Role of Prostate Ultrasonography to Predict The Efficacy of Bipolar Prostatectomy in Benign Prostatic Hyperplasia


 Background: We evaluated the role of prostatic ultrasonography to predict the clinical outcomes of Bipolar Transurethral resection of the prostate. Methods: 109 Patients complaining of lower urinary tract symptoms (LUTs) due to Benign Prostatic Hyperplasia (BPH) were evaluated preoperatively and postoperatively (at 1, 3, and 6 months) using ultrasonography (pelvi-abdominal and transrectal ), the International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual urine volume (PVR), ejaculatory domain, and the erectile function domain of the International Index of Erectile Function (IIEF-ED). The safety of the procedure was assessed by Modified Clavien classification of complications.Result: There was a close correlation between residual tissue of prostate detected by ultrasonography and clinical outcomes. The prostate volume was significantly decreased postoperatively with a concomitant significant improvement of IPSS, Qmax, and PVR over six months of follow-up (P <0.001 ). 57.8 % of the cases in this study were sexually active, and there was no significant difference in the IIEF-ED score between preoperative and postoperative evaluation.Conclusion: Prostate ultrasonography has a significant predictive value as a single investigating tool to evaluate the clinical outcomes after bipolar transurethral resection of the prostate (TURP). The maximum improvement in IPSS and ultrasonographic measurements were detected at six months postoperatively.

a risk of hemorrhage, particularly in patients with larger prostates or bleeding disorders. There is also a risk of Trans-urethral Resection (TUR) syndrome [8].
The most signi cant improvement of TURP was the incorporation of bipolar technology. The electric current completes the circuit without passing through the patient. This allows the saline solution to be used for irrigation during resection instead of electrolyte-free solutions, thereby eliminating hyponatremia and TUR syndrome with excellent hemostasis [9].
The aim of study is to evaluate the role of prostatic ultrasonography to predict the clinical outcomes of bipolar transurethral resection of the prostate.

Materials And Methods
Between December 2018 and June 2019, 109 patients were enrolled in the study and underwent bipolar TURP. Informed consent was obtained from all patients, and the institutional ethics committee approved the study.
A full medical history was obtained. The patients were evaluated preoperatively and postoperatively at (1,3,6) months using IPSS, ultrasonography, uro owmetry, and laboratory investigations (urine analysis, urine culture, serum electrolytes, kidney function, complete blood count, PSA). The patient's sexual function ( erection and ejaculation ) was assessed preoperatively and at 3,6 months postoperatively using a score derived from IIEF-ED.
Pelvi-abdominal ultrasonography and TRUS were carried out preoperatively while postoperatively at (1,3,6) months pelvi-abdominal ultrasonography was done, but TRUS was done only (3,6) months by an experienced sonographer. TRUS was not done early postoperatively at one month due to the painful manipulation of the rectal probe. Prostate volumes (total and transition zone) and PVR were estimated using TRUS and abdominal ultrasonography, respectively. Also, urinary bladder wall thickness and diverticulae were estimated by the pelvi-abdominal US.
The patients who met the following inclusion criteria were enrolled in our study, symptomatic BPH that required surgery owing to urinary retention, failed medical therapy, urinary bladder stones, obstructed uro owmetry, and IPSS more than 19. Patients with neurogenic bladder, previous prostatic or urethral surgery, prostate cancer, signi cant co-morbidities (liver failure, congestive heart failure), and Patient unable or unwilling to comply with follow-up schedule were excluded.
Under spinal anesthesia, cystourethroscopy is followed by bipolar resection of the prostate by a single experienced urologist under saline irrigation followed by a 22-F or 24-F three-way Foley catheter xation.
Operating time, length of hospitalization, intraoperative and postoperative complications, catheterization time, changes in hemoglobin levels were recorded.

