Perioperative management of transurethral surgery for benign prostatic hyperplasia: A nationwide survey in Japan

Authors


Kikuo Okamura M.D., Ph.D., Division of Urology, Department of Surgery and Intensive Care, National Center for Geriatrics and Gerontology, 35, Gengo, Morioka-cho, Obu 474-8511, Japan. Email: kokamura@ncgg.go.jp

Abstract

Objectives:  Various types of minimally invasive surgical treatments, including transurethral resection of prostate (TURP), are being carried out in Japan for patients with benign prostatic hyperplasia (BPH). The aim of the present study was to elucidate the current status of perioperative care for these treatments by carrying out a nationwide survey.

Methods:  Assisted by the Japanese Endourology and ESWL Association, perioperative data from 157 institutions participating in this survey were collected and analyzed.

Results:  This survey included 3918 patients undergoing TURP, 242 TUR in saline (TURis), 638 holmium laser enucleation of the prostate (HoLEP), 90 holmium laser ablation (HoLAP) and 241 photoselective vaporization (PVP). Mean operative time was shorter in TURP (71 min) and longer in HoLEP (127). Although no transfusions were required in cases undergoing HoLAP or PVP, blood was frequently transfused in those undergoing TURis (25.6%), TURP (10.2%) and HoLEP (7.8%), and the difference was significant. During the hospital stay, the incidence of TUR-syndrome, postoperative bleeding requiring bladder irrigation, acute urinary retention/difficulty on micturition and pad use at discharge was highest in TURP (2.3%), TURis (7.9%), HoLAP (16.7%) and HoLEP (15.1%), respectively. Two patients undergoing TURP died (0.05%). The shortest mean postoperative hospital stay was for PVP (1.6 days, even if the readmission rate within 90 days was the highest in this same group; 6.2%). Perioperative care during hospital stay varied among the five types of procedures.

Conclusions:  This survey provides useful documentation on the current status of minimally invasive treatments for BPH in Japan. Complication rates for TURP are not significantly higher as compared with other procedures. Thus, TURP can still be considered as the gold standard for BPH treatment.

Introduction

Transurethral resection of the prostate (TURP) has been long considered the gold standard surgery for benign prostate hyperplasia (BPH), with approximately 35 000 procedures carried out in Japan.1 However, this procedure has well-known disadvantages, such as bleeding and the absorption of irrigation fluid resulting in transurethral resection (TUR) syndrome. To improve surgical outcomes, several new procedures, such as Holmium-Yag laser ablation of the prostate (HoLAP), Holmium-Yag laser enucleation (HoLEP), photoselective vaporization (PVP) and transurethral resection using a new resectscope that can be carried out in normal saline (TURis), have evolved since the 1990s.2–5

However, recent systematic reviews showed that outcomes and perioperative care related to these new types of minimally invasive surgery remain controversial.6,7 Although many urologists have reportedly attempted these new procedures, it has not been shown how frequently each type of surgery is currently being carried out. Furthermore, the current state of perioperative care has not been elucidated. Assisted by the Japanese Endourology and ESWL (JEE) association, we carried out a large-scale survey of perioperative care in various types of BPH surgery.

Methods

After the approval of JEE, we sent a letter to 1155 institutions with staff urologists who were members of JEE, inviting them to participate in this survey. Of these, the Directors of Urology at 208 institutions agreed to submit data regarding perioperative care.

The spreadsheet database file and manual for response were downloaded to compact disk and delivered to each participating hospital. The contents of the database are shown in the Appendix I. Urologists participating in this survey then completed the database according to the clinical charts and returned the database to the Department of Urology, National Center for Geriatrics & Gerontology. Quality checking was carried out on data entry by each urologist and returned data were furthermore checked by YN. When data were thought to be unreliable or missing, inquiries were sent to obtain corrections. Percentages of missing data are shown in Appendix I. Records containing missing data were managed as submitted.

Finally, data were analyzed by KO using spss version 16. Pearson's χ2-test was used for categorical data and the Kruskal–Wallis H-test and Mann–Whitney U-test for numerical data. P-values less than 0.05 were considered significant. For multiple subanalyses, however, P-values less than 0.005 (0.05 divided by the number of comparisons [10]) were considered significant.

