SEARCH

SEARCH BY CITATION

Keywords:

  • Retention;
  • prostatectomy;
  • benign prostatic hyperplasia;
  • morbidity

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Objectives

 To determine the outcome of men with acute urinary retention undergoing prostatectomy and to assess whether discharge with a catheter before subsequent planned re-admission for prostatectomy had an adverse effect on outcome.

Patients and methods

 A prospective cohort study was conducted of all men undergoing prostatectomy in five health care regions over a 6-month period in 56 hospitals where prostatectomies were performed under the care of 103 surgeons. The study included 3966 men undergoing prostatectomy, of whom 1242 presented with acute urinary retention; the complication rates and symptomatic outcome were assessed.

Results

 Compared with those who underwent elective prostatectomy for symptoms alone, men presenting with acute retention had an excess risk of death at 30 days (relative risk [RR], 26.6, 95% confidence interval [CI], 3.5–204.5) and at 90 days after operation (RR 4.4, 95% CI 2.5–7.6), and an increased risk of peri-operative complications. Although men with retention were older, had larger glands and had more comorbidity, these factors did not totally explain the excess risk. The final symptomatic outcome of men with acute retention was no different from that of men presenting for elective treatment. Men with retention who were managed by initial catheterization, sent home and subsequently re-admitted for planned operation had similar pretreatment characteristics, post-operative complications and outcomes to those who were kept in hospital throughout, although the men kept in hospital had a total increased length of stay.

Conclusions

 Men with acute retention have a high risk of developing complications after undergoing prostatectomy. We were unable to confirm that a short- term period of catheter drainage at home before re-admission for planned surgery carried increased risks of peri-operative complications.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Men presenting with acute urinary retention account for 24% and 42% of all patients undergoing prostatectomy in North America and Britain [ 1[2][3][4][5]–6]. The outcome of surgery in this group has not been documented thoroughly, although the presence of a urethral catheter results in bacterial colonization of the bladder at a rate of 4% per day [ 7], increasing the risk of peri-operative sepsis. It remains common practice in the UK to allow men who present with acute retention to return home for a short period after catheterization to await subsequent planned re-admission for surgery, on the grounds that this decreases peri-operative in-patient stay and facilitates the planning of operating lists. Before the start of the National Prostatectomy Audit, the steering group wished to describe the characteristics of men presenting with acute retention and to explore the suggestion that discharge home with a catheter before operation might have an adverse effect on peri-operative outcome.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Information on the hospital stay of 5361 men undergoing prostatectomy under the care of 103 surgeons in five health care regions in the UK (Mersey, Northern, South-west Thames, Trent and Wessex) were collected prospectively over a 6 month period. The details of the methodology have been reported in detail previously [ 8]. Briefly, data on admission, discharge and the outcome 3 months after operation were collected. The particular variables pertinent to the present report were: the presence of acute retention, renal function, ASA classification of physical status, type and duration of surgery, resected weight of prostate, length of stay, complications including death, use of antibiotics and histology of the resected tissue. Mortality data were obtained from the Office of Population Census and Surveys (OPCS). The second component consisted of data on patient-defined outcome collected 3 months after operation.

Statistics

Completed data were available on 5361 men who represented 89% of those undergoing prostate surgery during the study period [ 8]. The present report compares the outcome of 2724 men undergoing prostatectomy for symptoms alone with 1242 who had acute retention. For the purposes of this study, the following men were excluded; those who had known prostate cancer, those with chronic retention (defined as residual urine >300 mL) or acute-on-chronic retention (significant improvement in renal function after catheterization), men with a pre-operative creatinine level of >295 μmol/L or a urea level of >15 mmol/L, and those for whom data on renal function were missing. This left 3966 cases for analysis. However, data from patients who had been excluded were analysed and reported to determine whether the results were similar to men with acute retention or those undergoing operation for symptoms. Data from the 3 month follow-up were available for 83% of patients.

