Transurethral resection of the prostate and bladder neck incision: a review of 700 cases

Evaluation of functional parameters, patient-reported outcomes and workload related to continuous urinary bladder irrigation after transurethral surgery

Background

Continuous saline bladder irrigation (CBI) is a common procedure after transurethral surgery and to treat gross hematuria. We conducted this study to gather data on parameters of CBI, medical staff’s work load associated with CBI monitoring, patients’ feeling of safety and of patients’ impairments during CBI.

Methods

We observed CBI taking place after transurethral surgery for a 2–9-hour period. Patients were asked to rank how safe they felt, general impairments and impaired mobility. Irrigation parameters and complications were documented at least every 30 minutes. The staff’s workload was evaluated through the frequency of visits and presence time.

Results

The patients’ mobility was notably reduced with an average of 10.5%±16.7% of time spent outside of bed, pain was low (mean 0.60±1.15). Patients felt very safe with CBI (8.8±1.9), hardly impaired overall (3.8±3.0), but restricted in mobility (5.9±2.8). Pain was associated with general impairment and impaired mobility. Clot retention occurred in 5 patients. Average irrigation speed was 9.46±8.69 mL/min (0 to 86.7 mL/min). Urine bags were emptied on average every 2.2±1.2 hours. Patients were visited by medical personnel 1 to 11 times.

Conclusions

CBI remains an improvable procedure in terms of the irrigation process itself to prevent complications, the patients’ feeling of safety and comfort during CBI and the amount of work associated with its monitoring. We have provided parameters for the implementation of more individualized CBI monitoring.

Trial registration

German Clinical Trial Registry; DRKS00023707; Registered retrospectively November 25 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023707

Re-epithelialization resulted from prostate basal cells in canine prostatic urethra may represent the ideal healing method after two-micron laser resection of the prostate

The purpose of this study is to characterize the re-epithelialization of wound healing in canine prostatic urethra and to evaluate the effect of this re-epithelialization way after two-micron laser resection of the prostate (TmLRP). TmLRP and partial bladder neck mucosa were performed in 15 healthy adult male crossbred canines. Wound specimens were harvested at 3 days, and 1, 2, 3, and 4 weeks after operation, respectively. The histopathologic characteristics were observed by hematoxylin and eosin staining. The expression of cytokeratin 14 (CK14), CK5, CK18, synaptophysin (Syn), chromogranin A (CgA), uroplakin, transforming growth factor-β₁(TGF-β₁), and TGF-β type II receptor in prostatic urethra wound were examined by immunohistochemistry and real-time polymerase chain reaction, respectively. Van Gieson staining was performed to determine the expression of collagen fibers in prostatic urethra and bladder neck would. The results showed that the re-epithelialization of the prostatic urethra resulted from the mobilization of proliferating epithelial cells from residual prostate tissue under the wound. The proliferating cells expressed CK14, CK5, but not CK18, Syn, and CgA and re-epithelialize expressed uroplakin since 3 weeks. There were enhanced TGF-β₁ and TGF-β type II receptor expression in proliferating cells and regenerated cells, which correlated with specific phases of re-epithelialization. Compared with the re-epithelialization of the bladder neck, re-epithelialization of canine prostatic urethra was faster, and the expression of collagen fibers was relatively low. In conclusion, re-epithelialization in canine prostatic urethra resulted from prostate basal cells after TmLRP and this re-epithelialization way may represent the ideal healing method from anatomic repair to functional recovery after injury.

The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction

OBJECTIVE

To describe a modified surgical technique for treatment of highly recurrent bladder neck contracture (BNC) after transurethral surgery for benign hyperplasia and to evaluate success rate and patient satisfaction of this novel technique.

METHODS

Ten patients with highly recurrent BNC and multiple prior attempts of endoscopic treatment underwent the T-plasty. Perioperative complications were recorded and classified according to the Clavien classification. Patient reported functional outcomes were retrospectively analysed using a standardized questionnaire assessing recurrence of stenosis, incontinence, satisfaction and changes in quality of life (QoL). The questionnaires included validated IPSS and SF-8-health survey items.

RESULTS

Mean age at the time of surgery was 69.2 years (range 61-79), and the mean follow-up was 26 months (range 3-46). No complications grade 3 or higher according to the Clavien classification occurred. Success rate was 100 %. No de novo stress incontinence occurred. Urinary stream was described as very strong to moderate by 80 % of the patients, mean post-operative IPSS-score was 11.3 (range 4-29), and mean post-operative IPSS-QoL was 2.4 (range 1-5). Patients satisfaction was very high or high in 90 %, and QoL improved in 90 %. The SF-8-health survey showed values comparable to the reference population.

