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Keywords:

  • transurethral resection;
  • prostate;
  • day-care surgery;
  • AUA symptom score

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

OBJECTIVE

To evaluate the feasibility of transurethral resection of the prostate (TURP) as catheter-free day-care surgery.

PATIENTS AND METHODS

The study comprised 64 patients (mean age 62.4 years) with a mean (range) American Urological Association symptom score of 21.4 (9–31) and prostate volume (by ultrasonography) of 32.8 (17–50) mL, and with no significant comorbidity. The patients were admitted on the morning of the surgery and, under brief spinal anaesthesia, underwent standard TURP. After surgery the urethral catheter was removed as soon as the effluent was clear. The patients were discharged after they could pass urine freely and with a good stream.

RESULTS

The mean duration of catheterization after TURP was 7.15 h; 59 patients (92%) had their catheter removed within 10 h (mean duration 6.42 h). There were no major complications during or after TURP. After removing the catheter, no patients required its reinsertion for failure to void or for clot retention. The mean hospital stay after TURP was 10.7 h and 98% of patients were discharged within 23 h of surgery.

CONCLUSION

TURP can be conducted safely in a day surgery setting in patients with mild to moderate benign prostatic enlargement and no coexisting medical illness.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

TURP is considered the reference standard in the surgical therapy of symptomatic BOO [1] secondary to BPH; it is characterized by immediate success, as it removes the obstructing tissue, and provides prolonged improvement of symptoms and voiding variables [2]. The options available to manage BOO are prodigious; the so-called minimally invasive procedures, which include transurethral needle ablation, laser therapy and thermotherapy, attempt to decrease the high cost and morbidity associated with TURP, while striving to maintain the efficacy. Despite the availability of these options, TURP has remained an effective and widely used procedure worldwide.

TURP is a safe procedure and in the last 30 years the mortality has decreased substantially, to < 0.25% in contemporary series [3]. However, the morbidity of TURP has remained unchanged at ≈ 18%. Because BPH is a disease of older men, some comorbid conditions are unavoidable. However, the morbidity related to haemorrhage, duration of catheterization and consequent hospital stay can be improved upon. The incidence of intraoperative haemorrhage requiring blood transfusion in various series is reported to be 2.5% [3]. In the last decade various new technologies have been developed in transurethral surgery in an effort to decrease the existing morbidity of TURP, especially for blood loss during surgery. The use of improved high-frequency current in transurethral surgery is an important recent advance. Coagulating and intermittent cutting current at a pulse-modulated sinusoidal voltage of high amplitude has provided a significant decrease in intraoperative blood loss [4]. Similarly, the use of band loops results in more efficient coagulation than do standard loops [3].

The high cost of TURP and its associated morbidity are important factors in decision-making, and in choosing between surgery and other treatment options. The length of hospital stay represents a major element of the cost of TURP [5]. Various studies have reported a mean duration of hospitalization after TURP of 2–7 days [6]. Early removal of the catheter and TURP as day-care surgery are attempts to decrease the cost and morbidity of the procedure.

Considering the negligible blood loss in patients with mild to moderate benign prostatic enlargement, the present pilot study was conducted to explore the possibility of early catheter removal, leading to TURP as a catheter-free day-care procedure in an Indian setting.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The study was conducted in the authors’ institution between March 2001 and October 2002, on 64 patients (mean age 62.4 years, range 50–75) who presented to the outpatient department with significant symptoms of BOO from BPH. All patients with LUTS caused by BPH (AUA symptom score > 8), a peak urinary flow rate (Qmax) of < 15 mL/s and a prostate volume of ≤ 50 mL on TRUS, and aged < 75 years, were included in the study. Patients with clinically large prostates (> 50 mL), a bleeding diathesis or on anticoagulant therapy and with any significant medical illness that would increase the anaesthetic risk, were excluded.

All the patients selected for the study were fully evaluated before TURP, including an assessment of their symptoms using the AUA symptom score, uroflowmetry with Qmax, and routine investigations including kidney function tests, a PSA estimate, urine analysis and culture, TRUS of the urinary tract to evaluate prostate size and postvoid residual volume, and for the presence of back-pressure changes in the bladder and the kidneys, cystoscopy to evaluate the bladder and urethra, an endoscopic assessment of the prostate, and pre-anaesthetic check.

