Scand J Urol Nephrol 26: 333-338, 1992
TRANSURETHRAL PROSTATECTOMY COMPARED WITH INCISION OF THE PROSTATE IN THE TREATMENT OF PROSTATISM CAUSED BY SMALL BENIGN PROSTATE GLANDS Torben Derrflinger, Frank Svendsen Jensen, Torben Krarup and Steen Walter From the Department of Urology, Aalborg Hospital Norlh, Aalborg, Denmark
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Newcastle on 01/04/15 For personal use only.
(Submitted September 1, 1991. Accepted for publication December 3, 1991)
Abstract. In a prospective, randomized study 60 patients with prostatism caused by small prostate glands (estimated weight < 20 g) had either transurethral prostatectomy (TURP, n = 31) or transurethral incision of the prostate (TUI, n=29). Operating time and blood loss were significantly less in the group that underwent TUI. There were no differences between the groups in number of days with an indwelling catheter or days in hospital after operation. Eight patients in the TUI group required further operation, as did four in the T U R P group, one of whom was discharged with a permanent indwelling catheter. In addition one patient developed a urethral stricture. Nine of the failures of treatment occurred within the first month. Fifty-one patients were followed up at 3 months and 47 were also seen at 12 months. Both operations significantly improved symptom scores and maximum flow rates compared with preoperatively. but the improvement in maximum flow rate was significantly better in the T U R P group than in the TUI group. At l:! months T U R P had also improved micturition time and voided volume, which TUI had not. Neither operation caused any significant change in sexual activity or erective potency postoperatively. Retrograde ejaculation was, however, seen in more than half of the patients in the T U R P group, and only one in the T U I group. We recommend TUI for the treatment of prostatism caused by small prostate glands in patients who want to preserve normal ejaculation or are at poor surgical risk. Key words: prostatism, prostatic incision, transurethral prostatic resection, potency, retrograde ejaculation.
Transurethral prostatectomy (TURP) is an accepted operation for the treatment benign prostatic hypertrophy. Half of the patients undergoing TURP will, however, have a relative small prostate (weighing 20 g or less) (3). These patients are more likely to develop secondary con-
tracture of the bladder neck (7,8), incontinence (1 ), urethral stricture (12) or sexual dysfunction (10). Orandi (1 3) suggested transurethral incision of the prostate (TUI) as an alternative in the treatment of prostatism caused by small prostate glands, and it is claimed that TUI is followed by fewer complications than TURP. We present the results of a prospective, randomised controlled study of TURP compared with TUI in the treatment of benign prostatic hypertrophy caused by small prostate glands.
PATIENTS AND METHODS The study comprised unselected patients who had not had any prostatic surgery. This included patients with prostatism and urinary retention as a result of benign prostatic hypertrophy, estimated prostatic weight of less than 20 g and a bladder neck to seminal crest distance of less than 2 cm. Patients with prostatic cancer, urethral stricture, those who had had previous pelvic operations, and those with obvious neurological or psychiatric diseases, or who were at poor surgical risk were excluded. The preoperative investigations included scoring of symptoms as recommended by Madsen & lversen ( 1 I ) , physical examination, spontaneous uroflowmetry, culture of urine and routine biochemical examination of the blood. In addition, information about sexual activity was obtained. Cystoscopy was done before operation. Bladder trabeculation, visual obstruction at the level of the prostate and the presence of bladder stones were recorded. The size of the prostate was estimated by rectal palpation while the cystoscope was in the bladder. Finally the distance from the bladder neck to the seminal crest was measured. Patients who fulfilled the criteria for enetering the study were randomly allocated to have either T U R P or TUI. T U R P was done with a 24 F resectoscope, and prostatic tissue was resected in a standard fashScand J Uro/ Nephrol26
334
T. Dsrflinger et al.
Table I. Comparability of the groups. Median values are given except where otherwise stated
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Newcastle on 01/04/15 For personal use only.
