Abstract
Objectives: To
report our experience, surgical results and complications of transurethral
resection of prostate for benign prostatic hyperplasia.
Methods: This is a retrospective study
of 162 patients who underwent transurethral resection of prostate for benign prostatic hyperplasia between January 2007 and January 2008 at Prince Hussein
Ben Abdullah
Urology Center.
The indications,
surgical results and the occurrence of
various complications were studied from the retrieved clinical records.
Results: Seventy-one patients (43.8%) underwent
elective transurethral resection of prostate for significant lower urinary
tract symptoms. Fifty patients (30.9%)
had resection because of recurrent urine retention that had failed a trial
without urinary catheter. The other patients had recurrent urinary tract infection
(4.3%), recurrent hematuria of prostatic origin (6.8%), renal impairment (6.2%)
or bladder stone (8.0%). Seven patients (4.3%) developed urinary tract
infection postoperatively. Secondary hemorrhage within four weeks
postoperatively developed in three patients (1.8 %). Six patients developed
urge incontinence. Urethral stricture occurred in two patients (1.2%) and one
patient developed bladder neck contracture. One patient had bladder
perforation. Only one patient (0.6%) suffered from transurethral resection
syndrome in this study. Seven patients (4.3%) required blood transfusion during
or after surgery. No episodes of immediate postoperative sepsis were
encountered. There was no postoperative mortality.
Conclusion: Transurethral resection of prostate
is considered safe with low associated morbidity rate. Accordingly, transurethral
resection of the prostate remains the ‘gold standard’ surgical treatment of
benign prostatic hyperplasia and its complications.
Key words: Benign prostatic hyperplasia, Complications,
Transurethral resection of prostate
JRMS
December 2010; 17(4): 28-34
Introduction
Benign prostatic hyperplasia
(BPH) is the most common benign neoplasm in males.(1) It
often produces chronic and progressive lower urinary symptoms or chronic
complications, leading many men to seek treatment. It has a significant impact
on the quality of life and sometimes the physical well-being of affected individuals.(2-4)
Surgical intervention remains the sole means of curing the resultant
obstruction of urinary tract.(5) The absolute indications for
surgery include refractory urinary retention, renal impairment, and hematuria
due to BPH. Urinary tract infection and bladder stone formation are also good
indications for surgical intervention. Another large group of surgical
candidates are those who had unsatisfactory medical management of lower urinary
tract symptoms (LUTS).(6,7)
Transurethral resection of the
prostate (TURP) is the most common surgical procedure for relieving symptoms of
benign prostatic hyperplasia.(8,9) Although special training
is required for surgeons performing TURP, morbidities may arise even in
experienced hands. With increased experience, improvements in operative
techniques, video endoscopy, anesthetic care and intraoperative monitoring of
fluid and electrolytes, the rates of intraoperative and postoperative morbidity
and mortality have been greatly reduced.(10,11)
Newer interventions for BPH
(transurethral microwave thermotherapy (TUMT), transurethral needle ablation,
laser prostatectomy) aim to attain the same benefits as TURP with minimal
morbidity. These procedures are
described as ‘minimally invasive procedures.(12-14) Most of
these ‘minimally invasive procedures’ appear to wane in popularity after a
short period of interest. Often, reports on such minimally invasive procedures
cite transurethral prostatectomy as the gold standard.(15,16)
This paper focuses on our
experience of TURP for BPH and associated surgical outcomes.
Methods
A total of 162 patients who
underwent TURP for BPH at Prince
Hussein Ben
Abdullah Urology
Center between January
2007 and January 2008 were included in this retrospective study. The inpatient
and outpatient records, operative reports, investigations and histology results
and discharge summaries were reviewed. The indications, the operative duration,
blood loss (need for blood transfusion), resected tissue weight, histology, changes
in hemoglobin and serum sodium level, duration of catheterization, and
complications were recorded. All patients gave a detailed history and had a
physical examination including a digital rectal examination, urine analysis,
urine culture, renal function tests, serum PSA levels, and prostatic U/S preoperatively.
Only new BPH cases without previous
prostate operations were included. Patients who had neurovesical dysfunction,
urethral stricture, bladder cancer, prostate cancer diagnosed preoperatively or
suspected of having carcinoma of the prostate because of very high PSA levels
or suspicious digital rectal examinations were excluded from this study.
The video camera-assisted TURPs
were performed by surgeons with varying degree of experience in our center,
ranging from a junior urologist under the supervision of a senior specialist to
a senior consultant. The procedure was
performed under spinal or general anesthesia and all the patients received
preoperative antibiotics.
