Does detrusor underactivity affect the results of transurethral resection of prostate?

International Urology and Nephrology - We aimed to evaluate the outcome of transurethral resection of the prostate (TURP) in patients with benign prostatic hyperplasia (BPH) and diagnosed to have...     

Is it oncologically safe performing simultaneous transurethral resection of the bladder and prostate? A meta-analysis on 1,234 patients

Purpose

It is not unusual to encounter the clinical scenario of a male patient undergoing endoscopic treatment for bladder cancer (TURBT) who also needs transurethral resection of prostate (TURP). The aims of this meta-analysis were to understand whether it is oncologically safe or advantageous to combine the two procedures in terms of subsequent overall recurrences with particular interest to that in the prostatic fossa and to understand whether some characteristics of the bladder tumors can influence the recurrence rate.

Methods

A bibliographic search covering the period from January 1950 to December 2011 was conducted in PubMed, MEDLINE and EMBASE. Meta-analysis approach was applied comparing prostatic fossa recurrences and total recurrences in simultaneous TURBT and TURP and control. Also, prostatic fossa recurrences and tumors?? grading and multifocality in patients treated with simultaneous TURBT and TURP were analyzed. To investigate to what extent observational time influenced relapses/recurrence, a random effect meta-regression logistic model?Cbased approach was applied. All statistical evaluations were performed using SAS version 9.2 and by RevMan 5.0. An ?? level of 0.05 was considered as statistically significant.

Results

Overall, there were 1,234 participants in the eight studies considered. The study group consists of 634 patients and the control group 600. Mean age was 67.88 and 61.64?years, respectively, in the study and control groups. In the study group, on a total of 634 patients, 65 recurrences in the prostatic fossa appear. In the control group, on a total of 600 patients, 58 recurrences in the prostatic fossa occurred. Data do not show a statistically significant difference in recurrence in the prostatic fossa between patients treated simultaneously with TURB and TURP and the control group. Meta-analysis does not show a statistically significant difference in recurrence in the prostatic fossa with the increased grading of the neoplasms. But there is a statistically significant increased recurrence in patients with multifocal tumors. There is a statistically significant reduction in recurrence between patients treated simultaneously with TURB and TURP and the control group, but there is no reduction in the recurrence rate in the time.

Conclusions

This meta-analysis emphasized that the two operations could be performed during the same session without any negative oncologic results. The resolution during the same session of bladder outlet obstruction will improve the patients?? quality of life and performing the procedures in the same session sparing the patients from a further anesthesiological maneuvers and the need for a further hospitalization for the surgical resolution of the prostatic obstruction.     

Does the presence of muscularis propria on transurethral resection of bladder tumour specimens affect the rate of upstaging in cT1 bladder cancer?

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? It is already known and accepted that the presence of mucularis propria (MP) on bladder biopsy is incremental to the clinical staging process for this disease entity. This study establishes that the lack of MP also portends a higher risk of pathologic upstaging at the time of radical cystectomy. OBJECTIVE

• ? To determine how the presence of MP on T1 biopsy specimens affects the outcome of patients undergoing RC as compared to when no MP is identified in the TURBT specimen.

PATIENTS AND METHODS

• ? Patients were retrospectively identified from the Columbia University Urologic Oncology Database.
• ? From January 1986 to October 2009, 114 patients diagnosed with cT1N0M0 bladder cancer who underwent RC within 4 months of their last biopsy were identified.
• ? Patients were stratified based on the presence of MP on T1 biopsy, and upstaging was defined as any tumor T2 or greater, N+, or M+ at the time of radical cystectomy.
• ? The rate of upstaging was assessed using univariate and multivariate regression models; Kaplan meier curves were also extrapolated for each cohort to compare disease specific and overall survival patterns.

RESULTS

• ? Of the 114 patients evaluated in this study, 24 (20.2%) did not have MP on their T1 biopsy before RC. The rate of upstaging (>=pT2) stratified by the presence of MP on biopsy was 50% and 78%, respectively (p = 0.017).
• ? On univariate analysis, lack of MP on biopsy was associated with an increased risk of upstaging (HR 3.52, p = 0.021, CI 1.2–10.3), however did not reach significance as an independent predictor (HR 2.9, p = 0.056, CI 0.97–8.9).
• ? At a mean follow‐up of 33.5 months, there was no difference in disease specific (p = 0.41) and overall survival (p = 0.68) between groups.

CONCLUSIONS

• ? The lack of MP on TURBT for high grade cT1N0M0 bladder cancer portends a high likelihood of upstaging at RC, although this risk did not translate into a detectable increased risk of disease specific mortality.

     

Does anaesthetic technique affect the outcome after transurethral resection of the prostate?

