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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 43-46

Transurethral resection of the prostate: An initial experience in a tertiary health institution


1 Department of Surgery, Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
2 Department of Surgery, Federal Medical Centre, Katsina, Kaduna, Nigeria
3 Department of Surgery, Barau Dikko Teaching Hospital, Kaduna State University, Katsina, Kaduna, Nigeria

Date of Submission01-Apr-2020
Date of Acceptance02-Aug-2020
Date of Web Publication20-May-2021

Correspondence Address:
Dr. Ahmad Tijjani Lawal
Division of Urology, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_15_20

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  Abstract 


Background: Transurethral resection of the prostate (TURP), is the gold standard treatment for prostatic obstruction. TURP is associated with less morbidity. Despite this obvious edge, limited availability, access, and affordability are major drawbacks to the utility of this treatment modality in our setting. The purpose of this study is to examine our initial experience with TURP.
Patients and Methods: Patients undergoing TURP in our institution over a period of 20 months (April 2013–November 2014) were prospectively followed. Consecutive patients who hadprostatic obstruction and indication for TURP were included in this study. Patients with contra-indications to TURP were excluded from this study. Informed consent was routinely obtained preoperatively. Patients' demographics, pre-, intra- and post-operative clinical records, and outcome details were entered into pro formas. The results were analyzed using descriptive statistics.
Results: Fourteen men with a median age of 66.5 years (50–102) were included in this study. The mean prostate size was 56 g (32–91). They all had bothersome lower urinary tract symptoms (LUTS). Nine (64.3%) were in the middle socioeconomic class, whereas five (35.7%) were in the lower class. The mean duration of hospital stay was 4.3 days. Thirteen of the patients (92.9%) stayed for ≤7 days. One of the patients (7.1%) had a duration of hospital stay of nine days. Three patients (21.3%) had postoperative complications. The mean follow-up was 10 months. All had a satisfactory patient-reported subjective outcome at follow-up.
Conclusion: TURP was found to be effective, and associated with few peri-operative morbidities. These findings, however, remain to be verified with long-term studies involving a larger number of patients.

Keywords: Benign prostatic hyperplasia, prostate cancer, resection of prostate, transurethral prostate resection


How to cite this article:
Lawal AT, Ahmed M, Isah MJ, Mudi A, Abdullahi S, Oyelowo N, Tolani MA, Kolapo HB, Bello A, Maitama HY. Transurethral resection of the prostate: An initial experience in a tertiary health institution. Arch Int Surg 2020;10:43-6

How to cite this URL:
Lawal AT, Ahmed M, Isah MJ, Mudi A, Abdullahi S, Oyelowo N, Tolani MA, Kolapo HB, Bello A, Maitama HY. Transurethral resection of the prostate: An initial experience in a tertiary health institution. Arch Int Surg [serial online] 2020 [cited 2021 Sep 16];10:43-6. Available from: https://www.archintsurg.org/text.asp?2020/10/2/43/316488




  Introduction Top


Transurethral resection of the prostate (TURP) remains the gold standard procedure against which all other surgical procedures for the treatment of prostatic obstruction are compared.[1] When compared to open surgery, TURP, especially in this bipolar era, is associated with decreased perioperative morbidity.[2]

Despite this enviable role of TURP in the management of prostatic obstruction, availability of facilities and adequately trained personnel, alongside the immediate high costs of set up, are major drawbacks to the use of this treatment modality.[3]

The objective of this work is to share our initial experience with the use of TURP.


  Patients and Methods Top


Patients undergoing TURP in our institution over a period of 20 months (April 2013–November 2014) were prospectively followed. Consecutive patients with prostatic obstruction, and who also have bothersome, moderate-to-severe lower urinary symptoms (LUTS), refractory urinary retention, or recurrent urinary tract infection (UTI) due to Benign prostatic hyperplasia (BPH), renal impairment due to BPH, or failed medical therapy, were included. Patients with bleeding diathesis, ankylosed hip or knee joints, were excluded. Patients with an indication for open surgery and medical therapy were also excluded from this study. Clearance was obtained from the institutional health research ethics committee. Informed consent was routinely obtained preoperatively. Demographic data, pre-, intra- and postoperative clinical records, laboratory data, and outcome details were entered into a pro forma, for each of the patients. The primary outcome measure was perioperative complications and morbidity. The secondary outcome measure was a subjective assessment of patient satisfaction. The results were analyzed using descriptive statistics.