Results

Perioperative data of 5297 patients undergoing transurethral surgery for BPH in 2007 were collected from 157 institutions. There were no data returned from the remaining 51 institutions. Certain types of surgery were excluded if procedures were carried out on less than 50 patients and/or in less than three institutions. Those were bipolar TUR with a PlasmaKinetic system (30 patients), transurethral electrovaporization of the prostate (24), visual laser assisted prostatectomy (13), transurethral enucleation with bipolar (10) and others (23). Furthermore, 68 patients diagnosed as having prostate cancer before surgery were excluded from this analysis.

As shown in Table 1, TURP was most frequently carried out in Japan. HoLEP was the second most frequent surgery. Regarding patients' backgrounds, the prostate volume was less in the HoLAP group. There was no significant difference in the distribution of diabetes mellitus as a comorbid disease. There were just 80 patients with poor control of diabetes mellitus. Oral warfarin intake was more frequent in patients receiving HoLAP and PVP.

Table 1.  Patient backgrounds
 TURPTURisHoLAPHoLEPPVPP-value
  1. * P = 0.001 among transurethral resection of the prostate (TURP), holmium laser ablation (HoLAP) and holmium laser enucleation (HoLEP); ** P < 0.001 between photoselective vaporization (PVP) and TURP or HoLAP, and P < 0.001 between HoLAP and transurethral resection in saline (TURis), HoLEP or PVP; *** P = 0.001 between HoLAP and TURP, P < 0.001 between PVP and TURP, P = 0.005 between PVP and TURis, and P < 0.001 between HoLEP and TURP; **** P < 0.001 between TURis and TURP, HoLAP, HoLEP, or PVP; ***** P = 0.005 between PVP and TURP, P < 0.001between PVP and TURis, and P = 0.005 between HoLEP and TURis. †Including clean intermittent catheterization, indwelling catheter and urethral stent. UTI, urinary tract infection.

No. hospitals143289273 
No. patients (%)3918 (76.4)242 (4.7)90 (1.8)638 (12.4)241 (4.7) 
Age (years)71.8 ± 7.4*71.1 ± 7.369.7 ± 8.4*70.8 ± 7.5*71.5 ± 7.5<0.001
Prostate volume (mL)48.2 ± 23.759.3 ± 30.645.8 ± 22.4**59.2 ± 28.962.6 ± 31.4**<0.001
Preoperative comorbidity      
 Diabetes mellitus12.1%10.8%8.9%9.4%12.9%0.286
 Oral intake of warfarin2.4%2.1%7.8%***3.8%7.5%***<0.001
 Oral intake of antiplatelet13.6%17.0%8.9%11.6%16.6%0.086
 Disturbance of cognition3.2%3.7%4.4%3.6%3.3%0.933
 Disturbance of activities of daily living3.8%3.7%8.9%3.9%2.1%0.079
 Preoperative UTI11.6%22.0%****5.6%12.5%10.0%<0.001
 Preoperative urethral catheter19.4%26.3%16.7%18.0%*****12.0%*****0.002
 Preoperative urethral stricture3.8%4.2%3.3%4.4%4.1%0.941

Surgical duration was the shortest in TURP and longest in HoLEP (Table 2). In HoLEP, significantly more tissue was extirpated and the resection rate was also the highest. Heterologous and autologous blood transfusion was carried out most frequently in TURis. In 21 hospitals, however, autologous blood was prepared for more than half of the patients. There were no blood transfusions required in either HoLAP or PVP. The incidence of bladder injury was highest in HoLEP (2.5%), and TUR syndrome occurred most frequently in TURP (2.3%).

Table 2.  Surgical outcome
 TURPTURisHoLAPHoLEPPVPP-value
  • *

    P < 0.001 between transurethral resection of the prostate (TURP) and transurethral resection in saline (TURis), holmium laser ablation (HoLAP), holmium laser enucleation (HoLEP), or photoselective vaporization (PVP) and P < 0.001 between HoLEP and TURis or PVP, and P = 0.002 between PVP and TURis;

  • **

    P < 0.001 between TURP and TURis or HoLEP, and P = 0.001 between TURis and HoLEP;

  • ***

    P < 0.001 between HoLEP and TURP or TURis;

  • ****

    P < 0.001 between TURis and TURP or PVP. P = 0.006 between TURis and HoLEP;

  • *****

    P < 0.001 between TURis and TURP, HoLAP, HoLEP or PVP. P < 0.001 between PVP and TURP, or HoLEP. P = 0.002 between TURP and HoLAP;

  • ******

    P < 0.001 between HoLEP and TURP;

  • *******

    P < 0.001 between TURP and HoLEP.