OBJECTIVE: To determine if the choice of anaesthetic (spinal or general) has any influence on outcomes after transurethral resection of the prostate (TURP). PATIENTS AND METHODS: The records of 261 patients undergoing TURP between October 1995 and July 1998 were selected for a matched-cohort study. There were 87 complete datasets for cases performed under general anaesthesia and each was matched to two patients (174) from those undergoing spinal anaesthesia. The cohorts were matched by age, physical status score and date of operation. The primary outcome measures were length of stay in the recovery room and satisfaction with postoperative analgesia. RESULTS: There were no significant differences in major outcomes. There was a higher incidence of some minor adverse events in the group having general anaesthesia. Back pain was more common after spinal anaesthesia. CONCLUSION: Spinal anaesthesia was not associated with an improved outcome after TURP. The choice of anaesthesia should be made by the patient, surgeon and anaesthetist on the basis of the known risks of particular adverse events.     

What is the available evidence to support immediate adjuvant intravesical chemotherapy after transurethral resection of superficial transitional cell carcinoma of the bladder?

The endpoints chosen for analysis of outcome following intravesical therapy can be quite varied. Precise definitions of endpoints are mandatory to permit any comparative assessment between agents or treatment regimens. Although the recurrence endpoint favorably impacts on quality of life by reducing the number of biopsies and resections, the endpoint of greatest importance is progression. Progression of disease is an indication for cystectomy. Unfortunately, the majority of trials testing intravesical agents have not shown significant reduction in disease progression or have been too small or followed for too short an interval to be able to adequately measure this endpoint. Tumor recurrence after initial tumor resection may be explained by a number of factors; one is tumor cell implantation. A number of small trials have suggested a reduction in tumor recurrences by instillation of chemotherapy immediately after resection. Based on these preliminary data, large prospective multicenter trials have been conducted and have confirmed the benefit of immediate adjuvant intravesical chemotherapy. Bacillus Calmette-Guerin (BCG) cannot be administered immediately postresection because of the potential for systemic dissemination via the recently resected tumor bed. Therefore, combination strategies using immediate instillation of a cytotoxic agent followed by BCG induction and maintenance presents an attractive strategy that is currently under study and one that may be more commonly employed in the future treatment of patients with superficial transitional cell carcinoma of the bladder.     

Is transurethral vaporization a remake of transurethral resection of the prostate?

PURPOSE: Transurethral resection of the prostate (TURP) is still the gold standard method to treat benign prostatic hyperplasia (BPH). Transurethral vaporization of the prostate (TUVP) is compared with the transurethral resection of benign prostatic hyperplasia. PATIENTS AND METHODS: Over a 10-month period, 78 patients presenting with moderate and severe symptomatic BPH were randomized into two groups. A total of 38 patients underwent TURP, and 40 men underwent TUVP. The protocol included urinary flow rate (Qmax), symptomatology evaluated by the International Prostatic Symptom Score (I-PSS), and an ultrasonographic estimate of the postvoiding residual volume (PVR). The TUVP was carried out using a regular loop with the electrical source set at 250 to 300 W in the pure cutting mode. The same technique was used in the TURP, but the electrosurgical unit was set at 50 to 80 W for cutting and 50 W for hemostasis. The mean follow-up was 17 months (range 11-23 months). RESULTS: The data showed significant improvement in the symptom score, maximum flow rate, and postvoiding residual urine volume after treatment (P<0.01) in both groups. Comparing the symptom score, there was no difference between the two techniques (P = 0.88), the same occurring with the PVR (P = 0.78). However, the Qmax was higher after TURP (P = 0.02). The amount of tissue resected showed no statistical difference between the two techniques (P>0.05). Operative time, postoperative irrigation, catheter removal, and hospital stay were better with TUVP (P = 0.001). There was a statistically significant difference (P = 0.003) when we compared the occurrence of retrograde ejaculation with TURP (32%) and TUVP (65%) The TUVP using a regular loop, in addition to the advantage of the equipment and technique already being familiar to urologists, is efficient and reduces capital expenditure. CONCLUSION: The TUVP is a remake of TURP, with higher energy offering better results.     

Is there a correlation between the outcome of transurethral resection of prostate and preoperative degree of bladder outlet obstruction?

To compare the impact of transurethral resection of prostate (TURP) on symptom scores and maximal flow rates (Qmax) in patients with equivocal bladder outlet obstruction (BOO) and definite BOO and to assess the relationship between the surgical outcomes and degree of preoperative BOO, we prospectively evaluated men with lower urinary tract symptoms and bladder outlet obstruction index (BOOI) greater than 20, who were refractory to conventional medical treatment and underwent TURP. Urodynamic evaluation, International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual volume (PVR) check and transrectal ultrasound were performed. 20相似文献   

Is transurethral vaporesection of the prostate better than standard transurethral resection?

