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The obstacle that represents the bladder neck posterior lip after a prostate transuretral resection is, sometimes, the cause of sugtrigonal perforations when a bladder catheterization is performed after the surgery. We explain an easy procedure that allows a safe catheterization, reducing the risk of complications added to those of the surgery.
PURPOSE: We compared urodynamic and uroflowmetry improvements in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) after transurethral prostate resection, contact laser prostatectomy and electrovaporization. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in men with lower urinary tract symptoms suggestive of BPH who met the criteria of the International Scientific Committee on BPH, had a prostate volume of between 20 and 65 ml., and a Schäfer obstruction grade of 2 or greater. Before and 6 months after treatment urodynamics and free uroflowmetry were performed. RESULTS: A total of 50, 45 and 46 men were randomized to transurethral prostate resection, laser treatment and electrovaporization, respectively. Baseline characteristics were similar in the 3 groups. Detrusor contractility did not change in any of the treatment groups. The average maximum free flow rate increased by a factor of 2.4 after transurethral prostate resection, 2.5 after laser prostatectomy and 2.4 after electrovaporization. The Schäfer obstruction grade decreased by a factor of 0.3 in all groups. Obstruction (Schäfer grade greater than 2) was not noted after transurethral prostate resection or electrovaporization but it was evident in 2 patients after laser prostatectomy. Effective capacity increased by a factor of 1.5 or more. The incidence of detrusor instability was decreased by half in all groups. The incidence of significant post-void residual urine volume decreased in all groups. CONCLUSIONS: There were no significant differences in the improvement in urodynamic and uroflowmetry parameters 6 months after treatment when comparing transurethral prostate resection, contact laser prostatectomy and electrovaporization in men with lower urinary tract symptoms suggestive of BPH.
PURPOSE: We assessed the effectiveness of laser therapy versus transurethral prostatic resection in men with symptomatic chronic urinary retention secondary to benign prostatic enlargement. MATERIALS AND METHODS: This trial was multicenter, pragmatic and randomized. Analysis was done by intent to treat. Laser therapy involved neodymium:YAG noncontact visual prostate ablation, while transurethral prostatic resection was performed by standard electroresection. Patients were included in our study if they reported moderate to severe lower urinary tract symptoms with an International Prostate Symptom Score (I-PSS) of 8 or more, benign prostatic enlargement and a persistent post-void residual urine volume of more than 300 ml. Followup was 7.5 months. Primary outcome measures included the I-PSS, I-PSS quality of life score, maximum urinary flow and post-void residual urine volume. Secondary outcome measures included treatment failure, complications, hospital stay and catheterization time. RESULTS: A total of 82 patients agreed to be randomized to receive laser therapy (38) or transurethral prostatic resection (44). There were significant improvements in all primary outcomes in each group from randomization to followup. Transurethral prostatic resection was significantly better than laser therapy for I-PSS and maximum urinary flow values (p = 0.035 and 0.029, respectively) but there were no differences in post-void residual urine volume and I-PSS quality of life score between the groups. We noted significantly more treatment failures with laser therapy than resection (8 versus 0, p = 0.0014), although only 3 patients required resection after laser therapy because of persistent symptoms. In addition, hospital stay after resection was 2-fold that after laser therapy (ratio of geometric means 2.01, 95% confidence interval 1.54 to 2.61, p <0.0001). However, time to catheter removal was 9 times longer in the laser therapy group (p <0. 0001). Complication rates were significantly higher for transurethral prostatic resection (chi-square 5.05, 1 df, p = 0.025). CONCLUSIONS: Transurethral prostatic resection is more effective than laser ablation in men with chronic urinary retention in terms of symptom score, maximum urinary flow and failure. However, men who underwent resection had significantly more treatment complications and were hospitalized longer than those who received laser therapy. This finding implies that laser ablation therapy may have a role in patients at higher risk who are willing to accept a lower level of effectiveness in exchange for decreased complication rates and hospital stay.
The absorption of large volumes of irrigation fluid is a major problem in transurethral prostatic surgery (TUR-P). Various indicators have been tested to monitor fluid absorption with regard to continuous registration and sufficient accuracy. The volumetric fluid balance is not suitable as a routine method because of its inaccuracy. Easily accessible parameters are unspecific because of surgical bleeding (haematocrit [Hct]), or are interfered with by physiological counter-regulatory actions (serum sodium [Na] concentration). In 1986 Hulten et al. suggested adding 2% ethanol to the irrigation fluid as a marker and investigated it intermittently in the expired air with an alcohol-test appliance. In a prospective clinical study of 17 patients undergoing TUR-P under spinal anaesthesia, expiratory concentrations of alcohol that was added to the irrigation fluid (2% ethanol in Purisole, Fresenius, Bad Homburg) were monitored. Gas was continuously sampled from the nasopharynx through a nasal cannula and the ethanol concentration was measured using a modified diverting anaesthetic gas monitor (Normac, Datex, Helsinki) that allows continuous as well as early detection of the absorbed irrigation fluid with reliable accuracy for clinical use. In addition, at intervals of 10 minutes we measured blood alcohol, end-tidal alcohol (Alcotest 7110, Dräger, Lübeck), haematocrit, serum Na concentration, and blood gases. Sixty-eight measurements were obtained from the 17 patients. As shown in other studies, serum Na (r2 = 0.68) and Hct (r2 = 0.39) correlated poorly with the irrigation fluid as determined by serum alcohol levels. In contrast, the expiratory alcohol measurements with the Alcotest 7110 (r2 = 0.93) and Normac devices (r2 = 0.85) were closely related. Continuous monitoring of the expiratory alcohol concentration with a Normac monitor closely reflects blood alcohol concentration, and may hence serve as a useful semiquantitative monitor of irrigation fluid absorption during TUR-P.
