Transurethral enucleation with bipolar (TUEB), one of endoscopic enucleation methods for the surgical treatment of benign prostatic hyperplasia (BPH), has more advantages in intraoperative hemostasis and specimen removal after enucleation. We investigated the outcomes of the TUEB using a specialized loop performed by a single surgeon.

From April 2016 to June 2021, 387 patients underwent TUEB by a single surgeon. TUEB was performed using the TURis system (Olympus) with TUEB spatula loop, which is characterized by a spatula attached to the standard tungsten wire loop. A 26-Fr continuous-flow resectoscope was used and one-lobe enucleation technique was implemented in most patients. Patients were stratified by surgery period (early period vs late period). They were evaluated 1, 3, 6, and 12 months after surgery, and then every year.

Baseline Qmax was 9.5 mL/sec and postvoid urine measured 106.6cc. Total prostate and transitional volumes were 73.1cc and 42.1cc, respectively. As for preoperative baseline characteristics, total operation time (116.0min vs 116.8min, p=0.863), detailed procedure time (enucleation time: 49.2min vs 46.1min, p=0.099; morcellation time: 26.5min vs 23.6min, p=0.162), and enucleated tissue weight (26.1g vs 27.9g, p=0.350), no significant difference was observed between groups. There were significant differences in enucleated tissue weight per time unit (g/min) (0.52 vs 0.58, p=0.037), rate of reoperation due to bleeding (9.8% vs 2.5%, p=0.002), rate of conversion to transurethral prostatectomy (TURP) (19.2% vs 1.5%, p<0.001). With median follow-up of 11.0 months, there were no significant differences at postoperative 6 months between groups in rate of de novo stress incontinence (1.4% vs 4.4%, p=0.188), urethral stricture (0% vs 1.5%, p=0.158) or bladder neck contracture (0.8% vs 0%, p=0.477).

One of the most prominent aspects of our findings is that the enucleation efficacy increased along with chronological time. This parameter is expressed as a simple fraction consisting of a numerator (enucleated weight) and a denominator (enucleation time) and this ratio was found to be increased in late group. As a consequence, we might deduce that surgeon can enucleate more adenoma as surgical experience is accumulated. The rate of reoperation due to bleeding and conversion to TURP was also decreased. As operation cases are accumulated, skills of hemostasis are suspected to get more sophisticated to achieve well bleeding control and clearer operative field to reduce reoperation and technique conversion.

In the initial experience by a single surgeon, TUEB performed with a spatula loop is a safe and effective technique for BPH treatment that brings out substantial improvement in subjective and objective symptoms. As the surgical experience increased, the proportion of bleeding-related complications and conversion to TURP decreased significantly.