CONCLUSION

The T-plasty represents a safe and valuable option in treating highly recurrent BNC after surgery for benign hyperplasia. It offers multiple advantages compared to other techniques such as a single-staged approach and the opportunity for reconstruction of a reliable wide bladder neck by usage of two well-vascularized flaps. Success rate, low rate of complications and preservation of continence are highly encouraging.

Is continuous bladder irrigation after prostate surgery still needed?

Continuous bladder irrigation (CBI) is commonly prescribed after certain prostate surgeries to help prevent the clot formation and retention that are frequently associated with these sometimes hemorrhagic surgeries. However, it remains unknown how effective CBI is in preventing clot formation/catheter blockage because these complications still frequently occur in the presence of CBI. On the other hand, the outcome of prostate surgeries has significantly improved over the years, and these surgeries have generally become much safer and, in many hands, less hemorrhagic. Newer surgical options such as holmium laser enucleation of the prostate with associated improved hemorrhagic control have also been introduced, further creating the opportunity to eliminate CBI. Furthermore, there is a lack of review articles on CBI. Hence, this article will review the evolution and contemporary role of CBI in prostate surgeries. To eliminate CBI after prostate surgeries, it is important to achieve good hemostasis during the surgeries. Having in place a policy of non-irrigation after prostate surgeries is also important if less CBI is to be the norm. A non-irrigation policy will hopefully help reduce those cases of CBI prescribed out of long-standing surgical tradition while allowing for cases prescribed out of compelling necessity. The author’s policy of a consistent non-CBI during prostate surgeries over the last 9 years will be highlighted.

Bipolar plasma vaporization versus standard transurethral resection in secondary bladder neck sclerosis: a prospective, medium-term, randomized comparison

OBJECTIVES

This prospective, randomized, medium-term trial aimed to assess the efficiency, safety and postoperative results of bipolar plasma vaporization (BPV) in comparison with monopolar transurethral resection (TUR) in cases of secondary bladder neck sclerosis (BNS).

METHODS

A total of 70 patients with BNS secondary to transurethral resection of the prostate (TURP; 46 cases), open prostatectomy for benign prostatic hypertrophy (BPH; 18 cases) and radical prostatectomy for prostate cancer (6 cases) were enrolled in the trial. The inclusion criteria consisted of maximum flow rate (Q max) <10 ml/s and International Prostate Symptom Score (IPSS) >19. All patients were evaluated preoperatively and at 1, 3, 6, 12 and 18 months after surgery by IPSS, quality of life score (QoL), Q max and postvoiding residual urinary volume (PVR).

RESULTS

The mean operation time (10.3 versus 14.9 minutes), catheterization period (0.75 versus 2.1 days) and hospital stay (1.1 versus 3.2 days) were significantly reduced in the BPV series. During the immediate postoperative follow up, recatheterization for acute urinary retention only occurred in the TUR series (5.7%). The medium-term retreatment requirements due to BNS recurrence were lower in the BPV study arm (2.8% versus 8.5%). At the 1, 3, 6, 12 and 18 months assessments, statistically similar parameters were found concerning the IPSS and QoL symptom scores, Q max and PVR values specific for the two therapeutic alternatives.

CONCLUSIONS

BPV constitutes a valuable endoscopic treatment approach for secondary BNS. The method emphasized superior efficacy, a satisfactory safety profile and similar medium-term follow-up features when compared with standard TUR.

Comprehensive study of bladder neck contracture after transurethral resection of prostate

OBJECTIVES

To test the validity of transurethral resection of the prostate (TURP) plus transurethral incision (TUI) of bladder neck as an alternative to TUI of the prostate, a nonrandomized and retrospective study was done to review comprehensively the incidence of, severity of, and risk factors for bladder neck contracture (BNC) in patients with benign prostatic hyperplasia who underwent transurethral surgery.

METHODS

The evaluation parameters included age, prostate-specific antigen level, urinalysis and uroflowmetry findings, voided volume, presence of vesical stones and urinary retention, surgical type, adenoma weight, and perioperative morbidities.

RESULTS

Of the 1470 patients studied, 1135 (77.2%) were eligible for analysis. At a mean follow-up of 37.9 months, 110 patients (9.7%) had developed BNC. The adenoma weight, blood transfusion, and postoperative maximal and mean flow rate in patients with BNC were significantly less than in patients without BNC. The incidence of BNC in the TURP group was greater than that in the TURP plus TUI group (12.3% versus 6%, P = 0.000). BNC was completely prevented using TURP plus TUI if the adenoma weight was greater than 30 g. However, in the TURP group, 4% of patients developed BNC even with an adenoma weight greater than 50 g. Multivariate analyses showed that adenoma weight and surgical type were significant risk factors for BNC. Patients with associated vesical stones were less prone to develop BNC.

CONCLUSIONS

TURP plus TUI provides a pathologic diagnosis, and with minimal morbidity, it can be an alternative to TUI of the prostate in selected patients. Personal diathesis may play a role in the pathogenesis of BNC.

