28 Apr

Is transurethral resection of the prostate safe and effective in the over 80-year-old?

Saturday morningWith a rising population of elderly patients and increasing public awareness of prostate disease, the indications for, morbidity and outcome of transurethral resection of the prostate (TURP) in the elderly male requires critical review. Although the morbidity and outcome of TURP is well reported, including in the over 80-year-old, the relevance of these studies to current urological practice may be questioned for two reasons. Firstly, the indications for (and, therefore, the outcome from) TURP have probably changed in the last decade as a result of effective medical therapy for patients with mild-to-moderate lower urinary tract symptoms (LUTS). Secondly, studies carried out in other health care systems may not reflect urological practice in the UK. Therefore, the aim of this study was to assess critically the current safety and effectiveness of TURP in the over 80-year-old in the setting of a UK district general hospital. Canadian Pharmacy prednisone

Patients and Methods
Theatre records were used to identify all patients over 80 years old undergoing TURP at the Royal Sussex County Hospital from August 1993 to March 1997. Medical records were obtained, where possible, and analysed retrospectively. A proforma was used to collect information from the records regarding: (i) patient presentation; (ii) operative information; (iii) complications during hospital stay; (iv) outcome of trial of voiding following catheter removal; and (v) complications after leaving hospital. All the patients studied had undergone TURP at least one year prior to the analysis of their records. canada pharmacy mall

Pre-existing medical conditions were scored according to number of systemic diseases present at the time of surgery. Subjective outcome was defined as a satisfied patient discharged from clinic. Objective outcome was defined as a successful trial of voiding in the presence of low postmicturition residual volumes.

Results
A total of 122 patients over 80 years old underwent TURP at the Royal Sussex County Hospital between August 1993 and March 1997. The medical records of 93 patients were obtained. The remaining 29 records were not available. Three sets of records had all or part of the urological records missing and were not included. A total of 90 patients with complete urological records were included in the study. cheap levitra

During the study period, a total of 93 TURP operations were carried out on 90 patients with a mean patient age of 84 years. Of the total, 29 patients (31%) underwent TURP for LUTS whilst 63 patients (68%) underwent TURP for urinary retention in whom the mean residual volume was 904 ml. One patient (1%) underwent a redo-TURP for persistent haematuria. The median number of pre-existing medical conditions was 1 (range 0-6).

Mean (± SD) resection weight was 29 g (±18 g). Overall, 70 patients (78%) had a benign histology whilst 20 patients (22%) were found to have carcinoma of the prostate. In all, 10 patients required blood transfusion for haemorrhage (11%) and 2 patients required transfusion for hypotension (2%) giving an overall blood transfusion rate of 13%. The median number of units transfused was 3.5 units with an interquartile range (IQR) of 2-4.75 units. Median number of days until trial of voiding was 2 days (IQR 2-3 days). Median number of days until discharge from hospital was 5 (IQR 3-7 days).  cialis super active

The short-term complications, outcome of trial of voiding and long-term complications are summarised in Tables 1,2 and 3, respectively. Only 6 patients were lost to follow-up. Of the remaining 84 patients, 67 patients (80%) were defined as having had a subjectively good outcome whereas 17 patients (20%) were subjectively dissatisfied.
No deaths occurred within 3 months of surgery. cialis professional canada

Table 1 Summary of early complications; 41 complications in total of 36 patients (early complication rate = 39%)
Early complications                                        n (%)

Urological 27
Haemorrhage 10 (11)
Clot retention 5(5)
Incontinence 3(3)
TUR syndrome 3(3)
Return to theatre 2(2)
Hypotension 2(2)
Persistent haematuria 2(2)
Medical 14
PUO 5(5)
Arrhythmia 3(3)
Chest infection 2(2)
Epileptic fit KD
Confusion KD
Poor mobility KD
GI bleed KD
Total 41

Table 2 Summary of outcome of trial of voiding

TOV First Number (%) 93 (100) Successful (%) 60 (65) Unsuccessful (%) 33 (35) Outcome if unsuccessfu2nd TOV at 1 week 2nd TOV at 6 weeks 17 26
1 week 7 (100) 7 (100)

0(0)

6 weeks 26 (100) 13 (50)

13 (50)

Indwelling catheter CISCRe-do TURP 7 5 1

CISC = clean intermittent self catheterisation; TOV = trial of voiding

Table 3 Summary of late complications; 20 complications in total of 20 patients (late complication rate = 22%)

Late complications

n(%)

Recurrent UTI

4(4)

Haematuria

4(4)

Incontinence

4(4)

Re-do TURP

3(3)

Hydronephrosis

2(2)

Clot retention

KD

Retention

KD

Bladder stone

KD

Total

20

n = Number of patients affected; % = overall complication rate; UTI = urinary tract infection.

