Study Type – Therapy (case series)
Level of Evidence 4
Study Type – Therapy (case series)
To investigate whether bladder outlet obstruction (BOO), detrusor underactivity (DUA) and detrusor overactivity (DO) affect the long-term outcome of transurethral resection of the prostate (TURP) for patients having lower urinary tract symptoms suggestive of benign prostatic obstruction.
PATIENTS AND METHODS
Of 92 patients who had TURP after a urodynamic study between 1995 and 1997, 43 (47%) were alive at the time of the survey in February 2008. Nine patients were excluded because of prostate cancer, neurological diseases and the impossibility of symptomatic examination. The International Prostate Symptom Score (IPSS) and quality-of-life (QoL) index were determined at baseline, 3 months, 3, 7 and 12 years after surgery for 34 patients.
Although the improved IPSS and QoL index at 3 months gradually deteriorated with time, patients at 12 years were still significantly better than those at baseline. The IPSS in patients without BOO deteriorated faster than in those with it, whereas neither DUA nor DO influenced the slope of change in IPSS. Regardless of the preoperative urodynamic findings, the QoL index remained improved for 12 years. Two-thirds of patients with DUA but not BOO were satisfied with their urinary condition at 12 years.
The symptomatic improvement provided by TURP lasts for >10 years, although there is a gradual deterioration with time. The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings.
benign prostatic obstruction
linear passive urethral resistance relation
maximum urinary flow rate
postvoid residual urine volume.
TURP is an effective surgical procedure for treating LUTS suggestive of benign prostatic obstruction (BPO) or BOO [1–8], but whether TURP should be avoided for patients without BOO or those with detrusor underactivity (DUA) is controversial [8–13]. Previously we reported the urodynamic characteristics of 92 patients with LUTS/BPO who had TURP, and the short-term efficacy of TURP compared to the preoperative urodynamic findings . Of the 92 patients, 55 (60%), 37 (40%) and 44 (48%) had BOO with linear passive urethral resistance relation (LinPURR) scores of 2–6, weak or very weak detrusor contractility and detrusor overactivity (DO), respectively. Thus, lack of obstruction, DUA and DO were the common findings in patients with LUTS/BPO who were clinically thought to be candidates for TURP. Although the overall treatment efficacy of TURP was better for patients with BOO than for those without it, neither the presence of DO nor status of detrusor contractility affected the efficacy at 3 months after surgery. Thus, we suggested that TURP might not be contraindicated for patients with LUTS/BPO and DUA, at least to achieve a favourable short-term outcome. However, our previous study did not assess the long-term outcome of TURP. In the present study, we investigated whether the efficacy of TURP lasted for >10 years in comparison to the preoperative urodynamic findings.
PATIENTS AND METHODS
The details of the patients analysed in this study were reported previously ; briefly, 92 patients with LUTS/BPO aged ≥50 years had TURP between July 1995 and March 1997. Before TURP, the patients had a symptomatic examination using the IPSS and quality-of-life (QoL) index, prostate volume determined by TRUS, uroflowmetry to evaluate the maximum urinary flow rate (Qmax), and the postvoid residual urine volume (PVR) measured by transabdominal ultrasonography. In addition, water-filling cystometry and a pressure-flow study were performed before surgery, according to the method previously described to evaluate the existence of DO, the degree of BOO and an assessment of detrusor contractility during voiding . If there was involuntary detrusor contraction during the filling phase, it was defined as DO. LinPURR and detrusor contractility were determined by using Schäfer’s nomogram provided by Qmax and detrusor pressure at Qmax. LinPURR scores of 2–6 and weak/very weak contractility were defined as BOO and DUA, respectively.
Three months after TURP, the IPSS, QoL index, Qmax and PVR were evaluated to determine the treatment efficacy of TURP according to the criteria proposed by Homma et al.. The results of the short-term outcome of TURP compared to preoperative urodynamic findings were reported previously . After the evaluation at 3 months, the patients were discharged from the outpatient clinic. If they felt symptomatic deterioration during the follow-up they could attend the clinic at will for examination and treatment.
In February 2008, 10–12 years after surgery, we surveyed the patients to evaluate the long-term outcome of TURP, using a mailed questionnaire. If we did not receive a reply by mail, we telephoned them to confirm their situation. If the patients were still alive, they had a symptomatic examination using the IPSS and QoL index at the time of the survey. In most survivors, the IPSS and QoL index at 3 and 7 years after surgery were available because the follow-up data after surgery had been systematically collected. In addition, they were queried about a history of urethral stricture, prostate cancer and disorders that might affect LUTS after TURP. We could confirm the medical history by their medical charts, as most patients with urological problems had received evaluation and treatment in our clinic because of the limited number of urology services in the area. If the patient had died, we asked the family to inform us of the date of death.
