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Transurethral prostatectomy for benign prostatic hyperplasia

In January Bandolier featured the AHCPR report [1] on benign prostatic hyperplasia (BPH). BPH is becoming a hot topic, and some recent papers help to shed new light on treatment choices - and especially watchful waiting.

Treatment in transition

BPH is a condition where there is beginning to be a wide range of treatment options, compared with the previous situation where transurethral resection of the prostate (TURP) was the main treatment option. These treatment options, not all of which are yet backed by randomised controlled trial evidence, are well laid out and reviewed by Joseph Oesterling [2], a widely respected US urologist.

There are new medical therapies. 5-alpha reductase inhibitors reduce the conversion of testosterone to di-hydrotestosterone, and alpha-adrenergic antagonists block the adrenergic receptors in hyperplastic prostatic tissue so that smooth muscle tone of prostatic structures is decreased.

There are new minimally invasive surgical techniques - prostatic stents, transurethral incision of the prostate, microwave therapy and laser prostatectomy.

Which is best? A good question with, unfortunately as yet no clear answers. Oesterling's review at least brings the reader up to date with the most recent techniques and their results - though not on an evidence-based basis.

RCT of TURP and watchful waiting

There are few randomised controlled trials of TURP. A recent multicentre study [3] compared watchful waiting with TURP in men aged over 54 years (average 66 years) with moderate symptoms of BPH. Using a symptom scoring system with a maximum score of 27 points, those with scores of 10 - 20 points were eligible (see Bandolier 11 ).

Men were randomised to watchful waiting (276) or TURP (280), which was carried out within two weeks of randomisation. They were seen at six to eight weeks, and then twice a year for three years of follow-up.

The primary outcome measure was treatment failure, defined as any of the following events:-
  • death
  • repeated or intractable urinary retention
  • residual urinary volume of over 350 mL
  • development of bladder calculus
  • new, persistent incontinence
  • a symptom score of 24 or higher at one visit
  • a symptom score of 21 or higher at two consecutive visits
  • doubling of baseline serum creatinine

Immediate postoperative results of TURP

There were no deaths associated with surgery. In the first 30 days after surgery there were no complications in 91% of men treated. The most frequent complications were placement of another urinary catheter (3.7%), perforation of the prostate capsule (2%) and haemorrhage requiring transfusion (1%). Prostate cancer was found in 10% of the specimens removed at surgery.

Treatment outcomes after 3 years

The treatment outcomes are shown in the Table.
Treatment failure was more common in watchful waiting, as was high residual urinary volume and the occurrence of a high symptom score. The failure rate in the watchful waiting group was 6.1 per 100 person years compared with 3.0 per 100 person years in the surgery group. The difference was largely due to intractable urinary retention, high residual volume and high symptom score.

Men who underwent TURP had a larger 3-year fall in symptom score (mean 10 points) than did those with watchful waiting (mean 5.5 points). They also had an increase in peak urinary flow rate of 6 mL/sec (to 18 mL/sec), compared with watchful waiting where the urinary flow rate at three years was 13 mL/sec, unchanged from baseline.

There were also some benefits in quality of life scores for men who underwent TURP - mainly in terms of less bother from urinary difficulties and improvements in daily living.

Who benefits?

A key message was that men who were most bothered by their symptoms at baseline benefited most from surgery. 91% of those who were substantially bothered by urinary difficulties at baseline had improvements, as compared with 62% of those who were less bothered. In the men assigned to watchful waiting, 48 of 155 men (31%) who were most bothered by their symptoms went on to surgery compared with 16 of 97 (16%) of men who were less bothered by their symptoms.

Take-home message from the RCT

Men with moderate symptoms of benign prostatic hyperplasia that substantially reduce the quality of their lives have most to gain from transurethral resection. For men who are less bothered by urinary difficulties, watchful waiting is a safe alternative.

TURP in the UK - deaths and complications

It is always useful to know the risks and benefits of any treatment, especially an operation. Some of the benefits of TURP compared with watchful waiting have been explored by the US RCT. However, this was a multicentre study in the US Veterans Medical Service, one of the best. There were no deaths associated with surgery, though other surveys have found death rates of about 1%.

A recent survey of deaths and complications following prostatectomy in 1400 men in the Northern Region paints a more realistic picture of prostatectomy in Britain [4]. This study looked at 12 hospitals which undertook prostatectomy for an eight month period in 1991.
An independent audit was carried out according to a predetermined protocol by two clinical co-ordinators who examined case notes three months after the operation.

The outcomes collected were early mortality (fewer than 30 days after operation) and late mortality (30 - 90 days after operation). Morbidity measures were return to theatre (for haemorrhage, clot evacuation and early reoperation for failure to void), a blood transfusion of two or more units and the development of postoperative sepsis.

Results from 12 hospitals

A total of 1431 operations were performed, 97.6% transurethrally, the remainder being retropubic prostatectomies. One hospital performed over 450 operations, four others over 100 operations and seven hospitals fewer than 100 operations.

Mortality

The early mean death rate was 13 of 1396 patients (0.9%). There was a wide intersite variation, from 0 to 3.8%. There was a small bias in favour of hospitals performing over 100 operations (0.5%) compared with those performing fewer than 100 operations (1.7%). Early mortality was lower in elective admissions (0.5%) than in emergency admissions (2.4%).

Morbidity

Overall 2.4% of patients needed a blood transfusion. There was a six-fold variation in transfusion rate across the 12 sites (0 - 6.6%).

A mean of 2% of patients were returned to theatre soon after operation for bleeding, clot evacuation and early repeat TURP. There was a seven-fold variation in early re-operation across the 12 sites (0 - 7.5%).

The mean incidence of postoperative sepsis was 8%. There was a 17-fold variation in sepsis rate across the 12 sites (0 - 16.9%).

Significantly more complications were found in low volume compared with high volume sites. Hospitals where fewer than 100 patients were treated had an average of 0.46 complications/patient compared with 0.24 complications per patients in hospitals performing more than 100 operations.

Take-home message

The authors conclude with a simple take-home message. Variation exists, there are reasons for it, audit demonstrates it, action changes it, and purchasers and providers should be aware of it.

References:

  1. JD McConnell, MJ Barry, RC Bruskewitz et al. Benign prostatic hyperplasia: diagnosis and treatment. AHCPR Department of Health and Human Services, Rockville Md USA.
  2. JE Oesterling. Benign prostatic hyperplasia. Medical and minimally invasive treatment options. New England Journal of Medicine 1995 332: 99-109.
  3. JH Watson, DJ Reda, RC Bruskewitz et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. New England Journal of Medicine 1995 332: 75-9.
  4. AC Thorpe, R Cleary, J Coles, S Vernon, J Reynolds, DE Neal. Deaths and complications following prostatectomy in 1400 men in the Northern Region of England. British Journal of Urology 1994 74: 559-65.



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