Long-term morbidity and mortality of transurethral prostatectomy: a 10-year follow-up

BACKGROUND

Long-term complication and reoperation rates in 1,211 patients undergoing TURP for symptomatic BPH between 1988 and 1991 were evaluated after a follow-up of at least 10 years.

METHODS

Of the 1,211 patients who underwent TURP, 577 (47.6%) were available for follow-up. Long-term complications as well as reoperation rates were evaluated on the basis of a patient questionnaire or a physician interview.

RESULTS

Repeat operation had to be performed in 35 patients (6%). TUR for bladder neck contracture had to be done in 14 patients (2.4%), while repeat TURP for BPH obstruction was required in 11 patients (1.9%). Finally, urethral strictures mandating surgical correction were present in 10 patients (1.7%).

CONCLUSIONS

TURP is associated with low reoperation rates and therefore remains the gold standard in BPH therapy. Nevertheless, follow-up of these patients must be continued, as late complications requiring intervention may occur even after 10 years postoperatively.

Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate, in patients with benign prostatic hypertrophy

One hundred patients with benign prostatic hypertrophy (BPH) were randomized to transurethral incision (TUIP) or transurethral resection of the prostate (TURP). The average prostate weight before operation was not more than 30.0 g. Indications for the operations were based on the disease history, physical examination, digital rectal examination, laboratory values, and pressure-flow examination. All operations were performed with patients under spinal anesthesia. TUIP was performed with a Collins knife, and TURP was performed with a resectoscope. Follow-up was performed 24 months after the operations. After treatment there were statistically significant daytime and nocturnal reduction in voiding frequencies of 2.9 and 1.7, respectively, after TUIP, and 2.0 and 1.5 after TURP. In both groups, there occurred significantly better maximal flow rate from 7.6 mL/s to 16.9 mL/s in group I and from 6.9 mL/s to 17.6 mL/s in group II. The mean values of linearized passive urethral resistance relation in both groups significantly decreased from 3.6 +/- 0.6 to 1.0 +/- 0.5 after TUIP and from 3.9 +/- 04 to 1.4 +/- 0.5 after TURP. The TUIP procedure is effective and safe for patients with a small number of complications.

Changing therapeutic regimens in benign prostatic hyperplasia. Clinical and economic considerations

About one-quarter of men aged 50 years and older experience voiding problems due to benign prostatic hyperplasia (BPH). Until about 10 years ago, surgery (particularly transurethral resection of the prostate) was the only effective treatment for symptomatic BPH. Over the last decade, several new treatments have been introduced. These include different types of medication (alpha-blockers and finasteride), thermotherapy, laser prostatectomy, needle ablation and vaporisation methods. The diffusion of these less invasive treatment modalities has resulted not only in a decrease in the age-adjusted surgery rates, but also in an increase of the total number of men treated for BPH. A large number of studies on clinical benefits and risks reveal that the conventional types of surgery remain the most effective treatments, whereas new interventional therapies require a shorter hospital stay and result in fewer short term complications. The efficacy of medication is lower than that of interventional treatments. Adverse effects include dizziness and orthostatic hypotension (alpha-blockers) and decreased sexual function (finasteride), but are generally mild. There is some evidence that medication and minimally invasive treatments may preclude eventual surgical treatment, but the precise effect is difficult to estimate because of differences in the study populations and the relatively short study periods. As a result of the dynamic nature of BPH treatment and the lack of long term data, the cost effects of the introduction of the various new treatments are also difficult to assess. Given the aging of the population and the growing percentage of patients with BPH for whom any type of treatment can be considered, a considerable increase of total costs can be expected. Long term prospective studies are necessary to gain insight into the most cost-effective treatment for different patient groups.

Urinary incontinence in patients who have a TURP/TUIP following prostate brachytherapy

PURPOSE

To determine urinary morbidity in patients who have transurethral resection of the prostate (TURP) after 125I brachytherapy.

MATERIALS AND METHODS

A total of 109 patients with Stage T1-T2 prostatic carcinoma were treated with 125I implantation from 1991 through 1995. Ten patients underwent TURP/transurethral incision of the prostate (TUIP) after brachytherapy to relieve urinary obstruction refractory to nonsurgical management.

RESULTS

Patients who developed refractory urinary retention had a slightly larger preimplant prostate volume than those who did not (62 vs. 54 ml; p = 0.16). Seven of the 10 patients developed some degree of permanent urinary incontinence following TURP/TUIP. Urinary incontinence was mild in three patients [Late Effects Normal Tissue Radiation Oncology Group (LENT) score = 1] and severe in four additional patients (LENT score = 3). There was no obvious relationship between the degree of incontinence and use of TURP vs. TUIP, amount of tissue resected, or time between brachytherapy and TURP/TUIP. In five patients for whom detailed urethral radiation dose information was available, the doses were higher than generally recommended.

