Massive prostatic bleeding after transurethral resection of the prostate in a patient with a congenital pelvic arteriovenous malformation.
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A prospective randomized study of combined visual laser ablation and transurethral resection of the prostate versus transurethral prostatectomy alone.
INTRODUCTION: Visual laser ablation of the prostate (VLAP) has a clinical failure rate of up to 18% which is 3 times higher than transurethral resection of the prostate (TURP) alone. Prolonged spontaneous passage of necrotic debris is the major shortcoming of this method. Therefore combined visual laser-assisted and transurethral prostatectomy was compared to TURP alone. MATERIALS AND METHODS: 105 patients were evaluated in a prospective randomized study comparing TURP alone and VLAP combined with TURP. The patients were evaluated 1, 3 and 12 months after surgery. First VLAP was performed using a neodymium:yttrium-aluminum-garnet laser with the prolase fiber followed by standard resection of the necrotic and remaining prostatic tissue. Treatment efficacy was assessed by the American Urological Association (AUA) symptom score, measurements of peak urinary flow, residual urine volume, intraoperative bleeding, and by the occurrence of intra- and postoperative complications. RESULTS: The use of VLAP and consecutive TURP improved the AUA symptom score, urinary flow and residual volume and was comparable in all patients treated. Intraoperative bleeding was significantly reduced from 522 +/- 45 ml by TURP to 214 +/- 33 ml by VLAP+TURP (p < 0.05). There was a significant improvement in the postoperative values of the parameters observed in both groups. CONCLUSIONS: It appears that the combined method for treatment of benign prostatic hyperplasia reduced the specific intraoperative morbidity of TURP while achieving the same clinical effect as TURP alone.
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A comparison of transurethral resection of the prostate and medical treatment for the patient with moderate symptoms of benign prostatic hyperplasia.
Transurethral resection of the prostate is the most common surgical treatment for benign prostatic hyperplasia. We conducted a prospective randomized clinical trial to compare this surgery with medical treatment in men with moderate symptoms of benign prostatic hyperplasia. Of 98 men over the age of 54 years who were screened between June 1993 and June 1995, 53 were studied (25 in the surgery group and 28 in the medication group). Patients' symptoms and the degree to which they were bothered by urinary difficulties were measured with standardized questionnaires and medical evaluations. The men randomly assigned to the surgery group underwent surgery within 2 weeks after the assignment. Surgery was not associated with an impotence or urinary incontinence. The follow-up period was 1 year. Surgery was significantly associated with improvement in residual urinary volume and peak flow rate; and also in the scores for urinary difficulties, sexual performance and interference with activities of daily living (P < 0.001 for all comparisons). We concluded that for patients with moderate symptoms of benign prostatic hyperplasia, surgery is more effective than medication in improving genitourinary symptoms and enhancing the quality of life. Thus, medication as treatment should be reserved for patients who are less bothered by urinary difficulty or who wish to delay surgery.
Chlormadinone Acetate↗
Laser prostatectomy in patients on anticoagulant therapy or with bleeding disorders.
PURPOSE: Bleeding disorders or the use of anticoagulant medication are contraindications to transurethral prostate resection in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Laser prostatectomy has proved to be adequate surgical therapy with less blood loss than transurethral prostate resection. MATERIALS AND METHODS: A prospective, controlled study was done in patients at high risk (HR) with LUTS suggestive of BPH. They were treated with contact laser prostatectomy (CLP) or the combination of CLP with visual laser ablation prostatectomy (VLAP). HR was defined as bleeding disorders or anticoagulants use. As a control, men at normal risk with LUTS suggestive of BPH were treated with CLP. Patients completed validated questionnaires and underwent urodynamics at baseline and 6 months postoperatively. RESULTS: A total of 75 patients were included, namely 19 in the HR-CLP group, 11 in the HR-CLP-VLAP group and 45 in the normal risk CLP group. Obstruction relief, and symptomatic and subjective improvement were equal in all 3 groups. Effective capacity (maximum cystometric capacity minus post-void residual volume) also improved significantly in all except the HR-CLP group. Maximum urine flow improved in all groups but not significantly in the HR-CLP group. Intraoperative and postoperative complications were slightly higher in HR cases. However, blood transfusion was never necessary and there was no mortality. CONCLUSIONS: CLP and especially CLP-VLAP perform almost as well in HR cases compared with CLP in those at normal risk. These procedures are safe for men at HR with LUTS suggestive of BPH.
