Oxybutynin in the treatment of early detrusor instability after transurethral resection of the prostate

OBJECTIVE: To evaluate the symptomatic and urodynamic effects of oxybutynin in the control of irritative micturitional symptoms during the first week after transurethral resection of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Fifty-three patients (median age 67 years, interquartile range 62-72) were included prospectively in a double-blind placebo-controlled study. Pre-operatively, uroflowmetry and cystometrography (CMG) were performed, and the post-void residual volume (PVR) measured; symptoms were rated according to the Boyarski score. CMG was repeated on the first post-operative day and medication was started on the third day. Before withdrawing the catheter on the fifth day. CMG was repeated. Three days later, symptoms were evaluated according to the Boyarski score and uroflowmetry and the estimate of PVR reassessed. RESULTS: In comparison with placebo, oxybutynin significantly decreased frequency, urgency and detrusor pressure at first sensation of filling. However, oxybutynin did not lower the rate of pre-operative detrusor instability and exerted no effect on the maximal capacity of the bladder and corresponding detrusor pressure. Dryness of mouth was reported in 13% and 65% of patients receiving placebo and oxybutynin, respectively. CONCLUSION: Oxybutynin alleviates early irritative symptoms after transurethral resection of BPH, without consistently modifying bladder urodynamics.     

Blood loss during transurethral resection of the prostate

Measurement of the perioperative blood loss during transurethral resection of the prostate was performed using the modern HemoCue photometer in 100 men. The measurement lasts only 5-10 minutes. The median weight of the removed prostate was 28 grams and the operating time 60 minutes. The median blood loss was 393 ml (range 8-1843 ml) and was positively correlated to operating time, change in the peroperative blood pressure, volume of the irrigating fluid and the drop in the postoperative serum sodium. Perioperative measurements of the blood loss draw the surgeons' attention to the haemostasis, provide an objective measure of the most important factor for morbidity during TURP and allow a rational policy for blood transfusion. It is an advantage to place this measurement in the hands of professionals, i.e. laboratory technicians, who are trained to quality-secure the measurement and preserve the photometer.     

Long-term results following transurethral resection of the prostate

Concentrations of neopterin, which is produced by human monocytes/macrophages upon stimulation by interferon-gamma, were measured in urine specimens in 23 patients with squamous-cell carcinoma of the oral cavity at diagnosis and in 12 treated patients with the same disease when recurrence of the tumor was recognized. Tumor histology and routine laboratory parameters were concomitantly determined. Urinary neopterin values showed no statistically significant correlation with tumor differentiation, tumor size or patient age, but they were significantly higher in patients with a recurrent tumor. Patients were followed for up to 4 years, and the ability of all variables to predict fatal outcome was assessed. In univariate analysis, only neopterin (p = 0.01) and the variable recurrent vs. first-diagnosed tumor were significant predictors of survival. In multivariate analysis, a combination of neopterin (p < 0.01) and the variable recurrent vs. first-diagnosed tumor (p = 0.06) was found to jointly predict survival. Thus, urinary neopterin concentrations provide valuable prognostic information in patients with squamous-cell carcinoma of the oral cavity.     

Catheter-free same day surgery transurethral resection of the prostate

PURPOSE: Transurethral resection of the prostate using electrocautery has long been the standard method of management of lower urinary tract obstructive symptoms. While there has been a trend towards reduced catheterization time following transurethral prostatic resection, this study outlines the methods and results of transurethral prostatic resection performed in the day surgery setting. MATERIALS AND METHODS: The study was performed at a free-standing licensed day surgical hospital serving a patient population of more than 150,000. A total of 58 patients of a mean age of 68.77 years (range 49 to 87) underwent same day conventional transurethral prostatic resection. Of the procedures 39 (67%) were performed with spinal and the remainder with general anesthesia. RESULTS: Mean overall duration of catheterization was 6.54 hours. Of the 48 patients (82.76%) undergoing single catheterization mean duration was 5.59 hours. Mean total duration of catheterization for 10 patients (17.24%) who required reinsertion of a catheter was 11.09 hours. Duration of catheterization was 7.69 hours for patients treated with spinal and 3.86 for those treated with general anesthesia. Repeat catheterization was required in 10 patients and was due to urethral discomfort in initiating micturition in 8. Postoperative urinary tract infections occurred in 2 patients. No patient was readmitted to the hospital for retention of urine but 1 was admitted to a private hospital for management of postoperative fever and 1 for monitoring of tachycardia. CONCLUSIONS: Conventional transurethral resection of the prostate can be effectively managed in the day surgery setting with minimal morbidity. There are significant advantages in reduction of catheterization time and duration of hospital stay, and the procedure compares favorably with new modalities.     

