Transurethral bipolar enucleation of the prostate (TUBE) utilizes the principles of enucleation but with the more familiar bipolar loop electrode and resectoscope. Although its adoption and development was never meant to replace the holmium laser enucleation of the prostate (HOLEP), the familiarity and availability of the instrumentation to non-fellowship trained urologists may make its implementation into routine clinical practice more likely. Herein we describe our current step-by-step technique for TUBE based on five years of experience and include perioperative outcomes .

The senior author in this study - a non-fellowship (HOLEP)-trained urologist - was asked to learn HOLEPs, but quickly abandoned them after approximately 6 months and 15 HOLEP procedures when operative times and surgical outcomes were not improving satisfactorily relative to their standard transurethral resection (TURP) experience. Wanting to continue enucleations, however, the enucleation principles were incorporated into more familiar resection bipolar devices, using the PlasmaButton (Olympus) and later the BandElectrode (Olympus).

The accompanying video illustrates a single surgeon’s technique using the Olympus BandElectrode. Channels are resected at the 5 o'clock and 7'oclock positions from the bladder neck back to the verumontanum down to the level of the capsule. These channels are connected just proximal to the verumontanum. A combination of bunt dissection and coagulation current using the resectoscope and working element the median lobe is enucleated. An anterior cut is made at the 12 o'clock position from the bladder neck to an area proximal to the sphincter complex. A lateral mucosal incision is made at the level of the verumontanum towards the anterior incision. The lateral lobes are then enucleated in a similar manner to the median lobe using blunt dissection and the coagulation current. The enucleated prostatic tissue can then be removed via morcellation through the rigid nephroscope or resected into smaller fragments and removed through the scope. Final hemostasis is achieved and a 22 French 3 way catheter is placed for continuous bladder irrigation.

A retrospective review of perioperative outcomes was performed on all patients who underwent TUBE from 2015 to 2020. Outcomes included operative time, amount of tissue recovered, resolution of urinary retention, and immediate postoperative complications.

There were 208 patients that underwent a TUBE procedure during the study period, of which 154 (74%) were performed with the plasma button and 58 (26%) with the band electrode. Prior TUR procedures had been performed in 25 (12%) of the patients (13 TURP, 5 Greenlight Laser, 7 Urolift) by referring providers. 

Median operative time was 80 minutes (range 3 to 261). The median amount of tissue recovered was 20 grams, with a maximum of up to 182 grams. There were no significant changes in either operative time or tissue resection during the study period. Morcellation was performed in 75% of patients. 

Perioperative transfusions were required in 3 (1.4%) patients. Two patients (0.9%) required a secondary endoscopic procedure for bleeding/clot retention.

Here we describe our step-by-step technique of a simplified approach to prostatic enucleation, TUBE, using the Olympus BandElectrode. Given the minimal learning curve, and familiar resection instruments, we believe TUBE presents additional option for the non-(HoLEP) fellowship-trained urologist to implement the principles of transurethral enucleation.