All the procedures were done
with a size 24 or 27F continuous–flow conventional monopolar resectoscope (Storz,
Germany) and
1.5% glycine for irrigation was administered in all cases. A standard technique
was used for TURP. At the end of the procedure, a 24F double-lumen urinary
catheter was left indwelling and continuous irrigation was commenced with 0.9%
saline to maintain a clear return. Irrigation was discontinued depending on the
color of the returning fluid and the catheter was removed 48-72 hours after
ensuring clear urine. Patients were usually discharged after they could pass
urine.
All patients in the study were
followed for at least three months at the out-patient urology clinic to note
complications and to assess patient satisfaction.
Results
The mean age of patients
undergoing TURP was 67.6 years (range, 55–85 years) (Table I). Symptomatic prostatism (LUTS) was the most
common indication for TURP (43.8%). The proportion of patients operated on for
recurrent urine retention was 30.9%. In 8.0% of TURP cases, concomitant removal
of bladder calculi was done. The majority of them were removed endoscopically
using lithoclast and cystolithalopexy. Only two open cystolithotomies were done
because of large stones. The other indications for TURP are shown in Table II.
The prostate size estimated by
transabdominal ultrasound was 100g or less in all patients. Of these patients,
70 (43.2%) had a prostate larger than 50g. In the retention group, 35 patients
had a large prostate and 27 patients had preoperative bacteriuria. Other
perioperative data are shown in Table I. Prostatic adenocarcinoma was detected in
TURP chippings of four patients. All of them subsequently had either surgical
or medical castration or observation in view of their age.
|
Table I. Patient
characteristics and perioperative data obtained on patients undergoing TURP
Variables
|
Mean
|
Range
|
|
Age (years)
|
67.6
|
55-85
|
|
Hemoglobin (g/dl) - Preoperative
- Postoperative
- Drop
|
12.9
12.3
0.60
|
10-17
9-17
0 - 6
|
|
Serum Na (mEq/L) - Preoperative
- Postoperative
- Drop
|
139.3
137.2
2.1
|
132-146
121-145
1-20
|
|
PSA (ng/mL)
|
3.1
|
1.5- 4.5
|
|
Prostate size (g)
|
46
|
30-100
|
|
Weight of resected tissue (g)
|
27
|
10-70
|
|
Surgical time (min)
|
38
|
20-90
|
|
Catheter duration (days)
|
2.9
|
2-3
|
|
Hospital stay (days)
|
3.2
|
2-4
|
|
Peak flow (ml/sec) - Preoperative
- Postoperative
|
4.8
20.4
|
0-14
11-40
|
|
|
Table II. Indications for
transurethral resection of prostate
|
Indications
|
Number of patients
|
%
|
|
Symptomatic prostatism
|
71
|
43.8
|
|
Acute urinary retention
|
50
|
30.9
|
|
Bladder stone
|
13
|
8.0
|
|
Recurrent hematuria
|
11
|
6.8
|
|
Renal function impairment
|
10
|
6.2
|
|
Recurrent UTI
|
7
|
4.3
|
|
Table III. Complications of
transurethral resection of prostate
|
Complications
|
Number of patients
|
%
|
|
UTI
|
7
|
4.3
|
|
Urge incontinence
|
6
|
3.7
|
|
Reoperation -evacuation
-redo TURP
|
2
3
|
1.2
1.8
|
|
Secondary hemorrhage
|
3
|
1.8
|
|
Urethral stricture
|
2
|
1.2
|
|
Bladder neck contracture
|
1
|
0.6
|
|
Bladder perforation
|
1
|
0.6
|
|
TUR Syndrome
|
1
|
0.6
|
|
Total
|
26
|
16.0
|
|
The overall complication rate was 16.0% (Table III). The most common postoperative complication was urinary tract infection (UTI), which occurred
in seven patients (4.3%). All of them occurred in patients operated for urinary
retention who already had bacteriuria preoperatively. Two patients (1.2%) who
developed clot retention due to persistent hematuria immediately in the
recovery room were returned to theatre for evacuation and diathermy. Both of
them originally had large prostates. Only one patient (0.9%) suffered from TUR
syndrome in this study; seventy grams of prostatic tissue was resected over 80
minutes, the intraoperative serum sodium was 121mEq/L. A hypertonic saline solution with a diuretic was
given. The patient was kept under monitoring for the next 24 hours. He
responded to hypertonic saline infusions and recovered fully with no
neurological deficit.
One patient needed a bladder
neck incision for bladder neck contracture. Another two had repeated
urethrotomies because of urethral stricture.
Seven patients (4.3%) required
blood transfusion during or after TURP, each patient received on average of 1.4
units of blood. No patient developed long term urinary incontinence, non TURP related
postoperative complications or septicemia. There was no mortality in the 162
patients studied.
Average postoperative hospital
stay and average indwelling urethral catheter time were 3.2 and 2.9 days respectively.
Regarding postoperative satisfaction, nine patients (5.6%) stated that they
were ‘unhappy’ with the results of their surgery. Three of them underwent re-do
TURP for persistent obstructive symptoms. The others were found to have bladder
instability.