Statistical Analysis
Data were analyzed using SPSS 21.0 for Windows (SPSS, USA). Normality tests (Kolmogorov-Smirnov test) were performed to evaluate the distributions of numeric variables. If the distribution of numeric variables were normal, statistical analysis was performed using parametric Student's t-tests. Mann-Whitney U-tests were used to evaluate numerical variables with a skewed distribution. Categorical variables were analyzed using chi-squared or Fisher's exact tests. The level of statistical signi cance was set at 5% (P < 0.05). A highly signi cant difference was present if p ≤ 0.001.

Discussion
According to the EAU ( European Association of Urology) guidelines, the "gold standard" approaches for surgical treatment BPH are monopolar TURP for patients when the prostate size ranges from 30 to 80 cc, and open prostatectomy or holmium laser enucleation (HoLEP) or Bipolar TURP for patients with prostate size > 80 ccs [10]. Bipolar TURP is associated with a high success rate re ected by substantial improvements in symptom scores, urinary ow rate, PVR, and low retreatment on long-term follow-up. Bipolar electrosurgical technology is a new modality, where the current ows from the loop (the active electrode) to the loop tube and the resectoscope itself [11]. In our study, 109 patients underwent bipolar TURP using saline irrigation with a good success rate postoperatively.
The correlation between prostate volume and many variables of BPH has been evaluated using different investigations, e.g., ultrasonography and cystourethroscopy. While Green et al. concluded that TRUS provided an accurate measurement of the prostate volume and could be used to evaluate the response to therapy for patients with BPH [12]. In our study, we use TRUS to evaluate the preoperative and postoperative prostate volume. We also detected that pelvi-abdominal ultrasonography is also essential for the assessment of PVR and urinary bladder changes.
The e cacy of bipolar TURP had been measured by the impact of such technique on residual prostatic tissue volume, Qmax, IPSS, and PVR, compared to baseline, which was provided at follow-up periods of 1,3 and 6 months. In our study, residual tissue measured by ultrasonography 1,3,6 months after TURP provided a good estimate of the clinical result; the correlation of the residual tissue with all outcome variables suggested that the smaller the residual tissue, the greater the improvement in the outcome variables. The explanation is that the better clinical result after TURP correlates signi cantly with the completeness of resection of the obstructing adenoma, and the maximum effect was obtained at six months.
In our study, The reported progressive decrease in the estimated residual prostate volume was associated with a dramatic improvement of IPSS, Qmax, and PVR over the six months of follow up.  [13]. ZhengX et al., in their study, indicated that bipolar TURP had improvement in 6-month IPSS, 1-, 6-and 12-month Qmax, 6-month PVR, and 3-and 6-month QoL [14]. Kumar  Suspected mechanisms in ED following TURP are thermal and/or chemical injuries of the erectile nerves traveling just beneath the prostatic capsule and may be due to the psychological effects post TURP [17,18,19,20]. In our study, according to IIEF-15 validated questionnaire, no change was observed in IIEF-ED scores at 3,6 months postoperatively compared with the preoperative scores. For the ejaculatory function, our study reported a signi cant decrease at 3, 6 months of follow up.  [22,23].
Three patients ( 2.8% ) of our study needed a blood transfusion after the surgery comparison to previously published studies where the transfusion rate in Bipolar TURP was 3.4% [24,25]. Bogdan et al., in their study, stated that 5.9% of patients who underwent Bipolar TURP needed recatheterization [21].while in this study, the cases needed recatheterization was nine patients (8.3%) due to clot retention .

Conclusion
The Pelvi-abdominal and Transrectal ultrasonography as a single non-invasive imaging tool is effective for predicting the clinical outcomes of Bipolar prostatectomy. The smaller the residual adenoma postoperatively correlates signi cantly with improvement in IPSS and bother scores mostly at six months after Bipolar TURP.

Declarations
Ethics approval and consent to participate: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all subjects .
Consent for publication: Formal consent was signed by the participants for sharing in this research.
Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests: there is no con ict of interest Funding: this research did not receive any speci c grant from funding agencies in the public, commercial, or not-for-pro t sectors.