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Laser prostatectomy versus transurethral resection of prostate in the treatment of benign prostatic hyperplasia.
OBJECTIVE: To assess the effectiveness of laser-prostatectomy compared with transurethral resection of prostate (TURP). METHODS: This randomized clinical trial with one year follow-up, was conducted on 87 patients with benign prostatic hyperplasia (BPH) at Shohada-e-Tajrish Hospital, Tehran, Iran, from 1999 to 2003. Fifty-two patients underwent TURP and 35 patients were treated by non-contact laser prostatectomy using ND: YAG laser at 40-60 watt power and 13000-29000 jules energy settings. RESULTS: Comparing variables of urinary maximum flow and residue, changes of urine volume and severity of symptoms during consequent periods of 3, 6 and 12 months after the operation in 3 groups revealed that differences in maximum urinary flow changes were significant only in the sixth month (p<0.05). Also, changes in the severity of symptoms before and after the operation showed more decrease in the TURP group during all 3 periods of follow-up (p=0.01). In the laser prostatectomy group duration of operation (p=0.01), amount of fluid used during the operation (p<0.001) and duration of bed rest (p<0.001) were less than those of the TURP group. CONCLUSION: Laser prostatectomy can decrease duration of operation, duration of bed rest and pathogenesis following the operation in patients. Although changes in the severity of symptoms are more pronounced in TURP patients, changes in urodynamic indexes are similar in both groups.
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[Age-related changes in lower urinary tract symptoms and urodynamic parameters in patients with benign prostatic hyperplasia treated by transurethral resection of the prostate].
PURPOSE: To characterize age-related clinical and urodynamic features of patients with benign prostatic hyperplasia (BPH) treated by transurethral resection of the prostate (TUR-P). MATERIALS AND METHODS: Between July 1994 and March 2000, a total number of 451 patients underwent TUR-P in Nagoya Urology Hospital. Out of these 451 patients, 15 (3.3%) were diagnosed as having an incidental prostate cancer on pathological examination of resected prostate tissue. The remaining 436 patients (48-92 years, 69.8 +/- 7.4 years), in whom 196 (45.0%), 208 (47.7%) and 32 (7.3%) were < or = 69, 70-79 and > or = 80 years, respectively, were subjects for the present study. Their clinical features before and after TUR-P and the therapeutic effects of the treatment were evaluated in terms of aging. RESULTS: Among preoperative variables evaluated, IPSS in patients aged < or = 69 years was significantly higher than in those aged 70-79 years (p < 0.05). The QOL index was significantly higher in patients aged > or = 80 years than in those aged 70-79 years (p < 0.05). The maximum bladder capacity decreased with age from 276 ml in patients aged < or = 69 years to 211 ml in those aged > or = 80 years. Postoperatively, both maximum and mean flow rates were significantly lower in patients aged 70-79 and > or = 80 years compared to those aged < or = 69 years. There was, however, no significant age-related difference in IPSS and QOL index. The assessment of treatment effects at 3 months following TUR-P revealed that the outcomes in function as evaluated by uroflowmetry, anatomy and ultrasonic measurement of prostate volume were significantly worse in patients aged > or = 80 years compared to those in younger patients. However, there was no significant age-related difference in outcomes in subjective symptoms and QOL. CONCLUSIONS: TUR-P could be performed safely even in patients aged > or = 80 years. It is concluded that although postoperative urinary condition might be worse in older patients, they would nevertheless be satisfied with the results of TUR-P in the same way as less aged patients. As long as subjects are selected properly based on the correct diagnosis of BPH and a sufficient evaluation of operation risks, TUR-P can be expected to be performed safely and be followed by satisfaction with the treatment effects.
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[Assessment of quality of life after transurethral resection of prostate for benign prostatic hyperplasia].
