Original Paper
Urologia Internationalis
Received: July 7, 2014 Accepted after revision: August 18, 2014 Published online: November 4, 2014
Urol Int DOI: 10.1159/000367667
Transurethral Resection of the Prostate in Recurrent Acute Bacterial Prostatitis Karel Decaestecker Willem Oosterlinck Department of Urology, Ghent University Hospital, Ghent, Belgium
Abstract Objective: To explore the outcome of transurethral resection of the prostate (TURP) in the treatment of refractory recurrent acute bacterial prostatitis. Patients and Methods: From 2004 to 2013, 23 TURP for this indication were performed in 21 patients; two patients underwent it twice. The files of these patients were retrospectively analysed for outcome and side effects. TURP intended to remove as much infected tissue as possible under appropriate antibiotherapy. Results: Twelve patients became free of symptoms during a follow-up of 3–108 months (median 44), two others became disease-free after one and two postoperative attacks, respectively; eight were not cured and had rapid recurrences; three patients had follow-up of a few weeks only. Two failures developed orchiepididymitis shortly after the procedure and one a year later. No incontinence or bladder neck contracture was noted. Conclusion: TURP is an acceptable procedure in the treatment of refractory recurrent bacterial prostatitis. It could cure about two thirds of patients. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Recurrent acute bacterial prostatitis with heavy dysuria, high fever, general malaise and sometimes urinary sepsis is an invalidating disease. This condition generally is treated with antibiotics [1–3]. However, if this has to be restarted several times, progressive bacterial resistance often develops, making treatment problematic. Since many years transurethral resection of the prostate (TURP) is proposed to these desperate patients by one of us (W.O.) in order to remove as much infected tissue as possible. The purpose of this study was to explore the results of this unusual treatment. Patients and Methods Within 10 years, between January 2004 and December 2014, 486 TURP were performed by W.O. and in only 23 of the them the indication was highly recurrent, symptomatic acute bacterial prostatitis. This means a rapid recurrence in spite of adapted antibiotherapy and increasing resistance of the responsible bacteria to the these drugs. The diagnosis was made clinically: fever, general malaise, acute lower urinary tract symptoms and pyuria. Prostate-specific antigen was not measured routinely or used as a diagnostic tool. All patients except one had at least three acute episodes of prostatitis before TURP was considered. In one, with only two attacks, lower tract obstruction played a role in the indication. The files of these patients were retrospectively analysed. Analysis was finished at the end of April 2014. A pre-TURP ultrasound of the prostate was done in all cases for volume estimation, detection of abscess or prostate stones.
Prof. W. Oosterlinck Department of Urology, Ghent University Hospital De Pintelaan 185 BE–9000 Ghent (Belgium) E-Mail willem.oosterlinck @ ugent.be
Downloaded by: University of Tokyo 157.82.153.40 - 5/17/2015 9:00:40 PM
Key Words Acute bacterial prostatitis · Chronic bacterial prostatitis · Transurethral resection of the prostate
Results
The age of the 21 men treated varied from 42 to 82 years (mean 66.2 years). Two patients underwent TURP for prostatitis twice because the disease was not under control after the first TURP and remaining prostatic tissue was detected on transrectal ultrasound. This brings the number of TURP for prostatitis to 23. In four of them the indication for TURP also was the presence of bladder outlet obstruction by benign prostatic hyperplasia (BPH). The weight of the amount of resected tissue varied from only 3 g (on re-TURP) to 29 g in those patients not treated for BPH, with a median of 13 g. Pathology reported prostatitis in 16 cases and one focus of Gleason 3+3 prostate tumour. In the remaining only BPH was reported. For three TURP there was no sufficient postoperative follow-up available. In the remaining 20 TURP follow-up varied from 3 months to 9 years, with a median of 44 months. Twelve patients remained without recurrence and were obviously cured. Eight were not cured and had new and mostly rapid recurrences. In two of them with a long follow-up the prostatitis attacks stopped definitively after one and two recurrences, respectively. The two patients who received a re-TURP were unfortunately lost to follow-up. We guess they were dissatisfied with the result. Two of the treatment failures developed orchiepididymitis shortly after TURP and one of the responders 1 year later. No incontinence was noted after surgery. There were no attacks of fever or sepsis in the immediate postoperative period.