Discussion
Treatment options for BPH in
older men include watchful waiting, medical therapy, TURP, minimally invasive
treatments, prostatic stenting, and open prostatectomy.(17,18,19)
Patients with complicated BPH certainly require surgical intervention. Although
medical therapy is the mainstay treatment for symptomatic control of BPH,
patients who respond unsatisfactorily should not be denied the opportunity of
effective surgery.(6,20)
Although open prostatectomy
has largely been replaced by TURP, it is still practiced in our center for
prostates larger than 100g. Nonetheless, some of our urologists safely perform
transurethral resection in the form of staged TURP on huge prostates. In the
past decade, many minimally invasive procedures have been introduced worldwide
in the hope of minimizing some of the problems associated with TURP such as haemostasis
and TURP syndrome.(21,22)
In our center, the Greenlight
laser prostatectomy (Photoselective Vaporization of the Prostate) was introduced
a few months ago. TUMT was introduced in 2001 and is performed only for
selected cases. Transurethral needle ablation was tried last year on a few
cases and the results were equivalent to TUMT. Other minimally invasive
procedures are not available therefore, TURP is the most common surgical
intervention routinely practiced in our hospital for BPH.
The age of our patients (range:
55-85 years), resection time, weight of resected tissue, length of hospital
stay, and catheter duration are comparable to other series.(23-26)
Our results confirmed that TURPs are still being performed on a statistically
older male population.
As reported by many authors,(27)
symptomatic prostatism is the most common indication for TURP in our study. Most of our patients had
received medical therapy for BPH symptoms before they underwent TURP. Of the
patients who underwent TURP, the indication was BPH complications in 56.2%
(recurrent urine retention, 30.9%; chronic complications, 25.3%). These
patients had larger prostates and more tissue was resected compared with
patients who had symptomatic prostatism. Most recent series reported similar
results and argued that because of the later presentation in the disease
process, larger amounts of prostatic tissue would need to be resected in order
to achieve symptomatic improvement.(27) The other main two
factors in our study influencing the resection time and the amount of tissue
resected during TURP were the health of the patient, and the surgeon’s
preference and experience.
Compared to some series,(25)
there were relatively fewer TURPs performed because of LUTS in our study and
more patients are presenting for TURP as a result of complications arising from
prostatic enlargement. Most likely, this is because of the widespread use of
effective pharmacological agents in our country which resulted in a sharp
decrease in the number of symptomatic patients treated surgically. Borth et
al. also reported a significantly higher percentage of patients presenting
with acute urinary retention (55%) and upper tract obstructive uropathy (12.5%)
in 1998 compared with 1988 (23% and 1.3%, respectively). Also, over the 10-
year study period (1990-2000), Wilson et al. reported that patients
presenting in urinary retention requiring TURP increased from 33% to 58%, an
increase of 75.8%, whereas LUTS as an indication for TURP fell from 65% to 42%,
a decrease of 35.4%.
TURP has played an important
role in prostate cancer detection in the 1970s and 1980s. In more recent years,
with the availability of PSA and fine-needle biopsy, the importance of TURP in
prostate cancer detection declined with little effect on prostate cancer
incidence.(28,29) This is confirmed by our low incidence
(2.5%) of TURP detected prostate cancer.
The morbidity associated with
TURP is still an important issue. Problems that have not yet been overcome in
monopolar TURP include bleeding, TUR syndrome, stricture formation,
incontinence, Reoperation, and in rare cases bladder perforation.(15,30,31)
Our complications rate of 16.0% is comparable to other series in the recent
literature,(32) bearing in mind that surgeons with varying
amounts of experience were involved in our study. The main early postoperative
complication is still urinary tract infections. Lim et al.(25)
reported a fall from 25% in the 1970s and 16% in the 1980s to 6% in 1999. All
infection cases in our study occurred in patients who already had a urinary
catheter preoperatively in which bacteriuria as common. However, our low rate
of urinary tract infection (4.3%) probably reflects on the routine use of prophylactic antibiotics before surgery, and
most likely because almost all of our patients who underwent elective TURP had preoperative sterile urine cultures.
