Outcome of 500 cases of transurethral resection of Prostate ( TURP ) in District level teaching Hospital

Type of Study: This is a prospective study in a district level teaching from 1sr march 2003 to December 2008. The sample size was n – 500. All Patients were evaluated with history, clinical examination and allied investigations. As per selection criteria we did TURP and each patient was followed up to six months. Purpose & Importance of TURP: It has been established that open prostatectomy has got higher morbidity than that of transurethral resection of prostate (TURP). The shorter hospital stay, early institution to working place, minimum blood loss, and acceptable financial involvement makes it excellent patient’s compliance. Method: The prospective studies include n – 500 cases of LUTS predominately obstructive voiding symptoms. After evaluation & fulfilling the selection criteria standard TURP were done in all cases. Result: The mean Q max improved in n – 476 cases (from 6.68 ml/ sec. to 17.47ml/second) in early post-operative period. Among others most of the cases improved within 06 months. Some of the cases (0.25%) needs secondary procedure for late complications like stricture urethra. Erectile dysfunction was not a major problem in our series. Death noticed in two cases in post operative ward due to cardiogenic shock. Conclusion: The outcome of the present study has been compared with other studies and it appears that TURP is an excellent minimally invasive procedure for the management of symptomatic BPH. Key Word: Benign hyperplasia of Prostate, TURP, Complications. Introduction The prostate is a male organ which most likely to be enlarged with the progression of age. Histopathologic evidence of BPH is present in approximately 8% of men in their fourth decade and in 90% of men by their ninth decade. In other studies it was concluded that BPH is first detectable around the fourth decade of life and nearly all men by the ninth decade. In the Olmsted county longitudinal study, it was very clearly observed that the progression of BPH is related to age. There was an average increase in the International Prostate Symptom Score (IPSS) of 0.18 points per year, ranging from 0.05 for men in their fifties to 0.44 for those in their seventies. There was also a decrease in peak flow rate of 2% per year and a median prostate growth of 1.9% per year. Symptom worsening is the most common sign of progression. Identifying those patients at risk of BPH progression is crucial to optimize their management3. However BPH may not produce any symptom unless it causes any obstruction to outflow of urine. For many decades (1909 until the late 1990s), transurethral resection of the prostate (TURP) has been considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) and its related complication. Despite the efficacy and safety of pharmacotherapy, the surgical management of BPH is still recommended when medical therapy fails. The aims and objectives of TURP over open surgery are designed to decrease blood loss, reduce hospital stay and other complications. After 1990 various newer techniques6 are being introduced some of which are unique but costly; transurethral vaporization of the prostate (TUVP), bipolar TURP, photoselective vaporization of the prostate (PVP), Electro vaporization of the prostate and holmium laser enucleation etc. Laser enucleation of prostate is more costly and morbidity may be lower but the overall outcome is comparable to TURP. 1. Md. Zohirul Islam Miah, MS (Urology), Associate Professor, Department of Urology, Diabetic Association Medical College, Faridpur. 2. Zahid Hassan Bhuiyan, FCPS (Surgery) MS (Urology) Professor (CC) Department of Urology, Bangladesh Medical College, Dhaka. Corresponds to: Dr. Md. Zohirul Islam Miah, MBBS, MS (Urology), Associate Professor, Department of Urology, Diabetic Association Medical College, Faridpur. E-mail: dr.zohirul@yahoo.com Bangladesh Journal of Medical Science Vol. 12 No. 02 April’13


