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Incision or resection for prostate surgery?

 

Clinical bottom line

Transurethral incision and transurethral prostatectomy for BPH are balanced in terms of benefits and harm. TURP gives marginally better maximum urinary flow rate, but TUIP gives lower rates of harmful effects of surgery.


Men with benign prostatic hyperplasia choose or need surgery to relieve bladder outlet obstruction. Different surgical techniques are available for smaller prostates. Should the operation be the standard one of transurethral resection, or is transurethral incision better?

Reference

Yang et al. Transurethral incision compared with transurethral resection of the prostate for bladder outlet obstruction: a systematic review and meta-analysis of randomized controlled trials. Journal of Urology 2001 165: 1526-1532.

Search

This study had an excellent search predicated on finding randomised studies that compared TUIP with TURP. Several databases were used, including the Cochrane Library and prostate review group. Nine studies were found with 691 patients.

Outcomes reported were varied, and at different times after the operation. For the purposes of the review the time of 12 months after operation was taken as a reasonable follow up, and primary outcomes were maximum urinary flow rate and symptom score. Secondary outcomes were complication rates.

Results

The mean prostate size in the nine studies was generally less than 30 grams, and in some less than 20 grams. One study had no limits of prostate size. The mean age of men was 60-70 years in the nine studies.

Maximum urinary flow rate

Maximum urinary flow rate before operation was below 10 mL/second in almost all trials. By 12 months the mean flow rate was higher for TURP than for TUIP, by an average of about 4 mL/second. Absolute flow rates were about 15 mL/second for TUIP and 19 mL/second for TURP. TURP was statistically and probably clinically better.

Figure 1: Mean maximum urinary flow rates at 12 months after operation for TUIP and TURP

Symptom score

Symptom scores before operation were about 15, indicating a moderate impact of disease. By 12 months after operation mean symptom scores were 6 or below, indicating a return to mild symptoms for men whose average age was 60-70 years.

Secondary outcomes

A number of secondary outcomes were available from some of the trials. These are summarised in Table 1.

Table 1: Summary of results of secondary outcomes

Outcome
Number of trials
Number of men
TUIP
TURP
Statistical significance
Reoperation (%)
8
not given
9.3
5.5
Not significant
Operative time (min)
4
not given
16
35
Favours incision
Blood transfusion
5
461
0.9
25.1
Favours incision
Hospital stay (days)
3
not given
4.4-6.2
4.4-8.4
Favours incision
12-month complications (%)
6
314
20
35
Favours incision
Retrograde ejaculation (%)
5
139
21
73
Favours incision

For most of these secondary outcomes, TUIP was favoured over TURP. There was a shorter operative time and hospital stay, and many fewer men needed a blood transfusion. In addition, the complication rate over 12 months was lower, and the incidence of retrograde ejaculation much lower in men having TUIP.

Comment

This is a cracking review of a small number of small trials. It shows us that TURP wins in terms of maximum urinary flow rate at a cost of being more complicated and perhaps being less attractive as an operation because of the higher costs and complications.