The quality of life (QOL) after transurethral resection of the prostate (TURP) was studied. A total of 113 patients were operated and released, and 86 (76%) cases responded to the TURP follow-up survey. The average age was 69 years and the average time elapsed after the operation was 220 days. Data regarding the patients undergoing TURP was gathered from a questionnaire consisting of 22 questions concerning the preoperative condition and 28 about the post-operative state. Performance status was not changed post-TURP. The patients showed improvements in nocturia, pollakisuria and dysuria. These urological symptoms were in accordance with the findings of uroflowmetry and American Urological Association Symptom Index. Ten questions addressing the patients mental and physical conditions revealed that good quality was generally retained. Sexual activity showed a tendency of gradual decrease in relation to increasing age. Ejaculatory function and actual satisfaction with the sexual act were obviously damaged by the operation. TURP showed no changes in regard to morning erection, sexual desire in an arousing atmosphere, penile hardness at sex and total satisfaction with the sexual life. Social life, family life and mental status were not influenced, but the physical status of 21 (26%) of the patients was decreased by the operation and hospital stay. Over all, 78% of the patients could maintain a good quality of life in post-TURP.
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Randomized clinical trial comparing balloon dilatation to transurethral resection of prostate for benign prostatic hyperplasia.
To evaluate the effectiveness and clinical outcome of patients treated by balloon dilatation of the prostate (BDP) compared with transurethral resection of the prostate (TURP) we performed a prospective, randomized clinical trial. Fifty-one men were randomized to either BDP or TURP. Both groups demonstrated a significant decrease in symptom score from preoperative levels (TURP 13.6 to 6.0 [p < 0.05]; BDP 14.1 to 8.1 [p < 0.01] at 1 year). The TURP group improved peak urinary flows; while, after initial improvement, the balloon group returned to pre-procedure levels. At twelve months 14 of 19 BDP patients (74%) and 14 of 18 TURP patients (78%) considered themselves improved. BDP results in symptomatic improvement; however, the effect may not persist. Objective improvement after BDP does not always occur. The morbidity of BDP is low and compares favourably to that of TURP. Thus BDP does not appear to be as effective as TURP and may offer only temporary relief of symptoms.
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First clinical experience with new transurethral bipolar prostate electrosurgery resection system: controlled tissue ablation (coblation technology).
BACKGROUND AND PURPOSE: Bipolar transurethral resection of the prostate (TURP) can allow transurethral debulking of the adenoma with a lower potential for complications from systemic absorption of hypotonic irrigant. We evaluated a new bipolar double-loop resection system with a dedicated controlled ablation (Coblation) generator in this context. PATIENTS AND METHODS: In our series of 36 patients, 32 underwent transurethral bipolar loop resection, of whom 12 had prostates >50 cc (range for entire series 30-126 cc) on transrectal ultrasonography. Ten men had indwelling catheters because of urinary retention. The four other patients underwent transurethral resection of bladder tumors. After an initial learning curve of eight TURPs, some minor technical modifications were made, both to the bipolar-loop resection technique and to the hardware. The modified Vista Coblation system was subsequently evaluated by 18 other urologists in 17 other centers throughout the U.S. RESULTS: The median resected dry weight was 22 g, and the median operating-room time was 48 minutes, giving a median resection rate of approximately 1 g every 2 minutes. Two of the eight men in our learning curve required treatment for delayed bleeding problems (clot obstruction of catheter), and one of these received a blood transfusion. Transfusion was not required subsequently regardless of prostate size, even in men with larger glands. One of the patients treated for bladder tumor had a minor perforation of the posterior bladder wall, which healed with conservative management. In the multicenter experience in the U.S., there were 59 evaluable patients. The median resected weight was 23 g, and the median resection time was 55 minutes. Two men required conversion to monopolar roller coagulation for intraoperative bleeding. Most patients (80%) were discharged from hospital within 24 hours. No adverse neuromuscular stimulation occurred. CONCLUSION: This first single-center and international multicenter experience with Coblation technology for bipolar double-loop saline TURP confirms the feasibility and safety of this procedure. Subjective evaluation showed the four most important perceived benefits of bipolar over monopolar TURP to be smoother cutting action, elimination of TUR syndrome, less tissue burning (and no smell), and reduced bleeding. The results of randomized studies with this technology are awaited, while its role in bladder tumor resection remains unclear.
