Prostate Enlargement (BPH)

Bipolar enucleation of the prostate at low energy (Low Energy BIPOLEP)

Short answer. Bipolar enucleation of the prostate is an endoscopic procedure for an enlarged prostate (benign prostatic hyperplasia, BPH): through the urethra, with no cuts in the skin, the part of the prostate that blocks the passage of urine (the adenoma) is detached and removed, using bipolar electrical energy. In the low-energy variant (Low Energy BIPOLEP), described by Dr. Calarco, the tissue is detached mainly by separating it along the anatomical planes and less with energy, with the aim of reducing the effects of heat on the tissues and, when possible, preserving ejaculation.

Dr. Calarco has been performing BIPOLEP for about ten years. Today BIPOLEP is giving more room to HoLEP, enucleation of the prostate performed with the holmium laser: the choice of technique is made at the consultation, case by case.

Enlarged prostate: why it causes symptoms

With age the central part of the prostate can enlarge and compress the urethra. The result is a weak stream, a need to urinate often including at night (nocturia), difficulty starting, a feeling of incomplete emptying and, in advanced cases, being unable to urinate (urinary retention).

Who it may suit

• moderate or severe urinary symptoms from an enlarged prostate that do not improve enough with medication, or medication that is not tolerated;
• complications of an enlarged prostate: urinary retention, recurrent infections, bladder stones, recurrent blood in the urine or kidney damage;
• medium and large prostates: the EAU guidelines indicate bipolar enucleation as an alternative to endoscopic resection (TURP) in medium-sized prostates and to open surgery in larger ones.

The indication is set after the consultation and tests: PSA, ultrasound, uroflowmetry with post-void residual urine, symptom questionnaire (IPSS) and, in selected cases, urodynamic study or urethrocystoscopy.

How it is performed

The procedure is performed under spinal or general anaesthesia. A bipolar resectoscope, an instrument with a micro-camera, is passed through the urethra and the adenoma is separated from the capsule of the prostate following the natural anatomical plane. The detached tissue is then removed by morcellation, that is, broken into fragments and suctioned out, and sent for histological examination.

What “low energy” means: to detach the adenoma, mainly separating manoeuvres along the anatomical planes are used, performed with the instrument, while manoeuvres that use electrical energy are kept to what is necessary.

Bipolar energy works in saline solution: for this reason it does not carry the risk of “reabsorption syndrome” (post-TURP syndrome) linked to the fluids used with traditional monopolar techniques.

At the end a catheter is placed, which generally stays in for 24–48 hours. The hospital stay is usually 48 hours.

After the procedure

In the first weeks burning, an urgent need to urinate and traces of blood in the urine are common. It is recommended to drink regularly and avoid strenuous effort for a few weeks, following the instructions received at discharge.

Continence and ejaculation

After enucleation most patients recover continence; in the first weeks there may be urgency or small leaks, usually temporary. Retrograde ejaculation (semen going into the bladder instead of out of the body), on the other hand, is common after enucleation: the low-energy variant seeks to reduce this effect, with results that vary from patient to patient. Erectile function is generally not impaired by endoscopic procedures.

Possible side effects and risks

• retrograde ejaculation or reduced ejaculate volume (common);
• stress or urge urinary leakage in the first weeks, usually temporary; rarely persistent;
• blood in the urine; rarely bleeding that requires a further procedure or a transfusion;
• urinary tract infection;
• difficulty urinating after the catheter is removed;
• later on: narrowing of the urethra (urethral stricture) or of the bladder neck;
• rarely: perforation of the prostatic capsule or bladder injuries during removal of the tissue;
• risks related to anaesthesia.

Risks and alternatives (medication, endoscopic resection, HoLEP laser enucleation, other techniques) are discussed at the consultation and set out in the informed consent.

What the data show

Bipolar enucleation is a technique studied in the literature and included in the EAU guidelines. The results of Dr. Calarco’s low-energy variant will be reported on this page only together with the reference of the publication that contains them.

Where it is performed

Dr. Alessandro Calarco performs the procedure at San Carlo di Nancy Hospital, Via Aurelia 275, and at Nostra Signora della Mercede Clinic, Via Tagliamento 25, Rome, privately, under agreement with insurers or through the Italian National Health Service (SSN). Consultations by appointment are also available at the practice in Viale Aventino 38, Rome. Bookings: +39 366 6856844.

Sources

• European Association of Urology (EAU). Guidelines on the Management of Non-neurogenic Male LUTS, current edition (section on enucleation techniques, including bipolar enucleation).