[Management of a patient treated with anticoagulation agents or platelet aggregation inhibitors undergoing transurethral resection of the prostate (TRUP)].
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Anticoagulants↗
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A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia.
OBJECTIVES: Transurethral resection of the prostate (TURP) represents the accepted standard of surgical therapy for the management of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia (BPH). However, this is a major operative procedure associated with significant perioperative morbidity. Visual laser ablation of the prostate (VLAP) utilizing a neodymium:yttrium-aluminum-garnet laser represents a new technologic approach to the surgical management of BPH. We compared the relative safety and efficacy of these two surgical approaches in a prospective, randomized trial. METHODS: At 6 investigational sites in the United States, 115 men with symptomatic BPH more than 50 years of age and not in retention, were randomly assigned to undergo either TURP (59 patients) of VLAP (56 patients). VLAP patients received a mean of 10,200 J of energy delivered in a mean of 5.5 intraprostate laser applications. At preoperative baseline, 3 months, 6 months, and 1 year postoperatively, all patients underwent clinical evaluations, including ultrasonic prostatic volume determination, standardized American Urological Association (AUA)-6 symptom score, peak urine flow, postvoid residual urine volume, and quality-of-life assessment. RESULTS: Compared to TURP, the VLAP procedure required less time (23.4 versus 45.2 minutes; P < 0.01) and shorter hospitalization (1.8 versus 3.1 days, P < 0.01). VLAP was associated with a significantly lower rate of serious treatment-related complications compared to TURP (10.7% versus 35.6%; P < 0.01). Only One (2.2%) patient undergoing VLAP experienced a greater than 2.2 g/dL decrease in hemoglobin compared to 40% of TURP patients (P = 0.01). No patient in the VLAP group required blood transfusion compared with 3.4% of those undergoing TURP. Of the 115 patients, clinical outcomes measured at 1 year showed a mean improvement in AUA-6 symptom scores of -9.0 for VLAP compared with -13.3 for TURP (P < 0.04), mean increase in peak urinary flow rate of 5.3 cc/s for VLAP compared with 7.0 cc/s for TURP (P = 0.27), and mean decrease in postvoid residual urine volume of -55.4 cc for VLAP compared with -138.8 cc for TURP (P < 0.01). At 1 year, 78.2% of patients undergoing VLAP indicated that their quality of life was improved compared with 93.0% of patients undergoing TURP (P = 0.03). When compared with TURP, treatment of BPH with VLAP is associated with less hemoglobin decrease, a lower likelihood of serious complication, and requires less procedure time and a shorter hospital stay. Through a 1-year follow-up, VLAP produced significant improvement over baseline in objective and subjective outcome measures. However, for 1-year improvement in AUA-6 symptom score, postvoid residual urine volume, and quality of life, VLAP was less effective than TURP. CONCLUSIONS: In this initial study in the United States, with relatively low-energy laser applications, VLAP did not result in as complete a removal of prostatic tissue as did TURP. Considering the lower morbidity, shorter procedure and hospitalization times, and the degree of effectiveness that was achieved even at the low-energy doses used in this study, VLAP appears to be a viable and safe alternative to standard TURP.
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Video-resection does not stop corneal contamination during transurethral resection of the prostate.
OBJECTIVES: To determine the efficacy of video-resection systems in reducing the risk of corneal contamination during transurethral resection of the prostate (TURP) and thus in decreasing the possibility of transmission of blood-borne diseases from the patient. MATERIALS AND METHODS: After performing a TURP using a video camera system in 30 patients, the number of potential corneal droplets was measured for one operator wearing a pair of spectacles and, for a second operator, over an identically sized area of a standard disposable plastic eyeshield. RESULTS: In 20 (67%) of cases, droplets were observed on the eye protection, correlating with potential corneal contamination. Splashes were also seen on the face-mask of the eyeshield. CONCLUSION: Urologists should use eye and face protection when performing TURP using a video system.
Blood-Borne Pathogens↗
[Autologous blood transfusion aided with erythropoietin in transurethral resection of the prostate].