Statistical tests

Differences in proportions were analysed using chi-square tests with correction for continuity, or Fisher’s exact test as appropriate, and differences between means were assessed using Student’s t-test. Possible associations between acute retention and outcome measures found on univariate analysis were further explored by linear logistic models controlling for possible confounding factors [ 9]. The relationship between possible confounding variables and the outcome measure of interest was first tested using forward stepwise analysis. Any significant factors identified were then entered first in a final model to determine the independence of the relationship between acute retention and the particular outcome measure. Significance was taken at P=0.01 level using two-tailed testing.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Characteristics of men presenting with acute retention

A total of 1242 of the 5361 men (23%) presented with acute retention of urine; 1395 men were not included in this study, most having chronic retention (n=699) or missing data on renal function (n=424). The remaining men underwent elective surgery for LUTS alone without prior catheterization (n=2724). The proportion presenting with acute retention varied between hospital units (range 0–56%, mean 32, sd 13.6; n=56). Such men were older, had higher ASA grades and increased pre-operative creatinine and urea levels than men admitted electively ( Table 1). There was a significant trend to lower social class in the acute retention group (chi squared 50.2, P<0.001) which disappeared when patients admitted privately were adjusted for (most private patients having operations for symptoms alone), but when this effect was adjusted for social status, it did not appear to influence clinical or symptomatic outcome. Similar proportions in both groups were undergoing their second or subsequent prostate operation (10.9%vs 10.1%, P=0.45). Most men with acute retention received peri-operative prophylactic antibiotics (86%), but the proportion varied between different units, with 74 units (78%) using antibiotics in ≥75% of patients and 13 units (14%) using antibiotics in ≤50%. A similar proportion of men with acute retention were operated upon by a consultant compared with the symptom-only group (71.0%vs 73.5%, P=0.11), this having no apparent effect on outcome. The type and duration of surgery performed is shown in Table 2.

Table 1.  Number (%) of men undergoing prostatectomy for acute retention or symptoms alone by age, pre-operative creatinine and urea level and ASA grade (Grade 1, normal healthy patient; Grade 2, patient with mild systemic disease; Grade 3, patient with severe systemic disease that limits activity but is not incapacitating; Grade 4, patient with incapacitating systemic disease that is a constant threat to life; Grade 5, moribund patient not expected to survive 24 h with or without an operation) Thumbnail image of
Table 2.  Characteristics of surgery performed on men undergoing either open or transurethral prostatectomy (TURP) for acute retention or symptoms alone. Theatre time and resected weight refer to TURP only Thumbnail image of

 Men with acute retention had an increased risk of peri-operative morbidity. Adverse events occurring during hospital stay are detailed in Table 3. Large prostate size (resected weight >40 g; chi squared 21.8; P<0.001) and comorbidity (ASA grade >2; chi squared 7.8; P<0.005) were confounding variables associated with intra-operative complications (chi squared 48.8, P<0.001). When this was taken into account the association of acute retention with increased morbidity remained significant (chi squared 6.4; P=0.001). Patient characteristics associated with the need for transfusion were large glands (chi squared 137; P<0.001) and age >70 years (chi squared 33.4; P<0.001); taking these factors into account the association with acute retention was no longer highly significant (P<0.04). However, presentation with acute retention was the only patient characteristic significantly associated with the requirement for a second operative procedure, usually for bleeding (chi squared 7.2; P<0.007). Although acute retention was significantly associated with the occurrence of major postoperative complications, several confounding factors including age (chi squared 11.1; P<0.001), comorbidity (chi squared 13.4; P<0.001) and gland size (chi squared 9.8; P<0.002) reduced its influence in multivariate analysis (P<0.07). Not surprisingly, operative factors including an operative duration >1 h, blood loss, difficulties during surgery and the need for a second procedure were all strongly associated with the occurrence of major post-operative complications. Unsuspected prostatic carcinoma was found in 19.2% of men with acute retention, compared with 16.0% of the remainder (chi squared 5.2, P=0.02); this difference was accounted for by the greater age of men with acute retention.