OBJECTIVE: The aim of this study was to undertake an evaluation of the comparative efficacy and morbidity of transurethral vaporesection (TUVRP) and standard transurethral resection (TURP), two resection techniques using loops of different thickness and power settings. METHODS: In a prospective study, 185 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction and benign prostatic enlargement were randomized to undergo either TUVRP or standard TURP. Inclusion criteria were benign prostatic enlargement, moderate or severe lower urinary tract symptoms and/or a significant urinary residual (>60 ml), while patients with previous prostatic surgery, prostate cancer or neurogenic bladder disorders were excluded. Prostate size, residual urine, urinary flow rate and symptoms as well as associated bother (using the International Prostate Symptom Score (IPSS) and the American Urological Association Bother Score (AUA-BS)) were assessed preoperatively. Intraoperative blood loss and fluid absorption were evaluated by measuring serum hemoglobin and respiratory alcohol concentration. Patients were followed for 1 year with the evaluation of flow rates, residual urine volumes, symptom scores and complications at 3, 6 and 12 months. RESULTS: A significant difference was seen in the weight of the resected tissue (TURP 30.3 g vs. TUVRP 21.9 g, p<0.003). There were no significant differences in blood loss, intraoperative fluid absorption or procedure time between TUVRP and TURP, although more patients in the TURP group required blood transfusions (13 vs. 7) and mean procedure time was longer for TUVRP (71.0 vs. 65.9 min). The postoperative improvements in IPSS, AUA-BS, residual and Q(max) were significant in both groups (p<0.01 for each) but without difference between the two groups. The rate of complications (urinary tract infections, urethral stricture, reintervention rate) during follow-up was the same in both groups. CONCLUSIONS: In this prospective randomized comparison of the clinical outcome and morbidity of standard TURP versus TUVRP, there were no significant differences in any of the parameters evaluated except for the weight of the resected tissue.     

Is laparoscopic bladder diverticulectomy after transurethral resection of the prostate safe and effective? Comparison with open surgery

PURPOSE: In a retrospective nonrandomized study, we compared our experience with transurethral resection of the prostate (TURP) plus sequential laparoscopic bladder diverticulectomy with a series of combined open bladder diverticulectomies with transvesical prostatectomy. PATIENTS AND METHODS: We considered 12 consecutive patients (group A) having 16 diverticula who underwent sequential TURP and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group B) having 13 diverticula who underwent open bladder diverticulectomy and transvesical prostatectomy. We evaluated the size and position of the diverticulum, adenoma volume, operative time, postoperative hemoglobin variations, analgesia requirement, complications, postoperative hospital stay, and uroflowmetry results. RESULTS: No statistically significant differences existed between the groups in adenoma volume or diverticulum size or position. However, a significantly longer operative time was recorded in group A. The endolaparoscopic approach proved to be statistically superior to open surgery regarding blood loss, postoperative analgesia requirement, and hospital stay. No intraoperative complications were recorded. In addition, no statistically significant difference was found in uroflowmetry results. CONCLUSIONS: In our experience, the endolaparoscopic approach has proved to be safe, effective, and minimally invasive and therefore superior to transvesical prostatectomy and open bladder diverticulectomy. Its only disadvantage is the longer operative time.     

Time to rebrand transurethral resection of the prostate?

PURPOSE OF REVIEW: Transurethral resection of the prostate remains the gold standard treatment for benign prostatic obstruction. Owing to the significant morbidity traditionally associated with the procedure, a large number of expensive, high-energy alternative treatments have been developed, which have enjoyed varying degrees of success. At the same time, transurethral resection of the prostate has evolved into a safer operation whilst maintaining its excellent efficacy. This review aims to outline the major advances that have occurred recently in transurethral resection of the prostate. RECENT FINDINGS: Optimizing each stage of transurethral resection of the prostate can result in reduced morbidity. Preoperative treatment with oral antiandrogens and 5-reductase inhibitors appears to reduce intraoperative bleeding, appropriate prophylactic antibiotic regimens reduce postoperative infection rates, improved instrumentation and diathermy delivery can reduce intraoperative bleeding and hence reduce postoperative irrigation requirements, and alcohol monitoring of irrigant absorption can eliminate transurethral resection syndrome. Careful patient selection, meticulous surgical technique combined with an aggressive postoperative irrigation and catheter removal policy can result in transurethral resection of the prostate being performed safely on a day-case basis. SUMMARY: Whilst our attention has been distracted by the many alternative treatments brought to the market over the past decade or so, transurethral resection of the prostate has been undergoing a quiet evolution. With fine tuning of all aspects of the patient journey we can now offer a procedure with excellent long-term efficacy combined with reduced morbidity and inpatient stay.