  • †Resection rate stands for resection weight divided by prostate volume estimated by ultrasonography.

Anesthesia      
 Spinal2808 (72%)141 (58%)63 (70%)351 (55%)230 (95%) 
 Epidural133 (3%)11 (5%)122 (3%)1 
 Spinal + epidural631 (16%)26 (11%)12 (13%)18 (2.8%)2 
 General alone288 (7%)61 (25%)14 (16%)247 (39%)7 (3%) 
 Others583000 
Surgical duration (min)71 ± 35*88 ± 4189 ± 39127 ± 66*101 ± 45<0.0001
Resection weight (g)24 ± 16**30 ± 22/35 ± 25**/<0.0001
Resection rate (%)49.648.8/58.9***/<0.0001
Heterologous blood transfusion (%)62 (1.7)12 (4.9)****012 (2.0)0<0.0001
Autologous blood transfusion (%)334 (8.5)50 (20.7)*****036(5.8)0<0.0001
Perforation (%)12.300.800.118
Urethral injury (%)0.50.800.900.366
Bladder injury (%)0.10.402.5******0.4<0.0001
TUR syndrome (%)2.3*******0.800.30<0.0001

Postoperative complications are shown in Table 3. Of the complications during hospital stay, the incidence of clot retention requiring irrigation was highest in TURis (7.9%), that of clean intermittent catheterization and/or re-catheterization was highest in HoLAP (16.7%) and that of pad use on discharge was the highest in HoLEP (15.1%). After discharge, urethral stricture frequently occurred in TURis (6.6%) and HoLEP (6.0%). Among various complications, two patients died (0.04%). Re-admission rates were significantly higher in PVP.

Table 3.  Postoperative complications
 TURPTURisHoLAPHoLEPPVPP-value
  1. * P = 0.002 between transurethral resection in saline (TURis) and transurethral resection of the prostate (TURP) or photoselective vaporization (PVP), and P < 0.001 between holmium laser enucleation (HoLEP) and PVP; ** P < 0.001 between holmium laser ablation (HoLAP) and TURP, HoLEP or PVP; *** P < 0.001 between HoLEP and TURP, TURis, or PVP. P = 0.002 between HoLAP and HoLEP; ****P = 0.005 between TURP and HoLEP, P = 0.002 between TURis and PVP, and P < 0.001 between HoLEP and PVP; *****P = 0.005 between PVP and TURP, P = 0.004 between PVP and HoLEP; ******P = 0.002 between PVP and TURP or HoLEP; *******P = 0.006 between PVP and TURP. CIC, clean intermittent catheterization.

During stay in hospital      
 Urological      
  Fever above 38°C (%)6.65.45.66.95.00.784
  Clot retention requiring irrigation (%)3.97.9*2.22.2*0.00.001
  Clot retention requiring fulguration (%)1.50.80.00.90.40.298
  Difficulty on micturition due to clot retention (%)1.52.12.21.41.20.918
  CIC/re-catheterization (%)6.08.316.7**6.44.60.001
  Pad use on discharge (%)3.95.83.315.1***1.2<0.001
  Postoperative urinary extravasation (%)0.10000
  Reoperation for residual adenoma (%)0.1000.30
 Medical      
  Death (%)0.050000
  Ischemic heart diseases/arrhythmia (%)0.15000.160
  Cerebral infarction (%)0.130000
  Delirium (%)0.1001.1100
  Miscellaneous (%)0.15000.470
After discharge (within 3 months)      
 Urological8.010.44.49.87.50.235
  Fever above 38°C (%)0.90.80.00.92.10.402
  Epididymitis after discharge (%)0.90.40.00.50.40.538
  Acute clot urinary retention (%)1.72.10.01.42.50.564
  Acute urinary retention not due to clot (%)1.60.83.31.93.30.140
  Urethral stricture after discharge (%)3.66.6****1.16.0****0.4<0.001
  Bladder neck contraction after discharge (%)0.50.80.00.60.40.900
Readmission during 3 months (%)2.82.90.02.06.2*****0.005
  Gross hematuria or clot urinary retention (%)1.71.70.00.91.70.467
  Urinary tract infection, Acute prostatitis or epidydimitis (%)0.50.40.00.22.5******<0.001
  Acute urinary retention not due to clot (%)0.10.00.00.20.40.521
  Urethral stricture/bladder neck contracture (%)0.40.40.00.50.40.976
  Miscellaneous (%)0.10.40.00.31.2*******0.002