CONCLUSION

Permanent urinary incontinence is common in patients who require a TURP or TUIP after prostate brachytherapy. Its cause is apparently multifactorial and may include the degree of physical damage to the urinary sphincters and the radiation dose to the urethral region.

TUIP in the treatment of BPH: Personal experience

The authors describe their experience with 40 patients subjected to TUIP for BPH from May ‘92 to November ‘96. The criteria used for including patients in the study were based on the prostatic weight calculated ultrasonically by means of the ellipsoid rule. Results were similar to those reported in world literature. The authors conclude that although TURP is the best endoscopic technique for BPH, TUIP is also important since both catheterisation and hospitalisation times are shorter with resulting cost savings.

Transurethral incision versus resection of the prostate for small to medium benign prostatic hyperplasia

OBJECTIVE

To compare the effects of transurethral incision and resection of the prostate in patients with small to medium benign prostatic hyperplasia.

PATIENTS AND METHODS

Patients were assessed preoperatively using the Madsen-Iversen symptom score, post- void residual urine volume, urinary flow and cystoscopy. Those eligible for the study were randomized to undergo either transurethral incision or resection of the prostate. Follow-up visits were scheduled at 2-3.6, 12, 24 and 60 months post-operatively with an assessment by symptom score and urinary flow rate; most patients also underwent cystoscopy at 24 and 60 months.

RESULTS

The maximum urinary flow rate was significantly higher in those undergoing resection than incision at all but the last follow-up visits. Cystoscopy 24 months after surgery showed adhesions between the lateral lobes, closed incisions or obstructing prostatic lobes in most of the patients undergoing incision, but not in those resected (P < 0.001, chi-square test). During follow-up, a second transurethral procedure was carried out for persistent or recurrent symptoms, combined with a maximum urinary flow rate of < 10.0 mL/s, in 10 patients who underwent incision and in three who were resected (P = 0.039, chi-square test).

CONCLUSION

Transurethral resection is preferable to transurethral incision of the prostate in the treatment of small to medium benign prostatic hyperplasia.

Mini-invasive treatment of BPH with TUIP

The authors report their experience in treating benign prostatic hypertrophy with transurethral incision of the prostate (TUIP) as an alternative to resection (TURP).

Clinical outcome at 3 months after transurethral vaporization of prostate for benign prostatic hyperplasia

OBJECTIVES

To evaluate the clinical outcome of transurethral vaporization of the prostate (TUVP) for the management of benign prostatic hyperplasia (BPH).

METHODS

Between March and June 1995, 30 patients with symptomatic BPH treated by TUVP were enrolled in this study. Transrectal ultrasonography (TRUS) was done preoperatively. American Urological Association (AUA) symptom score determination, pressure flow study, and questionnaire (for evaluating potency) were done preoperatively and 3 months postoperatively.

RESULTS

The average age was 70.5 years (range 60 to 83) and estimated prostate size by TRUS before surgery was 33.8 +/- 14.0 g. The average AUA symptom score decreased significantly 3 months after TUVP (6.2 +/- 7.8 versus 18.2 +/- 9.0; P < 0.01). The maximum urine flow rate (Qmax) was 11.1 +/- 3.7 mL/min before TUVP (mean +/- SD) and 17.0 +/- 6.5 mL/min 3 months after TUVP, whereas the detrusor pressure at maximum urine flow (Pdes at Qmax) was 61.0 +/- 23.9 and 41.2 +/- 15.2 cm H2O, respectively. Qmax increased and Pdes at Qmax decreased significantly 3 months after TUVP. Of the 30 patients, 3 (10%) developed bladder neck contracture. Of the 24 patients who were potent sexually before operation, 3 (12.5%) developed impotence 3 months after surgery.

CONCLUSIONS

TUVP is an effective alternative surgical procedure to relieve obstruction for patients with symptomatic BPH. However, cautious attitude on its usage is advocated based on our preliminary results indicating the occurrence of late complication such as impotence and bladder neck contracture.

Transurethral resection versus incision of the prostate: a randomized, prospective study

OBJECTIVES

To evaluate longer term effects of transurethral resection (TURP) and incision (TUIP) of the prostate in randomized patients.

METHODS

In a randomized, prospective study, 120 patients with symptoms of bladder outlet obstruction caused by smaller benign prostates (estimated resectable weight less than 20 g) were assigned to TURP or TUIP. Patients were evaluated preoperatively and at intervals postoperatively as to urinary symptoms (Madsen's questionnaire), sexual function, and uroflowmetry. Overall evaluation of outcome of surgery was also assessed at follow-up visits.

