Transurethral resection versus transurethral incision of the prostate. A prospective randomized study

In this ongoing study, patients with an estimated prostate size of no more than 20 gm are randomized to undergo either transurethral resection of the prostate (TURP) or transurethral incision (TUIP) at the 6 o'clock position. To date, 93 patients have been included, and 3 months postoperatively, 80 to 90 per cent of the patients in each group reported improvement. There was also a significant decrease in symptom scores and a significant increase in maximum urinary flow rate, with great variation within each group but without difference between the groups. In both groups, there appears to be some deterioration over time. Operating time, estimated blood loss, time to catheter removal postoperatively, and duration of postoperative hospital stay were all significantly in favor of TUIP. Loss of ejaculation was reported by 37 per cent of patients after TURP and by 13 per cent after TUIP (not statistically significant). There was no difference between the groups in the need for further surgery. Therefore, TUIP is recommended as an alternative to TURP in patients with small prostates.     

Transurethral resection syndrome after bladder perforation

The use of irrigating solutions is essential for distension of mucosal surfaces and visualization of the surgical field during resectoscopic resection of bladder tumors (TURBT). TURBT resection may be complicated with bladder perforation associated with intraperitoneal extravasation of irrigant fluid, which may rarely evolve in specific hydroelectrolyte imbalance characterized with hyponatremia, intravascular volume deficit, and renal impairment. We report four cases of TURBT syndrome during bladder surgery complicated by bladder perforation and discuss issues relevant to pathophysiology, diagnosis, and treatment of this rare condition.     

Transurethral resection syndrome after transurethral resection of bladder tumours

The transurethral resection syndrome has not previously been described after bladder surgery. This article reports four patients who developed signs of this syndrome after transurethral resection of bladder tumours (TURB). Symptoms included abdominal pain, arterial hypotension, nausea and vomiting. There was evidence in all cases that the cause was absorption of irrigating fluid by the extravascular route. Fluid absorption was detected by ethanol in two patients and the urologist noted a perforation during the third operation. The most complicated clinical course occurred in the case where there was a delay of three hours before the diagnosis was made. Medical treatment consisted of antiemetics and volume expansion of the extracellular fluid compartment as extravasation is associated with hypovolaemia. Diuretics were not given until the circulation had been restored.     

Transurethral resection

In five years 938 transurethral resections were performed in the Department of Urology of Semmelweis University Medical School. The indications were in 483 cases tumours of the bladder, in 179 adenoma of the prostate and in 182 cancer of the prostate; the indications of the remaining cases were miscellaneous. The indications, most important surgical parameters, postoperative complications and treatment of transurethral resections are discussed from the authors' point of view. The results prove the advantages of transurethral resection and confirm its importance as a basic surgical intervention in urological practice.     

Transurethral resection of prostate via perineal urethrostomy. Prospective study.

A controlled, prospective clinical study was undertaken to determine the incidence and cause of urethral strictures after transurethral resection. Patients were assigned to 1 of 3 groups. Group A consisted of patients in whom it was considered preferable for various reasons to perform prostatic resection through perineal urethrostomy; therefore, these were excluded from randomization. All other patients were randomized using a sealed-envelope method into Group B who underwent resection via perineal urethrostomy and Group C who underwent resection via the entire urethra. Strictures occurred in 6 of 42 patients in Group C postoperatively while patients in Group B remained free of strictures. This difference was statistically significant (p less than 0.05). It was concluded that strictures which occur result from the use of the resectoscope through the entire urethra and not from the use of indwelling catheters, and that performing prostatic resection via perineal urethrostomy is valuable in preventing the occurrence of such strictures.     

Curative resection in Zollinger-Ellison syndrome. Results of a 10-year prospective study.

Since 1980, 73 patients with Zollinger-Ellison syndrome (ZES) without radiographic evidence of liver metastases were studied on a prospective protocol including medical management of gastric acid hypersecretion, extensive radiographic tumor localization, and exploratory surgery to find and resect gastrinoma for potential cure. Each patient had gastric acid hypersecretion effectively controlled with either H2-blockers or omeprazole. Patients were divided prospectively into two groups, with all patients undergoing the same preoperative localization studies and extensive laparotomy. In contrast to group 1 (1980-1986) (36 patients), group 2 (1987-Oct. 1990) (37 patients) also underwent additional procedures (transillumination and duodenotomy) at surgery to find duodenal gastrinomas. Preoperative imaging studies localized tumor in 38 (52%) patients, and portal venous sampling for gastrin determinations was positive in 49 (67%) patients. Gastrinomas were found and resected in 57 (78%) patients. Significantly more gastrinomas (92% of patients) were found in group 2 than in group 1 patients (64%) (p less than 0.01). This increase was due to increased numbers of duodenal gastrinomas in group 2 than in group 1 patients (43% versus 11%; p less than 0.01). The increased ability to find duodenal gastrinomas did not significantly improve the immediate disease-free rate, which was 58% for all patients. Duodenal primary gastrinomas were found to have a significantly greater incidence of metastases (55%) and a significantly shorter disease-free interval (12 months) than pancreatic gastrinomas (22% and 84 months, respectively) suggesting that duodenal gastrinomas may be more malignant and not more frequently curable than pancreatic gastrinomas. Operations were performed with no deaths and 11% morbidity rate. Long-term follow-up showed that 50% of patients initially rendered disease free would develop recurrent disease by 5 years. Survival was excellent for all patients, and none died of malignant spread of the tumor or uncontrolled peptic ulcer disease, with a mean follow-up of 5 years. This finding is in contrast to patients who presented with metastatic disease on imaging studies and had a 20% 5-year survival rate. This study suggests that all patients with localized sporadic ZES can have the gastric acid hypersecretion managed medically, that overall survival of these patients is excellent, most (78%) can have all gastrinoma found and resected, and some (30%) will be cured (long-term disease-free survival).     

