Perioperative management of transurethral surgery for benign prostatic hyperplasia: A nationwide survey in Japan
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: firstname.lastname@example.org
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.
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.
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 ) were considered significant.
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
|No. hospitals||143||28||9||27||3|| |
|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 ± 7.3||69.7 ± 8.4*||70.8 ± 7.5*||71.5 ± 7.5||<0.001|
|Prostate volume (mL)||48.2 ± 23.7||59.3 ± 30.6||45.8 ± 22.4**||59.2 ± 28.9||62.6 ± 31.4**||<0.001|
|Preoperative comorbidity|| || || || || || |
| Diabetes mellitus||12.1%||10.8%||8.9%||9.4%||12.9%||0.286|
| Oral intake of warfarin||2.4%||2.1%||7.8%***||3.8%||7.5%***||<0.001|
| Oral intake of antiplatelet||13.6%||17.0%||8.9%||11.6%||16.6%||0.086|
| Disturbance of cognition||3.2%||3.7%||4.4%||3.6%||3.3%||0.933|
| Disturbance of activities of daily living||3.8%||3.7%||8.9%||3.9%||2.1%||0.079|
| Preoperative UTI||11.6%||22.0%****||5.6%||12.5%||10.0%||<0.001|
| Preoperative urethral catheter†||19.4%||26.3%||16.7%||18.0%*****||12.0%*****||0.002|
| Preoperative urethral stricture||3.8%||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
|Anesthesia|| || || || || || |
| Spinal||2808 (72%)||141 (58%)||63 (70%)||351 (55%)||230 (95%)|| |
| Epidural||133 (3%)||11 (5%)||1||22 (3%)||1|| |
| Spinal + epidural||631 (16%)||26 (11%)||12 (13%)||18 (2.8%)||2|| |
| General alone||288 (7%)||61 (25%)||14 (16%)||247 (39%)||7 (3%)|| |
| Others||58||3||0||0||0|| |
|Surgical duration (min)||71 ± 35*||88 ± 41||89 ± 39||127 ± 66*||101 ± 45||<0.0001|
|Resection weight (g)||24 ± 16**||30 ± 22||/||35 ± 25**||/||<0.0001|
|Resection rate (%)†||49.6||48.8||/||58.9***||/||<0.0001|
|Heterologous blood transfusion (%)||62 (1.7)||12 (4.9)****||0||12 (2.0)||0||<0.0001|
|Autologous blood transfusion (%)||334 (8.5)||50 (20.7)*****||0||36(5.8)||0||<0.0001|
|Urethral injury (%)||0.5||0.8||0||0.9||0||0.366|
|Bladder injury (%)||0.1||0.4||0||2.5******||0.4||<0.0001|
|TUR syndrome (%)||2.3*******||0.8||0||0.3||0||<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
|During stay in hospital|| || || || || || |
| Urological|| || || || || || |
| Fever above 38°C (%)||6.6||5.4||5.6||6.9||5.0||0.784|
| Clot retention requiring irrigation (%)||3.9||7.9*||2.2||2.2*||0.0||0.001|
| Clot retention requiring fulguration (%)||1.5||0.8||0.0||0.9||0.4||0.298|
| Difficulty on micturition due to clot retention (%)||1.5||2.1||2.2||1.4||1.2||0.918|
| CIC/re-catheterization (%)||6.0||8.3||16.7**||6.4||4.6||0.001|
| Pad use on discharge (%)||3.9||5.8||3.3||15.1***||1.2||<0.001|
| Postoperative urinary extravasation (%)||0.1||0||0||0||0||–|
| Reoperation for residual adenoma (%)||0.1||0||0||0.3||0||–|
| Medical|| || || || || || |
| Death (%)||0.05||0||0||0||0||–|
| Ischemic heart diseases/arrhythmia (%)||0.15||0||0||0.16||0||–|
| Cerebral infarction (%)||0.13||0||0||0||0||–|
| Delirium (%)||0.10||0||1.11||0||0||–|
| Miscellaneous (%)||0.15||0||0||0.47||0||–|
|After discharge (within 3 months)|| || || || || || |
| Fever above 38°C (%)||0.9||0.8||0.0||0.9||2.1||0.402|
| Epididymitis after discharge (%)||0.9||0.4||0.0||0.5||0.4||0.538|
| Acute clot urinary retention (%)||1.7||2.1||0.0||1.4||2.5||0.564|
| Acute urinary retention not due to clot (%)||1.6||0.8||3.3||1.9||3.3||0.140|
| Urethral stricture after discharge (%)||3.6||6.6****||1.1||6.0****||0.4||<0.001|
| Bladder neck contraction after discharge (%)||0.5||0.8||0.0||0.6||0.4||0.900|
|Readmission during 3 months (%)||2.8||2.9||0.0||2.0||6.2*****||0.005|
| Gross hematuria or clot urinary retention (%)||1.7||1.7||0.0||0.9||1.7||0.467|
| Urinary tract infection, Acute prostatitis or epidydimitis (%)||0.5||0.4||0.0||0.2||2.5******||<0.001|
| Acute urinary retention not due to clot (%)||0.1||0.0||0.0||0.2||0.4||0.521|
| Urethral stricture/bladder neck contracture (%)||0.4||0.4||0.0||0.5||0.4||0.976|
| Miscellaneous (%)||0.1||0.4||0.0||0.3||1.2*******||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
|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 ± 1.5||2.4 ± 1.5||2.5 ± 1.6||1.2 ± 0.7**||2.8 ± 1.6||<0.001|
|Oral antibiotic administration (days)||5.6 ± 9.9||3.0 ± 4.3||1.3 ± 1.9***||2.9 ± 3.7||6.2 ± 1.3***||5.1 ± 8.9||<0.001|
|Total antibiotic administration (days)||8.5 ± 10.4****||5.8 ± 5.0||3.7 ± 2.6****||5.4 ± 4.6||7.5 ± 1.6||7.9 ± 9.4||<0.001|
|Removal of urethral catheter (OD)||3.9 ± 1.9*****||3.9 ± 1.9*****||2.1 ± 1.0||2.6 ± 2.0||1.0 ± 0.3*****||3.6 ± 2.0||<0.001|
|Discharge from hospital (OD)||8.3 ± 7.8******||7.1 ± 3.6||5.7 ± 3.8||7.5 ± 4.5||1.6 ± 0.9******||7.7 ± 7.2||<0.001|
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.