The patients were admitted on the morning of the surgery after overnight fasting. They were advised to take two tablets of laxative (bisacodyl) and an anxiolytic (diazepam) during the night. All were given one dose of prophylactic antibiotics (usually an injected fluoroquinolone, ciprofloxacin or ofloxacin). All patients but two were given a brief spinal anaesthetic using 5% lignocaine (‘heavy’) via a 26 G or 27 G spinal needle. The effect lasted about 1–1.5 h, which was sufficient for the procedure. One hypertensive patient was given epidural anaesthesia and one was operated under local anaesthesia (perineal infiltration into the prostate lobes and periprostatic tissue).

Patients were placed in the lithotomy position and a standard TURP carried out using a continuous-flow resectoscope and a single wire loop for resection, in a video-assisted endourological system. Throughout the procedure 1.5% w/v isotonic glycine was used as the irrigant. Haemostasis was meticulous; at the end of the TURP, a 22 F three-way Foley catheter was placed, the bulb inflated (20 mL) and the bladder irrigated continuously with normal saline (0.9%).

In the postoperative ward, patients were constantly monitored for pulse, blood pressure, colour of catheter drainage and any other complications, e.g. clot retention, TUR syndrome, etc. Bladder irrigation was reduced as soon as feasible, depending on the colour of the effluent. Irrigation was stopped if the drainage was clear as early as 4 h after TURP and was continued in patients with blood-tinged drainage, until clear. Where the catheter drainage was clear or pink, the catheter was removed and the duration of catheterization recorded. The patients were discharged after they could pass urine freely and with a good stream two or three times. Antibiotics (ciprofloxacin or ofloxacin) were administered routinely for 3 days after surgery. Patients were followed closely to evaluate symptomatic improvement and the development of any complication.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The mean (range) AUA symptom score was 21.4 (9–31) and 40 patients (63%) presented with severe symptoms (AUA score ≥ 20). Thirty-four patients (53%) had an indwelling catheter before TURP because they had a history of retention of urine; all these patients had failed at least one trial without catheter and hence they were considered as having severe BOO. The mean (range) Qmax in the 30 patients without a catheter was 7.3 (4–11) mL/s, and the mean postvoid residual volume (by TRUS) was 120.6 (80–264) mL. The mean prostate volume by TRUS was 32.8 (17–50) mL. The incidence of headache after spinal anaesthesia, or of hypotension, was nil because a fine-bore spinal needle was used. The mean (range) duration of surgery was 37.8 (11–60) min, and the volume of prostate resected 22.1 (5–40) mL.

The outcome was considered successful in 63 patients (98%), as the catheter was removed successfully and they were discharged within 23 h. The mean duration of catheterization in these patients was 7.15 h. In the first four patients the catheter was removed at a mean of 18 h after TURP; in the remaining 59 (92%) the catheter was removed within 10 h, with a mean duration of catheterization of 6.42 h. One patient had three episodes of bleeding and catheter traction was applied for 5 h; the catheter was removed 44 h after TURP. Statistical analysis (using Student's t-test and the Mann-Whitney U-test) showed no significant relationship of age, preoperative prostate volume or AUA scores with the duration of catheterization, and no significant correlation between catheterization time and the duration of surgery or resected prostate volume.

The patients generally voided first at 0.25–1 h after catheter removal and all were discharged after two or three successful voids, on average 2–3 h after catheter removal. The hospital stay after TURP of the 63 successful patients was 10.7 (8–22) h. Only one patient had a catheter in place for 44 h and was discharged 48 h after surgery.

No blood transfusion was required in any patient during or after surgery; there were no cases of TUR syndrome or capsular perforation. There was only one case of bleeding and another of catheter blockage by clot. After catheter removal, no patients required reinsertion of a catheter for failure to void or for clot retention. No readmission to the hospital was required for any complications. There was a UTI in 10 patients (16%), treated on an outpatient basis with appropriate antibiotics. At 6 weeks after surgery, the mean AUA symptom score had decreased from 21.4 to 6.3, the mean Qmax had increased from 7.3 to 18.3 mL/s and the mean postvoid residual volume had decreased from 120.6 to 22 mL.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Attempts at early catheter removal, and thus conducting TURP as day-care surgery, have been underway since 1991 [7–9]. The concept of TURP in an outpatient setting has been possible through improvements in instrumentation, anaesthetic management during and after surgery, and increased experience with outpatient transurethral surgery. The advent of holmium laser resection of the prostate (HoLRP) revolutionized the concept of the surgical treatment of BPH. It combines the best features of previous laser prostatectomy technologies, including minimum complications and morbidity, with the efficacy and immediacy of voiding outcomes associated with conventional TURP, while eliminating the shortcomings of earlier lasers. HoLRP is relatively bloodless surgery that results in a brief catheterization and hospital stay (typically overnight), immediate symptomatic improvement and minimal irritative symptoms [10–12]. We consider that it is possible to achieve results comparable with HoLRP using conventional TURP techniques meticulously and judiciously in carefully selected patients with BPH.