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Recurrent prostatic stromal tumour of uncertain malignant potential (STUMP) presenting with urinary retention 6 Years after transurethral resection of prostate (TURP).
CLINICAL PRESENTATION: A 56-year-old Chinese male with previously diagnosed prostatic stromal tumour of uncertain malignant potential (STUMP) presented with urinary retention 6 years after transurethral resection of prostate (TURP). TREATMENT AND OUTCOME: Cystoscopy showed a papillary tumour of the prostatic urethra causing near-complete obstruction. Repeat TURP was performed. He has been asymptomatic since. CONCLUSION: There has been fewer than 100 cases of this lesion reported worldwide. Definitive treatment is not well established. Longterm follow-up to monitor progression and possible recurrence is required, and repeat TURP or radical surgery may be necessary.
Biopsy, Needle↗
[Inverted urothelial papilloma: report of 151 cases].
OBJECTIVE: To investigate the clinical features, pathology, diagnosis and treatment of inverted urothelial papilloma. METHODS: A total of 151 cases of urothelial inverted papilloma were analysed retrospectively. Of the cases, 134 were male and 17 were female, with a mean age of 54 years old. Most patients complained of painless gross hematuria. The diagnosis could be established mainly by ultrasonic, intravenous urography, retrograde pyelography, cystoscope and pathology. Among them, 7 cases who had the papilloma at upper urinary tract underwent nephroureterectomy except one. One hundred and forty-four cases had the papilloma at low urinary tract, with 124 treated by transurethral bladder tumor resection (TURBT), among which 11 cases accompanying benign prostatic hyperplasia were treated by transurethral prostatic resection, 3 by transurethral resection of prostatic urethral tumor, 15 by partial cystectomy, 2 by total cystectomy. RESULTS: One hundred and eighteen cases were followed up 1 year to 12.5 years (mean 6.3 years). Intravesical recurrence was found in 5 cases. Of them 2 cases developed malignance in 8 and 30 months postoperatively, and 1 case underwent total cystectomy. CONCLUSIONS: Inverted urothelial papilloma is a benign tumor, which appears male predominant. Most of the lesions are found in the bladder. TURBT is the preferred treatment choice for inverted papilloma of the bladder. Although this disease has a good prognosis, regular follow-up observations are necessary.
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[Economic evaluation of treatment for benign prostatic hyperplasia--transurethral resection vs thermotherapy vs laser vaporization].
OBJECTIVE: Cost containment has become an important issue in medical practice because of recent bad economic conditions. We analyzed the cost of benign prostatic hypertrophy (BPH) patients and cost-effective analysis was carried out comparing transurethral resection of prostate (TURP), visual laser ablation of the prostate (VLAP) and transurethral microwave thermotherapy (TUMT). MATERIALS & METHODS: Our series consists of 95 BPH patients treated with TURP, VLAP and TUMT between January 1, 1994 and March 31, 1997. The cost for each patient was calculated (46 were treated with TURP, 31 with VLAP and 28 with TUMT). Considering the clinical outcome, cost-effectiveness was compared in 3 groups retrospectively. RESULTS: The median level of total charges (insurance points) was 59,395 points for the TURP group, 66,784 points for the VLAP group and 14,927 points for the TUMT group. The median follow-up period was 12.4 months, 46.7 months and 14.4 months, respectively. Several patients needed medication after operation in the VLAP group. In the TUMT group, 3 patients needed re-operation and 5 other needed an alternative surgical method (TURP or transurethral needle ablation) and 1 needed both methods. DISCUSSION: TUMT is the most cost-effective method, however the recurent rate is highest in the follow-up period among the three groups. The costs of recurent cases were most expensive. We should select surgical treatment for BPH very carefully.
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Seminal vesicle tissue in "resectate" of transurethral resection of prostate.
