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.     

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.     

Can the need for palliative transurethral prostatic resection in patients with advanced carcinoma of the prostate be predicted?

PURPOSE: To identify the factors predicting the need for palliative transurethral resection of the prostate (channel TURP) in patients with advanced carcinoma of the prostate (CAP) receiving androgen ablation therapy. PATIENTS AND METHODS: From January 1996 to January 2004, 203 patients with advanced CAP were treated by androgen ablation. Patients presenting with retention were catheterized initially, and those (N = 12) who failed a catheter-free trial and had immediate channel TURP were excluded. The remaining 191 patients were followed every 3 months (mean 35.5 months, range 6-92 months). Patients requiring channel TURP (group 1; N = 42 [22%]) during follow-up were compared with those who did not (group 2) for predictive factors, viz. retention of urine, serum prostate specific antigen (PSA) concentration, Gleason sum, prostate size, and bony metastasis at presentation. RESULTS: Channel TURP was performed at a mean of 21 months (range 3-72 months). The mean Gleason sum in this group was 7.88, whereas it was 7.29 in group 2 (P = 0.013). Retention at presentation was significantly more common in group 1 (N = 26; 61.9%) than in group 2 (N = 46; 30.8%; P = 0.001). Patients who did not present with retention and had Gleason sums < or =7 (N = 32) did not require channel TURP. Of the 14 patients who voided successfully after a catheter-free trial but had Gleason sums of >7, 71.4% required channel TURP. Other factors were not found to be significantly different in the two groups. CONCLUSION: High Gleason sum and retention at presentation are significant factors predictors of the need for channel TURP during follow-up in patients with advanced CAP receiving androgen ablation therapy.     

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 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.     

Can histopathology predict treatment outcome following high-energy transurethral microwave thermotherapy of the prostate? Results of a biopsy study.

BACKGROUND: Despite good results of high-energy transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia, it is still difficult to predict the response to treatment on an individual basis. Besides clinical baseline parameters, intrinsic histological parameters are suggested to play a role in the response variance after TUMT. In this study we analyzed histological parameters (vessel density and epithelium-stroma (E/S) ratio) in patients who were selected for high-energy TUMT and related these parameters to clinical outcome. METHODS: We treated 42 patients with high-energy TUMT, who prior to treatment agreed upon ultrasonographic investigation of the prostate in combination with biopsies of the peripheral and transitional zones of the prostate. For all separate biopsy locations, the histological stained prostate slides were morphometrically quantified with computer assistance and analyzed for E/S ratio and vessel density. Response to treatment was measured by using standardized response evaluation criteria and was correlated with histological outcome. RESULTS: The E/S ratio in the inner gland biopsies tended to be higher in the good response group compared to the very poor responders. Furthermore, a clear trend was seen towards a lower vessel density in good responders. Large prostates and prostates with a high E/S ratio responded well to the high-energy thermotherapy. CONCLUSIONS: Histopathological parameters of the prostate tend to be moderately predictive for clinical response in this research population. Poor responders appeared to have a somewhat higher vessel density in all prostate biopsy sides, and there was also a trend towards a lower E/S ratio in these patients.     

Can haematologic parameters be used to predict testicular viability in testicular torsion?

The purpose of this study was to evaluate the predictive value of haematologic parameters for testicular survival in torsion. Children with testicular torsion (TT) treated in Beijing Children's Hospital from January 2006 to December 2018 were enrolled in this study. Patient data collected in this study included age, symptom duration, preoperative preparation time, cryptorchidism testicular torsion or not, spermatic cord torsion degree, orchiectomy/orchiopexy, testicular volume 3 months after operation by ultrasound in orchiopexy patients and haematologic parameters. The orchiopexy group comprised of 54 patients with a mean age of 135.6 ± 43.73 months, and the orchiectomy group included 58 patients with a mean age of 119.36 ± 60.82 months. The multivariate analysis showed that symptom duration (Odds Ratio = 1.11, p < 0.001), spermatic cord torsion degree (Odds Ratio = 1.006, p = 0.002) and mean platelet volume (MPV; Odds Ratio = 3.697, p = 0.044) were significant predictors of orchiectomy. The cut‐off value for MPV during window time for orchiectomy was 10.55 fl (10^?9 L) and provided a sensitivity of 47.8% and a specificity of 92.6%. This study found that symptom duration, spermatic cord torsion degree and MPV could be indicators of testicular viability in testicular torsion. MPV can provide valuable information before operation which can guide doctors and family members of the patients to select the appropriate treatment.     

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...     

Should stents be used in the treatment of ruptured intracranial aneurysms?

The indications for endovascular coiling of intracranial aneurysms continue to expand. This is due, in part, to the development of intracranial specific stents which permit remodelling of complex aneurysm necks. While this approach has several advantages in the setting of unruptured aneurysms, certain challenges, in particular the requirement of concomitant antiplatelet medication, may limit its use in treatment of ruptured intracranial aneurysms. These devices can be used safely and effectively in the treatment of selected ruptured aneurysms. One must weigh the potential hemorrhagic complications against the benefits of stent assisted coiling and the disadvantages of alternative approaches.     

