426
Journal of the Royal Society of Medicine Volume 71 June 1978
Do we overtreat patients undergoing transurethral resection of the prostate? R G Notley MS FRCS F A W Schweitzer MS FRCS Royal Surrey County Hospital, Guildford, Surrey
Introduction Patients undergoing routine surgery are liable to get routine treatment. Procedures carrying their own risks and complications may be routinely included in the management for traditional or time-hallowed reasons, regardless of the clinical situation and possibly to the patient's disadvantage. For some time we have felt that patients undergoing transurethral resection of the prostate may be unwittingly overtreated. In the not too distant past prostatectomy was synonymous with an abdominal operation, significant blood loss, postoperative pain and a variable mortality and morbidity. Transurethral resection ofthe prostate has changed this situation and 60 g or more of adenoma can be removed without opening the abdomen, with minimal blood loss, without pain and with a very low morbidity and mortality. However, there remains a tendency to manage these patients as for open prostatectomy. We have surveyed a series of patients using a much simplified regime in which we have tried to exclude (1) routine intravenous infusion of fluids of any description; (2) anaesthetic techniques involving relaxants, endotracheal intubation and intermittent positive pressure respiration; and (3) postoperative narcotic administration. -In order to introduce a simplified regime of management it was necessary to convince our anaesthetic colleagues of its safety. We had little difficulty in persuading them to abandon relaxants, endotracheal intubation and intermittent positive pressure respiration in this group of patients, but to eliminate the routine intravenous infusion set up before the operation commenced was more of a problem. However, measurement of blood lost during transurethral resection demonstrated that in the majority of cases it was unnecessary. Prevention of postoperative narcotic administration was achieved by simply forbidding its routine prescription. We explained to junior medical staff that it is more logical to see if a patient develops pain after a transurethral resection before giving analgesics, rather than giving them blindly. This resulted in virtually no drugs being used, but it became clear as we went along that it was necessary to omit prescribing any drugs at all, so that nursing staff had to refer to a doctor for advice. Until routine prescription was forbidden we had found that drugs written up to be given 'If Required' or 'If Necessary' always seemed to be administrated sooner or later, regardless of true need. Methods Two hundred unselected, consecutive patients undergoing transurethral resection of the prostate were surveyed. The first 100 patients were studied in detail, but in the second 100 1
Paper read to Section of Urology, 24 February 1977
0141-0768/78/0071-0426/$01.00/0
(D The Royal Society of Medicine 1978
Journal of the Royal Society of Medicine Volume 71 June 1978
427
patients observations were confined to age, weight of prostatic tissue resected and operative blood loss, in view of the results in the first part of the series. All patients were operated upon by one of the authors. A standard Storz resectoscope 27040 D using a 24-F calibre sheath was used. A 1.4% glycine solution was the irrigating fluid and the diathermy machine was either a Valleylab SSE 2 solid state electrosurgery apparatus or a GU 332 A combined spark gap and valve apparatus. Induction of anaesthesia was by intravenous administration of a short-acting barbiturate with subsequent maintenance of anaesthesia by inhalation of nitrous oxide, oxygen and halothane through a face mask on open curcuit. Blood loss was estimated by collecting and measuring all irrigation fluid during the procedure; after careful mixing the haemoglobin content of an aliquot was estimated and by reference to the patient's preoperative haemoglobin (in grams per 100 ml) and the total washout volume, total blood loss was calculated. Results Two hundred patients were surveyed. The detailed findings in the initial 100 patients are set out in Table 1. Of this group, 56 patients were routine admissions for elective surgery of bladder outflow obstruction and 44 were emergency admission with acute retention of urine. Table 2 shows the findings in these two sub-groups. Postoperative morbidity was minimal in spite of the advanced age of many of the patients, no postoperative deaths occurred and all the patients left the urological ward voiding urine spontaneously. Fifteen patients proved to have carcinoma of the prostate, the diagnosis in most cases being unsuspected before operation. The incidence ofcarcinoma of the prostate was the same in the elective and acute retention patients. Twenty-one patients had infected urine prior to operation, the incidence being trebled in the acute retention group (34%) compared with the elective group (1 0%). The incidence of infection was closely related to the length of the preoperative catheterization period, which was several weeks in some patients who developed acute retention during treatment of cardiac failure, pneumonia