Discussion
Frequent recurrent symptomatic bacterial prostatitis is a rather rare disease. This condition is mainly treated with recurrent antibiotherapy adapted to the sensitivity 2
Urol Int DOI: 10.1159/000367667
of the responsible bacteria. However, these can become progressively resistant to most of the drugs. These patients are seriously worried in daily life. The attacks are unpredictable and patients get suddenly severely ill, with need for hospitalization for intravenous antibiotherapy or for urinary sepsis. Often these patients, as well as their physicians, become desperate. This situation allows for unusual solutions. Several review articles on the subject [1–3] do not give any recommendation on this particular situation and a literature search does not reveal reliable suggestions. Some colleagues perform ‘radical’ TURP with removal of as much prostatic tissue as possible (personal communication). This means resection up to the prostatic capsule all around, a procedure which is not easy and needs experience. However, a literature search in PubMed until 2004 with the terms ‘bacterial prostatitis’ did not reveal any article on this type of treatment. One review [4] mentions that transurethral microwave therapy to ablate prostatic tissue can be offered, but that prostatectomy has been abandoned because of its bad results, without giving any reference for the last statement. It is unclear whether the authors refer more to chronic prostatitis symptoms and not to the situation which was treated in our study. We have been performing this for along time, but for logistic reasons only the last 10 years are considered in this study. It is clear from our data that this remains an exceptional procedure (about two per year). As a referral centre, we often see desperate cases; the number in ‘normal’ practice is probably lower. The number of cases did not increase over time. About half of the patients were immediately cured (12/21) and remained it for a long period. Nine were not cured, but finally two of them became asymptomatic after one and two recurrences, respectively, shortly after the operation. This brings the success rate to 14 in 21 patients (66%). In the non-responders the condition did not worsen after the operation. Because of the retrospective concept of the study we lost three cases to follow-up. As one operates in infected tissue, healing of the wound could be delayed and more scar formation could be expected. In this series, no strictures at the bladder neck or membranous urethra and no incontinence occurred. The aim of this study certainly is not to promote this treatment. However, in the absence of data on this kind of treatment, it serves as an information on what can be expected of TURP in desperate cases of recurrent acute bacterial prostatitis. The indication to propose this treatment to the patient depends on the severity of the symptoms, the treatment possibilities (narrowing of the bacteDecaestecker/Oosterlinck
Downloaded by: University of Tokyo 157.82.153.40 - 5/17/2015 9:00:40 PM
These two last conditions were not present in this series as the therapeutic approach would be different. The urine cultures revealed the normal uropathogens, mainly Escherichia coli (n = 13). The TURP technique is not different from the standard procedure but was intended to be as radical as possible in eliminating as much infected tissue as possible. All procedures performed, out of the acute phase of the disease, by an experienced urologist (W.O.). Per- and postoperative antibiotherapy according to sensitivity at last urine culture was given. One did not have the impression that per- and postoperative bleeding was more than with standard TURP, but it was not measured. The difficulty is the removal of as much tissue as possible, until the prostate capsule is seen all around.
rial sensitivity), the frequency of the attacks and patient preferences. It seems prudent to perform this at least a week away from acute symptoms. The guidelines of the European Association of Urology [5] mention drainage of a prostatic abscess as a treatment in these cases. In cases of prostatic stones one can also consider that infected stones are the source of recurrences, and removal by TURP seems indicated. However, these situations are different from the one described here, where no such condition was present. We have only bad anecdotal experience with intraprostatic injections, which are also mentioned but not defended as a possible treatment.
Conclusion
TURP with maximal removal of all prostatic tissue up to the prostatic capsule is a feasible treatment for intractable and recurrent acute bacterial prostatitis and was able to cure approximately two thirds of the patients in this small series. It should however remain a ‘last solution’ after failure of all conventional therapy.
Disclosure Statement No funding was received for this study.
References
Transurethral Resection of the Prostate in Acute Prostatitis
2 Schiller DS, Parikh A: Identification, pharmacologic considerations, and management of prostatitis. Am J Geriatr Pharmacother 2011; 9:37–48. 3 Anothaisintawee T, Attia J, Nickel JC, Thammakraisorn S, Numthavaj P, McEvoy M, Thakkinstian A: Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAMA 2011;305:78–86.
Urol Int DOI: 10.1159/000367667
4 Murphy AB, Macejko A, Taylor A, Nadler RB: Chronic prostatitis: management strategies. Drugs 2009;69:71–84. 5 Grabe M, Bartoletti R, Bjerlund-Johansen TE, Cek HM, Pickard RS, Tenke P, Wagenlehner F, Wult B: Guidelines on Urological Infections 2014. Arnhem, European Association of Urology, 2014.
3
Downloaded by: University of Tokyo 157.82.153.40 - 5/17/2015 9:00:40 PM
1 Wagenlehner FM, Pilatz A, Bschleipfer T, Diemer T, Linn T, Meinhardt A, Schagdarsurengin U, Dansranjavin T, Schuppe HC, Weidner W: Bacterial prostatitis. World J Urol 2013;31: 711–716.