Introduction
The prostate is a male organ which most likely to be enlarged with the progression of age.Histopathologic evidence of BPH is present in approximately 8% of men in their fourth decade and in 90% of men by their ninth decade 1 .In other studies it was concluded that BPH is first detectable around the fourth decade of life and nearly all men by the ninth decade 2 .In the Olmsted county longitudinal study, it was very clearly observed that the progression of BPH is related to age.There was an average increase in the International Prostate Symptom Score (IPSS) of 0.18 points per year, ranging from 0.05 for men in their fifties to 0.44 for those in their seventies.There was also a decrease in peak flow rate of 2% per year and a median prostate growth of 1.9% per year.Symptom worsening is the most common sign of progression.Identifying those patients at risk of BPH progression is crucial to optimize their man-agement3.However BPH may not produce any symptom unless it causes any obstruction to outflow of urine 4 .For many decades (1909 until the late 1990s), transurethral resection of the prostate (TURP) has been considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) and its related complication.Despite the efficacy and safety of pharmacotherapy, the surgical management of BPH is still recommended when medical therapy fails 5 .The aims and objectives of TURP over open surgery are designed to decrease blood loss, reduce hospital stay and other complications.After 1990 various newer techniques6 are being introduced some of which are unique but costly; transurethral vaporization of the prostate (TUVP), bipolar TURP, photoselective vaporization of the prostate (PVP), Electro vaporization of the prostate 7 and holmium laser enucleation 8 etc. Laser enucleation of prostate is more costly and morbidity may be lower but the overall outcome is comparable to TURP.Mean Pre-operative PVR was 289.95 ml and post operative PVR was significantly improved to 15.31ml (Table II).Pair t test was done and showed the difference was statistically significant (p value was < 0.001 ).Mean pre -operative Q max was 6.68 ml/ sec.and postoperative Q max was improved to 17.47ml/sec...Pair t test was done and showed the difference was statistically significant (p value was < 0.001) In n -22 (4.40%) cases mean Q max was <10ml/sec and there was no noticeable improvement (Table I).Deaths due to acute MI in first post -operative day in n -02 (0.4%) cases; though the preoperative blood pressure and ECG was unremarkable.However there may be pre existing silent ischemic heart disease; leading to acute MI.III) noticed in n -20 (4.0%) cases immediately after removal of catheter.Reassurance and perineal exercise (Kegel exercises) adopted.Incontinence improved in n -15 cases within 03 months.Rest of the cases (n -05, 01%) were managed by use of pads and referred for further work -up and management.Post operative urethral stricture was noticed in n -07 (1.40%) cases.Of them n -03 was (0.6%) in bulber urethra and n -04 (0.8%) was in the navicular fossa.Bulbar urethral stricture was managed by optical internal urethrotomy and stricture at navicular fossa was managed by OMG substitution meatoplasty.In n -03 (0.6%) cases bladder neck contracture which was noticed, managed by bladder neck incision (BNI) with Collin's knife.Erectile dysfunction was noticed in n -52 cases initially which improved with time in n -40 cases.In rest of the cases has given the options various treatment were but response was not remarkable may be due elderly aged patients or lack of sexual interest.