or myocardial infarction, or in those who required prolonged bladder drainage to lower a high blood urea. The blood loss during operation averaged 200 ml and was generally related to the amount of tissue resected and the duration of the operation. In only 10 patients did it exceed 500 ml and in these the weight of the resected tissue averaged 49 g - the largest resection, 80 g, being associated with the largest blood loss, 950 ml. Five patients were given one dose each of a strong narcotic postoperatively (in each case pethidine). Three of these doses were given unnecessarily early in the series by inexperienced house staff and 2 patients were given pethidine because of restlessness associated with the Table 1. One hundred patients undergoing transurethral prostatectomy
Average age Average weight of tissue resected Average measured per-operative blood loss Average duration of resection Average period of postoperative catheterization Intravenous infusion Endotracheal intubation Postoperative analgesia Epidural anaesthesia Urine infected preoperatively Urine infected postoperatively
70.6 years 24.7 g 200.3 ml
Gram-negative septicaemia Malignant prostate
2% 15°o
Deaths
37.5 min 4.8 days
160"20l 5°0
15°.0
21°,,
14/0
(42-92 years) ( 5-80 g)
(25-950 ml)
(lI0-90 min) ( 2-13 days)
428
Journal of the Royal Society of Medicine Volume 71 June 1978
Table 2. One hundred patients (routine and emergency admissions) undergoing transurethral prostatectomy Elective operation (56 patients)
Average age Average weight of tissue resected Average measured peroperative blood loss Average duration of resection Average period of postoperative catheterization Average period of preoperative catheterization Intravenous infusion Endotracheal intubation Postoperative analgesia Epidural anaesthesia Urine infected preoperatively Urine infected postoperatively Gram-negative septicaemia Malignant prostate Deaths
67.1 years 22.0g
161.3 ml 34.9 min 5.0 days
Operation for acute retention (44 patients) 74.9 years 28.1 g
319.6 ml 40.8 min 4.45 days 13.9 days
7% (4 patients) 3.6% (2 patients) 7°" (4 patients) 5.4% (3 patients) 10.7% (6 patients) 8.9% (5 patients) 1.8%" (1 patient) 14.3%' (8 patients)
27.3% (12 patients) 2.3% ( 1 patient) 27.3%' (12 patients) 34.1% (15 patients) 20.5% ( 9 patients) 2.3% ( 1 patient) 15.90/0 ( 7 patients)
unaccustomed catheter. After discussion with the house staff, routine prescription of postoperative narcotics was withdrawn and postoperative sedation became unnecessary as a more critical evaluation of its indications was developed. As a result, very early mobilization of patients was achieved. Two patients required endotracheal intubation during surgery because an adequate airway could not be maintained with a face mask. Muscle relaxation and intermittent positive pressure respiration was never used. Epidural anaesthesia was used in 15 patients suffering from chronic respiratory disease. Having studied 100 consecutive patients in some detail, a simplified study of the next 100 patients was carried out applying our now strict criteria of 'no intravenous infusions, simple anaesthesia and no postoperative narcotic drugs'. The findings (Table 3) are essentially the same as in the original study group, i.e. an operative blood loss averaging 222 ml and a correspondingly slightly higher weight of prostatic tissue resected (29 g). In this second 100 patients, one man aged 92 years died of pneumonia on the eighteenth postoperative day after returning to his geriatric unit. Table 3. Additional 100 patients undergoing transurethral prostatectomy
Average age Average weight of tissue resected Average blood loss Deaths
73 years (27-92 years) 29 g (10-75 g) 222 ml (10-830 ml) 1 (92-year-old man, at 18 days, of pneumonia)
Discussion It is clear from the evaluation of these patients that transurethral prostatectomy is not necessarily accompanied by dangerous blood loss and that under such circumstances the risks of routine intravenous fluid administration to the elderly patient may outweigh the possible benefits conferred. Only 6 of the first 100 patients received blood replacement, the requirement
Journal of the Royal Society of Medicine Volume 71 June 1978
429
being judged on clinical grounds. In the remaining 94 patients (losing less than 500 ml of blood), the average blood loss was 151 ml and none of these patients received blood replacement. Two had intravenous infusions set up in association with the management of their concomitant diabetes mellitus and a third had an infusion because the prostatic resection was performed in association with a ureterolithotomy for ureteric calculus. In this first half of the series, therefore, 7 patients received an apparently unnecessary intravenous infusion during the operative period. In the second 100 patients no infusions, unnecessary by these criteria, were administered. Postoperative blood loss was not formally estimated, but was regarded as insignificant. Careful haemostasis was obtained at operation and a closed system of intermittent bladder washout through the Foley catheter was used to maintain drainage postoperatively for an average of 36 hours. Only one patient, with granulomatous prostatitis, bled