TRANSURETHRAL RESECTION OF PROSTATE IMMEDIATELY AFTER RENAL TRANSPLANTATION YURI REINBERG, M.D. J. CARLOS MANIVEL, M.D. A. A. SIDI, M.D. CESAR J, ERCOLE, M.D. From the Department of Urologic Surgery and Laboratory, and Department of Laboratory Medicine and Pathology, University of Minnesota Hospital and Clinic. Minneapolis, Minnesota ABSTRACT-The subject of transurethral resection of the prostate (TUHP) after renal transplantation has not been evaluated in the urologic literature. We r&ospectively compared the outcome of renal transplantation in 8 patients who underwent transurethral resection of the prostate within ten days of renal transplantation with 8 patients who did not undergo prostate surgery. Patients were computer-matchedfor Seven parameters. There was no statistically .significant difference in patient survival (6 us 7) and graft survival (56 Y vs 88 74) between the two groups. However, there was a 25 percent incidence of major perioperative complications (including one mortality) in the TURP group directly attributable to the procedure. Transurethral resection of the prostate can be safely performed immediately after renal transplantation only if urine is sterile, antibiotics and steroids are carefully administered perioperatively. lowgravitrt irrigation is used, and hemostasis is meticulous.
Material and Methods From 1970 to 1988, 8 patients underwent transurethral resection of the prostate within ten days of renal transplantation. The case-control system was used to computer match these patients with 8 renal transplant recipients who did not undergo transurethral resection of the prostate. The following parameters known to influence the outcome of renal transplantation were used for matching: donor type; diabetes mellitus; number of transplant surgeries performed; age at the time of transplantation +5 years; immunosuppressive regimen., including preliminary blood transfusion; multiple organ transplantation; and year + 1 of transplantation. Patient and graft survival were analyzed using actuarial statistics and the Gehan generalized Wilcoxon test. The patholohT of the prostate specimens was re-examined. All patients have been followed to the present or until death.
Renal transplantation is currently the best treatment for end-stage renal disease and is increasingly more common among older patients. At our institution, 2.6 percent (46 of 1,736) of male renal transplant recipients are more than sixty years of age. The incidence of benign prostatic hypertrophy (BPH) among men over sixty years of age is high. Transurethral resection of the prostate (TURP) can be performed before or after renal transplantation,‘,2 but we know of no reports that discuss the results of TURP in patients who have undergone renal transplantation. Of particular interest would be the outcome of transurethral resection of the prostate performed soon after transplantation on an immunosuppressed man with acute urinary retention and a fresh ureterovesical anastomosis. In a contro’lled, retrospective study we evaluated the results of transurethral resection of the prostate performed in the period immediately following renal transplantation.
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Group
Mean Age at Transplantation (Range)
TURP (N = 8) Control (N = 8)
62 yrs. (957-69) Fj8 yrs. (49-67)
Mean Follow-up (Range) 5.5 yrs. (1-16) 5.1 yrs. (1-13)
No. of x0. of Crafts Patients Surviving Alive (Total Graft) 6
5
7
7
Results Data on patient age, length of follow-up, and patient and graft survival are presented in Table I. There was no statistically significant difference in actuarial survival or graft survival between control patients and patients who underwent a transurethral resection of the prostate. The Foley catheter was removed two or three days after TURP, and the mean hospital stay after TURP was six days (range 2 to 13 days). One patient died of Candida urosepsis two weeks after transurethral resection of the prostate. Two other patients, 1 in the TURP group and 1 in the control group, died of unrelated causes. In 1 patient epididymo-orchitis developed as a result of Candida infection and orchidectomy was done fifteen days after TURP. None of the surviving patients had bladder neck contracture, urethral stricture, or prostatic regrowth, and none required additional urologic procedures during follow-up. Pathologic evaluation of the resected prostate tissue revealed nodular hyperplasia of the prostate (benign prostatic hyperplasia) in all 8 cases. In one instance, focal squamous cell metaplasia was observed adjacent to a remote infarct. In another case, a recent infarct, focal basaloid hyperplasia, and xanthogranulomatous prostatitis were detected. In this second case an orchidectomy specimen demonstrated acute epididymo-orchitis and abscess of the spermatic cord; gram-negative bacterial colonies were also detected in the testes. Vacuolization of arteriolar smooth muscle cells, similar to that described for cyclosporin-associated arteriopathy,” was observed in 1 of 7 patients treated with cyclosporin (Fig. 1). Comment There are tance in the and urinary Should we