The mean values between groups were compared statistically using paired and unpaired t-tests, with P < 0.05 considered to indicate statistical significance.
Of the 92 patients who had TURP between July 1995 and March 1997, 43 (47%) were alive and 25 (27%) were dead at the time of the survey in February 2008; no information was obtained from 24 patients (26%). Among the three groups, there were no significant differences in the baseline variables of IPSS, QoL index, Qmax, PVR and prostate volume, except for age, which was younger for survivors than for those dead and lost (data not shown). The mean (sd) follow-up was 12.0 (0.6) years until the time of the survey for the 43 survivors, 5.0 (3.7) years until death for the 25 who died and 1.5 (1.1) years for the 24 lost to follow-up.
Of the 43 survivors, two had been diagnosed as having prostate cancer during the period. We excluded from the analysis five patients who developed diseases such as cerebral infarction and Parkinson’s disease that caused lower urinary tract dysfunction. Of the remaining 36 patients, symptomatic examination at the time of the survey was possible for 34, of whom one used an anticholinergic agent at the time of the survey and one had a history of administration of distigmine bromide. Seven of the 34 (21%) had a history of internal urethrotomy for bladder neck contracture or urethral stricture after TURP (4 months after TURP for two, 5 months for three, 8 years for one, and 9 years for one). All seven were free from complications at the time of symptomatic examination at 3 and 7 years after TURP, and the time of the survey. One man had a repeat TURP because of recurrent adenoma 6 years after the initial TURP.
The mean (range) ages of the 34 patients at TURP and the time of the survey were 67.4 (56–78) and 79.4 (68–90) years, respectively. Preoperative urodynamic findings showed BOO in 18 (53%), DUA in 12 (35%) and DO in 14 (41%), percentages that were not significantly different from the original cohort. The short-term outcome was ‘excellent’ for 21 (62%), ‘good’ for eight (24%) and ‘fair’ for four patients (12%). Only one man (3%) had a ‘poor/worse’ short-term outcome.
Although the improved IPSS and QoL index at 3 months gradually deteriorated with time, those at 12 years were still significantly better than those at baseline (Table 1). The mean (sd) annual slopes of the IPSS and QoL index between 3 months and 12 years were 0.48 (0.75) and 0.063 (0.145), respectively. There was no difference in the annual slopes of storage symptoms (daytime frequency, urgency, nocturia) and voiding symptoms (intermittency, weak stream, hesitancy), at 0.16 (0.35) vs 0.26 (0.37) (P = 0.282, unpaired t-test). If the QoL index of 0–2 was defined as ‘satisfaction’, then 9% of patients at baseline, 82% at 3 months, 77% at 3 years, 71% at 7 years and 68% at 12 years, were satisfied with their urinary condition. Although the patients who were ‘unsatisfied’ had a higher IPSS than those who were ‘satisfied’ at 12 years, of 19.3 (8.3) vs 5.4 (6.2), there was no significant difference in the storage symptoms/voiding symptoms ratio (1.16 vs 1.46). No specific symptoms contributed to the IPSS in the patients who were ‘unsatisfied.
|Mean (sd) variable (n)||baseline||3 months||3 years||7 years||12 years||slope/year§||P¶|
|All patients||16.7 (8.6) (34)||4.1 (3.7)‡ (34)||5.6 (4.2)‡ (30)||8.1 (7.5‡ (28)||9.9 (9.5)† (34)||0.48 (0.75)|
|No BOO||13.5 (8.1) (16)||4.9 (4.0)‡ (16)||7.5 (5.1)† (14)||10.0 (9.7) (13)||14.2 (11.2) (16)||0.77 (0.91)||0.029|
|BOO||19.5 (8.2) (18)||3.5 (3.3)‡ (18)||3.9 (2.3)‡ (16)||6.5 (4.7)‡ (15)||6.1 (5.6)‡ (18)||0.22 (0.44)|
|No DUA||18.5 (8.9) (22)||3.6 (3.2)‡ (22)||4.7 (3.3)‡ (18)||9.1 (7.7)† (18)||9.8 (9.8)† (22)||0.52 (0.76)||0.693|
|DUA||13.3 (7.0) (12)||5.2 (4.4)‡ (12)||6.9 (5.1)† (12)||6.5 (7.3)† (10)||10.1 (9.3) (12)||0.41 (0.74)|