Erythropoietin (EPO) with an established clinical efficacy in renal anemia has in recent years become applied as an aid to autologous blood transfusion in surgical patients. This report describes our experience with autotransfusion along with the use of EPO in transurethral resection of the prostate (TUR-P), indicating its usefulness. Ten patients with benign prostatic hypertrophy aged 60 to 74 years received 3000 units of EPO, with an iron preparation, nine times beginning 3 weeks prior to operation. Autologous blood of 300 ml was collected from the patient each at 2 and 1 week before operation and was used at TUR-P. Five other patients who underwent TUR-P with the same volume of autotransfusion accompanied by preparative medication with the iron alone served as controls. In the EPO treated group (mean age, 68.3 years) the mean value for hemoglobin concentration (Hb) was 14.0 +/- 1.6 g/dl on the day of operation, which showed a recovery rate of 94.9 +/- 5.4% (Hb recovery rate) as against the pre-EPO treatment value (mean: 14.8 +/- 1.3 g/dl). This Hb recovery rate was significantly greater (p less than 0.001) when compared to 82.2 +/- 2.5% in the control group (mean age, 68.2 years). Of the EPO treated patients, those in their sixties (n = 6; mean age, 66.3 years) exhibited a significantly higher Hb recovery rate (98.3 +/- 3.5%) than the rate (89.9 +/- 3.0%) for patients in their seventies (N = 4; mean age, 71.3 years) (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Transfusion, Autologous↗
Analysis of prognostic factors regarding the outcome after a transurethral resection for symptomatic benign prostatic enlargement.
AIMS: To identify preoperative predictive variables regarding treatment outcomes following transurethral resection of the prostate (TURP) of patients with symptomatic benign prostatic enlargement (BPE). METHODS: A retrospective study was conducted in 384 patients of 1,397 men who had undergone TURP for symptomatic BPE. All the patients had completed the evaluation of International Prostate Symptom Score (I-PSS), and quality of life (QOL) index, and had undergone full urodynamics before the surgery. Outcomes were assessed at 12 months after surgery. The association between baseline variables and the improvement in outcome variables was statistically analyzed. RESULTS: Preoperative urodynamic abnormalities included bladder outlet obstruction (BOO) in 315 (82.0%), detrusor underactivity in 91 (23.7%), and detrusor overactivity (DO) in 160 (41.7%). Multivariate analysis showed that the presence of DO and a higher degree of BOO were both associated with postoperative improvement both in I-PSS and the QOL. The initial level of storage symptoms correlated with an improvement in the QOL. CONCLUSIONS: The association between those variables obtained by preoperatively performed urodynamic analysis and the degree of improvement in lower urinary tract symptom and QOL following TURP was statistically elucidated in a large number of patients with symptomatic BPE. A higher degree of baseline BOO positively predicts the postoperative improvement in I-PSS and QOL, while the baseline DO negatively predict it.
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Hydraulic hemostasis in transurethral resection of the prostate using the Iglesias continuous suction resectoscope.
An intravesicoprostatic hydrostatic pressure less than 10 mm. Hg maintains normal anatomy and physiology of the muscular and vascular prostatic structures. An increase in hydrostatic intravesicoprostatic pressure to more than 10mm. Hg produces a distortion in the musculature of the prostate, especially at the true capsule, opening the cut vessels and making possible the absorption of the irrigant free of electrolytes (transurethral resection syndrome). A low hydrostatic intravesicoprostatic pressure permits the compression of cut vessels by the inflow hydraulic pressure of 90 cm. water, achieving hydraulic hemostasis during transurethral resection of the prostate. Less electrocoagulation is necessary, resulting in more rapid patient recovery.
Hemostasis, Surgical↗
High-power KTP laser prostatectomy: the new challenge to transurethral resection of the prostate.
PURPOSE OF REVIEW: The quest for a successful surgical modality that can be used in the day-case setting, with minimal risk of complications and without the need for postoperative catheter drainage, may finally be fulfilled in the form of the new-generation, high-power potassium titanyl phosphate (KTP) lasers. In this review we will trace the development of KTP laser technology and its use by urologists over the years and describe why its physical properties make it so different from the lasers of the past. RECENT FINDINGS: The most high powered (80 W) incarnation has a relatively short history, particularly in terms of peer-reviewed publications. We will, however, outline the data so far and demonstrate what an exciting tool this represents for the urologist not only in terms of qualitative and quantitative improvements in lower urinary tract symptoms, but also in offering a day case, and in some instances catheterless, procedure with the prospect of a significantly lower impact on sexual function compared with standard surgical options. SUMMARY: Despite the lack of long-term data it is certainly possible that high-power KTP lasers represent a very significant challenge to the 'gold standard' status of transurethral resection of the prostate. Furthermore, the ability to use this technology to safely and effectively treat very large prostates represents an opportunity to assign the associated morbidity of the open prostatectomy to the annals of history.
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[Transurethral thermotherapy of the prostate--a very promising treatment method for benign prostatic hyperplasia].
Transurethral resection of the prostate remains the most common method for the treatment of benign prostatic hyperplasia (BPH). Due to unsatisfactory results in about 18% of the patients new methods to treat BPH have been developed. We evaluated 45 patients 6 and 12 months after transurethral microwave thermotherapy using the Prostatron device with Prostasoft 2.5 software. There was a significant improvement of the urinary symptoms and of the quality of life index from 18 to 9.5 and from 3.2 to 1.6 points, respectively. Urinary flow rate improved from 8.8 to 12.1 ml/sec and residual urine was reduced from 101 to 52 ml. The treatment was well tolerated and side effects were minimal. High-energy transurethral microwave thermotherapy is an effective and safe minimal invasive alternative to treat BPH in selected patients. As no anesthesia is required transurethral microwave thermotherapy can also be offered to high risk and elderly patients.