Urologia Internationalis
Received: July 7, 2014 Accepted after revision: August 18, 2014 Published online: November 4, 2014
Urol Int DOI: 10.1159/000367667
Transurethral Resection of the Prostate in Recurrent Acute Bacterial Prostatitis Karel Decaestecker Willem Oosterlinck Department of Urology, Ghent University Hospital, Ghent, Belgium
Abstract Objective: To explore the outcome of transurethral resection of the prostate (TURP) in the treatment of refractory recurrent acute bacterial prostatitis. Patients and Methods: From 2004 to 2013, 23 TURP for this indication were performed in 21 patients; two patients underwent it twice. The files of these patients were retrospectively analysed for outcome and side effects. TURP intended to remove as much infected tissue as possible under appropriate antibiotherapy. Results: Twelve patients became free of symptoms during a follow-up of 3–108 months (median 44), two others became disease-free after one and two postoperative attacks, respectively; eight were not cured and had rapid recurrences; three patients had follow-up of a few weeks only. Two failures developed orchiepididymitis shortly after the procedure and one a year later. No incontinence or bladder neck contracture was noted. Conclusion: TURP is an acceptable procedure in the treatment of refractory recurrent bacterial prostatitis. It could cure about two thirds of patients. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Recurrent acute bacterial prostatitis with heavy dysuria, high fever, general malaise and sometimes urinary sepsis is an invalidating disease. This condition generally is treated with antibiotics [1–3]. However, if this has to be restarted several times, progressive bacterial resistance often develops, making treatment problematic. Since many years transurethral resection of the prostate (TURP) is proposed to these desperate patients by one of us (W.O.) in order to remove as much infected tissue as possible. The purpose of this study was to explore the results of this unusual treatment. Patients and Methods Within 10 years, between January 2004 and December 2014, 486 TURP were performed by W.O. and in only 23 of the them the indication was highly recurrent, symptomatic acute bacterial prostatitis. This means a rapid recurrence in spite of adapted antibiotherapy and increasing resistance of the responsible bacteria to the these drugs. The diagnosis was made clinically: fever, general malaise, acute lower urinary tract symptoms and pyuria. Prostate-specific antigen was not measured routinely or used as a diagnostic tool. All patients except one had at least three acute episodes of prostatitis before TURP was considered. In one, with only two attacks, lower tract obstruction played a role in the indication. The files of these patients were retrospectively analysed. Analysis was finished at the end of April 2014. A pre-TURP ultrasound of the prostate was done in all cases for volume estimation, detection of abscess or prostate stones.
Prof. W. Oosterlinck Department of Urology, Ghent University Hospital De Pintelaan 185 BE–9000 Ghent (Belgium) E-Mail willem.oosterlinck @ ugent.be
Downloaded by: University of Tokyo 157.82.153.40 - 5/17/2015 9:00:40 PM
Key Words Acute bacterial prostatitis · Chronic bacterial prostatitis · Transurethral resection of the prostate
Results
The age of the 21 men treated varied from 42 to 82 years (mean 66.2 years). Two patients underwent TURP for prostatitis twice because the disease was not under control after the first TURP and remaining prostatic tissue was detected on transrectal ultrasound. This brings the number of TURP for prostatitis to 23. In four of them the indication for TURP also was the presence of bladder outlet obstruction by benign prostatic hyperplasia (BPH). The weight of the amount of resected tissue varied from only 3 g (on re-TURP) to 29 g in those patients not treated for BPH, with a median of 13 g. Pathology reported prostatitis in 16 cases and one focus of Gleason 3+3 prostate tumour. In the remaining only BPH was reported. For three TURP there was no sufficient postoperative follow-up available. In the remaining 20 TURP follow-up varied from 3 months to 9 years, with a median of 44 months. Twelve patients remained without recurrence and were obviously cured. Eight were not cured and had new and mostly rapid recurrences. In two of them with a long follow-up the prostatitis attacks stopped definitively after one and two recurrences, respectively. The two patients who received a re-TURP were unfortunately lost to follow-up. We guess they were dissatisfied with the result. Two of the treatment failures developed orchiepididymitis shortly after TURP and one of the responders 1 year later. No incontinence was noted after surgery. There were no attacks of fever or sepsis in the immediate postoperative period.