Routine cystoscopy was done in all patients at the time of TURP. Standard Monopolar TURP with power settings of 100–120W/80W for cutting/coagulation, respectively, was carried out in all the patients using 26F Karl Storz continuous flow sheath with a 4 mm/30° telescope. 1.5% glycine set at the height of 60 cm above the patients' precordium, was used for irrigation. A 24 Fr 3-way silicone urethral catheter was passed after the procedure and bladder irrigation commenced.


  Results Top


A total of 14 patients had TURP over the period of this study.

Their ages range between 50 and 102 years, with a median age of 66.5 years. Nine (64.3%) were in the middle socioeconomic class and five (35.7%) were in the lower socioeconomic class. Twelve (85.7%) had up to secondary education, while two of the patients (14.3%) had only primary education. All patients had bothersome LUTS, and three of them (21.5%) had refractory acute urinary retention (AUR). The mean prostate size was 56 g, with a range of 32–91 g. Three of the patients (21.5%) had comorbidities. Nine of them (64.3%) had prostates that felt benign on DRE, and 5 (35.7%) were suspect for cancer of the prostate. Of these five (5), only two turned out to have malignant prostatic obstruction following prostate biopsy. One patient (7.1%) had a short segment incomplete bulbar urethral stricture co-existing with BPH. All had normal hemograms and renal function. Urine culture yielded uropathogens in four (28.6%) of the patients, and these were treated preoperatively. All had TURP. The two patients (14.3%) with carcinoma of the prostate had Bilateral Subcapsular Orchidectomy (BSO) in addition, whereas 1 (7.1%) had urethral dilatation. Perioperative complications and morbidity were assessed. None required blood transfusion. None had transurethral resection (TUR) syndrome. The length of hospital stay was 2–9 days with a mean duration of 4.3 days. Thirteen of the patients (92.9%) stayed for ≤7 days. One of the patients (7.1%) stayed for 9 days. Ten patients (71.4%) had irrigation stopped 24 h after the surgery, while for the remaining four patients (28.6%), it was stopped on the 3rd postoperative day. All the patients had their urethral catheters removed removed between 48 and 72 h postoperatively. One patient each (7.1%), had postoperative urinary retention, orchitis, and urge incontinence. The one patient who had AUR had urethral catheter repassed and was subsequently removed on the 7th postoperative day. The mean follow-up period was 10 months. All had a satisfactory patient-reported subjective outcome at initial and subsequent follow-up visits.


  Discussion Top


Despite the significant role of TURP in the treatment of prostatic obstruction, it is still a new addition to the treatment armamentarium in this hospital. This is sadly so, in most hospitals within Nigeria and probably beyond.