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[Elevation of serum and urine tumor necrosis factor levels after transurethral resection of the prostate].
BACKGROUND: Recent studies have suggested that inflammatory cytokines are major mediator of the acute phase protein response after surgery. The aim of the present study is to investigate the relationship between the degree of surgical trauma and the change of serum and urine cytokine levels after transurethral resection of the prostate (TUR-P). METHOD: Serum and urine concentrations of tumor necrosis factor-alpha (TNF), interleukin-6 (IL 6), and interleukin-1 (IL 1) were evaluated in 55 patients who underwent TUR-P and in 23 patients who underwent abdominal surgery. The samples were collected periodically before and after an intervention, and the concentrations of cytokines were measured by enzyme-linked immunosorbent assay. RESULTS: The concentration of serum TNF was significantly increased 6 hours after TUR-P. Since serum TNF level was not increased after abdominal surgery, serum TNF level was significantly higher after TUR-P than after abdominal surgery. Serum IL 6 and IL 1 levels were not increased after TUR-P. Urine levels of TNF, IL 6 and IL 1 were significantly increased after TUR-P, meanwhile no significant elevation of urine cytokine levels was recognized in the patients who underwent abdominal surgery. The elevation of urine cytokine levels was thought to be caused by the increased production of cytokines at the surgically resected sites. The urine TNF level after TUR-P was increased related to the resected tissue volume and irrigation fluid volume. The preoperative urinary tract infection caused excessive elevation of the urine TNF level after TUR-P. The urine TNF level after TUR-P also tended to be increased depending on the degree of postoperative pyrexia. CONCLUSION: These results indicate the unique response of TNF to TUR-P. Measurement of serum and urine TNF levels after TUR-P can be a useful index for evaluating the perioperative condition of the patients undergoing TUR-P.
Adult↗
Visual disturbances and transurethral resection of the prostate: the TURP syndrome.
A 73-year-old man with a history of a cerebral and a cardiac vascular disease and atrial flutter developed visual disturbances characterized by vision being dark in both eyes and by seeing as through a color photographic negative immediately after an uncomplicated transurethral resection of the prostate (TURP) for prostatic hyperplasia under spinal anesthesia. There was complete remission of the symptomatology after 2.5 h. A cerebrovascular workup was negative. Considering postoperative hyponatremia and hypoosmality, we discuss the possible role of glycine-induced visual disturbances as described in the TURP reaction syndrome, to our knowledge an entity almost unknown in the neurologic literature. Glycine-induced visual disturbances should therefore be considered in the differential diagnosis of bilateral transient visual loss.
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Haemodynamic changes detected during open prostatectomy and transurethral resection for benign prostatic hyperplasia.
To detect possible intraoperative haemodynamic differences, 60 patients undergoing transurethral (n = 18) or open prostatectomy (n = 42) for benign prostatic hyperplasia were evaluated. The same type of general anaesthesia was used in the two groups. Data, including temperature and cardiac output, were collected at five standard times during the procedures. No significant differences were found between the two groups. However, in all patients, irrespective of the operation, significant decreases in cardiac output and increases in systemic resistance occurred during surgery. Body temperature showed a mild, insignificant decrease, which may play a role in determining the mild haemodynamic derangement observed in all patients. Our patients subjected to open prostatectomy and transurethral resection presented the same kind of haemodynamic derangement, with no significant differences. Therefore it seems unlikely that the kind of surgery could play a relevant role in the late mortality rate of these patients.
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[Evaluation of new technical alternative procedures for therapy of symptomatic benign prostatic hyperplasia].
Transurethral resection of the prostate is still the gold standard in the treatment of symptomatic benign prostatic hyperplasia. It has proved possible to reduce the mortality of this treatment almost to zero, while the morbidity has remained unchanged at 18% for decades. Therefore, understandably, procedures are being looked for that will be similarly effective but have lower morbidity. Current developments in this field are transurethral implants (spiral, intraurethral catheter, Wall-Stent), the balloon dilatation, transurethral incision (TUIP), laser therapy (TULIP, ITK), ultrasound-induced aspiration of tissue and heat treatment (hyperthermia, thermotherapy). Chances and risks inherent in these different technical procedures and the amount of investment they involve are reviewed. Potential for the future can at best be attributed to the Wall-Stent, TUIP, the application of laser and the thermotherapy.