320
three questions of urologic imporpatient with renal transplantation retention secondary to BPH: (1) try to identify the patient with
urinary outflow obstruction and remove the obstruction prior to transplantation? (2) If done post-renal transplantation, should TURP be performed immediately or postponed for number of months? (3) What are the dangers of pcrforming transurethral resection in the presence of fresh ureteroneocystostomy and at the point of maximal immunosuppression? None of these questions has been previously addressed in the urologic literature and our article, being retrospective, can answer them only partially. A controlled prospective study is warranted to fully answer these questions. Benign prostatic hyperplasia can be asymptomatic in an elderly oliguric or anuriz patient with end-stage renal disease. A patient undergoing chronic hemodialysis who has a low urine output may not be diagnosed with benign prostatic hyperplasia before transplantation because of the absence of symptoms of prostatism. However, with high urinary output and the effects of pain medication and anesthesia after transplantation, such a patient can experience acute urinary retention. TURP, clean intermittent catheterization (CIC), or indwelling Foley catheter drainage should all be considered. Indwelling Foley catheter may cause recurrent urinary tract infections which can be life threatening in the immunosuppressed patient. CIC can be used safely in patients with renal transplantation4; however, in patients with a large prostate, CIC can be technically difficult or impossible. Transurethral resection of the prostate after transplantation can be pcrformcd if certain guidelines are carefully followed, including aggressive prophvlactic antibiotic therapy preand postoperatively and perioperative steroid
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therap!.. I,ow-gravity irrigation and absolute hemost,asis to prevent clot retention arid disruption of the llreteroneoc!.stostonl?. anastomosis are ma!ndator\~. The onl! rjrortalit!. among patients in the TURP grorlp in the immediate postoperative period was a patient with candiduria and an indwyelling Double-J stent in the donor kidne\p lvho experienced immediate postoperative septic shock. The patient in whom pst-transplantation orchio-epididymitis developed had mild candiduria ax well. We recommend complete sterilization of the N&ler with intra\wical irrigation using amphotericin B mm if candidllria is nlodcratcl. Intra\xnous amphotericin B should be considered if candiduria persists and TURP postponed until the urine becomes sterile. Removing an indlvelling Foley catheter and starting CIC can facilitate urinary tract sterilization. A Double-J stent, if present, should be removed prior to transurethral resection of the prostate> and reinserted after the procedure, if necessar!: Postoperative urologic management of these patients is similar to that after TURP in patients ivho have not undergone transplantation. Pretransplantation TURP is complicated b!. a high risk for bladder neck contractrlre and urethral stricture secondary to oliguria or amria. I 9 \.Vt~did not encounter these complications in our group of patients. Even though there \verc no statistically significant differences between the two groups in patient and graft survival, lrve believe that the mortality and morbidity encountered in our TURP patients can be preventabl(a in the frlture if the aforedescribed