We reviewed the histologic specimens from 123 consecutive patients undergoing transurethral resection of the prostate to determine the presence of seminal vesicle tissue. Additionally, relevant patient data were collected from the records, and a questionnaire regarding pre- and postoperative sexual function was given. The incidence of seminal vesicle tissue in the resectate was 23 per cent. No significant morbidity such as acute epididymitis or impairment of sexual function was associated with the occurrence of seminal vesicle tissue in the specimens. Consequently, no prophylactic measures seem indicated in patients undergoing partial resection of the seminal vesicles in connection with transurethral resection of the prostate.
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Transurethral microwave thermotherapy versus transurethral resection of prostate.
PURPOSE: Invasiveness, delayed morbidity, and the high cost of transurethral resection of the prostate (TURP) have resulted in the proposal of transurethral microwave thermotherapy (TUMT) as an alternative and less invasive treatment. METHODS: Only a few randomized studies have evaluated the functional results of TUMT vs. TURP. Despite restricted inclusion criteria, they all concluded that TUMT is as effective as TURP in relieving subjective symptoms, but that it generally leads to less improvement in objective symptoms. RESULTS: TUMT results seem to last at least 36 months; at 1-year follow-up, the rate of repeat treatment is 3.2%. The rates of morbidity in both groups are roughly in the same range. Acute urinary retention (10-13.5%) and postoperative voiding discomfort are the main occurrences after TUMT; bleeding, retrograde ejaculation (50-80%), and urethral strictures (3.1-6.6%) occur after TURP. Cost evaluation, related only to Targis and U.S. data, favors TUMT. However, it seems likely that the overall cost of TUMT procedures may decrease if TUMT becomes a widely used technique, including fair reimbursement from private insurance companies or from social security departments in European countries. TUMT is safe and effective to treat BPH. CONCLUSIONS: Nevertheless, to date, the improvement that occurs in most variables seems to be less than that after TURP.
Humans↗
Predictives regarding outcome after transurethral resection for prostatic adenoma associated with detrusor underactivity.
OBJECTIVES: To elucidate the predictive factors regarding the treatment outcomes after transurethral resection of the prostate for symptomatic benign prostatic enlargement with detrusor underactivity. METHODS: A retrospective study was conducted in 190 patients with detrusor underactivity of 1397 men who had undergone transurethral resection of the prostate. All patients had completed the International Prostate Symptom Score and quality-of-life (QOL) questionnaires and had undergone a full urodynamic analysis before surgery. The outcomes were assessed at 3 and 12 months postoperatively using the International Prostate Symptom Score, QOL score, and peak urinary flow rate. The association between the baseline variables and improvement in the outcome variables was analyzed statistically. RESULTS: Preoperative urodynamic abnormalities included bladder outlet obstruction in 58.9% and detrusor overactivity (DO) in 32.1%. Multivariate analysis suggested that the initial level of storage symptoms, as well as the QOL score, were predictive of an improvement in the QOL. Postoperative improvement in symptoms and QOL was consistently influenced by the presence of DO before surgery. The baseline degree of bladder outlet obstruction, as well as patient age, consistently influenced the improvement in the peak urinary flow rate. CONCLUSIONS: In selected patients with benign prostatic enlargement associated with detrusor underactivity, greater baseline storage symptom scores and the presence of DO were negative predictive factors for QOL improvement. Baseline DO was also predictive of poorer improvement in the subjective symptoms after transurethral resection of the prostate. A greater degree of baseline bladder outlet obstruction positively predicted for postoperative peak urinary flow rate improvement, and patient age predicted negatively for it.
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A prospective randomized study of transurethral resection of the prostate and transurethral vaporization of the prostate as a therapeutic alternative in the management of men with BPH.