Disscussion
TURP was the first successful, minimally invasive transurethral surgical procedure which stands with time.Till 1990; the only standard endoscopic procedure for symptomatic BPH was TURP 13 when medical therapy fails or inadequate 14 .
The relative frequency of TURP compared to open prostatectomy varies from country to country.In 1990, the relative frequency rate of TURPs in United States was 97%, with similar rates in Denmark and Sweden.The lower rate of TURP were noted in Japan (70%) and France (69%) 1 .Various other minimally invasive procedures are available including laser ablation of prostate.But still TURP is a good choice throughout the world for its efficacy and cost benefit effect 14.In our series we use spinal anaesthesia in all of our cases although general or epidural anaesthesia are other options.In a large national survey in 13  Symptom score and flow rate improvement with TURP is superior or comparable to that of any minimally invasive therapy 16.The degree of outflow obstruction is closely related to the increasing amount of PVR.Barry and colleagues found a significant correlation between high PVR and low flow rate 17..But in our study two patients (0.4%) were died due to acute MI though per-operative cardiac status was good but there may be silent coronary diseases.
Once it was the belief that TURP is intimately related to erectile dysfunction in some of the cases.These studies were based on relatively poor evidence from uncontrolled studies; published prior to 1994.It is now observed that the effect of TURP on erectile dysfunction is controversial.In 1995 VA Cooperative Study comparing the outcomes of TURP and watchful waiting in 556 men with moderate LUTS 21 .In this study, TURP was not associated with changes in sexual performance immediately.At the end of the 3-year of the study it was observed that 19% of patients in the surgery group and 21% of those in the watchful waiting group reported that their sexual performance was worse, while 3% in each group reported that it was improved.In general, the spouses thought that the patients' sexual performance was unaffected over the course of the study.Many authors have carefully analyzed sexual function before and after either minimally invasive treatments for patients with BPH or surgical resection of benign enlarged prostates.In the majority of the cases, sexual function was affected at least in a small cohort.It appeared safe to assume erectile dysfunction would not follow a TURP as estimated originally but some patients may have deterioration of sexual function following intervention 22 .In our series we have no control group in this regard.Erectile dysfunction noticed in n -52 (10.40%) cases initially which improved with time in n -40 (08%) cases.In rest of the cases we have offered the options of medical and other management but they were not interested to receive the treatment may be due older age or unresponsiveness of their spouse.
In various studies about 1% of the patient may notice incontinence 23 after TURP and this is consistent to the present study (n -05, 01%).In different studies 2% of patients may develop iatrogenic urethral stricture diseases; may be related to narrow urethra or longer resection time 23 .In this study the 1.4% patients developed post TURP stricture urethra; consistent to reference international studies.In reviewing the literature, the AHCPR guideline panel used Meta analysis to combine the various clinical studies, They noted that the chance of improvement of patient symptoms following a TURP was 70% to 96% with a mean confidence interval (CI) of 88% 24 .
In this study the rate of improvement is 95.20%.
The overall outcome in terms of patient's satisfaction and complications are comparable with other international studies (Table IV).However longer follow -up may preclude the efficacy of the procedure in the present set up.

Conclusions
Transurethral resection of the prostate is considered as one of the best effective minimally invasive treatment for BPH.Here the morbidity and mortality is less than that of open prostatectomy.It is costeffective and the hospital stay is short.Other minimally invasive options like laser enucleation etc are costly but the final outcome is comparable to TURP.In any case careful case selection is the primary factor will influence the outcome.In doubtful cases; urodynamic study is extremely helpful for proper selection of cases.
Commonly used irrigation fluid was 1.5 % glycine.A 20 -22 Fr. foly trichannel catheter (BARD) was used at the end of the procedure.Normal saline irrigation was started immediately.A gentle traction to catheter was maintained up to 06 to 24 hours.
Zahid Hassan Bhuiyan, FCPS (Surgery) MS (Urology) Professor (CC) Department of Urology, Bangladesh Medical College, Dhaka.Corresponds to: Dr. Md.Zohirul Islam Miah, MBBS, MS (Urology), Associate Professor, Department of Urology, Diabetic Association Medical College, Faridpur.E-mail: dr.zohirul@yahoo.comInvestigationssuchasurinalysis,cultureand sensitivity (C/S), complete blood count, fasting blood sugar, creatinine, LFT (liver function test), prostate specific antigen (PSA), ultrasonogram of the kidney, ureter bladder (KUB) prostate with PVR, uroflowmetry, chest X -ray and electrocardiogram.Patients with mild to moderately enlarged and fibrous prostate, predominately obstructive voiding symptom, bothersome IPSS score mild(8-19)to moderate (20-30), Q max less than 10 ml/sec in uroflowmetry and PVR more than 100ml were included in the study.Patient with hugely enlarged prostate, high PSA, suspicious DRE finding (malignancy), having associated symptomatic bladder diverticulum or a big hard bladder calculus, unilateral and bilateral inguinal hernia was excluded from the study.All patients were evaluated cystoscopically and standard TURP was done under spinal anaesthesia.The mean operating time was 31 + SD 3.5 minute.A total 500 patients were selected for TURP.The age range was 42 -96 years, mean 70.96 (TableI).Significant improvement of symptoms following TURP was noticed in n -476 (95.20%) patients.

Table - III shows Overall outcome (n -500)
After TURP, PVR improved in majority of the patients up to 20.10 + (SD) 13.80 ml.Only in 22 patients PVR was more than 90 ml.So it is clearly evident that TURP improved PVR significantly.Uroflowmetry is the electronic recording of the urinary flow rate throughout the course of micturation.