guidelines are followed carefull!,. (:hanges found in the prostatic tissue of the patient treated with qrclosporin have heretofore never been described and may warrant f’llturch studies to determine, the clinical importance of this finding (Fig. 1). In summary post-transplantation TURP decreases the incidence of bladder neck contractllre and urethral stricture seen in pre-transplant TURP.’ There is no danger for clisruption of ureteroneocystostomy if low-gravit!, rcsection is performed. TURP in post-transplant period is dangerous when urine is not >,terile and should be postponed until rlrinaq tract strrilization is achieved. Future studies are necessary to compare TURP performed at later date, \\rhen immunosuppression tapering is maximal Lvith TURP immediately follow4ng renal transplantation. Patient should be on CIC and not \\.ith an indwelling Foley during the waiting period. lJni\,ersity of Minnesota Hoy)it al & (Znic Box 394 Minneapolis, Minnesota 554.55-0321 (DR. J
Material and Methods From 1970 to 1988, 8 patients underwent transurethral resection of the prostate within ten days of renal transplantation. The case-control system was used to computer match these patients with 8 renal transplant recipients who did not undergo transurethral resection of the prostate. The following parameters known to influence the outcome of renal transplantation were used for matching: donor type; diabetes mellitus; number of transplant surgeries performed; age at the time of transplantation +5 years; immunosuppressive regimen., including preliminary blood transfusion; multiple organ transplantation; and year + 1 of transplantation. Patient and graft survival were analyzed using actuarial statistics and the Gehan generalized Wilcoxon test. The patholohT of the prostate specimens was re-examined. All patients have been followed to the present or until death.
Renal transplantation is currently the best treatment for end-stage renal disease and is increasingly more common among older patients. At our institution, 2.6 percent (46 of 1,736) of male renal transplant recipients are more than sixty years of age. The incidence of benign prostatic hypertrophy (BPH) among men over sixty years of age is high. Transurethral resection of the prostate (TURP) can be performed before or after renal transplantation,‘,2 but we know of no reports that discuss the results of TURP in patients who have undergone renal transplantation. Of particular interest would be the outcome of transurethral resection of the prostate performed soon after transplantation on an immunosuppressed man with acute urinary retention and a fresh ureterovesical anastomosis. In a contro’lled, retrospective study we evaluated the results of transurethral resection of the prostate performed in the period immediately following renal transplantation.
l’KOI.O(
iI’
.AI’Hl I, I’192
\‘OLUhlE
SSSIS.
NIJhfHElt
1
,319
Group
Mean Age at Transplantation (Range)
TURP (N = 8) Control (N = 8)
62 yrs. (957-69) Fj8 yrs. (49-67)
Mean Follow-up (Range) 5.5 yrs. (1-16) 5.1 yrs. (1-13)
No. of x0. of Crafts Patients Surviving Alive (Total Graft) 6
5
7
7
Results Data on patient age, length of follow-up, and patient and graft survival are presented in Table I. There was no statistically significant difference in actuarial survival or graft survival between control patients and patients who underwent a transurethral resection of the prostate. The Foley catheter was removed two or three days after TURP, and the mean hospital stay after TURP was six days (range 2 to 13 days). One patient died of Candida urosepsis two weeks after transurethral resection of the prostate. Two other patients, 1 in the TURP group and 1 in the control group, died of unrelated causes. In 1 patient epididymo-orchitis developed as a result of Candida infection and orchidectomy was done fifteen days after TURP. None of the surviving patients had bladder neck contracture, urethral stricture, or prostatic regrowth, and none required additional urologic procedures during follow-up. Pathologic evaluation of the resected prostate tissue revealed nodular hyperplasia of the prostate (benign prostatic hyperplasia) in all 8 cases. In one instance, focal squamous cell metaplasia was observed adjacent to a remote infarct. In another case, a recent infarct, focal basaloid hyperplasia, and xanthogranulomatous prostatitis were detected. In this second case an orchidectomy specimen demonstrated acute epididymo-orchitis and abscess of the spermatic cord; gram-negative bacterial colonies were also detected in the testes. Vacuolization of arteriolar smooth muscle cells, similar to that described for cyclosporin-associated arteriopathy,” was observed in 1 of 7 patients treated with cyclosporin (Fig. 1). Comment There are tance in the and urinary Should we