Discussion
It is known that men undergoing TURP for retention tend to be older and less fit than those with symptoms, and more men with retention develop in-patient complications. This increased risk may be explained by a worse ASA grade and increased co-morbidity. The association between increasing age and increasing morbidity and mortality for TURP is thus well recognised. Despite the increasing use of pharmacotherapy to manage patients with mild to moderate LUTS, a substantial number of elderly patients are still likely to require TURP either for significant LUTS or urinary retention. The aim of this study was to assess whether TURP is a safe and effective treatment in these patients. Although this was a retrospective study, attention was specifically focused on the indications for surgery, early and late complications and outcome assessed both subjectively and objectively. No attempt was made to subdivide patients with urinary retention into those with acute or chronic retention.

With the increasing use of medical therapy to manage patients with mild to moderate LUTS, one might have expected that the majority of TURPs carried out in this study would be for urinary retention. In fact, although 68% of patients underwent TURP for retention, 31% of patients underwent the procedure for LUTS. These results are similar to the National Prostatectomy Audit and a previous study from the UK by Wyatt et al., but are significantly different from other studies from Germany by Matani et al. and the US by Mebust et al. in which the figures are effectively reversed, with two-thirds of operations carried out for LUTS. These findings may reflect differences in practice and resources in different countries. buy cheap levitra

Although the median number of pre-existing medical conditions was one, nearly 20% of patients had three or more pre-existing medical conditions. However, although the early complication rate for TURP was 39%, only one-third of these complications were purely medical. These results suggest that, although many patients over the age of 80 years undergoing TURP have significant preexisting medical disease, the majority of complications following TURP are related to the surgical procedure itself, rather than the consequence of pre-existing medical conditions. canadian pharmacy generic viagra

Of all patients, 13% required a blood transfusion, a figure that is somewhat higher than reported in previous studies, which range from 6.2-9% This may reflect differences in study populations, since urinary retention (which was present in 68% of our patients) has been shown to be associated with a significantly higher postoperative complication rate.

Forty-one early complications occurred in 36 patients, giving an early complication rate of 39%. The most significant early complication was haemorrhage requiring blood transfusion, which occurred in 11% of all cases but accounted for nearly 25% of all early complications. Our overall early complication rate is nearly half that reported by Wyatt et al. (71%), but higher than the 25.9% reported by Matani et al. and the 22.6% reported by Mebust et al. buy abilify online

Twenty late complications occurred in 20 patients, giving a late complication rate of 22%. Recurrent urinary tract infection, persistent haematuria and incontinence accounted for 60% of all late complications. Once again, our reported complication is significantly higher than the 13.2% late complication rate reported by Matani et al.

Although these findings may reflect differences in surgical care, the likely explanation, at least in part, is that about two-thirds of patients undergoing TURP in our study had urinary retention as opposed to about one-third in the other studies and urinary retention is recognised to be associated with a significantly higher complication rate following TURP.

No patients died within a 30 day postoperative period compared with other reports of mortality ranging from 1.2-2.1%. The absence of any postoperative deaths in this series of elderly patients was slightly surprising; however, it is also re-assuring and maybe a reflection of advances in anaesthetic practice.

In terms of subjective outcome, 80% of all patients were satisfied with the outcome of their operation when discharged from clinic; 20% of patients were dissatisfied with the outcome of their operation. Using the definition of a successful trial of voiding with a low residual volume as an objective measure of outcome, 86% of all patients were able to void satisfactorily following surgery. In the subgroup of 63 patients with retention, 51 (81%) were voiding satisfactorily by 6 weeks.

Conclusions
TURP for LUTS or retention in the over 80-year-old produces an 80% subjective success rate. Around 80% of patients undergoing TURP for urinary retention void successfully within 6 weeks of the operation with a satisfactory postmicturition residual volume. The operation is, however, associated with a significant short-term complication rate of approximately 40% and a long-term complication rate of 22%, although in this series there was no deaths within 30 days of surgery. Clearly, co-morbidity rather than age is generally considered a more reliable predictor of outcome; but, as a whole, we believe that TURP remains a safe and effective treatment for LUTS or retention in the over 80-year-old.

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