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 Introduction
In the past decade, there have been significant changes in the available
treatment options for Lower Urinary
Tract Symptoms (LUTS) secondary to
Benign Prostatic Hyperplasia (BPH). New
forms of medical(1) and minimally
invasive(2) treatments have been
introduced, while other therapies have
become obsolete and well-established
surgical treatments are being
reassessed. The absolute indications for
surgical intervention remain unchanged
and include refractory urinary
retention, recurrent urinary tract
infection, recurrent hematuria
refractory to medical treatment, renal
insufficiency secondary to BPH and
bladder stones. The standard surgical
options for LUTS/BPH are transurethral
resection of the prostate (TURP),
transurethral incision of the prostate (TUIP)
and open prostatectomy. The aim of the
present review is to discuss the most
recent advances in the standard surgical
treatment options of LUTS/BPH
TUIP
Is indicated for treatment of small
prostates (< 20-30 g) with no
enlargement of the middle lobe. The
technique is well-known and involves
incision by an electrical knife from the
inside of the bladder neck down to the verumontanum.
The incision is done at 6 O'clock or may
be performed at 5 and/or 7 O'clock. The
incision should be deep enough to
penetrate the prostate tissue down to
the prostatic capsule. The presence of
fat tissue at the bottom of the incision
indicates correct depth. Comparison
between TUIP and TURP shows similar
improvements of LUTS in patients with
small prostates and no middle lobe
enlargement. The operation is fast,
safe, easy and less expensive than other
surgical procedures.
TURP
TURP is the most frequently used method in patients requiring
instrumental management for BPH. It is
the treatment of choice for prostates up
to 80-100g resection weight. Various
techniques have been suggested for
systematic removal of the adenomatous
tissue. They are all based on the
principle that the resection should be
done step by step. Detailed description
of the technique of TURP is beyond the
scope of this review. Nevertheless, the
procedure should be completed in < 60
minutes, because intra-and postoperative
complications are correlated with the
size of the prostate and the length of
the procedure. The advances in TURP can
be divided into four categories:
preoperative, intraoperative,
postoperative, and prognostication.
1. Preoperative advance in TURP
The
preoperative advance is the option to
consider the use of finasteride in the
appropriate patients, the goal being to
reduce the risk of significant
intraoperative bleeding. A recent
study(3) compared the rate of
intraoperative bleeding during TURP in
patients pretreated with finasteride for
3 months versus patients not treated
with the drug. In patients with resected
tissue Weight (RTW) of < 30 g, there was
no significant bleeding in both groups.
On the other hand with RTW > 30 g,
finasteride group had an incidence of
bleeding of 8.3%; a difference of
significant value (P < 0.05). The
authors concluded that pretreatment with
finasteride for 3 months prior to TURP
in patients with large prostates
(transition zone > 30 g) appears to
reduce intra operative bleeding.
2. Intra-operative advances in TURP
Intra-operative advances include the
following:
a- Use of coagulating
intermittent cutting device.
b-
Transurethral Vaporization Resection of
the Prostate (TUVRP).
c- Holmium Laser
Resection (HoLR).
d- Ethanol-glycine
irrigation.
a- Coagulating intermittent cutting device
In coagulating
intermittent cutting, phases with
predominant cutting effect alternate
with coagulating phase during each cut.
This principle results in an efficient
coagulation zone with excellent cutting
quality. The impact of coagulating
intermittent cutting on bleeding and
blood transfusion rates as well as the
occurrence of the TUR syndrome were
evaluated in a prospective multicenter
trial including 778 patients from 5
different European institutions(4).
Using coagulation intermittent cutting,
blood transfusions were required in 25
patients (3.2 %) and clinical signs of
irrigation fluid absorption were noted
in 1.3% of patients.
b- TUVRP
TUVRP is a modification of the standard
TURP, in which a thick loop is used in
conjunction with increased
electrosurgical settings. A prospective
randomized study by Talic et al(5)
looked at 68 patients assessed to have
prostatic outflow obstruction. These
patients were randomized into TURP and
TUVRP groups. The International Prostate
Symptom Score (IPSS) and the maximum
flow rates were better in TUVRP group
than in the TURP group. The resection
time was greater in the TUVRP group.
This was attributed to the slower swipes
necessary for vaporization. The
catheterization time was shorter in the TUVRP group. The changes in hemoglobin,
hematocrit and sodium levels were
statistically significant in favour of
TUVRP. There were no major
complications, no one experienced TUR
syndrome, and no blood transfusion were
required in either group. The authors of
this study concluded that TUVRP is as
safe and effective as TURP, and also has
the advantages of less bleeding, grater
debulking and shorter catheterization
time.
c- HoLR
HoLR was compared with TURP in
a prospective randomized study including
121 men with BPH by Fraundorfer et
al(6). Sixty one patients underwent HoLR
and 59 underwent TURP. The authors
concluded that HoLR yields significant
advantages over TURP, including a
shorter catheter time, a shorter
hospital stay, and a reduced risk of
bleeding. In addition, it offers
equivalent rapid relief of urinary
symptoms and a saving of 24.5% when
in-hospital and post-discharge costs are
considered. However, the resection time
was longer for the HoLR compared to TURP.