Seven patients had
intraoperative and postoperative hemorrhage requiring blood transfusions. Most
of them occurred in patients who had chronic complications and/or a large
prostate. The possible causes may be the higher percentage of recurrent
hematuria and the significant incidence of preoperative anemia in these
patients. Furthermore, it is hypothesized that because of the increasing usage
of pharmacological therapy, more patients would present later in the natural
history of the disease process for TURP. This would imply that larger glands
would be resected with longer resection times and potentially more
complications and transfusion rates.(23,26,27,33) The improvement
in the TURP technique, resectoscopes, and electrosurgical equipment has
improved endoscopic views, with better-controlled haemostasis. This improvement
is reflected in the lower transfusion rate in our study as compared to previous
years.(23,25,34) Recently, some reports have shown that
preoperative medications for two to three months with five alpha-reductase
inhibitors significantly reduce transfusion rate and hemoglobin drop or blood
loss in large prostates.(7,22,28,35)
The TUR syndrome is a
potential complication of TURP in countries where bipolar saline TURP is not
available.(36,37) The incidence of TUR syndrome in our study
was 0.6%. The reported rates range from
0.18% to 10.9%.(30,38) Our recommended TURP technique
completely removes almost all adenomatous tissue. The risk of TUR syndrome
increases with a larger prostate (>45g) or longer resection time (>90
min).(22,26,31) Therefore, limited resection techniques (minimal
TURP, channel TURP) have been introduced to reduce the morbidity of
transurethral resection, and have gained some popularity.(29,39)
Many authors claimed that inexperienced
urologists and training residents more frequently induce irrigating fluid absorption
and TUR syndrome than experienced urologists, who are capable of resecting more
tissue per unit time.(38,40) Today, the introduction of
bipolar resection devices for TURP has allowed for coagulation of tissue during
resection, using normal saline as the irrigant fluid. This technique has
reduced the potential for TUR syndrome and allowed for earlier removal of the
urinary catheter and discharge from the hospital, while simultaneously
decreasing complications, as indicated by some recent studies.(22,31)
Therefore, in this environment, the influence of a surgeon's experience on the
results and complications of TURP is questionable. Other authors have claimed
that no advantages in terms of intraoperative and postoperative bleeding,
resected tissue, catheterization time, hospital stay, operation time, or late
complications were observed for bipolar TURP as compared to monopolar TURP.(37)
Strictures of the urethra and
bladder neck occur in 1- 10% of patients after transurethral resection. This
figure has remained relatively stable over the decades.(25,26)
Our complication rate of 1.8
% is
similar to other major series. Strictures
complicate any procedure which requires urethral instrumentation, and they can
therefore be expected to occur with any one of the physical methods of
destroying prostatic tissue.(9) In our study, overzealous
resection of small prostate glands by less experienced urologists when a
transurethral incision of the prostate would suffice are contributing factors. Three
of the nine patients who were dissatisfied with transurethral resection of the prostate
underwent redo-TURP for incompletely resected prostates. All of them had
primarily large prostates and urine retention. Here, we suggest that the level
of experience is of great importance, as it indicates that resections performed
by experienced urologists should have a lower frequency of re-TURP due to
recurrent adenomas or adenomas that were incompletely resected. The other five patients who had diabetes
and/or a cerebrovascular accident preoperatively were found to have detrusor
instability postoperatively, and arguably the operation was inappropriate for
them. Therefore, we suggest that a urodynamic
study in the preoperative evaluation of such patients may be needed to rule out
the possibility of concomitant bladder dysfunction.
Urinary bladder perforation is
one of the complications of the procedure and it occurs in less than 1% of
cases in some series.(8) We had one case of bladder
perforation from TURP performed by a junior urologist during training. The
perforation was recognized during surgery and managed by laparotomy and closure
of the perforation.
Lastly, there are multiple
studies comparing TURP and other “less invasive” therapeutic options such as
microwave therapy, needle ablation, high intensity focused ultrasound, Holmium
laser resection of the prostate, and photoselective vaporization of the
prostate (PVP) with KTP laser.(41,42,43) These studies reported mainly short-term
results and showed that the “less invasive” surgical options offered less
morbidity, shorter duration of the procedure and earlier discharge from
hospital.(21,22,26,44) However, longer follow up in some
studies showed that there is a higher re-operation rate and unplanned secondary
catheterization for those who underwent “less invasive” treatments and found no
evidence of a difference in outcomes for symptoms using any of the newer
technologies for endoscopic ablation of benign enlargement of the prostate over
transurethral resection.(10,45,46)
Therefore, it is appropriate to consider these “less invasive”
treatments as alternatives to and not a substitute for TURP.
Conclusion
The findings of this study are
consistent with worldwide opinion: TURP remains the gold standard of surgical
intervention for BPH and must remain the basis for comparison. Conventional
monopolar TURP is considered safe with a low associated morbidity rate. The
introduction of video camera-assisted TURP and the development of virtual
reality training systems for TURP have enhanced training in this procedure; they
have also provided more physical comfort for the urologist and improved the
technical skills of the operating surgeons. As a result, both complication
rates and the hospital stay have been significantly reduced.
However, other technologies
are currently emerging as alternatives to TURP. None of them is capable of completely
eliminating complications. The current vogue is for laser induced prostatectomy,
which gives impressive results. Recently, transurethral resection and vaporization
(GreenLight Laser) has been introduced to our center. We will use this technique,
review our results, and compare them with our TURP experience before
introducing it into routine clinical practice.
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