lateral lobes. The medium lobe was first isolated between 2 tunnels at 5 and 7 o’clock deep to the capsule and extended to apex preserving the veru montanum; the resection was than performed between the 2 tunnels going parallel to the posterior wall, from one side to the other, and upward to downward. For both the large lateral lobes a deep tunnel between the lobe and the prostate capsule (starting at 1 o’clock for the left lobe down to almost 4 o’clock; and at 11 o’clock for the right lobe down to almost 8 o’clock) was first made in order to allow the resection of each lobe from the lateral side to the median part.
The 5 patients with large bladder stone had the stones fragmented and removed during the same procedure, but before starting the TURP (for statistical purpose only the TURP time was calculated).

==fine methodsresults==

==inizio results==

Average operative time was 78 minutes (range 50-120); mean hospitalization time was 5 days (range 2-13); no patient had TUR syndrome, neither serum sodium level drop; no one required blood transfusion; only 4 had persistent mild haematuria that just prolonged their hospitalization time, one with a 260 ml prostate had on purpose a 2 time operation to not exceed the 1 hour time due to his co-morbidities; no other adverse events were registered. Catheter was removed after 8 days (range 3-36) and all of them could void again. After 2 months, one patient, who suffered also Parkinson’s disease preferred to have the catheter indwelled again to better manage, according to his opinion, the relapse of severe LUTS.

==fine results==

==inizio discussions==

The bipolar plasma TURP was performed using normal saline solution (NaCl 0.9%) as fluid for continuous irrigation, instead of a non conductive solution, offering the advantage of minimal absorption by the open vessels and eliminating the risk of electrolytic disorders, both TUR syndrome and the serum sodium level drop (2).
The resection with the bipolar plasma edge technology is faster with less bleeding because of the attitude of the instrument to cut, vaporize and coagulate smaller vessels at the same time. After the cutting the prostate tissue looks white, not carbonized and it is still soft for further cuttings.
We believe that the modified approach for the large lateral lobes gives 2 other important advantages. One is to set immediately the capsular limit of the resection. The second is to create a flap from the lateral lobe which is already ischemized and ready to be fast removed by lateral to median resection going from upward to downward.
We believe that both the ultimate plasma technology and the modified approach contributed to a faster and less bleeding resection, allowing a safe operative time for those oversized prostate with volume up to 200 mL.

==fine discussions==

==inizio conclusion==

According to other Authors (3) the treatment of oversized prostate with bipolar plasma TURP is an effective endoscopic technique and seems to offer surgical results equivalent to those encountered for smaller prostate volumes.
The use of saline solution and short operative time confirm the safety of the procedure also for large size prostate. In our single center study bipolar plasma TURP represents a valid alternative to open prostatectomy in large benign prostatic hyperplasia < 200 mL, up today. Because of the low cost, comparable to standard TURP, it may be used in centers that do not have yet laser equipment. Larger studies and longer follow up are mandatory to confirm our results. ==fine conclusion== ==inizio reference== 1) https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts 2) Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP).Omar MI, Lam TB, Alexander CE, Graham J, Mamoulakis C, Imamura M, Maclennan S, Stewart F, N'dow J. BJU Int. 2014 Jan;113(1):24-35. doi: 10.1111/bju.12281. Epub 2013 Oct 24. Review. 3) A Prospective Study of Bipolar Transurethral Resection of Prostate Comparing the Efficiency and Safety of the Method in Large and Small Adenomas.Mertziotis N, Kozyrakis D, Kyratsas C, Konandreas A. Adv Urol. 2015;2015:251879. doi: 10.1155/2015/251879. Epub 2015 Dec 7. ==fine reference==