Care of the patient undergoing transurethral resection of the prostate

Transurethral resection of the prostate (TURP) for benign prostatic hypertrophy is a common surgical procedure in the United States. Left untreated, benign prostatic hypertrophy can lead to detrimental consequences such as renal failure from urinary obstruction. Although TURP is a common procedure, it is not without risk. Complications can occur, and the perianesthesia nurse must be familiar with them and their treatment. Complications related to the surgical procedure and the anesthesia technique must be assessed and treated quickly to prevent morbidity and mortality in these patients. The perianesthesia nurse is instrumental in managing and preventing complications associated with transurethral resection of the prostate.     

Testing to predict outcome after transurethral resection of the prostate

PURPOSE: We assessed the ability of routine clinical tests to predict outcome following transurethral resection of the prostate. MATERIALS AND METHODS: A total of 556 men randomized into a trial of surgery versus watchful waiting was evaluated preoperatively with symptom interview, quality of life assessment, uroflowmetry, urinalysis, standard chemistry panel, post-void residual urine determination and cystoscopy. The ability to predict avoidance of postoperative complications, and improvement in quality of life and genitourinary symptoms was assessed in the 249 men randomized to undergo transurethral resection of the prostate. RESULTS: Patients with the highest symptom scores were most likely to have symptom improvement and those most bothered by the symptoms were most likely to have improvement in quality of life. No objective tests measuring physiological parameters made clinically significant contributions toward predicting these outcomes. Lower obstructive symptom scores and larger perioperative infusions of intravenous fluids were associated with a greater chance of complications. CONCLUSIONS: Symptom analysis and quality of life assessment are most useful in selecting patients for transurethral resection of the prostate. Objective diagnostic tests are of limited additional benefit.     

A cost-effectiveness analysis of transurethral resection of the prostate and transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia: two-year follow-up

The clinical course and prognosis of ulcerative colitis was studied in a group of 413 Greek patients. The study lasted for 16 years and follow-up was achieved in 95% of the patients. Both sexes were almost equally affected, mainly between the ages of 40-49. Most of the patients lived in cities and had high educational levels. Familial clustering for inflammatory bowel disease was found in 2.7% of the patients. In most of them the disease was confined to the rectosigmoid area or left bowel and was of mild to moderate severity. The disease course included exacerbations--mainly of mild to moderate severity--and remissions. Mortality was absent during first attack, and it was generally low at the completion of the study. Excluding deaths caused by colorectal cancer, most of the deaths were unrelated to the ulcerative colitis itself. Unusual combinations of ulcerative colitis with other diseases, including diseases of autoimmune origin, were noted. There were no differences between men and women in the various clinicoepidemiologic parameters or in the course of the disease. Surgery was performed in 16.7% of patients, whereas surgery at first attack was required in 0.5%. In comparison with the nonoperated group, patients who were operated on were significantly younger at the time of onset of symptoms and had significantly more extensive disease. Factors prognostic of severe attacks and colectomy were extensive disease, young age at onset, and severe recurrences. Evolution to cancer was observed in 1.45%, whereas extraintestinal cancers also appeared in 1.5%. At the completion of the follow-up period, 5.8% of the patients were dead, 16% had only one attack, 2.7% experienced continuous symptoms, whereas in 58.8% of them, the disease course included exacerbations and remissions. On the basis of the outcome of severe attacks and the more favorable short-term prognosis, it could be argued that ulcerative colitis in Greece runs a milder course compared with that of other developed countries in Western Europe and North America.     