Several forms of perioperative management varied from surgery to surgery (Table 4). Although intravenous antibiotic administration was shortest in PVP, total antibiotic use in PVP was longer than that in any of the remaining procedures except for TURP. Urethral catheter was removed earliest in PVP and earlier in HoLAP and HoLEP than in TURis and TURP. Postoperative hospital stay was shortest after PVP and longest after TURP.

Table 4.  Perioperative management
 TURPTURisHoLAPHoLEPPVPAverageP-value
  1. * P < 0.001 between photoselective vaporization (PVP) and transurethral resection of the prostate (TURP), transurethral resection in saline (TURis), holmium laser ablation (HoLAP) or holmium laser enucleation (HoLEP), and P < 0.001 between HoLAP and TURP; ** P < 0.001 between PVP and TURP, HoLAP, or HoLEP, between TURP and HoLAP or HoLEP, and P = 0.003 between TURis and HoLAP; *** P < 0.001 among TURP, TURis, HoLAP, HoLEP and PVP; **** P < 0.001 among TURP, TURis, HoLAP, HoLEP and PVP except between HoLEP and TURis or HoLAP; ***** P < 0.001 among TURP, TURis, HoLAP, HoLEP and PVP except between TURP and TURis, and HoLAP and HoLEP; ****** P < 0.001 among TURP, TURis, HoLAP, HoLEP and PVP except between TURis and HoLEP. Surgery was performed on day 0. OD, operative day.

Hospitalization (OD)−2.2 ± 3.5−1.8 ± 2.8−2.5 ± 2.9*−2.2 ± 3.4−0.6 ± 0.8*−2.1 ± 3.3<0.001
Intravenous antibiotics administration (days)2.9 ± 1.6**2.9 ± 1.52.4 ± 1.52.5 ± 1.61.2 ± 0.7**2.8 ± 1.6<0.001
Oral antibiotic administration (days)5.6 ± 9.93.0 ± 4.31.3 ± 1.9***2.9 ± 3.76.2 ± 1.3***5.1 ± 8.9<0.001
Total antibiotic administration (days)8.5 ± 10.4****5.8 ± 5.03.7 ± 2.6****5.4 ± 4.67.5 ± 1.67.9 ± 9.4<0.001
Removal of urethral catheter (OD)3.9 ± 1.9*****3.9 ± 1.9*****2.1 ± 1.02.6 ± 2.01.0 ± 0.3*****3.6 ± 2.0<0.001
Discharge from hospital (OD)8.3 ± 7.8******7.1 ± 3.65.7 ± 3.87.5 ± 4.51.6 ± 0.9******7.7 ± 7.2<0.001

Discussion

Although there have been many outcome studies of transurethral surgery for BPH in a single institution, multi-institutional surveys have seldom been carried out in Japan.8,9 The present study was characterized as a large-scale cross-sectional survey in more than 150 hospitals in Japan. We speculate that the samples in this survey should be representative in Japan based on the following points: (i) the proportion (14%) of the participating hospital numbers (157) divided by a total number of hospitals (1155) is almost equivalent to that (15%) of the number of patients (5297) included in the present study divided by the annual number (35 000) of transurethral surgeries in Japan; and (ii) when seven districts are distinguished in Japan, the proportion of the respective hospitals participating in this survey were very similar: from 11 to 17% (data not shown).1,10

Regarding patient background, warfarin was orally administered more frequently in patients receiving HoLAP and PVP. It is reported that vaporization techniques might be useful in patients requiring anticoagulants.11 Actually, in this survey, blood transfusion was never required for patients undergoing either HoLAP or PVP.4,6,7 However, it appeared that the other antiplatelet agents and diabetes mellitus were not associated with the type of surgery.