Transurethral incision (n=29)
Transurethral resection (n=31)
69 30
Age (years) Duration of symptoms (months) Symptom score Total (maximum 27) Indicating irritation (maximum 9) Indicating obstruction (maximum 18) No. (Yo) with urinary retention Maximum flow rate (mllsec) Voided volume (ml) Micturition time (sec) No. (Yo) with positive urine culture No. (Yo) with bladder stones
ion, completely and circumferentially from the bladder neck to the seminal crest, visualising the surgical capsule through the fossa. TUI was done with a 24 F resectoscope and a Collin’s knife. An incision to the depth of the surgical capsule was made through the bladder neck down to the seminal crest in the 7 o’clock position. Bleeding vessels were coagulated. At the end of the operation a balloon catheter was inserted into the bladder and left in until the urine was clear. Operating time was recorded, and blood loss during operation was estimated for the first 38 patients by measuring the haemoglobin concentration of the irrjgating fluid that had been collected during the operation. Finally, the weight of resected prostatic tissue was measured. Postoperatively the following variables were recorded: number of patients who required blood transfusion, the highest rectal temperature, whether antibiotics were given, number of days with indwelling catheter, and number of days before discharge from hospital. The patients had their symptoms assessed and uroflowmetry carried out 3 and 12 months postoperatively. In addition, they were asked about sexual activity including whether they had complete retrograde ejaculation.They were also asked to assess their micturi-
tion as much better, better, unchanged, worse or much worse. Treatment failure was defined as the need for reoperation or a permanent indwelling catheter. The significance of differences between groups was assessed by Fisher’s exact test (two-tailed) or the Mann-Whitney test as appropriate, and a p-value of less than 0.05 was accepted as significant.
RESULTS Thirty-one patients had TURP and 29 TUI (Table I). There were no significant differences between the groups. A median weight of 8 grams (range 1-26) was resected during TURP. Length of operation and the extent of bleeding were significantly less in the TUI than in the TURP group (Table 11). Four patients in the TURP group had blood transfusions compared to none in the TUI group (p=O.11 (Fisher’s exact test)). Postoperatively there were no differences between groups in incidence of fever, antibiotic
Table 11. Operative variables. Median values are given except where otherwise stated
Length of operation (min) Blood lost (ml) No. (Yo) who required blood transfusion Scand J Urol Nephrol26
Transurethral incision (n=29)
Transurethral resection (n=31)
p-value
15 10 0
30 65 4 (13)
TRANSURETHRAL PROSTATECTOMY COMPARED WITH INCISION OF THE PROSTATE IN THE TREATMENT OF PROSTATISM CAUSED BY SMALL BENIGN PROSTATE GLANDS Torben Derrflinger, Frank Svendsen Jensen, Torben Krarup and Steen Walter From the Department of Urology, Aalborg Hospital Norlh, Aalborg, Denmark
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Newcastle on 01/04/15 For personal use only.
(Submitted September 1, 1991. Accepted for publication December 3, 1991)
Abstract. In a prospective, randomized study 60 patients with prostatism caused by small prostate glands (estimated weight < 20 g) had either transurethral prostatectomy (TURP, n = 31) or transurethral incision of the prostate (TUI, n=29). Operating time and blood loss were significantly less in the group that underwent TUI. There were no differences between the groups in number of days with an indwelling catheter or days in hospital after operation. Eight patients in the TUI group required further operation, as did four in the T U R P group, one of whom was discharged with a permanent indwelling catheter. In addition one patient developed a urethral stricture. Nine of the failures of treatment occurred within the first month. Fifty-one patients were followed up at 3 months and 47 were also seen at 12 months. Both operations significantly improved symptom scores and maximum flow rates compared with preoperatively. but the improvement in maximum flow rate was significantly better in the T U R P group than in the TUI group. At l:! months T U R P had also improved micturition time and voided volume, which TUI had not. Neither operation caused any significant change in sexual activity or erective potency postoperatively. Retrograde ejaculation was, however, seen in more than half of the patients in the T U R P group, and only one in the T U I group. We recommend TUI for the treatment of prostatism caused by small prostate glands in patients who want to preserve normal ejaculation or are at poor surgical risk. Key words: prostatism, prostatic incision, transurethral prostatic resection, potency, retrograde ejaculation.