OBJECTIVE: The common goals of new surgical treatment for benign prostatic hyperplasia (BPH) are to improve subjective and objective symptoms, to decrease the risk of postoperative complications and short hospitalization. Transurethral electrovaporization of the prostate (TUVP) is a new, minimally invasive and a promising alternative to standard transurethral resection of the prostate (TURP) in the treatment of BPH. The aim of this study is to compare the efficacy and safety of these two treatment alternatives. METHODS: A prospective randomized trial of 60 patients with symptomatic BPH was performed. Preoperative and postoperative International Prostate Symptom Score (IPSS), maximum flow rates (Qmax) and complications were recorded in each patient. The volume of the prostate was measured preoperatively and postoperatively using transrectal ultrasound. RESULTS: Of the 30 patients who underwent TURP, mean hospital stay was 4.5 days. The Foley catheter was removed on postoperative day 4 following surgery. IPSS decreased from 21.6 to 5.2, Qmax increased from 9.2 to 19.2 ml/s at 3 months. Mean prostatic volume at 3 months decreased from 51.7 to 26.2 g, a 49.3% reduction. Of 30 patients undergoing TUVP, mean hospital stay was 2.5 days and the catheter was removed within 2 days following surgery. Postoperative urinary retention did not occur in any patient. IPSS decreased from 19.4 to 4.1 and Qmax increased from 7.9 to 17.7 ml/s at 3 months. Mean prostatic volume decreased from 48.9 to 27.8 g, a 43.1% reduction at 3 months. In the TUVP group, none of the patients required blood transfusions or developed clinical transurethral resection syndrome. There were no major complications. Sphincteric incontinence, urethral strictures or bladder neck contractures were not recorded. At 3 months postoperatively, 13 patients in the TURP group and 7 patients in the TUVP group had retrograde ejaculation. CONCLUSION: Our initial experience of TUVP suggests advantages over conventional TURP through reduced blood loss and shorter hospital stay. It appears to be an effective treatment for BPH; however, long-term results should be evaluated.
Electrosurgery↗
Depressed myocardial function after transurethral resection of prostate.
Cardiovascular physiologic monitoring was undertaken in 12 patients undergoing transurethral resection of the prostate with the aid of flow-directed Swan-Ganz catheter and the Automated Physiologic Profile. Cardiac and pulmonary pressures and physiologic parameters were derived pre- and postoperatively. Resecting time, body temperature, intravenous fluid administered, serum hemoglobin, and sodium also were recorded. Of the 12 patients studied, 66 per cent experienced a drop in their cardiac index as well as their left ventricular function after surgery. Myocardial function curves revealed that 7 patients (58 per cent) had decreased cardiac function, 2 had no change, and 3 had increased function. Four patients with preoperative pulmonary wedge pressures (PAW) over 9 mm. Hg experienced depressed cardiac function. Three patients were resected for over sixty minutes, and all experienced depressed cardiac function. Vital signs, serum hemoglobin, or serum sodium did not reflect this change. We believe that relative hypervolemia, undetected elevation of pulmonary wedge pressure. We believe that relative hypervolemia, undetected elevation of pulmonary wedge pressure, and prolonged resection are factors that depress cardiac function and increase the risk of cardiovascular complication in transurethral surgery.
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[Prophylactic antibiotics after transurethral resection of prostate].
We studied whether or not prophylactic use of antibiotics following transurethral resection of prostate (TUR-P) was needed. The subjects were 152 patients preoperatively passing sterile urine who underwent TUR-P. They were divided into three groups: 35 with no use of antibiotics (no prophylaxis group), 70 with one day use of antibiotics (one day-prophylaxis group) and 47 with use of antibiotics until pyuria disappeared (long term-group). The three groups did not differ in their rates of fever episodes (greater than or equal to 38.0 degrees C) during the first two weeks nor in the time of disappearance of pyuria. The no prophylaxis group and the one day-group differed statistically in their cumulative rates of bacteriuria (greater than 10(4) CFU/ml) on the postoperative third day: 4 patients (11.4%) in the no prophylaxis group and none in the one day group (p less than 0.01). On the 90th day, however, no significant difference was found in that rate: 22 patients (62.9%) in the no prophylaxis group and 32 patients (45.7%) in the one day group, 70% of the bacteria isolated from urine during the follow up were Gram positive cocci. The time to the elimination of pyuria was not influenced by the use of antibiotics. Our study suggests that postoperative antibiotics for patients passing sterile urine is not necessary following TUR-P.
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