The heterologous blood transfusion rate was highest in TURis in this survey, although Chen et al. reported that hemoglobin and serum sodium after surgery decreased significantly less in TURis than in TUR.12 Because the postoperative clot retention rate was also high in TURis, there appeared to be a hemostatic problem with TURis.

On the whole, autologous blood transfusion was carried out in 420 patients (8.2%). However, just 22 (4.8%) of these developed postoperative clot retention requiring irrigation or fulguration. In some hospitals, autologous blood transfusion was planned for more than half of the patients. We consider it appropriate that autologous blood transfusion should be planned for patients with a high risk of bleeding.

Postoperative fulguration in an emergency setting was seldom carried out equally in the five types of transurethral surgery. In most cases, continuous irrigation might be effective for clot retention.13 As a particular intraoperative complication, TUR syndrome was highest in TUR (2.3%) and bladder injury was highest in HoLEP (2.5%). Interestingly, TUR syndrome rarely occurred in TURis and HoLEP. This might be a result of insufficient hemostasis during those techniques and additional TUR might cause the response. It is noteworthy that the main postoperative complication was clot retention in TURis, catheterization in HoLAP and pad use in HoLEP. These are the limitations that should be overcome in the future.

Death occurred in two patients (0.04%), and ischemic heart and cerebral diseases in 12 (0.24%) of 5129 patients. The rates of medical complications including death were lower than expected.14 Approximately one-quarter of the patients requiring transurethral surgery had diabetes mellitus and/or took medication with warfarin or an antiplatelet agent. The risks of unexpected medical complications should be explained to the patients and their families.

The readmission rate was higher in PVP. This might have been affected by the short length of hospital stay. In Japan, all people are covered by the national health insurance system. The patients have a co-payment (10–30% payment) for treatments that the Ministry of Health, Labour and Welfare (MHLW) has approved, but when the treatment is not approved, the patient must pay the entire expense. Most patients want to be discharged with relief after the Foley catheter is removed. Because PVP is not approved by MHLW, the patients might be readmitted under Japanese health insurance system when complications occur.

After discharge, there were similar occurrence rates of urological complications in the five types of surgery except for urethral stricture, which occurred more frequently in TURis and HoLEP. These types of procedures might cause more urethral damage than the other procedures. However, Lourenco et al. reported similar stricture rates among various types of transurethral surgery for BPH7.

Perioperative management in PVP also significantly differed from those for other types of transurethral surgery. This might also be caused by the difference in health insurance coverage in addition to lower complication rates. The charge for the patients undergoing PVP was estimated to be extremely expensive (¥450 000–550 000 for 2–3 days hospitalization vs approximately ¥35 000–80 100 for a 10–30% co-payment for 6–10 days hospitalization for TURP, TURis, HoLAP or HoLEP) according to their age and income.

There were also several differences in perioperative management among the remaining four types of surgery. In HoLAP and HoLEP, the Foley catheter was removed earlier and the postoperative stay was shorter. Okamura et al. pointed out that earlier removal of the urethral catheter might promote a shorter hospital stay.15 Because there might be biases, such as the number of patients and/or participating hospitals, the appropriate duration of Foley catheter should be determined to lessen the complication rates as well as to shorten the hospital stay.

Average total prophylactic antimicrobial administration varied from surgery to surgery, between 3.7 to 8.5 days. According to the Japanese guidelines for the prevention of perioperative infections in the urological field, Matsumoto et al. recommended that single antibiotics just before surgery or multiple antibiotics should be given within 72 h.16 In Japan, the duration of antimicrobial prophylaxis should be shortened in patients without risk of urinary tract infection.

To improve the surgical outcome of TURP, many urologists have been attempting new types of transurethral surgery.2–5 From the perspective of complications, however, it appeared that the rate of complications in TURP was not more frequent than those in the other types of procedure in this survey. Each type of surgery has its own limitations and we are not indicating that TURP is inferior to the other types of surgery. Lourenco et al. also explained that the lack of any clearly more effective procedure suggests that transurethral resection should remain the standard approach.7

This survey has three limitations: (i) changes in urination after surgery were not investigated; (ii) the follow-up duration was short – just 90 days after the surgery; and (iii) there were no data on cost collected. Therefore, we cannot comment on symptomatic improvement or long-term outcome. Although a cost-effectiveness study was reported from the UK, differences in the health insurance system among the countries might affect the analyses.17 Nevertheless, this survey provides useful documentation on the current status of endoscopic transurethral surgery for BPH in Japan.