significantly postoperatively, requiring syringe bladder washouts. No patient needed to return to theatre for evacuation of retained blood clot. Diuretics were never used to facilitate bladder drainage. The management of infection of the urine in association with transurethral prostatectomy is a much debated problem. Our policy has been to work to prevent infection by meticulous catheter care and closed drainage, but not to treat until the day of operation. In the early part of the series the policy was to give a course of an appropriate antibiotic by intramuscular injection commencing one hour before operation and continuing until the catheter was removed, but 2 patients developed gram-negative septicaemia in spite of administration of ampicillin in full dosage. Subsequently, therefore, gentamicin and later cephazolin were used to cover the operative period in infected patients and gram-negative septicaemia was thereby avoided. Table 4 indicates the outcome in the 21 patients of the series who had urinary infection at the time of operation. Table 4. Twenty-one patients undergoing transurethralprostatectomy with urine infected preoperatively Organisms
No. of patients
Pseudomonas aeruginosa Proteus mirabilis
1 4
Streptococcus faecalis Coliform species Staphylococcus albus Staphylococcus aureus Mixed growth
2 7 I
Organisms Urine after operation: Converted to sterile Remained infected - same organism - different organism
No. of patients 16 3 2
1 5
Postoperative sedation with strong narcotics proved totally unnecessary in this group of patients, and its avoidance permitted earlier mobilization of even very aged and infirm patients with a consequent reduction in postoperative morbidity. It is interesting to note, in passing, that none of those patients developed clinically detectable venous thrombosis or pulmonary embolism. On the basis of these results we would confidently recommend a simplification in the mode of management of patients subjected to transurethral prostatectomy along the lines set out.
Summary Two hundred unselected patients undergoing transurethral resection of the prostate have been surveyed. The routine use of endotracheal intubation, muscle relaxants, intermittent positive pressure respiration, intravenous fluids and postoperative sedation was avoided wherever possible. The results of this survey are presented and indicate that such measures can be omitted from the management of patients undergoing transurethral resection of the prostate with no significant increase in morbidity or mortality and, indeed, morbidity and mortality may be decreased by their exclusion.
Journal of the Royal Society of Medicine Volume 71 June 1978
Do we overtreat patients undergoing transurethral resection of the prostate? R G Notley MS FRCS F A W Schweitzer MS FRCS Royal Surrey County Hospital, Guildford, Surrey
Introduction Patients undergoing routine surgery are liable to get routine treatment. Procedures carrying their own risks and complications may be routinely included in the management for traditional or time-hallowed reasons, regardless of the clinical situation and possibly to the patient's disadvantage. For some time we have felt that patients undergoing transurethral resection of the prostate may be unwittingly overtreated. In the not too distant past prostatectomy was synonymous with an abdominal operation, significant blood loss, postoperative pain and a variable mortality and morbidity. Transurethral resection ofthe prostate has changed this situation and 60 g or more of adenoma can be removed without opening the abdomen, with minimal blood loss, without pain and with a very low morbidity and mortality. However, there remains a tendency to manage these patients as for open prostatectomy. We have surveyed a series of patients using a much simplified regime in which we have tried to exclude (1) routine intravenous infusion of fluids of any description; (2) anaesthetic techniques involving relaxants, endotracheal intubation and intermittent positive pressure respiration; and (3) postoperative narcotic administration. -In order to introduce a simplified regime of management it was necessary to convince our anaesthetic colleagues of its safety. We had little difficulty in persuading them to abandon relaxants, endotracheal intubation and intermittent positive pressure respiration in this group of patients, but to eliminate the routine intravenous infusion set up before the operation commenced was more of a problem. However, measurement of blood lost during transurethral resection demonstrated that in the majority of cases it was unnecessary. Prevention of postoperative narcotic administration was achieved by simply forbidding its routine prescription. We explained to junior medical staff that it is more logical to see if a patient develops pain after a transurethral resection before giving analgesics, rather than giving them blindly. This resulted in virtually no drugs being used, but it became clear as we went along that it was necessary to omit prescribing any drugs at all, so that nursing staff had to refer to a doctor for advice. Until routine prescription was forbidden we had found that drugs written up to be given 'If Required' or 'If Necessary' always seemed to be administrated sooner or later, regardless of true need. Methods Two hundred unselected, consecutive patients undergoing transurethral resection of the prostate were surveyed. The first 100 patients were studied in detail, but in the second 100 1
