Benign prostatic hyperplasia. Part 6: Treatment
Surgical: TURP
The main intervention for the treatment of benign prostatic hyperplasia is still TURP. So common is this operation, that a probability of prostatectomy occurring in the lifetime of a 40-year-old in the US has been calculated as 29%. The main benefit of TURP is towards obstructive symptoms, but irritative symptoms may also improve where bladder preoperative changes are not prolonged or excessive. Indications
The UK National Prostatectomy Audit found that 62% of men (3326/5361) had at least one strong indication for operation. These were:
• Acute retention; n = 1507 (28.1%),
• chronic retention (residual urine volume of > 196 ml); n = 1403 (26.2%),
• elevated creatinine/urea; n = 826 (15.4%),
• suspected malignancy; n = 725 (13.5%),
• haematuria; n = 392 (7.3%), and
• bladder stones; n = 91 (1.7%).
Although the remaining 38% (2035) had none of the above indications for operation, 1531 of these men did complete an AUA symptom score. This indicated mild symptoms in 55 men (3.6%); moderate symptoms in 591 (38.6%) and severe symptoms in 885 (57.8%). In the US, in marked contrast to the UK, the overwhelming majority of TURPs are undertaken for symptoms only. Mortality and morbidity comparisons between the US and UK should, therefore, be treated cautiously. However, in both countries TURP is being undertaken on men who have a significant level of co-morbidity in up to 75% of cases. The rate of complications is around 17%,” and is not significantly different for those with co-morbidity, nor does the rate increase with ageing in those below 80 years.
Mortality and morbidity
Average mortality at all ages occurring within a month of the operation has improved significantly in the US from 2.5% in 1962 (n = 2015) to 1.3% in 1974 (n = 2223) and 0.23% in 1989 (n = 3885). In the UK, recent reports indicate levels of below 1% (n = 388, n = 1400). However, higher rates occur in older men, especially those aged over 80 years, in operations where malignancy is present and in sites where less than 100 operations per annum were undertaken. Some studies have suggested that the longer-term mortality from TURP is worse than open prostatectomy, however, Fugslig found no greater mortality than that of the background population in a 10-year follow-up.
Morbidity appears to be associated with longer operating times (>90 minutes), larger gland size (> 45 g), and acute urinary retention. Immediate complications include:
• Bleeding, with or without clot retention, with patients reporting higher rates (15%) than surgeons (11%),
• failure to void,
• UTI,
• TURP syndrome (hypovolaemia from absorption of irrigant solution),
• myocardial arrhythmia, and
• indwelling catheters (2.4% of Mebust’s sample in 1989).
Longer-term problems include retrograde ejaculation in a majority of men.’ Thorpe reported no verifiable evidence of pre-operative sexual counselling in 70% of men (977/1396). A worsening in the quality of sex life has been reported in up to 25% of men.
Roos, reviewing 12 090 Canadians, 36 703 Danish and 5284 English procedures, found a re-operative rate of 12-15%. Stress (2.9%), urge (1.9%), or total incontinence (1%) is another important outcome. Urethral stricture or bladder neck obstruction may occur in between 3% and 16% of cases.
Outcome studies concur that greatest improvement in symptoms and quality of life is found in patients who had severe symptoms pre-operatively, with >90% reporting satisfaction compared to <80% for patients with moderate symptoms, and even lower levels for those with mild symptoms. Although flow rates of >15 ml/sec may predict a poorer outcome, other maximum flow rates do not predict the outcome of prostatectomy.