Table 3.  Number (%) of men suffering complications in hospital and mortality. TUR syndrome comprises confusion, hypotension and hyponatraemia <48 h after surgery Thumbnail image of

 Hospital and OPCS-reported mortality rates are given in Table 3. The higher death rate at 90 days in men with acute retention remained significant (chi squared 10.3; P<0.0015) when the independent confounding factors of malignant histology (chi squared 8.6; P<0.003) greater age (chi squared 18.8; P<0.001) and higher ASA grade (>2; chi squared 73.5; P<0.001) were taken into account. Interestingly, the occurrence of major complications was the only marker of post-operative morbidity statistically associated with increased 90 day death rates (chi squared9.7; P=0.002; relative risk, RR=3.0, 95% CI 1.5–5.9).

 Overall, 9.2% of men with acute retention could not pass urine after prostatectomy and were sent home with a catheter, which was stated to be permanent in 0.9%. This compares with rates of 2.3% and 0.1%, respectively, in men who underwent surgery for symptoms alone (chi squared 87.2, P<0.001).

 There were no differences in the incidence of adverse events reported by men with acute retention compared with those with symptoms alone in the 3 months after discharge; about 30% consulted their GP and about 10% were readmitted to hospital (over a half of these were planned re-admissions for the removal of a catheter, etc.). Symptomatic outcomes were also similar in both groups, with only minor statistically significant but clinically unimportant differences being found ( Table 4).

Table 4.  The proportion of men presenting to each hospital unit (n=56) with acute retention who were sent home with a catheter to await subsequent prostatectomy Thumbnail image of

Men sent home after catheterization and those treated during the same admission

Six hundred and forty-nine (52.3%) men catheterized for acute urinary retention underwent surgery during their initial hospital stay, at a mean (sd, range) of 6.2 (7.1, <1–84) days after admission. In contrast, 559 (45.0%) men with acute retention were sent home with a catheter; planned surgery took place within 1 month in half the cases and within 3 months in 88%. These proportions varied between hospitals ( Table 4); data were missing in 34 (2.7%) men. Men kept in hospital stayed a mean of 5.0 days (95% CI 4.1–6.0; P<0.001) longer than men sent home with a catheter. This comprised an extra 4.1 days (95% CI 3.4–4.8; P<0.001) before surgery and an extra 1 day (95% CI 0.5–1.6; P<0.001) afterward.

 There were no differences in age, ASA grade, creatinine level or other pre-operative variables between men discharged before surgery and those kept in hospital. Peri-operative antibiotics were given in 86% of patients in both groups. Men who underwent surgery during the original admission were more likely to require a second procedure for bleeding (4.6% vs. 1.7%, P=0.004, RR 2.8, 95% CI 1.3–6.0). In addition, uncomplicated post-operative urinary infection was more common in men who had been sent home before surgery (15.6%vs 9.5%, chi squared 9.5, P=0.002); consequently more men in this group received antibiotics after operation (53.7%vs 45.9%, chi squared 6.5, P=0.01). More men who stayed in hospital before surgery were unable to pass urine after operation (10.9%vs 7.2%), but the difference was not significant (P=0.04). Hospital and OPCS-reported mortality was similar for men sent home and those kept in hospital (OPCS 90 days; 3.0%vs 3.1%, P=1.00). Symptomatic outcome was no different in men who were discharged home compared with those who were kept in ( Table 5).

Table 5.  Results of self-administered outcome scores in men presenting with acute retention (n=1242), those undergoing prostatectomy for symptoms alone (n=2724), men presenting with acute retention who were sent home before prostatectomy (n=559) and those with retention who stayed in hospital (n=649). The instruments used were the AUA-7 symptom score (range 0–35), a 7-question symptom bother score linked to symptoms contained in the AUA score (bother, range 0–28), an 8-question disease-specific quality-of-life assessment (SQoL, range 0–30) and a generic quality-of-life score (GQoL, range 0–33). In each case, lower scores indicate a lesser degree of impairment. Scores before surgery were completed by recollection (pre-op) and at 3 months after surgery (post-op). For each complete dataset the change in score after surgery was calculated. Results are expressed as mean group score with n=number of men (%) completing each or both parts of each instrument. The difference between groups is expressed as the mean (95% CI) Thumbnail image of

