Urethral strictures after bipolar transurethral resection of prostate may be linked to slow resection rate

The role of irrigation fluid in transurethral resection of the prostate outcomes and surgeon performance

INTRODUCTION

Transurethral resection of the prostate (TURP) is the gold-standard for the treatment of benign prostate enlargement (BPE) associated with lower urinary tract symptoms (LUTS), after failure of conservative therapy. At present, only resection-rate (grams of prostate resected over time) is regarded as an efficiency parameter to evaluate the skill of the operator and to assess the outcome of the procedure.

MATERIALS AND METHODS

Five surgeons performed TURP using a Gyrus-type bipolar system in 123 patients with BPE/LUTS who came to our observation from June 2016 to December 2019. The amount of irrigation fluid used during the procedure was registered and correlated to the operating time, resection-rate, prostate adenoma weight, post-operative bladder irrigation time, intraoperative bleeding and days of catheterization.

RESULTS

We found an inverse correlation between the amount of irrigation fluid used during TURP and the resection-rate recorded for all operators, according to Spearman's Correlation (r = -0.78, p = 0.002); a direct correlation was also found between the amount of irrigation fluid and the adenoma weight. Finally, we also found a direct correlation with intraoperative bleeding and the duration and amount of bladder irrigation during and after TURP.

CONCLUSIONS

The amount of irrigation fluid used is proposed as a reliable parameter to estimate the efficiency of the endoscopic procedure as well to assess the skill of the operator and shortterm results. The observed data encourage the possibility of applying this new efficiency indicator to all endoscopic maneuvers.

Transurethral resection of the prostate stricture management

For more than nine decades, transurethral resection of the prostate remains the gold standard for the surgical treatment of lower urinary tract symptoms due to benign prostatic obstruction. The occurrence of urethral strictures after transurethral resection of the prostate is one of the major late complications and has been reported as the leading cause of iatrogenic urethral strictures in patients older than 45 years who underwent urethroplasty. Although several postulations have been proposed to explain the urethral stricture after transurethral resection of the prostate, the exact etiology of urethral stricture after TURP is still controversial. Suggested etiological factors of urethral stricture formation after transurethral resection of the prostate include infection, mechanical trauma, prolonged indwelling catheter time, use of local anesthesia, and electrical injury by a stray current. One single treatment option is not appropriate for all stricture types. The management of urethral stricture following transurethral resection of the prostate includes minimally invasive endoscopic methods, including urethral dilation and direct visual incision, or open surgical procedures with varying urethroplasty techniques. Although scientific studies focusing on urethral strictures after transurethral resection of the prostate are relatively limited and sparse, we can apply the principles of urethral stricture management before making decisions on individual stricture treatment.

Bipolar vaporization of the prostate may cause higher complication rates compared to bipolar loop resection: a randomized prospective trial

INTRODUCTION

Transurethral resection of the prostate (TURP) by resection loop or vaporization button is becoming a standard of care due to its better safety profile (less bleeding and less incidence of TUR syndrome). However, there are published data showing bipolar vaporization may be associated with increased late complications. In this study, we compared results of bipolar TURP using the resection loop versus vaporization button for treatment of benign prostatic hyperplasia (BPH) to determine the relative safety profile.

PATIENTS AND METHODS

Between January 2013 and March 2014, 89 patients with BPH were randomized to surgical intervention either by Olympus (Gyrus) Bipolar loop TURP or Olympus (Gyrus) Bipolar button vaporization. Inclusion criteria were; BPH with Q-max < 10 ml/s, IPSS  > 18 and prostate volume > 40 g. All patients were evaluated preoperatively and at 1, 3 and 9 months. Evaluation included IPSS, uroflowmetry, prostate volume by ultrasound. Clavien complications and operative time were recorded. Statistical analysis was done using Statistical Package of Social Science (SPSS) version 17 software.