Catheterization↗
[Indirect electrochemical blood oxidation in the prophylaxis of suppurative-inflammatory complications after transurethral resection of the prostate].
To investigate efficiency of indirect electrochemical blood oxidation in prophylaxis of infectious complications, 28 patients were treated with 0.06% hypochlorite solution (2 infusions, 2-3 days before TURP). These patients belonged to a high-risk group of infectious complications (80% of them had chronic prostatitis, 8 patients had bladder stones, 8 had undergone cystostomy). The results demonstrated that the complication rate in the above prepared patients fell four times as compared to the control group and the postoperati hospital stay was reduced by 3 days.
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A critical evaluation of the results of transurethral resection of the prostate.
In a review of 1057 consecutive prostatectomies of which 95% were performed transurethrally, carcinoma was present in 11.8%. There were 10 deaths within a month of operation (0.9%), 9 of these patients having been exceptionally old and unfit. The rate of complications and the end results appear to justify using transurethral resection as the method of choice for prostatectomy whenever it is feasible.
Adult↗
Visual evoked potentials and changes in serum glycine concentration during transurethral resection of the prostate.
Visual evoked potentials were recorded in 10 patients undergoing transurethral prostatectomy under subarachnoid anaesthesia. They were compared with those obtained in a control group (n = 5) having other operative procedures also under spinal anaesthesia. Serum concentrations of glycine, ammonia, glucose and sodium, and osmolality, were determined during the perioperative period. The prostatectomy group demonstrated a significant prolongation of visual evoked potential P2 latency in the postoperative period when compared with preoperative values (P less than 0.01). No significant changes in latency occurred in the control group when measured at similar times. The prostatectomy group demonstrated a significant increase in serum glycine concentration (P less than 0.01); changes in serum ammonia and sodium concentrations and osmolality were not significant. There was no correlation between visual evoked potential latency and changes in serum glycine concentration. Changes in visual evoked potential during transurethral prostatectomy may be the result of an accumulation of a metabolite of glycine.
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Routine cross-matching is not necessary for a transurethral resection of the prostate.
Two hundred and fifty-five consecutive patients undergoing transurethral prostatectomy were studied prospectively to test a policy of not routinely cross-matching blood. Blood was ordered only for patients with anaemia, a major medical risk factor, a prostate gland estimated to be greater than 60 g, or the presence of red cell alloantibodies. Of the 203 patients who were "grouped and saved" only, 30 (12%) were subsequently cross-matched and 22 (8.5%) transfused. There were no significant problems as a result of the operation of this policy. The value of these pre-operative criteria for cross-matching was confirmed, apart from the clinical estimation of prostatic size. The use of such a policy could be of significant value to the hospital blood transfusion services.
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Transurethral resection of the prostate in the anticoagulated patient.
OBJECTIVE: To assess the safety of transurethral prostatectomy (TURP) in patients on long-term full anticoagulation. PATIENTS AND METHODS: Twelve TURPs were performed on 11 patients with urinary retention or severe symptoms from prostatic obstruction who also required anticoagulation for a history of life-threatening thromboembolic disease (seven) or prosthetic heart valves (four). Patients stopped taking warfarin 3 days before surgery; on admission a day later, full intravenous heparinization was commenced. Heparin was stopped 4 h before TURP and re-commenced with an initial bolus in the recovery room, and warfarin re-started that evening. RESULTS: The mean weight of prostate resected was 23 g and the mean peri-operative decrease in haemoglobin was 1.6 g/dL. Only one patient required a transfusion of 3 units, but the activated partial thromboplastin time (APTT) had risen to >4. The mean pre- and post-operative APTT were 1.7 and 2.64, respectively, and the mean total length of hospital stay 6.7 days. Three patients were re-admitted for secondary haemorrhage at 8, 9 and 28 days after TURP, but all resolved with catheterization for 24 h only. There were no other major complications or thrombo-embolic phenomena. CONCLUSION: TURP can be conducted safely in this high-risk group of patients with a regimen that allows a brief but controlled interruption to their full anticoagulation. This protects from the risks of thromboembolic incidents with no major increase in haemorrhage or hospital stay.
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[Changes in temperature during transurethral resection of the prostate under peridural anesthesia].
Superficial and central body temperatures were measured during anaesthesia and recovery in eleven elderly patients undergoing transurethral resection under epidural anaesthesia. A significant decrease in central body temperature as measured on the tympanic membrane was found during surgery. After a significant increase during induction of anaesthesia, mean skin temperature remained stable throughout surgery. Mean body temperature calculated from central body temperature and mean skin temperature decreased significantly during surgery. During recovery, all temperatures increased significantly. But mean body temperature returned to normal faster than central body temperature. Routine monitoring of core temperature and the use of warmed irrigation fluids are recommended during transurethral resections in elderly patients.
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