Excluded men

Aside from chronic retention, the largest single category of excluded men were those in whom the pre-operative creatinine or urea assessment was missing. In such men it was not possible to be sure whether they had chronic retention, acute-on-chronic retention or acute retention. The outcome in these men with respect to peri-operative complications and death was worse than men operated on electively, but similar to those with acute retention. A greater percentage of the excluded men were discharged with a catheter after surgery, suggesting that they had greater impairment of detrusor function consistent with a diagnosis of chronic retention. In multivariate analysis, adding the diagnoses of chronic retention, acute-on-chronic retention or a persistently increased creatinine (>295 μmol/L) or urea (>15 mmol/L) did not alter differences in outcome for either elective and acute-retention groups.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The proportion of men undergoing prostatectomy for acute retention in this study was similar to that found in previous British series [ 1, 2, 8, 10, 11] suggesting that these men form a consistently present subgroup who will usually need an operation. They are older and less fit than those who present only with symptoms. The present results confirm the view that men with acute retention have larger prostate glands and more often need open surgery [ 12, 13] or a longer transurethral resection.

 More men with acute retention suffered in-patient complications [ 14]. The increased OPCS-notified mortality at 30 and 90 days after acute retention supports previous data [ 14] that these men are at high risk of developing peri-operative complications. Part of this increased risk may be explained by increased ASA grade and age, factors that are known to be risk factors for complications after prostatectomy [ 3, 11, 15[16][17][18][19]–20]. Men with acute retention also had larger prostates and hence greater operative duration [ 21]; previous data show that longer resection times are closely related to risks of major morbidity [ 3].

 Men with and without acute retention reported a similar proportion of late complications after discharge. We were unable to confirm that the presence of a catheter before surgery in men with straightforward acute retention significantly increased the risk of delayed infection or secondary haemorrhage. Failure to void on removal of the catheter occurred more often after retention than in men undergoing elective prostatectomy. This finding suggests that acute retention is associated with failure of the detrusor muscle.

 One way of managing acute urinary retention is to place a catheter and send the man home to await planned prostatectomy. The present study audited this practice amongst urological units in England. Prolonged catheterization leads inevitably to bacterial colonization of the urinary tract and might increase the risks of sepsis. The study showed an increased risk of simple urinary infection in men sent home with a catheter, but despite the large sample size, no increased risk of major infective complications was detected, suggesting that this risk may be avoided by the use of peri-operative antibiotics. Men sent home with a catheter had just as good a result as those who were operated on within a few days, and actually had a shorter stay in hospital, albeit at the expense of waiting at home for admission. These findings suggest that a period of time at home may have improved their fitness for surgery and allowed detrusor function to recover whilst the bladder was catheterized.

 A source of concern in actively pursuing a policy of catheterization in the community whilst waiting urgent urological assessment and admission for surgery would be the stringent requirement to identify ill men or those with sepsis, and those with chronic retention or acute-on-chronic retention who have impaired renal function. Men with chronic retention and acute-on-chronic retention were excluded from this analysis. Such men need admission to allow renal failure to be treated and to deal with the major changes in fluid and electrolyte balance which may occur after catheterization.

 In conclusion, men with acute retention are at increased risk of death and complications after prostatectomy; this is only partly accounted for by age, comorbidity and renal impairment. The future management of uncomplicated acute retention presents a fertile field for collaboration between GPs, community urological nurses [ 22] and urologists. The study showed that when a man develops acute retention of urine it is safe for him to be catheterized and sent home to await an elective prostatectomy in the next few weeks, provided he is not ill, septic, uraemic or dehydrated. It follows logically that a GP or community nurse could catheterize such patients, check that the catheter was properly maintained and that infection is prevented; the urologist could then plan the admission as an urgent elective case, the danger being that in routine clinical practice some high-risk men would not be identified.