Paper read to Section of Urology, 24 February 1977
0141-0768/78/0071-0426/$01.00/0
(D The Royal Society of Medicine 1978
Journal of the Royal Society of Medicine Volume 71 June 1978
427
patients observations were confined to age, weight of prostatic tissue resected and operative blood loss, in view of the results in the first part of the series. All patients were operated upon by one of the authors. A standard Storz resectoscope 27040 D using a 24-F calibre sheath was used. A 1.4% glycine solution was the irrigating fluid and the diathermy machine was either a Valleylab SSE 2 solid state electrosurgery apparatus or a GU 332 A combined spark gap and valve apparatus. Induction of anaesthesia was by intravenous administration of a short-acting barbiturate with subsequent maintenance of anaesthesia by inhalation of nitrous oxide, oxygen and halothane through a face mask on open curcuit. Blood loss was estimated by collecting and measuring all irrigation fluid during the procedure; after careful mixing the haemoglobin content of an aliquot was estimated and by reference to the patient's preoperative haemoglobin (in grams per 100 ml) and the total washout volume, total blood loss was calculated. Results Two hundred patients were surveyed. The detailed findings in the initial 100 patients are set out in Table 1. Of this group, 56 patients were routine admissions for elective surgery of bladder outflow obstruction and 44 were emergency admission with acute retention of urine. Table 2 shows the findings in these two sub-groups. Postoperative morbidity was minimal in spite of the advanced age of many of the patients, no postoperative deaths occurred and all the patients left the urological ward voiding urine spontaneously. Fifteen patients proved to have carcinoma of the prostate, the diagnosis in most cases being unsuspected before operation. The incidence ofcarcinoma of the prostate was the same in the elective and acute retention patients. Twenty-one patients had infected urine prior to operation, the incidence being trebled in the acute retention group (34%) compared with the elective group (1 0%). The incidence of infection was closely related to the length of the preoperative catheterization period, which was several weeks in some patients who developed acute retention during treatment of cardiac failure, pneumonia or myocardial infarction, or in those who required prolonged bladder drainage to lower a high blood urea. The blood loss during operation averaged 200 ml and was generally related to the amount of tissue resected and the duration of the operation. In only 10 patients did it exceed 500 ml and in these the weight of the resected tissue averaged 49 g - the largest resection, 80 g, being associated with the largest blood loss, 950 ml. Five patients were given one dose each of a strong narcotic postoperatively (in each case pethidine). Three of these doses were given unnecessarily early in the series by inexperienced house staff and 2 patients were given pethidine because of restlessness associated with the Table 1. One hundred patients undergoing transurethral prostatectomy
Average age Average weight of tissue resected Average measured per-operative blood loss Average duration of resection Average period of postoperative catheterization Intravenous infusion Endotracheal intubation Postoperative analgesia Epidural anaesthesia Urine infected preoperatively Urine infected postoperatively
70.6 years 24.7 g 200.3 ml
Gram-negative septicaemia Malignant prostate
2% 15°o
Deaths
37.5 min 4.8 days
160"20l 5°0
15°.0
21°,,
14/0
(42-92 years) ( 5-80 g)
(25-950 ml)
(lI0-90 min) ( 2-13 days)
428
Journal of the Royal Society of Medicine Volume 71 June 1978
Table 2. One hundred patients (routine and emergency admissions) undergoing transurethral prostatectomy Elective operation (56 patients)
Average age Average weight of tissue resected Average measured peroperative blood loss Average duration of resection Average period of postoperative catheterization Average period of preoperative catheterization Intravenous infusion Endotracheal intubation Postoperative analgesia Epidural anaesthesia Urine infected preoperatively Urine infected postoperatively Gram-negative septicaemia Malignant prostate Deaths
67.1 years 22.0g
161.3 ml 34.9 min 5.0 days
Operation for acute retention (44 patients) 74.9 years 28.1 g
319.6 ml 40.8 min 4.45 days 13.9 days
7% (4 patients) 3.6% (2 patients) 7°" (4 patients) 5.4% (3 patients) 10.7% (6 patients) 8.9% (5 patients) 1.8%" (1 patient) 14.3%' (8 patients)
27.3% (12 patients) 2.3% ( 1 patient) 27.3%' (12 patients) 34.1% (15 patients) 20.5% ( 9 patients) 2.3% ( 1 patient) 15.90/0 ( 7 patients)