RESULTS

44 patients were included in bipolar TURP and 45 patients in vaporization arm. Preoperative mean prostate volume (59 g versus 58 g, p = 0.52) and mean IPSS (19 versus 20, p = 0.38) were equivalent in both groups. Vaporization was associated with a significant increase in operative time (mean of 81 ± 15 min range 40-110 versus 55 ± 10 min range 30-70 min, p < 0.001), less blood loss (0.8% versus 2.0% drop in hemoglobin, p < 0.001) but increased postoperative urinary frequency (80% versus 50%, p < 0.001), hematuria with clots up to 4 weeks post surgery (20% versus 2%, p < 0.001) and postoperative urethral stricture (11% versus 0%, p < 0.001). Both techniques improved urine flow with Q-max (17 ml/s versus 18 ml/s p = 0.22). Prostate volume (32 g versus 31 g, p = 0.31) and IPSS (6 versus 5, p = 0.22), were comparable in both treatment arms.

CONCLUSIONS

Bipolar vaporization of the prostate, despite being a technically robust, speedy and with less intraoperative bleeding, appears to be associated with increased postoperative irritative symptoms, increased late-onset postoperative bleeding and high urethral stricture rates.

Urethral stricture after bipolar transurethral resection of prostate - truth vs hype: A randomized controlled trial

INTRODUCTION

Bipolar transurethral resection of prostate (B-TURP) was introduced as an alternative procedure to minimize the surgical complications of monopolar TURP (M-TURP). However, there are concerns about increased incidence of stricture urethra (SU) post B-TURP. This study was designed to analyze the incidence of SU among patients undergoing M-TURP versus B-TURP.

MATERIALS AND METHODS

This is a randomized controlled, single-blinded study; randomization was performed using a stratified permuted randomization algorithm (1:1 ratio) and only the patients were blinded. Both M-TURP and B-TURP were performed with a 26 Fr resectoscope; the electrosurgical generators were Karl Storz Autocon II 400 and Olympus UES-40 SurgMaster (TUR in saline [TURIS] method), respectively. Follow-up visits were scheduled at 3, 6, and 12 months post surgery and patients with lower urinary tract symptoms and a maximum urinary flow rate of <10 ml/sec on uroflowmetry underwent retrograde urethrography to assess for development of SU.

RESULTS

Forty patients were randomised to each arm. None developed SU in the monopolar group, whereas there were three cases in the bipolar group (P = 0.2). Among these three patients, two belonged to the failed medical management subgroup and one to the refractory urinary retention subgroup (P = 1.0).

CONCLUSION

The incidence of SU following B-TURP using the TURIS system was comparable to the conventional M-TURP. Moreover, the incidence of SU was same for both the techniques when sub-grouped according to the indication for surgery that is failed medical management versus refractory urinary retention.

Prostate resected weight and postoperative prostate cancer incidence after transurethral resection of the prostate: A population-based study

To analyze whether different volumes of tissue resected during transurethral resection of the prostate (TURP) would associate with the subsequent development of prostate cancer.This population-based retrospective cohort study recruited 49,206 patients with benign prostate hyperplasia (BPH) undergoing TURP between 2005 and 2012. Patients were recruited from the Taiwan National Health Insurance Research Database. Patients were separated into three groups, based on different volumes of tissue resected during TURP (5-15 g, 15-50 g, >50 g).Of the 49,206 patients, 633 patients were diagnosed with new onset of prostate cancer following TURP. Older age was a risk factor contributing to the onset of prostate cancer (P = .0196) and different volumes of tissue resected were significantly related to the incidence of postoperative prostate cancer (P = .0399). The group of patients with a smaller volume of prostate resected had a higher risk of prostate cancer with a hazard ratio (HR) of 1.221 (95% confidence interval [CI]: 1.035, 1.440; P = .0179). However, the risk in the group of patients with a larger volume of prostrate resected was not significantly different, with an HR of 1.277 (95% CI: 0.981, 1662; P = .0690). The incidence of prostate cancer in Taiwanese males over 30 years of age has previously been reported to be 0.0560%; the mean incidence was 0.2282% in our present study.This study shows that BPH patients who had a smaller volume of tissue resected during TURP show a higher incidence of prostate cancer postoperatively. Currently, no clear mechanism is shown to demonstrate the relationship between resected prostate weight and the incidence of tumors. Patients with a larger prostate volume might have lower urinary tract symptoms earlier and then seek professional help. It is possible that surgical procedures might remove the potentially carcinogenic prostate tissue and thus reduce the risk of an aggressive tumor developing in the future.