RESULTS

Fifty-six patients received a TURP and 61 a TUIP. Three patients refused to participate in the project after randomization, and 5 patients were lost to or excluded from follow-up. A group of 112 patients were obtainable for postoperative evaluation with a mean follow-up time of 34 months (1 to 82 months). Improvements in mean urinary peak flow rates were seen in both groups throughout the study period. The peak flow rates generally were higher (but not statistically so) in the TURP group. Postoperative irritative, obstructive, as well as total symptom scores decreased significantly at all follow-up visits after both TURP and TUIP (P < or = 0.034). Preoperatively and at all postoperative follow-up there was no statistically significant difference in irritative, obstructive, or total symptom scores between TURP and TUIP. The patients indicated an overall subjective improvement at all follow-ups in both groups, with no statistically significant difference between the treatment groups. Fifteen of 22 (68%) patients receiving TURP and 8 of 23 (35%) in the TUIP group who were sexually active before and after surgery developed postoperative retrograde ejaculation (P = 0.020). Postoperatively, 9 (16%) of the patients in the TURP and 14 (23%) in the TUIP group received further treatment for benign prostatic hyperplasia (BPH)-related infravesical obstruction. This difference was not statistically significant (P = 0.908).

CONCLUSIONS

In small prostates TURP and TUIP were generally equally effective in relieving bladder outlet obstruction secondary to BPH. Most surgically treated BPH cases can be well managed by the incision technique, which is an underutilized procedure.

Transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia: clinical utility at one-year follow-up and imaging analysis

OBJECTIVE

The clinical utility of transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia (BPH) and the laser effect on prostatic tissue were investigated.

METHODS

TULIP was carried out under epidural anesthesia on 30 patients with symptomatic BPH (aged 63-92 years; mean, 73.9 years).

RESULTS

Excluding 4 cases that were lost to follow-up, the mean modified Boyarsky symptom score significantly improved (P < 0.001) from a preoperative level of 22.2 +/- 5.3 to 7.7 +/- 4.3 at three months and 6.2 +/- 4.1 at one year. Maximum flow rate increased from 7.9 +/- 3.4 mL/sec to 14.5 +/- 5.9 mL/sec at three months and 14.7 +/- 6.3 mL/sec at one year (P < 0.001). A decrease in residual urine volume from 72 +/- 65 mL to 10 +/- 18 mL at three months and 16 +/- 17 mL at one year was also noted (P < 0.005). Transrectal ultrasonography revealed that estimated prostate volume was decreased from 39.7 +/- 20.4 mL to 26.9 +/- 20.3 mL at three months (P < 0.05) but it regrew to 32.2 +/- 26.2 mL at one year. Magnetic resonance imaging clearly showed less enhanced area to a depth of approximately 10 mm in the periurethral region, which could be attributable to coagulation necrosis in the prostatic tissue. Adverse effects were limited to epididymitis in 2 cases and no sexual dysfunction was associated with the procedure.

CONCLUSIONS

TULIP is an effective and safe alternative procedure to induce long-lasting relief of prostatic obstruction by coagulation necrosis in the periurethral region.

Transurethral incision of the prostate: an objective and subjective evaluation of long-term efficacy

The emergence of less invasive therapies has demanded the reassessment of surgical procedures for the treatment of benign prostatic hyperplasia. This study was designed to evaluate the long-term efficacy of transurethral incision of the prostate using objective (urodynamic) and subjective (symptom score and assessment of satisfaction) parameters, and investigate sexual function. The results of transurethral incision of the prostate in 41 men (mean age 63.4 years) were reviewed, with a mean followup of 53 months (range 12 to 96). Preoperative symptom score (based on the Madsen-Iversen score) and urodynamic evaluation were compared to recent post-transurethral incision symptom score, urodynamic evaluation and interview to determine patient satisfaction. Total symptom score, as well as obstructive and irritative components, significantly decreased after transurethral incision of the prostate (p < 0.0001). Mean detrusor pressure at peak flow decreased from 85 to 44 cm. water (p < 0.0001) and mean maximal detrusor pressure decreased from 114 to 55 cm. water (p < 0.0001). Mean peak urine flow rates increased from 10.3 to 15.3 cc per second (p = 0.019). Of the men 32 (82%) reported long-term improvement after transurethral incision of the prostate, with an overall satisfaction rate of 67% (range 0 to 100). Regardless of objective urodynamic criteria (indicating obstruction or relief of obstruction), the number of men reporting subjective improvement and the degree of improvement were similar. Only 4 men (11%) reported new retrograde ejaculation. The proportion of men with improvement after transurethral incision of the prostate compares favorably to long-term data available on transurethral resection of the prostate. Assessing the degree of improvement (overall satisfaction) is unique and has not been previously reported. These results clearly demonstrate that in selected patients transurethral incision of the prostate is an effective procedure for long-term relief of outlet obstruction.