NORTHERN

Mr T.G. Armitage (South Tyneside District Hospital), Mr P.M. Atkinson (Darlington Memorial Hospital), Mr R.G. Bentley (Hexham General Hospital), Mr P.J. English (Dryburn Hospital), Mr J.G.W. Feggetter (Ashington Hospital), Mr E.L. Gilliland (North Tees General Hospital), Mr R.R. Hall (Freeman Hospital), Mr J.R. Hindmarsh (South Cleveland Hospital), Mr R. Hole (South Cleveland Hospital), Mr F.J. Holmes (North Tyneside General Hospital), Mr I.A. Miller (Queen Elizabeth Hospital), Professor D.E. Neal (Freeman Hospital), Mr C. Parker (Sunderland Royal Infirmary), Mr R. Pollard (North Tyneside General Hospital), Mr P.H. Powell (Freeman Hospital, Newcastle), Mr P.D. Ramsden (Freeman Hospital, Newcastle), Mr J.R. Rhind (Hartlepool General Hospital), Mr D.G. Richards (West Cumberland Hospital), Mr C. Roberts (Bishop Auckland General Hospital), Mr R.R. Roy (Sunderland Royal Infirmary), Mr W.G. Staff (Westmorland County Hospital), Mr R.W. Thomson (North Tees General Hospital), Mr R.Y. Wilson (Furness General Hospital), Mr Vadanan (Queen Elizabeth Hospital), Mr R.G. Willis (Cumberland Infirmary), Ms. J. Whiteway (South Cleveland Hospital).

WESSEX

Mr G.F. Abercrombie (St Mary’s Hospital, Portsmouth), Mr F.J. Bramble (Bournemouth General Hospital), Mr C.A. Charlton (Royal United Hospital), Mr T.J.C. Cooke (Salisbury General Hospital), Mr J. Cumming (Southampton General Hospital), Mr P. Donaldson (St Mary’s Hospital, Isle of Wight), Mr M. Harrison (Royal Hampshire County Hospital), Mr P.J. Jeffery (Weymouth and District Hospital), Mr J.D. Jenkins (Southampton General Hospital), Mr M.G. Johnson (Weymouth and District Hospital), Mr D.B. Mackie (Salisbury General Hospital), Mr G.S. McIntosh (Salisbury General Hospital), Mr D. Meikle (Weymouth and District Hospital), Mr C.U. Moisey (Royal United Hospital, Bath), Mr B. Morgans (Princess Alexandra Hospital), Mr J. Iacovou (Princess Margaret Hospital, Swindon), Mr A.B. Richards (Basingstoke District Hospital), Mr J.S. Rundle (Bournemouth General Hospital), Mr C.J. Smart (Southampton General Hospital), Mr B.H. Walmsley (St Mary’s Hospital, Portsmouth), Mr J. Vinnicombe (St Mary’s Hospital, Portsmouth), Mr T. Walsh (St Mary’s Hospital, Isle of Wight).

MERSEY

Mr T. Brightmore (Chester Royal Infirmary), Mr R. Crosbie (Arrowe Park Hospital, Upton), Mr A. Desmond (Broadgreen Hospital Trust, Liverpool), Mr J. Elkington (Arrowe Park Hospital, Upton), Mr M. Fordham (Broadgreen Hospital Trust, Liverpool), Mr G. Foster (Chester Royal Infirmary), Mr M. Heal (Leighton Hospital Trust, Crewe), Mr Holden (Macclesfield District General Hospital), Mr J. Kane (Chester Royal Infirmary), Mr W. Lloyd-Jones (Broadgreen Hospital Trust, Liverpool), Mr D. Machin (Fazakerley Hospital, Liverpool), Mr J. Massey (Whiston Hospital Trust, Prescot), Mr K. Parsons (Royal Liverpool), Mr J.E. Pollet (Halton District General Hospital), Mr C. Powell (Leighton Hospital Trust, Crewe), Mr J. Shennan (Arrowe Park Hospital, Upton), Mr Soin (Walton Hospital, Liverpool), Mr Williamson (Fazakerley Hospital, Liverpool), Mr Vesey (Southport and Formby District General Hospital), Mr K. Woolfenden (Royal Liverpool University Hospital), Mr Wu (Walton Hospital, Liverpool), Mr R. Ewing (Halton District General Hospital).