The mean prostate size in this series, of 56 g is within the limits described for safe TURP[4],[5] There were 2 (14.3%) outliers, with prostate sizes much >60 g. These two had channelization for malignant prostatic obstruction. Twenty-one point five percent (21.5%) of the patients had comorbidities and this was similar to the report by Alhasan et al. in which 502 patients were reviewed.[3] Eighty-five point seven percent (85.7%) of the patients had an educational level of secondary school and above. This, in a lot of cases, is a surrogate for socioeconomic class and thus, a predictor of affordability.[6],[7],[8] Twenty-one point five percent (21.5%) of them had refractory AUR, and this correlated closely with those that had uropathogens isolated (28.6%). This is not surprising, as all who had AUR were also catheter dependent before the procedure. This is associated with a 100% rate of UTI when urethral catheterization is prolonged.[9] The 14.3% incidence of cancer of the prostate in this series remained so even postoperatively. This may be due to the combined use of DRE, prostate-specific antigen and transrectal ultrasonography for preoperative evaluation of patients with prostatic obstruction. Thus, enabling most prostate cancers to be diagnosed preoperatively.[10] None of the patients had perioperative blood transfusion. This is an encouraging observation because of the associated potential complications of blood transfusion.[11],[12] Furthermore, this is in sharp contrast to open prostatectomy, in which case the transfusion rate may be as high as 15%.[5] None had TUR syndrome. This seems surprising, as a number of the procedures lasted beyond 90 min, and the irrigant used was hypotonic. This observation is further amplified by the fact that the mean age of 66.5 years noted in this study, (being in the age bracket for the elderly) is an independent risk factor for TUR syndrome.[13] Furthermore, capsular perforation was also not noted in any of the cases. It has been shown by several researchers that true predictors of risk for TUR syndrome are the amount of fluid absorbed and serum level of sodium at the end of the procedure.[13],[14] These two variables were, however, not documented perioperatively. Moreover, it is difficult to accurately assess the impact of time as a variable, on the amount of fluid absorbed and the subsequent serum level of sodium.[13],[14] From the foregoing, it seems likely that a combination of factors with varying degrees of impact rather than any single parameter, will more accurately determine the risk for TUR syndrome. The duration of hospital stay ranged between 2 and 9 days. The mean duration of hospital stay was 4.3 days. This is similar to the findings reported by Kubba et al. who noted a mean duration of hospital stay of 5 days in a study of 539 men undergoing TURP in a district general hospital in the UK.[15] This finding is, however, at variance with the duration of hospital stay in other reports, which ranged between 2 and 2.7 days.[16],[17],[18] In our series, only one patient (7.1%) stayed beyond 7 days (9 days). This patient, aged 67 years, was also the only patient that had postoperative AUR necessitating recatheterization. Studies in the literature have shown old age and persistence of voiding symptoms as statistically significant risk factors for a prolonged hospital stay.[15],[19] However, postoperative AUR in this patient may be associated with the postoperative edema or detrusor failure. Furthermore, inadequate resection is also a possibility, in this stage of our learning curve.


  Conclusion Top


TURP is effective and associated with a low incidence of perioperative morbidities and complications, and high patient satisfaction rates. These obvious advantages notwithstanding, it remains largely inaccessible and unaffordable to the bulk of the poor patients. Provision of needed equipment and rigorous training of the younger urologists and residents along this line will help bridge this gap. These findings, however, remain to be verified with a long-term study involving a larger number of patients.

Limitations

This study is limited by several issues.

First, assessment of outcome was done subjectively. Objective assessment of outcome using International Prostate Symptom Score (IPSS) and uroflowmetry would definitely have lent more strength to this study. However, as at the time this study was carried out, the center had no facility for uroflowmetry. Even though IPSS could have been done in the least, this instrument was not routinely used at that time in our center for no obvious reasons.

Second, the study participants were heterogeneous. Most cases were BPH. Two cases of prostate cancer were, however, also included in the study. This is a documentation of initial experience, as such, the two cases were not excluded so that a larger sample size could be attained. This heterogenicity of cases may affect the parameter specific or overall outcomes, because the outcomes of malignant prostatic diseases largely differ from those of benign prostatic diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There were no conflicts of interest



 
  References Top

1.
Madersbacher SM. Is transurethral resection of the prostate still justified? BJU Int 1999;83:227-37.  Back to cited text no. 1
    
2.
Marszalek M, Ponholzer A, Pusman M, Berger IM. Transurethral resection of the prostate. Eur Urol 2009;Suppl 8:504-12.  Back to cited text no. 2
    
3.
Alhasan SU, Aji SA, Mohammed AZ, Malami S. Transurethral resection of the prostate in Northern Nigeria, problems and prospects. BMC Urol 2008;8:18.  Back to cited text no. 3
    