Transurethral grooving of the prostate in the treatment of patients with benign prostatic hyperplasia. An alternative to transurethral incision

Various alternatives exist for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia (BPH). Incision of the bladder neck and prostate has proved its efficacy in many studies, especially in small prostates. The major drawback of the procedure is inability to obtain tissue specimens to exclude malignancy. We introduced a method to overcome this drawback by incising grooves at 5 and 7 o'clock with standard resection loops which created not only the incisions but also provided enough tissue for pathological examination. Twenty-five patients with BPH underwent transurethral grooving. Pre- and post-operative urodynamic studies revealed significant improvement in both maximum and average flow rates. The re-operation rate in the entire group was 12%. Transitional cell carcinoma of the prostatic urethra was detected in 1 patient, which proved its superiority to standard incision procedures.

Sexual function after transurethral prostatectomy

The potency of 98 men who underwent transurethral resection for benign prostatic enlargement was assessed before and after operation in a prospective study. Preoperatively, 38 could not maintain their erections long enough to achieve coitus. Three months after operation a decrease in erectile ability had been experienced by three of the remaining 60 patients, while two reported an improvement. At the six-month follow-up two of these patients stated that they had recovered their preoperative potency, while the third patient still experienced reduced erectile function. Examination showed normal penile blood pressure but testing with papaverine showed reduced tumescence.

Clinical information system that enhances the use of resources in endoscopic prostatic procedures

In this study we evaluated, by means of an automated management system, the identification of subgroups of patients within certain operative categories whose predictable length of stay was compatible with treatment on a 5-day ward. This was achieved by using a computer directed analysis of urological workload on prospectively collected clinical data. Graphical presentation of the results was achieved by a technique known as the patient-bed dissociation curve. Patients with bladder outflow obstruction treated by transurethral prostatic resection (701) and bladder neck incision (113) were selected from a total of 7,162 hospital admissions. The main outcome measures were length of stay and complication rates for the 2 procedures. The results demonstrated that a group of patients about to undergo transurethral resection could be selected by age and source which would indicate an 18% greater probability of discharge within 5 days. These patients were easily identifiable in advance and would be suitable for treatment on a 5-day ward. It was concluded that computer-held clinical data were easily accessible to the surgeon. The process of detailed analysis need not take time. With properly directed studies the information retrieved could be used to effect change. The patient-bed dissociation curve may prove a valuable tool in examining and comparing discharge patterns in any groups of patients.

Transurethral incision versus transurethral resection of the prostate. A subjective and objective analysis

A prospective study was undertaken comparing transurethral incision of the prostate (TUIP) with transurethral resection (TURP) in the treatment of 220 patients with urinary obstruction caused by a small, benign prostate. Patients were managed alternately by TUIP and TURP, and their symptoms and urodynamic findings evaluated before and after surgery. Subjectively and objectively, the results were comparable in both groups. Pre- and post-operative complications were significantly less for the TUIPs than the TURPs. TUIP was significantly better than TURP in terms of shorter operating time, duration of hospitalisation and reduced need for transfusion. We recommend TUIP as the operation of choice for the relief of obstruction in the presence of a small, benign prostatic enlargement.

Transurethral incision and posterior resection of prostate (TUI-PRP) for selected patients with benign obstructive prostatic disease

Transurethral incision and posterior resection of the prostate (TUI-PRP) is described and used to overcome my three concerns in performing transurethral incision of the prostate (TUIP). The favorable result from TUI-PRP is presented.

A comparison of bladder neck incision and transurethral prostatic resection

Between 1978 and 1988, 108 patients underwent bladder neck incision (BNI) for bladder outflow obstruction. These patients were compared to a similar group who underwent transurethral resection of the prostate (TURP), during the same time period. Only patients with minimal prostatic enlargement (less than 10 g) with prominent bladder necks and small lateral lobes were included in the study. In addition, all patients in the resection group had a resection weight of less than 10 g on the histopathology report. Patients were followed up by means of a posted questionnaire to which 59 patients in the BNI group and 86 in the TURP group responded. Pre-operative and peri-operative data were also collected from these respondents by a retrospective case record review. This found both operations to be safe with low morbidity and mortality. BNI was better than TURP in terms of shorter operation length (P less than 0.017) and shorter duration of catheterization (P less than 0.004). No other peri-operative differences were found. Follow-up results from the questionnaire showed no significant differences in symptoms between the two groups. Similarly, there was no difference in the number of re-operations performed over the 10 year period studied. Patient assessment of their operation was initially favourable in both groups (greater than 80% patient approval) however, both treatment groups experienced a gradual drop in patient approval over the 10 year period. There were no differences in the level of approval between the BNI and TURP groups.