TRENT

Mr J.K. Wightman, Miss R. Styles (Chesterfield Royal Hospital).

SOUTH-WEST THAMES

Mr E.C. Ashby (Royal West Sussex Hospital, Chichester), Mr M.J. Bailey (Epsom Hospital), Mr R.C. Beard (Worthing Hospital), Mr P.J.R. Boyd (St Helier Hospital, Carshalton), Mr P. Britton (Royal West Sussex Hospital, Chichester), Mr J. Bull (Crawley Hospital), Mr C.R. Charig (Epsom Hospital), Mr R.S. Cole (St Peter’s Hospital, Chertsey), Mr J. Davenport (St Peter’s Hospital, Chertsey, Mr G. Das (Mayday, Thornton Heath), Mr J.A. Dick (Kingston Hospital), Mr B.W. Ellis (Ashford Hospital), Mr S. Ghazali (Queen Marys Hospital, Roehampton), Mr E. Gordon (St George’s Hospital, London), Mr H. Hills (St Peter’s Hospital, Chertsey), Mr N.G. Hopkins (Crawley Hospital), Mr M.C. Jennings (East Surrey Hospital, Redhill), Mr C. Jones (St Helier Hospital, Carshalton), Mr M. Lavelle (Princess Royal Hospital, Haywards Heath), Mr J. Maynard (Princess Royal Hospital, Haywards Heath), Mr R.G. Notley (Royal Surrey Hospital), Mr E. Palfrey (Frimley Park Hospital), Mr D. Parr (Worthing Hospital), Mr T.G. Rao (St Peter’s Hospital, Chertsey), Mr P. Rid le (Parkside Hospital, Wimbledon), Mr Rogers (New Victoria Hospital, Kingston-Upon-Thames), Mr M. Royle (Princess Royal Hospital, Haywards Heath), Mr F.A.W. Schweitzer (Royal Surrey Hospital, Guildford), Mr R.A.P. Scott (Royal West Sussex Hospital, Chichester), Mr R. Southcott (Mayday Hospital, Thornton Heath), Mr B. Ujam (Mayday Hospital, Thornton Heath), Mr C. Woodhouse (St George’s Hospital, London), Mr Yates-Bell (Ashstead Hospital).

