I read this article [1] with great interest. The authors must be congratulated for addressing certain issues involved in palliative TURP. These issues are: (i) the safety of the procedure; (ii) the functional outcome; and (iii) probably the most important, oncological aspects [1]. However, there are certain issues in terms of ‘safety’ and ‘functional outcome’ in palliative TURP that need serious thought.

It is of utmost important that we consider the safety of the procedure, especially in a palliative setting. One of the important factors to consider before operating on these patients is the risk of uncontrolled bleeding and disseminated intravascular coagulopathy (DIC). It appears that the authors are not aware of this complication, but mentioned about eight patients who needed blood transfusion. They quoted a peri-operative mortality (<30 days) of 2.2%, but is not clear if these patients died from conditions like DIC, or something else. The incidence of DIC during and after surgical manipulation in advanced prostate cancer is significant, at ≈ 13% in published reports [2]. In our experience of 28 palliative TURPs in advanced prostate cancer, six patients developed DIC after TURP, presenting with profuse bleeding, and were d-dimer-positive. All except one patient could be saved with supportive care, fresh frozen plasma and heparin, etc.

The reason that these patients have a significant risk of developing DIC is that certain antigens are liberated during surgery. In addition, significantly many patients with prostate cancer have complexed PSA in serum, i.e. PSA complexed with antichymotrypsin (ACT) [3]. It is also a crucial observation that the PSA-containing prostate epithelium also produces ACT. This in turn explains the haemolytic problems encountered during surgery for advanced prostate cancer, even in the presence of normal bleeding and clotting values [4]. The association of advanced prostate cancer with the production of fibrinolytic compounds, leading to bleeding or clotting disorder, is also well documented [5].

The second issue is ‘functional outcome’; the authors achieved a significant functional outcome, with 79% of the patients voiding spontaneously. However, there are many studies that have shown a higher incidence of urinary incontinence than for conventional TURP [6,7]. Perhaps the minimal resection technique described by the authors has helped them to achieve better success. However, the technical difficulties encountered during palliative TURP, e.g. distortion of anatomy, sphincteric involvement by the tumour, rigid prostatic urethra especially after radiotherapy or brachytherapy, cannot be ignored. It is also difficult to decide what an ‘adequate channel’ is and when to stop. These factors certainly hamper the continence rate that could be achieved with this procedure. It is surprising that although in their study 28 patients who had had external beam radiotherapy and 10 who had had brachytherapy before palliative TURP had no incontinence problems.

In conclusion, I think serious consideration must be given to bleeding after TURP, DIC and the risk of incontinence, before operating on these patients, and it is certainly worth including these factors in the informed consent and preoperative counselling. After all, these palliative procedures are aimed at improving the quality of life and the surgeon must think carefully before embarking on this course.