|No DO||16.0 (8.5) (20)||5.1 (4.4)‡ (20)||6.6 (4.7)‡ (18)||9.2 (8.7)* (17)||12.3 (10.7) (20)||0.60 (0.87)||0.273|
|DO||17.7 (8.8) (14)||2.8 (1.7)‡ (14)||4.1 (2.8)‡ (12)||6.5 (5.1)† (11)||6.5 (6.4)† (14)||0.31 (0.51)|
|No BOO + DUA||12.3 (8.0) (8)||5.6 (5.1)† (8)||8.1 (5.8)* (8)||8.0 (8.2) (7)||11.4 (10.7) (8)||0.47 (0.89)||0.985|
|BOO ± no DUA||18.0 (8.4) (26)||3.7 (3.1)‡ (26)||4.7 (3.2)‡ (22)||8.2 (7.5)† (21)||9.4 (9.3)† (26)||0.48 (0.72)|
|All patients||4.6 (1.2) (34)||1.5 (1.2)‡ (34)||1.9 (1.7)‡ (30)||2.2 (1.7)‡ (28)||2.2 (1.8)‡ (34)||0.063 (0.145)|
|No BOO||4.3 (1.4) (16)||1.8 (1.5)‡ (16)||2.2 (1.7)‡ (14)||2.5 (1.9)‡ (13)||2.8 (2.1)† (16)||0.080 (0.173)||0.529|
|BOO||4.9 (0.9) (18)||1.2 (0.8)‡ (18)||1.7 (1.7)‡ (16)||1.9 (1.4)‡ (15)||1.7 (1.5)‡ (18)||0.048 (0.117)|
|No DUA||4.8 (1.1) (22)||1.3 (0.9)‡ (22)||2.0 (1.9)‡ (18)||2.2 (1.6)‡ (18)||2.2 (1.6)‡ (22)||0.076 (0.129)||0.456|
|DUA||4.3 (1.2) (12)||1.8 (1.6)† (12)||1.8 (1.5)‡ (12)||2.1 (1.9)‡ (10)||2.2 (3.3)† (12)||0.037 (0.173)|
|No DO||4.7 (1.2) (20)||1.6 (1.4)‡ (20)||2.2 (1.7)‡ (18)||2.5 (1.7)‡ (17)||2.6 (1.9)‡ (20)||0.081 (0.163)||0.380|
|DO||4.6 (1.2) (14)||1.3 (0.8)‡ (14)||1.6 (1.7)‡ (12)||1.7 (1.6)‡ (11)||1.7 (1.7)‡ (14)||0.036 (0.115)|
|No BOO + DUA||4.1 (1.5) (8)||2.0 (1.8)* (8)||1.8 (1.3)‡ (8)||2.6 (2.1)* (7)||2.1 (2.5)† (8)||0.013 (0.208)||0.278|
|BOO ± no DUA||4.8 (1.0) (26)||1.3 (0.9)‡ (26)||2.0 (1.9)‡ (22)||2.0 (1.5)‡ (21)||2.2 (1.7)‡ (26)||0.078 (0.120)|
The relatively few patients did not allow an analysis according to stratification into eight categories by a combination of the preoperative urodynamic findings, as was done in the previous study . In the patients with BOO, the IPSS continued to be significantly improved even at 12 years (Table 1, Fig. 1). However, the IPSS in the patients with no BOO showed an improvement at 3 years, but no differences at 7 and 12 years. Although the IPSS showed a significant improvement at 7 years regardless of preoperative detrusor contractility, the statistical significance disappeared at 12 years in the patients with DUA. However, the IPSS of 10.1 at 12 years in the patients with DUA was comparable to that of 9.8 in those without DUA, and there was no significant difference in the IPSS slope between patients with and without DUA. The IPSS for the patients without DO approached the baseline level with time and the statistical significance disappeared at 12 years, although there was no significant difference in the IPSS slope between the patients with and without DO. In eight patients with DUA but not BOO, the statistical significance of the IPSS disappeared after 7 years. However, the IPSS slope was similar between eight patients with DUA but not BOO and the remaining 26 patients with BOO and/or normal detrusor contraction. In addition, the preoperative existence of DO did not influence the IPSS slope in any group: no BOO + DUA, 0.30 (0.42) with DO, 0.53 (1.03) without DO (P = 0.772); BOO and/or no DUA, 0.31 (0.53) with DO, 0.63 (0.84) without DO (P = 0.273).
Regardless of the existence of BOO, DUA or DO, the QoL index showed a significant improvement at 12 years (Table 1, Fig. 2). Even in the patients with DUA but not BOO, the QoL index showed a significant reduction until 12 years. The satisfaction rates were 25% at baseline, 50% at 3 months, 88% at 3 years, 71% at 7 years and 63% at 12 years. There were no significant differences in the QoL slope from 3 months to 12 years after TURP between those with and without BOO, DUA or DO.
Although TURP is the standard procedure for LUTS/BPO to relieve LUTS by release of BOO, only a few reports have analysed the long-term outcomes for ≥5 years after TURP [12,16–18]. To our knowledge, the present study is the first to report the long-term outcome of TURP, using the IPSS and QoL index, which are standard tools to evaluate LUTS suggestive of BPO, compared to the preoperative urodynamic findings based on cystometry and pressure-flow study.