Use of the holmium:YAG laser in urology

The tissue effects of a holmium:YAG (Ho:YAG) laser operating at a wavelength of 2.1 mu with a maximum power of 15 watts (W) and 10 different energy-pulse settings was systematically evaluated on kidney, bladder, prostate, ureteral, and vasal tissue in the dog. In addition, various urologic surgical procedures (partial nephrectomy, transurethral laser incision of the prostate, and laser-assisted vasovasostomy) were performed in the dog, and a laparoscopic pelvic lymph node dissection was carried out in a pig. Although the Ho:YAG laser has a strong affinity for water, precise tissue ablation was achieved in both the contact and non-contact mode when used endoscopically in a fluid medium to ablate prostatic and vesical tissue. Using the usual parameters for tissue destruction (blanching without charring), the depth of thermal injury in the bladder and ureter was kept superficial. In performing partial nephrectomies, a 2-fold reduction in the zone of coagulative necrosis was demonstrated compared to the use of the continuous wave Neodymium:YAG laser (Nd:YAG). When used through the laparoscope, the Ho:YAG laser provided precise cutting and, combined with electrocautery, allowed the dissection to proceed quickly and smoothly. Hemostatic control was adequate in all surgical procedures. Although the results of these investigations are preliminary, our initial experience with the Ho:YAG laser has been favorable and warrants further investigations.

Transurethral incision of the prostate using the holmium:YAG laser

Transurethral incisions of the prostate were made endoscopically in 5 dogs under a fluid medium using a holmium:YAG (Ho:YAG) laser operating at a wavelength of 2.1 microns and with delivery of 1.0 J/pulse in 15 Hz (15 W). Histopathologic examination of tissues collected immediately after surgery revealed irregular crevices outlined by a narrow zone of coagulative necrosis. Ulcerated fissures persisted at 5 and 7 days with the initial stages of epithelial regeneration partially re-epithelializing the ulcerated surfaces. A modest inflammatory response characterized by edema, hemorrhage, and a mixed inflammatory cell infiltrate was also associated with the laser incision sites at 5 and 7 days. Three weeks postlasing, the ulcerated surfaces of the fissures were completely re-epithelialized. At 5 weeks only a slight indentation persisted at the incision sites with minimal changes in the subjacent submucosa and prostatic glandular architecture. Although the results of these investigations are preliminary, we believe that the Ho:YAG laser warrants further clinical evaluation for treating patients with benign prostatic hyperplasia (BPH), urethral strictures, bladder neck contractures, and constrictions of the upper urinary tracts.

The Madigan prostatectomy

A total of 59 patients with bladder outflow obstruction underwent the Madigan prostatectomy. The method, results and complications are described. For select patients with large benign adenomas without a median lobe or hematuria we believe the technique to be the operation of choice, particularly in younger patients. Advantages include absence of postoperative hematuria and clot retention, a decreased requirement for blood transfusions, a 16F postoperative catheter with early removal, avoidance of post-catheter stricture, a low rate of postoperative urinary infection, a short comfortable period of hospitalization and, in the long term (median followup 6 years), preservation of potency and antegrade ejaculation.

Internal urethrotomy of the prostatic urethra or transurethral resection in benign prostatic hyperplasia

Transurethral resection of the prostate is the most common technique for the treatment of benign prostatic enlargement. The inconveniences of prostatic resection are retrograde ejaculation and bladder neck stenosis in small prostates. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate in 22 patients and urethrotomy of the prostatic urethra in 27 with respect to postoperative retrograde ejaculation, persistent urinary symptomatology and maximal flow rates. After a mean followup of 25 months we concluded that internal urethrotomy of the prostatic urethra is the operation of choice in patients with a prostate of up to 30 gm.

Transurethral incision of the bladder neck and prostate

Between March 1983 and December 1988, 66 men 50 years old and older with symptomatic bladder outlet obstruction underwent transurethral incision of the bladder neck and prostate. Patients selected for incision had a small, clinically benign, prostate and peak urinary flow rate of less than 15 ml. per second. Preoperative and postoperative evaluation included symptom questionnaires and uroflowmetry. A single midline incision was made extending from the bladder neck to the verumontanum. Results were available in 64 of the 66 men who underwent the procedure with a mean followup of 2.24 years. Mean symptom scores decreased from 9.66 preoperatively to 4.59 postoperatively (p less than 0.001) and peak urinary flow rates increased from 7.4 to 14.7 ml. per second (p less than 0.0001). Antegrade ejaculation was preserved in 83.3% of the men who preoperatively had antegrade ejaculation. Subsequent transurethral resection of the prostate was required in 5 patients (7.6%). With a mean followup of greater than 2 years transurethral incision of the bladder neck and prostate was effective in treatment of bladder outlet obstruction caused by a small prostate while maintaining antegrade ejaculation in the majority of patients.

