What are the advantages and disadvantages of monopolar (monopolar transurethral resection of bladder tumor) versus bipolar (bipolar transurethral resection of bladder tumor) TURBT in older adult patients with potential bleeding disorders or anticoagulant use?

Comparison of Monopolar and Bipolar TURBT

For older adult patients with potential bleeding disorders or anticoagulant use, bipolar TURBT is the preferred approach due to its superior safety profile, particularly regarding reduced bleeding risk and elimination of TUR syndrome, though both techniques demonstrate equivalent oncologic efficacy.

Safety Profile Differences

Bleeding and Hemostasis

• Bipolar TURBT demonstrates superior hemostatic properties with reduced intraoperative bleeding requiring intervention compared to monopolar techniques, though some studies show comparable hemoglobin drops between techniques 1, 2, 3.
• The improved coagulation with bipolar energy is particularly advantageous in patients on anticoagulation, as preoperative anticoagulant use leads to longer catheterization times and higher transfusion rates with monopolar approaches 4.
• Blood transfusion rates tend to be lower with bipolar TURBT, making it safer for patients with baseline bleeding disorders 1, 3.

TUR Syndrome Risk

• Bipolar TURBT eliminates the risk of TUR syndrome because it uses normal saline irrigation instead of glycine, removing the risk of hyponatremia and associated complications 4, 1.
• Monopolar TURBT carries inherent risk of TUR syndrome due to glycine absorption, with complications increasing with prolonged resection times 4, 5.
• This safety advantage allows bipolar techniques to accommodate longer resection times when needed, particularly relevant for larger or multiple tumors 4, 5.

Obturator Nerve Stimulation and Perforation

• The evidence on obturator jerk is contradictory: some studies show significantly reduced obturator jerk with bipolar TURBT (4.6% vs 21.5%, p=0.013) 6, while others paradoxically show higher rates with bipolar technique 1, 3, 7.
• Bladder perforation rates are significantly lower with bipolar TURBT (6.1% vs 21.5%, p=0.039) in the highest quality randomized trial 6.
• One study showed lower hematocrit changes and fewer obturator jerks with bipolar technique (p<0.05) 1.

Oncologic Efficacy

Tumor Resection Quality

• Both monopolar and bipolar TURBT demonstrate equivalent oncologic outcomes with no significant differences in 12-month recurrence-free survival (70% vs 74%, p=0.410) 2.
• Complete tumor resection rates are comparable between techniques, with no clinically significant differences affecting cancer control 2, 3, 6.
• Neither technique proved to be a risk factor for postoperative complications in multivariate analysis of 568 patients 4.

Histopathologic Specimen Quality

• Bipolar TURBT provides superior tissue quality with significantly fewer thermal artifacts (27.5% without artifacts vs 5% with monopolar, p<0.0001) 7.
• The reduced thermal damage facilitates more accurate pathologic interpretation, particularly important for grading and staging decisions 7.
• Muscle tissue sampling rates are equivalent between techniques (64.6% vs 72.3%, p=0.345), ensuring adequate staging information 6.

Operative Considerations

Procedure Duration

• Operative times are essentially equivalent between monopolar and bipolar TURBT, with no clinically meaningful differences (approximately 1 minute longer for bipolar, p=0.536) 2.
• Bipolar technology allows for longer resection times when necessary without TUR syndrome risk, beneficial for complex cases 4, 5.

Technical Expertise

• The American Urological Association states that clinicians may use either monopolar or bipolar approach depending on their expertise with these techniques 4.
• Both approaches serve as valid standards for measuring efficacy and safety of other interventions, with the main distinguishing factor being TUR syndrome risk unique to monopolar technique 4.

Clinical Algorithm for Technique Selection

For older adults with bleeding disorders or anticoagulant use:

1. First-line recommendation: Bipolar TURBT due to:

   • Elimination of TUR syndrome risk
   • Reduced bleeding complications
   • Lower perforation rates
   • Superior tissue quality for pathology
   • Ability to accommodate longer resection times safely 4, 1, 7, 6

2. Monopolar TURBT remains acceptable when:

   • Surgeon has greater expertise with monopolar technique
   • Bipolar equipment unavailable
   • Small tumors with anticipated short resection time (<30 minutes)
   • Patient can safely discontinue anticoagulation perioperatively 4, 5

3. Critical caveats:

   • Prolonged resection times should be avoided with monopolar approaches to minimize TUR syndrome risk 4, 5
   • Preoperative anticoagulant use increases catheterization time, hospitalization, and transfusion rates regardless of technique 4
   • Age ≥75 years independently increases UTI risk (OR 2.65, p=0.036), but technique choice does not affect infection rates 4