Selecting the patients is the most crucial part of outpatient surgery. The present study included only patients with smaller prostates (< 50 mL) and those with no significant comorbidity (e.g. chronic obstructive pulmonary disease or chronic arterial disease) which would increase the anaesthetic risk or affect the course of hospital stay after surgery. The mean age of patients was 62.4 years, lower than that in previous studies because of selection bias in favour of younger patients (Table 1) [6–9,13–15].

Table 1.  Comparison of results from various studies of TURP as day surgery
StudyNAge, yearsVolume resected, mLDuration of catheterization, hHospital stay, h
[ 6 ] 3885   6922   72120–168
[ 15 ]  150< 7017.2   72–120Outpatient
[ 9 ]  127   69.829.3   21.5/45.4  68.6
[ 14 ]  125   7114.7   48Outpatient
[ 7 ]    83   69.923.6< 24  72
[ 8 ]  100   7227< 24/36–40  67.2/127.2
[ 13 ]    58   68.712.58    6.54  13.9
Current    64   62.422.1    7.15  10.7

The mean volume of prostate resected (22.1 mL) was higher than that reported by Gordon [13] (12.5 mL) in his series of day-care TURP. The two other series of outpatient TURP reported a mean resection weight of 14.7 and 17.2 g [14,15]. The larger volume of prostate resected in the present series could be because we attempted radical resection in most of the patients, as we considered that it required less irrigation after surgery than in those with only the adenoma resected. Although the mean resected volume was high there were no major related complications, e.g. haemorrhage or fluid absorption. Correlation studies (Pearson's and Spearman's coefficient) detected no statistically significant correlation between either the volume of prostate resected or the duration of surgery and of catheterization.

The duration of catheterization after TURP depended primarily on the colour of the catheter effluent. As there was either a clear or lightly tinged effluent at the end of TURP the duration of catheterization was short, at 7.15 h in 63 patients. This is comparable with the results in the study by Gordon [13] in which the mean duration was 6.54 h, and 7.69 h for patients given spinal anaesthesia.

Various previous studies have recommended that the catheter can be safely removed after TURP within 24 h, with no significant increase in morbidity. The two series on outpatient TURP reported discharging patients with the catheter in place, the patients returning for catheter removal after 2 and 3–5 days, respectively. Although no patient in the present study was discharged with the catheter in place, there was no significant morbidity related to early catheter removal, comparable with previous studies (Table 1).

The mean hospital stay was ≈ 11 h, with 63 patients discharged within 23 h of surgery; in the previous studies, the mean hospital stay was 2.8–5.3 days [7–9,14,15] (Table 1). Gordon [13] reported a mean hospital stay of 13.9 h, and in that series all patients were discharged within 14 h of surgery.

There were no significant complications except UTI, in 16% of the present patients. The predominant complication in previous studies was reinsertion of the catheter, which was required in 12–14% of patients in one study [8] and 17.5% in another [13]; no patient in the present study required reinsertion of the catheter after removal.

In conclusion, TURP can be conducted safely as catheter-free day-care surgery in relatively young patients (< 75 years) with moderate BPH (< 50 mL) and with no significant comorbidity. Early catheter removal is not associated with a significant increase in morbidity. Whether this conclusion can be extended to all patients undergoing TURP requires further evaluation.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  • 1
    Gordon NSI, Hadlow G, Knight E, Mohan P. Transurethral prostatectomy: still the gold standard. Aus NZ J Surg 1997; 67: 3547
  • 2
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    Mamo GJ, Cohen SP. Early catheter removal versus conventional practice in patients undergoing transurethral resection of prostate. Urology 1991; 37: 51922
  • 10
    Gilling P, Cass C, Cresswell M, Fraundorfer M. Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 1996; 47: 4851
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    Kabalin JN, Gilling PJ, Fraundorfer MR. Application of the holmium:YAG laser for prostatectomy. J Clin Laser Med Surg 1998; 16: 217
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    Gilling PJ, Kennet KM, Fraundorfer MR. Holmium laser resection v transurethral resection of the prostate: results of a randomised trial with 2 years follow up. J Endourol 2000; 14: 757 6015
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    Gordon NSI. Catheter-free same day surgery transurethral resection of the prostate. J Urol 1998; 160: 170912
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Abbreviations
Qmax

peak urinary flow rate

HoLRP

holmium laser resection of the prostate.