Discussion
Frequent recurrent symptomatic bacterial prostatitis is a rather rare disease. This condition is mainly treated with recurrent antibiotherapy adapted to the sensitivity 2
Urol Int DOI: 10.1159/000367667
of the responsible bacteria. However, these can become progressively resistant to most of the drugs. These patients are seriously worried in daily life. The attacks are unpredictable and patients get suddenly severely ill, with need for hospitalization for intravenous antibiotherapy or for urinary sepsis. Often these patients, as well as their physicians, become desperate. This situation allows for unusual solutions. Several review articles on the subject [1–3] do not give any recommendation on this particular situation and a literature search does not reveal reliable suggestions. Some colleagues perform ‘radical’ TURP with removal of as much prostatic tissue as possible (personal communication). This means resection up to the prostatic capsule all around, a procedure which is not easy and needs experience. However, a literature search in PubMed until 2004 with the terms ‘bacterial prostatitis’ did not reveal any article on this type of treatment. One review [4] mentions that transurethral microwave therapy to ablate prostatic tissue can be offered, but that prostatectomy has been abandoned because of its bad results, without giving any reference for the last statement. It is unclear whether the authors refer more to chronic prostatitis symptoms and not to the situation which was treated in our study. We have been performing this for along time, but for logistic reasons only the last 10 years are considered in this study. It is clear from our data that this remains an exceptional procedure (about two per year). As a referral centre, we often see desperate cases; the number in ‘normal’ practice is probably lower. The number of cases did not increase over time. About half of the patients were immediately cured (12/21) and remained it for a long period. Nine were not cured, but finally two of them became asymptomatic after one and two recurrences, respectively, shortly after the operation. This brings the success rate to 14 in 21 patients (66%). In the non-responders the condition did not worsen after the operation. Because of the retrospective concept of the study we lost three cases to follow-up. As one operates in infected tissue, healing of the wound could be delayed and more scar formation could be expected. In this series, no strictures at the bladder neck or membranous urethra and no incontinence occurred. The aim of this study certainly is not to promote this treatment. However, in the absence of data on this kind of treatment, it serves as an information on what can be expected of TURP in desperate cases of recurrent acute bacterial prostatitis. The indication to propose this treatment to the patient depends on the severity of the symptoms, the treatment possibilities (narrowing of the bacteDecaestecker/Oosterlinck
Downloaded by: University of Tokyo 157.82.153.40 - 5/17/2015 9:00:40 PM
These two last conditions were not present in this series as the therapeutic approach would be different. The urine cultures revealed the normal uropathogens, mainly Escherichia coli (n = 13). The TURP technique is not different from the standard procedure but was intended to be as radical as possible in eliminating as much infected tissue as possible. All procedures performed, out of the acute phase of the disease, by an experienced urologist (W.O.). Per- and postoperative antibiotherapy according to sensitivity at last urine culture was given. One did not have the impression that per- and postoperative bleeding was more than with standard TURP, but it was not measured. The difficulty is the removal of as much tissue as possible, until the prostate capsule is seen all around.
rial sensitivity), the frequency of the attacks and patient preferences. It seems prudent to perform this at least a week away from acute symptoms. The guidelines of the European Association of Urology [5] mention drainage of a prostatic abscess as a treatment in these cases. In cases of prostatic stones one can also consider that infected stones are the source of recurrences, and removal by TURP seems indicated. However, these situations are different from the one described here, where no such condition was present. We have only bad anecdotal experience with intraprostatic injections, which are also mentioned but not defended as a possible treatment.
Conclusion
TURP with maximal removal of all prostatic tissue up to the prostatic capsule is a feasible treatment for intractable and recurrent acute bacterial prostatitis and was able to cure approximately two thirds of the patients in this small series. It should however remain a ‘last solution’ after failure of all conventional therapy.
Disclosure Statement No funding was received for this study.
References
Transurethral Resection of the Prostate in Acute Prostatitis
2 Schiller DS, Parikh A: Identification, pharmacologic considerations, and management of prostatitis. Am J Geriatr Pharmacother 2011; 9:37–48. 3 Anothaisintawee T, Attia J, Nickel JC, Thammakraisorn S, Numthavaj P, McEvoy M, Thakkinstian A: Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAMA 2011;305:78–86.
Urol Int DOI: 10.1159/000367667
4 Murphy AB, Macejko A, Taylor A, Nadler RB: Chronic prostatitis: management strategies. Drugs 2009;69:71–84. 5 Grabe M, Bartoletti R, Bjerlund-Johansen TE, Cek HM, Pickard RS, Tenke P, Wagenlehner F, Wult B: Guidelines on Urological Infections 2014. Arnhem, European Association of Urology, 2014.
3
Downloaded by: University of Tokyo 157.82.153.40 - 5/17/2015 9:00:40 PM
1 Wagenlehner FM, Pilatz A, Bschleipfer T, Diemer T, Linn T, Meinhardt A, Schagdarsurengin U, Dansranjavin T, Schuppe HC, Weidner W: Bacterial prostatitis. World J Urol 2013;31: 711–716.