Acknowledgments

This study was supported by funding from the Longevity of Science (2007B-1) Ministry of Health, Labour and Welfare. The authors thank the members of the Japanese Society of Endourology & ESWL who cooperated with this survey.

Appendix

Appendix I

Contents of survey

ItemsContentsMissing data (%)
  1. AUR, acute urinary retention; CIC, clear intermittent catheterization; HoLAP, holmium laser ablation; HoLEP, Holmium laser enucleation; PVP, photoselective vaporization; TUEB, transurethral enucleation with bipolar; TUI, transurethral incision; TURBT, transurethral resection of bladder tumor; TURis, transurethral resection in saline; TURP, transurethral resection of prostate.

Background  
 AgeYears28 (0.55)
 Prostate volume measured by ultrasonographymL492 (9.59)
 Diabetes mellitusAbsent, present (well controlled, poorly controlled)3 (0.06)
 Warfarin intakeAbsent, present (change to heparin, discontinue, continue)0
 Other antiplatelet agentsAbsent, present (change to heparin, discontinue, continue)21 (0.41)
 Cognitive impairmentAbsent, present3 (0.06)
 Impairment of ability of daily livingAbsent, present0
 Urinary tract infectionAbsent, present34 (0.66)
 Foley catheter/clean intermittent catheterizationAbsent, Foley, CIC1 (0.02)
 Urethral strictureAbsent, present2 (0.04)
 MiscellaneousFree description
Surgery  
 Day of surgery2007.xx.xx0
 Surgery typeTURP, TURis, TUEB, HoLEP, HoLAP, PVP, other (specify)0
 Surgeon's experience30 cases or less, 30–99, 100 or greater0
 AnesthesiaSpinal, epidural, spinal + epidural, general, other (specify)23 (0.45)
 Simultaneous treatment/surgeryProstate biopsy, cystolithotomy, TURBT, TUI, passing sound, other (specify)
 Surgical durationMinutes18 (0.35)
 Weight of resected tissueg90 (1.88)
 Blood transfusionAbsent, intraoperative/postoperative heterologous blood, autologous blood49 (0.96)
Intraoperative complications  
 TUR responseAbsent, present1 (0.02)
 If present, specify serum Na concentrationmEq/L
 PerforationAbsent, present (no treatment, prolonged Foley catheter, placing pelvic drain)2 (0.04)
 Urethral injuryAbsent, present51 (1.00)
 Bladder injuryAbsent, present52 (1.01)
 MiscellaneousFree description
Perioperative care  
 Preoperative admission dayWhen surgery was done on admission day, 0.3 (0.06)
 Foley catheter removalPostoperative day4 (0.08)
 Duration of intravenous antibioticsDays1 (0.02)
 Duration of oral antibioticsDays0
 The day leaving hospitalPostoperative day8 (0.16)
Postoperative complications during hospital stay  
 Fever greater than 38°CAbsent, present1 (0.02)
 Clot retention requiring bladder irrigation during catheterizationAbsent, present1 (0.02)
 Clot retention requiring hemostasis during catheterizationAbsent, present2 (0.04)
 Clot retention after Foley removalAbsent, present2 (0.04)
 Difficulty on micturition/AUR requiring re-catheterizaion or CICAbsent, present2 (0.04)
 Urinary incontinence at dischargeAbsent, present62 (1.21)
 MiscellaneousFree description
Complications after discharge, during postoperative 90 days  
 Fever greater than 38°CAbsent, present86 (1.68)
 Acute epidydimitisAbsent, present85 (1.66)
 AUR caused by bleedingAbsent, present86 (1.68)
 AUR due to other causeAbsent, present86 (1.68)
 Urethral/bladder neck strictureAbsent, present85 (1.66)
 MiscellaneousFree description
Re-admission during postoperative 90 daysAbsent, present147 (2.87)
 ReasonFree description

Ancillary