|Year : 2020 | Volume
| Issue : 2 | Page : 43-46
Transurethral resection of the prostate: An initial experience in a tertiary health institution
Ahmad Tijjani Lawal1, Muhammed Ahmed1, Muhammad Jami'u Isah2, Awaisu Mudi1, Sudi Abdullahi1, Nasir Oyelowo1, Musliu Adetola Tolani1, Hamza Babatunde Kolapo3, Ahmad Bello1, Hussaini Yusuf Maitama1
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 Submission||01-Apr-2020|
|Date of Acceptance||02-Aug-2020|
|Date of Web Publication||20-May-2021|
Dr. Ahmad Tijjani Lawal
Division of Urology, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
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 Aug 2];10:43-6. Available from: https://www.archintsurg.org/text.asp?2020/10/2/43/316488
| Introduction|| |
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. When compared to open surgery, TURP, especially in this bipolar era, is associated with decreased perioperative morbidity.
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.
The objective of this work is to share our initial experience with the use of 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 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|| |
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|| |
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, 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. 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.,, 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. 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. None of the patients had perioperative blood transfusion. This is an encouraging observation because of the associated potential complications of blood transfusion., Furthermore, this is in sharp contrast to open prostatectomy, in which case the transfusion rate may be as high as 15%. 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. 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., 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., 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. This finding is, however, at variance with the duration of hospital stay in other reports, which ranged between 2 and 2.7 days.,, 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., 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|| |
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.
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
Conflicts of interest
There were no conflicts of interest
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