In this study, LUTS evaluated by the IPSS and QoL index gradually deteriorated with time, from 3 months after TURP. However, they were still significantly better even at 12 years than before surgery. Two-thirds of men reported satisfaction, defined as a QoL index of 0–2, at 12 years. Nielsen et al. showed that LUTS evaluated by the Madsen-Iversen symptom score remained unchanged for 7 years after TURP. Jensen et al. also reported that symptom scores were still reduced after 8 years and the success rate, defined as a ‘much better’ or ‘better’ outcome based on the patient’s overall subjective evaluation, was 79%. Thus, TURP contributes to the relief of LUTS and LUTS-related bother for ≥10 years. However, the reasons why the IPSS and QoL index showed a mild deterioration in slope were unknown, because we did not use a systematic evaluation incorporating urodynamic studies, cystoscopy or urethrography. Impaired detrusor function due to ageing and mild obstruction due to recurrent adenoma and/or urethral stricture, etc. might be involved . Thomas et al. showed that the long-term decrease in Qmax and symptomatic failure after TURP were mainly associated with detrusor failure rather than with obstruction. We also reported that poor voiders after TURP showed DUA but not BOO in a pressure-flow study . As the patients who developed recurrent adenoma and/or urethral stricture had been properly treated in the present study, it is likely that impairment of detrusor function, probably by ageing, mainly caused gradual symptomatic deterioration with time.
There is agreement that patients with BOO have a higher success rate from TURP than those without BOO [1–8]. However, we previously reported that the IPSS, QoL index, Qmax and PVR at 3 months after TURP were comparable among the groups with a LinPURR of 0–1, 2–3, and 4–6 . In addition, there was no difference in treatment efficacy between patients with strong/normal and weak/very weak detrusor contraction. Thus, a promising short-term effect of TURP can be expected even in patients with no obvious BOO or with DUA, as several studies have indicated [1,8,11,13]. However, only a few reports analysed the long-term outcome of TURP for patients without obvious BOO or with DUA.
In the present study, although deterioration of the IPSS in patients without BOO was faster than in those with it, the IPSS at 12 years was still comparable to that before TURP, despite the passage of 12 years. In addition, the QoL index showed a durable improvement up to 12 years. The preoperative status of detrusor contractility influenced neither the IPSS slope nor the QoL slope. It is hard to interpret why the IPSS in patients with DO showed a sustained improvement for 12 years, whereas in those without DO it did not, because we did not confirm whether preoperative DO disappeared after surgery. However, the QoL index showed a durable reduction in both the groups with DO and without DO. Thus, TURP can provide an acceptable long-term outcome regardless of the preoperative urodynamic findings. However, Thomas et al. reported that there were no long-term symptomatic and urodynamic gains from TURP in men with DUA but not BOO. In their study of 84 neurologically intact men who could be followed at least for 10 years after initial urodynamic evaluation, 22 underwent immediate or deferred TURP, 58 were untreated and the remaining four were treated by immediate clean intermittent catheterization. Between the baseline and the follow-up (mean 11.3 years), there were no significantly sustained improvements in LUTS, such as nocturia and weak stream, and urodynamic variables such as Qmax and PVR. In addition, there were no significant differences in the IPSS, QoL index, Qmax and PVR at the follow-up between men who had TURP and those who were untreated. However, they did not show the short-term efficacy of TURP. It is valid to speculate that many men with DUA but not BOO had short- to middle-term benefits of TURP, according to our results. Even at 12 years after surgery, two-thirds of the patients with DUA but not BOO were satisfied with their urinary condition.
Jensen et al. also reported that BOO and DO were not statistically significant predictors of success at 8 years after TURP. However, as we previously concluded , the surgical indication should be circumspect for patients having DO but not BOO, because the short-term overall treatment efficacy was inferior.
There were several limitations in the present study. The few survivors did not allow a stratification into eight categories by a combination of the preoperative urodynamic findings. In addition, we could not collect information on incontinence, which is a key component of overactive bladder syndrome, and objective variables like Qmax and PVR during the long-term follow-up. Furthermore, cystometry and pressure-flow study were not possible for the unsatisfied patients to determine the causes. However, as the goal of treatment for LUTS/BPO is a definite improvement in QoL through the relief of symptom-related bother, our study provides essential information to evaluate the efficacy of TURP.
In conclusion, the symptomatic improvement obtained by TURP lasts for ≥10 years, although there is a gradual deterioration with time. The QoL index remained improved for 12 years regardless of the preoperative urodynamic findings.
CONFLICT OF INTEREST