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.
Contents of survey
|Background|| || |
| Age||Years||28 (0.55)|
| Prostate volume measured by ultrasonography||mL||492 (9.59)|
| Diabetes mellitus||Absent, present (well controlled, poorly controlled)||3 (0.06)|
| Warfarin intake||Absent, present (change to heparin, discontinue, continue)||0|
| Other antiplatelet agents||Absent, present (change to heparin, discontinue, continue)||21 (0.41)|
| Cognitive impairment||Absent, present||3 (0.06)|
| Impairment of ability of daily living||Absent, present||0|
| Urinary tract infection||Absent, present||34 (0.66)|
| Foley catheter/clean intermittent catheterization||Absent, Foley, CIC||1 (0.02)|
| Urethral stricture||Absent, present||2 (0.04)|
| Miscellaneous||Free description||–|
|Surgery|| || |
| Day of surgery||2007.xx.xx||0|
| Surgery type||TURP, TURis, TUEB, HoLEP, HoLAP, PVP, other (specify)||0|
| Surgeon's experience||30 cases or less, 30–99, 100 or greater||0|
| Anesthesia||Spinal, epidural, spinal + epidural, general, other (specify)||23 (0.45)|
| Simultaneous treatment/surgery||Prostate biopsy, cystolithotomy, TURBT, TUI, passing sound, other (specify)||–|
| Surgical duration||Minutes||18 (0.35)|
| Weight of resected tissue||g||90 (1.88)|
| Blood transfusion||Absent, intraoperative/postoperative heterologous blood, autologous blood||49 (0.96)|
|Intraoperative complications|| || |
| TUR response||Absent, present||1 (0.02)|
| If present, specify serum Na concentration||mEq/L||–|
| Perforation||Absent, present (no treatment, prolonged Foley catheter, placing pelvic drain)||2 (0.04)|
| Urethral injury||Absent, present||51 (1.00)|
| Bladder injury||Absent, present||52 (1.01)|
| Miscellaneous||Free description||–|
|Perioperative care|| || |
| Preoperative admission day||When surgery was done on admission day, 0.||3 (0.06)|
| Foley catheter removal||Postoperative day||4 (0.08)|
| Duration of intravenous antibiotics||Days||1 (0.02)|
| Duration of oral antibiotics||Days||0|
| The day leaving hospital||Postoperative day||8 (0.16)|
|Postoperative complications during hospital stay|| || |
| Fever greater than 38°C||Absent, present||1 (0.02)|
| Clot retention requiring bladder irrigation during catheterization||Absent, present||1 (0.02)|
| Clot retention requiring hemostasis during catheterization||Absent, present||2 (0.04)|
| Clot retention after Foley removal||Absent, present||2 (0.04)|
| Difficulty on micturition/AUR requiring re-catheterizaion or CIC||Absent, present||2 (0.04)|
| Urinary incontinence at discharge||Absent, present||62 (1.21)|
| Miscellaneous||Free description||–|
|Complications after discharge, during postoperative 90 days|| || |
| Fever greater than 38°C||Absent, present||86 (1.68)|
| Acute epidydimitis||Absent, present||85 (1.66)|
| AUR caused by bleeding||Absent, present||86 (1.68)|
| AUR due to other cause||Absent, present||86 (1.68)|
| Urethral/bladder neck stricture||Absent, present||85 (1.66)|
| Miscellaneous||Free description||–|
|Re-admission during postoperative 90 days||Absent, present||147 (2.87)|
| Reason||Free description||–|