d- Ethanol-glycine irrigation
Glycine (1.5% solution) is widely
used for irrigation during TURP, and is
well-tolerated. However, intraopeative
transfusion of irrigation fluid occurs
in most resections, the reported
incidence of TUR syndrome ranging
between 2 and 10% (7). Moreover, a risk
of cardiac injury has been reported as
an adverse effect of glycine (7). Okeke
et, al(8) evaluated the usefulness of
adding 1% ethanol to 1.5% glycine for
early detection of irrigation-fluid
absorption during TURP through early
detection of ethanol in the expired air.
The authors concluded that ethanol (1%)
in glycine solution provides an early
warning and reliable detection of fluid
absorption. Fluid absorption occurred in
more than 50% of the patients undergoing
TURP and was a clinical problem in up to
12% of them. No adverse effects of the
alcohol were recorded.
3- Postoperative advances in TURP P
Postoperative advances in TURP include:
a- The use of Pelvic Muscle Exercises (PMEs).
b- The use of bladder infusion prior to
trial voiding.
a- The use of PMEs
The impact of PMEs following TURP on the
early postoperative recovery was
recently evaluated by Porru et al (9).
The study included 58 consecutive
patients in whom TURP was indicated. The
patients were randomly assigned into 2
groups: control group (TURP only) and
investigational group (TURP + PMEs for
15 minutes, 3times a day for 4 weeks).
In the early postoperative period
(within the first 4 weeks), PMEs
strengthen the pelvic floor muscles
after TURP resulting in less
incontinence, less frequency and more
improvement of the quality of life.
However, after 4 weeks both groups
become equal. The authors concluded that
PMEs facilitate a more tolerable
recovery within the first 4 weeks after
TURP. However, a vast improvement in
voiding symptoms will occur by week 4
with or without PMEs.
b- The use of bladder irrigation prior to trial voiding
A recent study examined the effect of
bladder infusion before catheter removal
on patients readiness for discharge(10).
The study included 75 patients of TURP
who were randomized into 2 groups:
standard group (the urethral catheter
was removed without irrigation of the
bladder) and investigational group (the
bladder was infused by its filling with
saline before removal of the catheter).
Sixty two % of the patients in the
infusion group were ready of discharge
on the same day of their trial voiding
compared with 37% in the standard group
(P < 0.05). The authors concluded that
bladder infusion prior to trial voiding
lessens the hospital stay.
4- Advance in prognostication
A recent study examined the impact of resected tissue
weight (RTW) on symptom improvement
after TURP in men with BPH (11). RTW
showed a significant correlation with
the first maximum flow rate (Q max) on
the day of discharge, but not with the
subsequent Q max measured at 3 months
and 6 months postoperatively. RTW also
correlated negatively with the symptom
and bother score 3 months after TURP,
but not at 6 months of follow-up. The
authors concluded that patients with the
largest prostates and the most tissue
resected are apt to improve the most.
Open prostatectomy
The most commonly used approaches for
open prostatectomy are the suprapubic
approach popularized by Peter Freyer in
1900 and retropubic prostatectomy
popularized by Millin's in 1945(12).
Suprapubic prostatectomy is indicated in
large prostate (> 80-100 g) with a large
median lobe protruding into the bladder.
It is also suitable for a concomitant
symptomatic bladder diverticulum or
large bladder stones. Suprapubic
prostatectomy has the advantage of
allowing greater visualization of the
bladder neck and bladder. Retropubic
prostatectomy is also indicated for
treatment of large prostates (> 80-100
g) with no enlargement of the middle
lobe and in thin patients. Compared to
suprapubic prostatectomy the retropubic
one has the following advantages:
. Excellent anatomic exposure of the prostate.
. Direct visualization of the prostatic adenoma during enucleation to
ensure complete removal.
. Precise transection of the urethra distally to
preserve urinary continence
. Clear visualization of the prostatic fossa after enucleation to
control all bleeding sites.
. Minimal to no trauma to the urinary bladder.
Conclusions
TUIP, TURP and open
prostatectomy can still be considered
the gold standard for treatment of LUTS/BPH
for their respective indications. The
advances in TURP can be divided into 4
categories: preoperative, intraoperative,
postoperative and prognostication. The
preoperative advance in TURP is the
option to consider the use of
finasteride in the appropriate patients.
The goal is to reduce the risk of
significant intra-operative bleeding
during TURP. The intraoperative advances
in TURP include the use of coagulating
intermittent cutting, TUVRP, HoLR and
ethanol-glycine irrigation. The
postoperative advances in TURP included
the use of PMEs to facilitate early
postoperative recovery and the use of
bladder infusion prior to trials of
voiding. The advance in the
prognostication after TURP can be summed
up by the statement that patients with
the largest prostates and the most
tissue resected are apt to improve the
most.
References
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