Transurethral resection syndrome detected and managed using transesophageal Doppler

Transurethral resection syndrome during transurethral resection of the prostate (TURP) results from excessive absorption of electrolyte-free irrigation fluids causing acute hypervolemia and hyponatremia. Neuraxial anesthesia is often recommended for TURP procedures because early signs of neurological deterioration can be detected. However, in patients requiring general anesthesia, other continuous and noninvasive measures are needed. Acute intravascular hypervolemia should be reflected by changes in hemodynamic values. Transesophageal Doppler ultrasonography of the aorta allows determination of stroke volume and other advanced hemodynamic variables related to intravascular volume status. We describe the first case of intraoperative detection of a TURP syndrome by noninvasive Doppler monitoring of hemodynamic variables during TURP.     

Transurethral prostatotomy versus transurethral prostatectomy in benign prostatic hypertrophy. A prospective randomised study

Transurethral prostatotomy (TUT) in 24 patients was compared with transurethral prostatectomy (TUR) in 25 patients in a prospective randomised trial. All patients were aged 60 years or more and presented with symptomatic benign hypertrophy. One half of the patients had acute retention. Shorter operative time and less post-operative bleeding were found in the TUT group, which included 3 failures. No difference was found in post-operative duration of catheterisation or duration of hospitalisation. No significant differences were seen after 1 year's follow-up in the number of patients with positive urinary culture or urinary flow rate. One patient in the TUT group had a recurrence of symptoms, thus giving a total of 4 failures and a success rate of 82%. One patient became incontinent after TUR and 4 developed a stricture. The success rate after TUR was 78%. It was concluded that TUT and TUR produce similar functional results in cases where the gland is not too large.     

Cremaster resection in Shouldice repair. A prospective controlled bicenter study

The aim of this prospective controlled trial was to determine the value of the resection of the cremaster muscle in Shouldice's hernia repair. 237 Shouldice operations with resection of the cremaster muscle of the Department of Surgery of the RWTH of Aachen were compared with 153 Shouldice repairs without resection of the cremaster muscle of the Department of Surgery of the Elisabeth Hospital in Essen. A comparable follow-up of 12 to 26 months in both groups revealed no significant differences in postoperative complications. In the group without resection of the cremaster muscle four indirect recurrent hernias were diagnosed. In the group with resection of the cremaster muscle no indirect recurrent hernia was detected, only one direct recurrent hernia was documented. The significantly elevated rate of recurrent hernias (p less than 0.05) and the occurrence of atypical indirect recurrent hernias in the group without resection of the cremaster muscle demonstrate the important influence on the technique of repair. Based on our results the resection of the cremaster muscle in an essential part of Shouldice's hernia repair.     

The Mallory-Weiss syndrome. A prospective study in 130 patients.

The clinical features of the Mallory-Weiss syndrome were prospectively documented in 130 of 1 667 patients submitted to endoscopy for gastro-intestinal haemorrhage, an incidence of 7,8%. The important clinical features found in these patients were: alcohol abuse (21%); retching or vomiting (38%); salicylate ingestion (36%); dyspepsia (39%). The correct clinical diagnosis was therefore often difficult to make. Additional lesions were found in 40% of patients at endoscopy. Blood loss was relatively small, and surgery was not required in any patient. The 2 deaths that occurred were not attributable to haemorrhage. A high index of suspicion and early endoscopy are required to establish the diagnosis.     

Transurethral resection in regionally advanced bladder cancer.

Various treatments have proved useful for disease control in some patients with regionally advanced bladder cancer. Transurethral resection may cure some patients with invasive disease, but identifying patients with such potential early in their course is difficult. A restaging transurethral resection helps indicate whether conservative management is feasible and, if not, which operation is appropriate. In some patients, transurethral resection may enhance the response to chemotherapy. Research is needed to identify those tumor characteristics associated with good results of conservative management of regionally advanced bladder cancer.     

Transurethral resection of transvaginal tape

Urethral erosion is an uncommon complication after tension-free vaginal tape (TVT) procedure. However, management is a challenge and morbidity significant because of the necessity to incise the urethra to gain access to the material. This is a report of a case of transurethral resection of such mesh. A 77-year-old women presented at 7 months postoperatively with complaints of incomplete emptying and persistent incontinence. Urodynamic testing and cystoscopy revealed intrinsic sphincter deficiency, an elevated post void residual and erosion of the TVT tape into the urethral lumen. The tape was removed without any incisions via an operative cystoscope and hysteroscopic scissors. All urinary symptoms resolved. Partial urethral transection can be managed successfully with transurethral resection of the material. This diagnosis should be considered in patients with incomplete emptying and recurrent incontinence.     

Transurethral resection using glycine irrigation

An accident is described which occurred during a transurethral resection of a prostatic adenoma using a 1.5% glycine solution in a 68 yr old patient. The surgery was performed under spinal anaesthesia with bupivacaine. After 14 l of irrigation fluid had been used, visual disturbances, bilateral mydriasis and drowsiness appeared, with no haemodynamic disturbances. Three hours after the end of surgery, there appeared convulsions, with the blood sodium level at 118 mmol X l-1. Symptomatic treatment resolved the problem, and the clinical examination was normal 12 h after surgery. The role of hyponatraemia in the clinical state is discussed. The usefulness of regional anaesthesia in the early detection of this type of accident is recalled.