Is transurethral resection of the prostate safe and effective in the over 80-year-old?

OBJECTIVE: To assess the safety and effectiveness of transurethral resection of the prostate (TURP) in patients over 80 years old. PATIENTS AND METHODS: The records of all patients over 80 years old undergoing TURP at one institution over a 3.5-year period were studied retrospectively. RESULTS: 31% of patients underwent TURP for symptoms and 68% for urinary retention. The early complication rate was 41%. The late complication rate was 22%. There were no deaths within 30 days of surgery. Of all patients, 80% were satisfied with the outcome of their operation. Of all patients with retention, 80% were able to void with small residual volumes by 6 weeks after operation. CONCLUSIONS: Although TURP in the over 80-year-old male is associated with significant morbidity, it is an effective treatment for urinary symptoms or retention. The majority of patients are able to void afterwards and are satisfied with the outcome of their surgery.     

Can peripheral DXA measurements be used to predict fractures in elderly women living in the community?

While axial dual energy X-ray absorptiometry (DXA) is the accepted gold standard method both for diagnosing osteoporosis and predicting fractures, appropriate equipment is not universally available. Peripheral bone mass measurements may have the potential to identify patients at risk of fracture and to be used to target appropriate treatment. We assessed the effectiveness of peripheral DXA (PIXI, GELunar) in the assessment of risk and targeting treatment to prevent future fracture in 7,604 women aged 60–80 from five centres across Britain. At enrolment women completed a lifestyle and risk factor questionnaire and had a PIXI DXA scan of the heel. Women were categorised by PIXI DXA bone mineral density (BMD) into high, medium or low risk of future osteoporotic fracture. Treatment was recommended to those at highest risk. Follow-up was by simple questionnaire 18–24 months after baseline assessment. Seventy-four percent returned the follow-up questionnaire. The area under the receiver operator characteristic (ROC) curves for any fracture and osteoporotic fracture were comparable to those published using other sites and technologies. A 1-SD decrease in PIXI BMD was associated with an 86% increase in risk of osteoporotic fracture. Of the women identified as high risk, 74% had started treatment following their heel scan and 84.7% continued to take treatment at follow-up. No significant difference was noted in fracture rates in those who started treatment after assessment compared to those who did not. While peripheral DXA is highly effective for predicting older women who are at increased risk of future fracture, it has yet to be established as an effective method for targeting bisphosphonate or other therapy.     

How did the endoscopic video camera change our practice in transurethral resection of the prostate? A retrospective study of 200 cases

PURPOSE: Video camera-assisted transurethral resection of the prostate (TURP) is an invaluable teaching tool and provides physical comfort to the surgeon. However, whether it improves technical skills and reduces complications rates and hospital stay has not been well documented. PATIENTS AND METHODS: We retrospectively reviewed 100 cases of video camera-assisted (VCA) TURP and 100 cases of non-video camera-assisted (NVCA) TURP randomly chosen from 1490 cases performed over a 5-year period. The patients' mean age was similar in the two groups (70 years in the NVCA group and 71 years in the VCA group). RESULTS: The mean weight of prostatic chips was 33.2 g in the VCA and 19.02 g in the NVCA group (P < 0.05). The mean operative time was identical in the two groups (VCA 41 minutes and NVCA 42.2 minutes). The mean postoperative hospital stay was shorter in the VCA group than in the NVCA group (1.56 and 3.39 days, respectively) (P < 0.05), as was the urinary drainage time (1.68 and 4.04 days, respectively) (P < 0.05). In the NVCA group, three patients had profuse hemorrhage necessitating blood transfusions and two had TURP syndrome, while in the VCA group, one patient had TURP syndrome and no patient experienced intraoperative or postoperative hemorrhage. Urethral stricture was less frequent in the VCA group than in the NVCA group (1% and 3%, respectively). CONCLUSIONS: With video camera-assisted TURP, we resected larger prostate glands with minimal intraoperative bleeding, better hemostasis, and a shorter hospital stay.     

Can traumacel be used in the treatment of chronic wounds?

Traumacel (calcium salt of oxidised cellulose) has previously only been used in the treatment of acute wounds. To assess its safety and effectiveness in the management of chronic wounds a 12-week pilot study was undertaken which involved 11 patients with 15 non-healing leg ulcers and assessed ulcer size, ulcer pain and degree of exudate. Five ulcers healed within the study period. Significant pain relief was experienced by three patients. Use of the dressing did not appear to be related to a reduction in exudate. No patients experienced sensitisation to the product or had to be withdrawn because of adverse effects. Traumacel was found to be safe in the management of chronic ulceration, and appeared to promote healing in some recalcitrant ulcers.