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We are particularly grateful to Professor J.P. Blandy who helped greatly in the drafting of this manuscript. The study was funded by a grant from the Department of Health to the Surgical Audit Unit. Mr R. Pickard is funded by the Northern Counties Kidney Research Fund. The Prostatectomy Audit Steering Group consisted of: D.E. Neal, Professor of Surgery, University of Newcastle upon Tyne; Nick Black, Reader in Public Health Medicine, London School of Hygiene and Tropical Medicine; Mark Fordham, Consultant Urologist, The Royal Liverpool Hospital, Liverpool; Mark Harrison, Consultant Urologist, Royal Hampshire Count Hospital, Winchester; M.P. McBrien, Consultant Surgeon, The West Suffolk Hospital, Bury St. Edmunds; R.E. Williams, Consultant Urologist, The Royal Infirmary, Leeds; Klim McPherson, Professor of Public Health Epidemiology, London School of Hygiene and Tropical Medicine; John Blandy; Professor of Urology, London Hospital Medical College; H. Brendan Devlin, Director, The Surgical Epidemiology and Audit Unit, The Royal College of Surgeons of England. We are indebted to the following surgeons and their junior staff for their enthusiastic participation in the National Prostatectomy Audit.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • 1
    Chilton CP, Morgan RJ, England HR, Paris AMI, Blandy JP A critical evaluation of the results of transurethral resection of the prostate. Br J Urol 1978; 50: 542 6
  • 2
    Malone PR, Cook A, Edmonson R, Gill MW, Shearer RJ Prostatectomy: patients’ perception and long term follow up. Br J Urol 1988; 61: 234 8
  • 3
    Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989; 141: 243 7
  • 4
    Malenka DJ, Roos N, Fisher ES et al. Further study of the increased mortality following transurethral prostatectomy: a chart-based analysis. J Urol 1990; 144: 224 8
  • 5
    Mud DG, Deans GT, Lee BG Prostatectomy in a district hospital. J Roy Coll Surg Edin 1990; 35: 365 8
  • 6
    Lynch TH, Waymont B, Beacock CJM, Dunn JA, Hughes MA, Wallace DMA Follow up after transurethral resection of prostate: who needs it. Br Med J 1991; 302: 27
  • 7
    Garibaldi RA, Burke JP, Dickman ML, Smith CB Factors predisposing to bacteriuria during indwelling urethral catheterisation. New Engl J Med 1974; 291: 215 9
  • 8
    Emberton M, Neal DE, Black N et al. The national prostatectomy audit: the clinical management of patients during hospital admission. Br J Urol 1995; 75: 301 16
  • 9
    Doll HA, Black NA, McPherson K Transurethral resection of the prostate for benign prostatic hypertrophy: factors associated with a successful outcome at 1 year. Br J Urol 1994; 73: 669 80
  • 10
    Doll HA, Black NA, McPherson K, Flood A, Williams G, Smith J Mortality, morbidity and complications following transurethral resection of the prostate for benign prostatic hypertrophy. J Urol 1992; 147: 1566 73
  • 11
    Thorpe AC, Cleary R, Coles J, Vernon S, Reynolds J, Neal DE Deaths and complications following prostatectomy in 1400 men in the northern region of England. Br J Urol 1994; 74: 559 65
  • 12
    Roos NP & Ramsey EW A population based study of prostatectomy: outcomes associated with differing surgical approaches. J Urol 1987; 137: 1184 8
  • 13
    Crowley AR, Horowitz M, Chan E, Macchia RJ Transurethral resection of the prostate versus open prostatectomy: long-term mortality comparison. J Urol 1995; 153: 695 7
  • 14
    Doll HA, Black NA, McPherson K, Williams GB, Smith JC Differences in outcome of transurethral resection of the prostate for benign prostatic hypertrophy between three diagnostic categories. Br J Urol 1993; 72: 322 30
  • 15
    Cullen DJ, Apolone G, Greenfield S, Guadagnoli E, Cleary P ASA physical status and age predict morbidity after three surgical procedures. Ann Surg 1994; 220: 3 9
  • 16
    Seacroft V & Goldacre M Measures of early postoperative mortality: beyond hospital fatality rates. Br Med J 1994; 309: 361 6
  • 17
    Holtgrewe HL & Valk WL Factors influencing the mortality and morbidity of transurethral prostatectomy: a study of 2015 cases. J Urol 1962; 87: 450 9
  • 18
    Melchior J, Valk WL, Foret JD, Mebust WK Transurethral prostatectomy in the azotemic patient. J Urol 1974; 112: 643 6
  • 19
    Roos NP, Wennberg JE, Malenka DJ et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. New Engl J Med 1989; 320: 1120 4
  • 20
    Concato J, Horowitz RI, Feinstein AR, Elmore JG, Schiff SF Problems of comorbidity in mortality after prostatectomy. J Am Med Assoc 1992; 267: 1077 82
  • 21
    Melchior J, Valk WL, Foret JD, Mebust WK Transurethral prostatectomy: computerised analysis of 2,223 consecutive cases. J Urol 1974; 112: 634 42
  • 22
    Grose K, Brooman PJC, O’Reilly PH Urological community nursing: a new concept in the delivery of urological care. Br J Urol 1995; 76: 440 2