Six cases of acute nonoliguric renal failure following transurethral prostatectomy were studied. This condition usually has a milder clinical course than the oliguric type; but some patients will need dialysis and fatalities can occur. Although it is relatively rare, every urologist shoud be aware of the entity. The first clue is usually increasing azotemia despite a normal or increased urine output.
Transurethral resection of hyperplastic prostate was carried out in 667 patients. Complications associated with the intervention occurred in 146 (21.89%) patients: intraoperative in 31 (4.6%), immediately after surgery in 68 (10.2%), and during remote period in 47 (7.04%) patients. Causes of complications are discussed, probable errors in transurethral resection are enumerated, and recommendations on prevention of complications in endosurgery for prostatic hyperplasia are offered.
This study was undertaken to analyse the results in 192 patients who 3 to 4 years earlier had undergone transurethral resection (TUR) in a controlled clinical trial on the value of a short peri-operative course of antibiotics. The survival rate was comparable in both groups. Most deaths were due to cardiovascular disease and/or cancer of the prostate and the gastrointestinal tract. Infectious events predominated in the control group and more antibiotics were prescribed for these patients during follow-up than for the patients in the peri-operative antibiotic group. Bacteriuria was found in 24% of patients, evenly distributed between the groups. Eighty-three per cent were satisfied with the results of prostatectomy but 38% complained of symptoms from the lower urinary tract. The maximum urinary flow rate was not influenced by the presence of bacteriuria and/or symptoms. There was no difference between the groups regarding mortality or morbidity except for the frequency of post-operative urethral stricture formation, which was significantly higher in the controls. It was concluded that prospective long-term follow-up is indicated to assess the effect of short peri-operative antibiotic courses.
BACKGROUND AND PURPOSE: In recent years, various minimally invasive alternatives to transurethral resection have become available for treatment of benign prostatic hyperplasia (BPH). Transurethral electrovaporization has become popular, with reported improvements in subjective and objectives measures, but a high rate of postoperative irritative symptoms and lack of tissue for histologic examination are the two most commonly reported disadvantages of this procedure. To decrease the postoperative irritative symptoms while minimizing intraoperative and postoperative bleeding and also to obtain tissue samples, we have combined the techniques of vaporization, which was termed "vapor-cut." The aim of this randomized study was to compare the efficacy and safety of vapor-cut with those of the gold standard, transurethral resection. PATIENTS AND METHODS: A series of 100 consecutive men (mean age 63.5 +/- 3.4 years) with moderate to severe symptoms of prostatism were randomized to receive transurethral resection of the prostate (TURP) or vapor-cut since November 1997. Adverse events during the procedure, including serial changes in both serum hematocrit and sodium and postoperative irritative symptoms, were recorded after removal of the urethral catheter. Preoperative and postoperative symptom scores and maximum flow rates (Qmax) were obtained from all patients. The volume of the prostate was measured preoperatively and postoperatively using transrectal ultrasonography. The mean follow-up of the patients was 6.7 months (range 6-10 months). RESULTS: The mean operative times for the vapor-cut group and the TURP group were 48.2 minutes and 42.7 minutes, respectively (P > 0.05). In the TURP group and the vapor-cut group, the International Prostate Symptom Score (I-PSS) decreased from 21.6 to 5.0 (P < 0.01) and from 19.4 to 4.0 (P < 0.01), respectively, at 6 months. The Qmax increased from 9.2 +/- 2.6 mL/sec to 24.6 +/- 3.4 mL/sec (P < 0.01) in the TURP group and from 7.9 +/- 2.1 mL/sec to 26.7 +/- 3.7 mL/sec (P < 0.01) in the vapor-cut group. The mean reductions in the weight of the prostate were 49.8% in the TURP group (P < 0.05) and 53.6% in the vapor-cut group (P < 0.05). Both catheterization time and hospital stay were significantly shorter for the vapor-cut group (P < 0.05). The decreases in the mean serum sodium concentration were statistically insignificant in both groups. However, the decrease in the mean hematocrit was statistically significant in the TURP group but not in the vapor-cut group. No patient in either group had the transurethral resection syndrome or required blood transfusion. After removal of the urethral catheter, irritative voiding symptoms, usually associated with frequency, were greater in those patients treated with TURP than in those having vapor-cut. None of the patients demonstrated sphincteric incontinence, bladder neck contracture, or urethral stricture. CONCLUSION: From our preliminary experience, vapor-cut seems to give results comparable to those of TURP. Because there is almost no bleeding during vapor-cut, the procedure is performed under excellent visibility, which permits more rapid and effective resection.
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The successful treatment of a patient who developed the TUR syndrome is described. Glycine 2.2% in water was used as irrigating fluid. Initial symptoms were visual disturbances and hypertension. Repeated blood chemistry analyses revealed elevations in the serum concentrations of most non-essential amino acids. Later on the patient experienced vivid hallucinations.
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