Transurethral incision of the prostate: a preoperative and postoperative analysis of symptoms and urodynamic findings

The efficacy of transurethral incision of the prostate was evaluated prospectively in 26 men with urodynamic evidence of outlet obstruction secondary to small prostate glands (estimated size less than 30 gm). All men completed preoperative and postoperative symptom questionnaires and extensive urodynamic testing with a median postoperative followup of 16.25 months. There was a significant improvement in subjective symptom analysis and objective urodynamic parameters (peak and mean uroflow rates, maximal detrusor pressure at peak flow, volume at first urge and post-void residual volume) as a result of transurethral incision of the prostate with minimal postoperative morbidity. Antegrade ejaculation was preserved in 55% of the men with normal preoperative ejaculation. Based on subjective and objective criteria, transurethral incision of the prostate is an effective treatment option for selected men with outlet obstruction.

Long-term assessment of 107 patients undergoing bladder neck incision

The notes of 134 consecutive patients undergoing bladder neck incision (BNI) were analysed retrospectively. Details of pre-operative symptoms and the short-term results of the operation were studied, as well as the need for reoperation. Long-term results of the operation were not available in 100 patients and a questionnaire was sent to them asking for details of their present symptoms. This produced results on the long-term follow-up of 107 patients with a mean follow-up of 31 months (range 18-48); 86% of patients showed an improvement in symptoms in the short term whilst 68% maintained a subjective improvement in symptoms in the long term. Further surgery was required in 18 patients (13%). Possible reasons for this are discussed.

Physician-generated cost containment in transurethral prostatectomy

Cost containment need not be imposed on physicians by government, insurance companies and hospital administrators. Decreases in hospital cost can be achieved voluntarily by physicians without sacrificing quality of care, especially for common procedures with relatively homogeneous patient populations, such as transurethral prostatectomy. Variations in existing practice were identified and shared, and optimal scientific practice was discussed at 5 meetings of the division of urology during a 16-month period. Strict guidelines were not developed; surgeons were encouraged to apply cost-related knowledge individually. Resource use was measured before, during and after the intervention. A total of 356 transurethral prostatectomies was studied. There were significant decreases in preoperative and postoperative length of stay, specific ordering practices and total hospital charges. University faculty differed from community urologists and individual surgeons varied considerably. Suggestions for scientific cost management in prostatectomy are presented.

Long-term follow-up of unilateral bladder neck incision

Sixty-four patients who underwent unilateral bladder neck incision (BNI) between 1980 and 1983 were reviewed. In 53 cases the flow rates showed no significant change from immediate post-operative values. All patients were interviewed or completed a questionnaire which demonstrated that 87% were satisfied with the long-term outcome of surgery. The incidence of repeat bladder neck incision or transurethral resection of prostate (TURP) compared well with the incidence reported in other studies, as did the recorded incidence of retrograde ejaculation at 16%, although 52.5% of patients noted a reduction in the volume of ejaculate.

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.

Symptom severity and patients' values in the decision to perform a transurethral resection of the prostate

To develop and validate a method to assess patients' subjective values for outcomes of surgical and nonsurgical management of benign prostatic hypertrophy (BPH), the authors studied 20 patients who had symptoms of BPH. Eight were scheduled for prostatic surgery and 12 were not. They conducted an interview, including a time-trade-off (TTO) exercise to elicit values for single and combined outcomes and questions about symptoms used to complete a symptom severity score. Expected gain and symptom severity were independent and significant (p less than 0.001 for both comparisons) determinants of whether surgery was scheduled, while the correlation between these two factors was limited (Spearman = 0.058, p = 0.004). Based on a decision analytic model incorporating TTO values, a high expected gain in quality from surgery was strongly related to whether surgery was scheduled (p = 0.002), and had a higher positive predictive value (0.86) than symptom severity score (0.73). This small study demonstrates the feasibility and validity of using value assessment in this setting and suggests that this approach can be useful to clinicians when counseling patients.

Bladder neck resection and transurethral resection of the prostate: a randomized prospective trial

Transurethral resection of the prostate and bladder neck incision are accepted methods in the treatment of obstructive prostatic hyperplasia. Bladder neck incision is particularly useful in cases of small prostates. We have modified the method of bladder neck incision to bladder neck resection. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate (30 patients) and the new method of bladder neck resection. Bladder neck resection was comparable to transurethral resection of the prostate with respect to postoperative hospital stay, maximal flow rates and postoperative complications. Bladder neck resection was better than transurethral resection with respect to the operating time, transfusion requirement, volume of irrigation fluid and postoperative urinary infection. We conclude that bladder neck resection is the operation of choice in patients with a prostate of 30 gm. or less.

Noninvasive transvesical pressure monitoring using controlled continuous flow resectoscope

This is a review of 400 cases performed with a controlled continuous flow (CCF) resectoscope which incorporates the use of a noninvasive transvesical pressure monitor. Two series of 200 cases each are compared. The results indicate that the second group of cases performed more recently, had a lower incidence of CVP elevation and serum sodium change. An alteration in surgical technique using the CCF may be responsible for the improved outcome in the second set of cases.