Transurethral prostatectomy (TURP) is an accepted operation for the treatment benign prostatic hypertrophy. Half of the patients undergoing TURP will, however, have a relative small prostate (weighing 20 g or less) (3). These patients are more likely to develop secondary con-
tracture of the bladder neck (7,8), incontinence (1 ), urethral stricture (12) or sexual dysfunction (10). Orandi (1 3) suggested transurethral incision of the prostate (TUI) as an alternative in the treatment of prostatism caused by small prostate glands, and it is claimed that TUI is followed by fewer complications than TURP. We present the results of a prospective, randomised controlled study of TURP compared with TUI in the treatment of benign prostatic hypertrophy caused by small prostate glands.
PATIENTS AND METHODS The study comprised unselected patients who had not had any prostatic surgery. This included patients with prostatism and urinary retention as a result of benign prostatic hypertrophy, estimated prostatic weight of less than 20 g and a bladder neck to seminal crest distance of less than 2 cm. Patients with prostatic cancer, urethral stricture, those who had had previous pelvic operations, and those with obvious neurological or psychiatric diseases, or who were at poor surgical risk were excluded. The preoperative investigations included scoring of symptoms as recommended by Madsen & lversen ( 1 I ) , physical examination, spontaneous uroflowmetry, culture of urine and routine biochemical examination of the blood. In addition, information about sexual activity was obtained. Cystoscopy was done before operation. Bladder trabeculation, visual obstruction at the level of the prostate and the presence of bladder stones were recorded. The size of the prostate was estimated by rectal palpation while the cystoscope was in the bladder. Finally the distance from the bladder neck to the seminal crest was measured. Patients who fulfilled the criteria for enetering the study were randomly allocated to have either T U R P or TUI. T U R P was done with a 24 F resectoscope, and prostatic tissue was resected in a standard fashScand J Uro/ Nephrol26
334
T. Dsrflinger et al.
Table I. Comparability of the groups. Median values are given except where otherwise stated
Scand J Urol Nephrol Downloaded from informahealthcare.com by University of Newcastle on 01/04/15 For personal use only.
Transurethral incision (n=29)
Transurethral resection (n=31)
69 30
Age (years) Duration of symptoms (months) Symptom score Total (maximum 27) Indicating irritation (maximum 9) Indicating obstruction (maximum 18) No. (Yo) with urinary retention Maximum flow rate (mllsec) Voided volume (ml) Micturition time (sec) No. (Yo) with positive urine culture No. (Yo) with bladder stones
ion, completely and circumferentially from the bladder neck to the seminal crest, visualising the surgical capsule through the fossa. TUI was done with a 24 F resectoscope and a Collin’s knife. An incision to the depth of the surgical capsule was made through the bladder neck down to the seminal crest in the 7 o’clock position. Bleeding vessels were coagulated. At the end of the operation a balloon catheter was inserted into the bladder and left in until the urine was clear. Operating time was recorded, and blood loss during operation was estimated for the first 38 patients by measuring the haemoglobin concentration of the irrjgating fluid that had been collected during the operation. Finally, the weight of resected prostatic tissue was measured. Postoperatively the following variables were recorded: number of patients who required blood transfusion, the highest rectal temperature, whether antibiotics were given, number of days with indwelling catheter, and number of days before discharge from hospital. The patients had their symptoms assessed and uroflowmetry carried out 3 and 12 months postoperatively. In addition, they were asked about sexual activity including whether they had complete retrograde ejaculation.They were also asked to assess their micturi-
tion as much better, better, unchanged, worse or much worse. Treatment failure was defined as the need for reoperation or a permanent indwelling catheter. The significance of differences between groups was assessed by Fisher’s exact test (two-tailed) or the Mann-Whitney test as appropriate, and a p-value of less than 0.05 was accepted as significant.
RESULTS Thirty-one patients had TURP and 29 TUI (Table I). There were no significant differences between the groups. A median weight of 8 grams (range 1-26) was resected during TURP. Length of operation and the extent of bleeding were significantly less in the TUI than in the TURP group (Table 11). Four patients in the TURP group had blood transfusions compared to none in the TUI group (p=O.11 (Fisher’s exact test)). Postoperatively there were no differences between groups in incidence of fever, antibiotic
Table 11. Operative variables. Median values are given except where otherwise stated
Length of operation (min) Blood lost (ml) No. (Yo) who required blood transfusion Scand J Urol Nephrol26
Transurethral incision (n=29)
Transurethral resection (n=31)
p-value
15 10 0
30 65 4 (13)