320
three questions of urologic imporpatient with renal transplantation retention secondary to BPH: (1) try to identify the patient with
urinary outflow obstruction and remove the obstruction prior to transplantation? (2) If done post-renal transplantation, should TURP be performed immediately or postponed for number of months? (3) What are the dangers of pcrforming transurethral resection in the presence of fresh ureteroneocystostomy and at the point of maximal immunosuppression? None of these questions has been previously addressed in the urologic literature and our article, being retrospective, can answer them only partially. A controlled prospective study is warranted to fully answer these questions. Benign prostatic hyperplasia can be asymptomatic in an elderly oliguric or anuriz patient with end-stage renal disease. A patient undergoing chronic hemodialysis who has a low urine output may not be diagnosed with benign prostatic hyperplasia before transplantation because of the absence of symptoms of prostatism. However, with high urinary output and the effects of pain medication and anesthesia after transplantation, such a patient can experience acute urinary retention. TURP, clean intermittent catheterization (CIC), or indwelling Foley catheter drainage should all be considered. Indwelling Foley catheter may cause recurrent urinary tract infections which can be life threatening in the immunosuppressed patient. CIC can be used safely in patients with renal transplantation4; however, in patients with a large prostate, CIC can be technically difficult or impossible. Transurethral resection of the prostate after transplantation can be pcrformcd if certain guidelines are carefully followed, including aggressive prophvlactic antibiotic therapy preand postoperatively and perioperative steroid
UHOI.O(:Y
I)
APIIII.
I!)!)”
\‘ol,u\lI~:
SSSIS.
NI!.\lHE:I~ 1
therap!.. I,ow-gravity irrigation and absolute hemost,asis to prevent clot retention arid disruption of the llreteroneoc!.stostonl?. anastomosis are ma!ndator\~. The onl! rjrortalit!. among patients in the TURP grorlp in the immediate postoperative period was a patient with candiduria and an indwyelling Double-J stent in the donor kidne\p lvho experienced immediate postoperative septic shock. The patient in whom pst-transplantation orchio-epididymitis developed had mild candiduria ax well. We recommend complete sterilization of the N&ler with intra\wical irrigation using amphotericin B mm if candidllria is nlodcratcl. Intra\xnous amphotericin B should be considered if candiduria persists and TURP postponed until the urine becomes sterile. Removing an indlvelling Foley catheter and starting CIC can facilitate urinary tract sterilization. A Double-J stent, if present, should be removed prior to transurethral resection of the prostate> and reinserted after the procedure, if necessar!: Postoperative urologic management of these patients is similar to that after TURP in patients ivho have not undergone transplantation. Pretransplantation TURP is complicated b!. a high risk for bladder neck contractrlre and urethral stricture secondary to oliguria or amria. I 9 \.Vt~did not encounter these complications in our group of patients. Even though there \verc no statistically significant differences between the two groups in patient and graft survival, lrve believe that the mortality and morbidity encountered in our TURP patients can be preventabl(a in the frlture if the aforedescribed
guidelines are followed carefull!,. (:hanges found in the prostatic tissue of the patient treated with qrclosporin have heretofore never been described and may warrant f’llturch studies to determine, the clinical importance of this finding (Fig. 1). In summary post-transplantation TURP decreases the incidence of bladder neck contractllre and urethral stricture seen in pre-transplant TURP.’ There is no danger for clisruption of ureteroneocystostomy if low-gravit!, rcsection is performed. TURP in post-transplant period is dangerous when urine is not >,terile and should be postponed until rlrinaq tract strrilization is achieved. Future studies are necessary to compare TURP performed at later date, \\rhen immunosuppression tapering is maximal Lvith TURP immediately follow4ng renal transplantation. Patient should be on CIC and not \\.ith an indwelling Foley during the waiting period. lJni\,ersity of Minnesota Hoy)it al & (Znic Box 394 Minneapolis, Minnesota 554.55-0321 (DR. J