unaccustomed catheter. After discussion with the house staff, routine prescription of postoperative narcotics was withdrawn and postoperative sedation became unnecessary as a more critical evaluation of its indications was developed. As a result, very early mobilization of patients was achieved. Two patients required endotracheal intubation during surgery because an adequate airway could not be maintained with a face mask. Muscle relaxation and intermittent positive pressure respiration was never used. Epidural anaesthesia was used in 15 patients suffering from chronic respiratory disease. Having studied 100 consecutive patients in some detail, a simplified study of the next 100 patients was carried out applying our now strict criteria of 'no intravenous infusions, simple anaesthesia and no postoperative narcotic drugs'. The findings (Table 3) are essentially the same as in the original study group, i.e. an operative blood loss averaging 222 ml and a correspondingly slightly higher weight of prostatic tissue resected (29 g). In this second 100 patients, one man aged 92 years died of pneumonia on the eighteenth postoperative day after returning to his geriatric unit. Table 3. Additional 100 patients undergoing transurethral prostatectomy
Average age Average weight of tissue resected Average blood loss Deaths
73 years (27-92 years) 29 g (10-75 g) 222 ml (10-830 ml) 1 (92-year-old man, at 18 days, of pneumonia)
Discussion It is clear from the evaluation of these patients that transurethral prostatectomy is not necessarily accompanied by dangerous blood loss and that under such circumstances the risks of routine intravenous fluid administration to the elderly patient may outweigh the possible benefits conferred. Only 6 of the first 100 patients received blood replacement, the requirement
Journal of the Royal Society of Medicine Volume 71 June 1978
429
being judged on clinical grounds. In the remaining 94 patients (losing less than 500 ml of blood), the average blood loss was 151 ml and none of these patients received blood replacement. Two had intravenous infusions set up in association with the management of their concomitant diabetes mellitus and a third had an infusion because the prostatic resection was performed in association with a ureterolithotomy for ureteric calculus. In this first half of the series, therefore, 7 patients received an apparently unnecessary intravenous infusion during the operative period. In the second 100 patients no infusions, unnecessary by these criteria, were administered. Postoperative blood loss was not formally estimated, but was regarded as insignificant. Careful haemostasis was obtained at operation and a closed system of intermittent bladder washout through the Foley catheter was used to maintain drainage postoperatively for an average of 36 hours. Only one patient, with granulomatous prostatitis, bled significantly postoperatively, requiring syringe bladder washouts. No patient needed to return to theatre for evacuation of retained blood clot. Diuretics were never used to facilitate bladder drainage. The management of infection of the urine in association with transurethral prostatectomy is a much debated problem. Our policy has been to work to prevent infection by meticulous catheter care and closed drainage, but not to treat until the day of operation. In the early part of the series the policy was to give a course of an appropriate antibiotic by intramuscular injection commencing one hour before operation and continuing until the catheter was removed, but 2 patients developed gram-negative septicaemia in spite of administration of ampicillin in full dosage. Subsequently, therefore, gentamicin and later cephazolin were used to cover the operative period in infected patients and gram-negative septicaemia was thereby avoided. Table 4 indicates the outcome in the 21 patients of the series who had urinary infection at the time of operation. Table 4. Twenty-one patients undergoing transurethralprostatectomy with urine infected preoperatively Organisms
No. of patients
Pseudomonas aeruginosa Proteus mirabilis
1 4
Streptococcus faecalis Coliform species Staphylococcus albus Staphylococcus aureus Mixed growth
2 7 I
Organisms Urine after operation: Converted to sterile Remained infected - same organism - different organism
No. of patients 16 3 2
1 5
Postoperative sedation with strong narcotics proved totally unnecessary in this group of patients, and its avoidance permitted earlier mobilization of even very aged and infirm patients with a consequent reduction in postoperative morbidity. It is interesting to note, in passing, that none of those patients developed clinically detectable venous thrombosis or pulmonary embolism. On the basis of these results we would confidently recommend a simplification in the mode of management of patients subjected to transurethral prostatectomy along the lines set out.
Summary Two hundred unselected patients undergoing transurethral resection of the prostate have been surveyed. The routine use of endotracheal intubation, muscle relaxants, intermittent positive pressure respiration, intravenous fluids and postoperative sedation was avoided wherever possible. The results of this survey are presented and indicate that such measures can be omitted from the management of patients undergoing transurethral resection of the prostate with no significant increase in morbidity or mortality and, indeed, morbidity and mortality may be decreased by their exclusion.