4.
Fitzpatrick, JM. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW and Peters CA. editors. Campbell-Walsh Urology. Philadelphia: Saunders; 2008; p. 2647-86.  Back to cited text no. 4
    
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PhuongDo D. The dynamics of income and neighbourhood context for population health: Do long-term measures of socioeconomic status explain more of the black/white health disparity than single-point-in-time-measures? Soc Sci Med;2009; 68:1368-75.  Back to cited text no. 6
    
7.
Durkin MS, Islam S, Hasan ZM, Zaman SS. Measures of socioeconomic status for child health research: Comparative results from Bangladesh and Pakistan. Soc Sci Med 1994;38:1289-97.  Back to cited text no. 7
    
8.
Parker JD, Schoendorf KC. Associations between measures of socioeconomic status and low birth weight, small for gestational age and premature delivery in the United States. Ann Epid 1994;4:271-8.  Back to cited text no. 8
    
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Ansari MZ, Costello AJ, Ackland MJ, Carson N, McDonald IG. In-hospital mortality after transurethral resection of the prostate in Victorian public hospitals. Aust N Z J Surg 2000;70:204-8.  Back to cited text no. 9
    
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Dawam D, Rafindadi AH, Kalayi GD. Benign prostatic hyperplasia and prostate carcinoma in native Africans. BJU Int 2000;85:1074-7.  Back to cited text no. 10
    
11.
Ankra-Badu GA 2nd. Blood transfusion, normal and abnormal hemostasis. In: Badoe EA, Archampong EQ da RA, editors. Principles and Practice of Surgery Including Pathology in the Tropics. Accra: Ghana Publishing Corporation; 2010. p. 130-48.  Back to cited text no. 11
    
12.
Brohi K. Shock and blood transfusion. In: Williams NS, Bulstrode CJK, O'Connell PR, editors. Bailey and Loves Short Practice of Surgery. London: Hodder Education; 2008. p. 13-23.  Back to cited text no. 12
    
13.
Silva JM, Barros MA, Chahda MA, Santos IM, Marubayashi LY. Risk factors for peri-operative complications in endoscopic surgery with irrigation. Rev Bras Anestesiol 2013;64:327-33.  Back to cited text no. 13
    
14.
Clemente Ramos LM, Ramasco Rueda F, Platas Sancho A, Archilla Esteban J, Romero Cajigal I, Corbacho Fabregat C, et al. Reabsorption syndrome after transurethral resection of the prostate: Review of physiology, diagnostic and therapeutic features. Actas Urol Esp 2001;25: 14-35.  Back to cited text no. 14
    
15.
Kubba AK, Greig JD, Wallace IW. Transurethral resection of the prostate in 539 patients at a district general hospital. J R Coll Surg Edinb 1995;40:240-2.  Back to cited text no. 15
    
16.
Skolarikos A, Rassweiler J, de la Rosette JJ, Alivizatos G, Scoffone C, Scarpa RM, et al. Safety and efficacy of bipolar versus monopolar transurethral resection of the prostate in patients with large prostates or severe lower urinary tract symptoms: Post hoc analysis of a European multicenter randomized controlled trial. J Urol 2016;195:677-84.  Back to cited text no. 16
    
17.
Barboza LE, Malafaia O, Slongo LE, Meyer F, Nassif PA, Tabushi FI, et al. Enucleação da próstata com holmium laser (HoLEP) versus ressecção transuretral da próstata (RTUP). Rev Col Bras Cir 2015;42:165-9.  Back to cited text no. 17
    
18.
Fagerström T, Nyman CR, Hahn RG. Complications and clinical outcome 18 months after bipolar and monopolar transurethral resection of the prostate. J Endourol 2011;25:1043-9.  Back to cited text no. 18
    
19.
Kirolles MM. Length of postoperative hospital stay after transurethral resection of the prostate. Ann R Coll Surg Engl 1997;79:284-8.  Back to cited text no. 19
    




 

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Abstract
Introduction
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