Study on the duration of pyuria after transurethral resection of prostate

Recent Canadian, American and European studies have reported increased ampicillin and trimethoprim/sulfamethoxazole resistance among urinary tract isolates of Escherichia coli. This trend suggests that a reevaluation of first- and second-line therapies for the treatment of community-acquired urinary tract infections is necessary. Mecillinam, a beta-lactam with preferential activity against gram-negative penicillin binding protein 2 (unlike other beta-lactams which preferentially bind gram-negative penicillin binding proteins 1a, 1b or 3), may offer clinically significant activity against ampicillin-resistant and trimethoprim/sulfamethoxazole-resistant E. coli. To test this assertion, the activity of mecillinam was compared with ampicillin, trimethoprim/sulfamethoxazole, nitrofurantoin and ciprofloxacin against 258 consecutive gram-negative urinary tract isolates collected at a Canadian tertiary care hospital. Mecillinam demonstrated significantly better activity than ampicillin and trimethoprim/sulfamethoxazole and significantly less activity than ciprofloxacin and nitrofurantoin against the 258 isolates tested. Against E. coli isolates specifically, mecillinam was significantly more active than ampicillin and trimethoprim/sulfamethoxazole (p < 0. 001) and as active as ciprofloxacin and nitrofurantoin. Mecillinam was active against 91.9% of ampicillin-resistant E. coli and 95.9% of trimethoprim/sulfamethoxazole-resistant E. coli. We conclude that mecillinam should be reevaluated for potential use in the treatment of community-acquired urinary tract infections.     

Electrovaporization as a treatment modality for transurethral resection of the prostate: influence of generator type

OBJECTIVES: To study the influence of the electrosurgical generator on the vaporization efficacy during electrovaporization (EVAP) using different vaporization elements. METHODS: Electrical properties of human prostatic (in vivo) and bovine myocardium (in vitro) tissue were measured under electroresection and electrovaporization conditions. The effective output power of four different generators ("old generation" Force 4 and Force 40 and "new generation" Force 300 and Force FX) was measured at different impedance loads. In vitro, the coagulation and vaporization capabilities of the electrosurgical generators in combination with resection and vaporization elements were studied on homogeneous tissue (bovine myocardium). RESULTS: The electrical impedance of human prostatic tissue and bovine myocardium increases from 400 to 1000 ohms when coagulated. The effective output power of the old generation electrosurgical devices depends strongly on tissue impedance. This implies that working on already coagulated tissue using such devices is not well controlled and not reproducible. By contrast, new generation electrosurgical devices correct for the higher impedance of coagulated tissue, thus delivering constant output power and corresponding tissue effects. CONCLUSIONS: For an effective application of the EVAP technique, the use of a new generation impedance independent electrosurgical unit is highly recommended.     

The role of repeat transurethral resection in stage A1 carcinoma of the prostate

In order to evaluate the significance of repeat transurethral resection (TUR) in differentiating stage A1 prostatic adenocarcinoma from those with stage A2, we performed repeat TUR in 34 patients with an initial diagnosis of stage A1 prostatic adenocarcinoma. It was found that residual adenocarcinoma was present in five cases (14.7%), but the diagnosis was changed from stage A1 to stage A2 in only one case (2.9%). In one patient with final diagnosis of stage A1 carcinoma, bone metastases were detected seven months after the repeat TUR. It was concluded that repeat TUR for stage A1 prostatic adenocarcinoma did not yield clinically significant information.     

Urethral stricture following transurethral resection of the prostate. The role of local anaesthetics

In a multicentre prospective study, 261 patients undergoing transurethral resection of the prostate (TURP) in 17 urology departments were randomised to receive lubricating jelly containing either 3% tetracaine hydrochloride, 1% lignocaine hydrochloride, or no local anaesthetic. No patient had a history of urethral instrumentation or a previous urethral stricture. After 6 months' follow-up, 25/79 patients (32%) treated with 3% tetracaine jelly developed urethral strictures, as did 4/92 patients (4%) who received 1% lignocaine and 2/90 (2%) who received the jelly without anaesthetic. It was concluded that the use of 3% tetracaine jelly is associated with a high incidence of post-TURP urethral strictures.     

Failure to void after transurethral resection of the prostate and mode of presentation

OBJECTIVES: Contemporary audits and reviews of outcome after transurethral resection of the prostate (TURP) make little reference to failure to void following catheter removal after this operation. There have been few reports of the likelihood of a successful trial without a catheter after TURP related to mode of presentation. We report the results of a retrospective review of outcome of TURP related to mode of presentation, age, and prostate histologic findings in a consecutive series of patients in a London Teaching Hospital. METHODS: A consecutive series of 379 patients (381 TURPs) was reviewed to document the incidence of and risk factors for failure to void following initial trial without a catheter after TURP. RESULTS: Twelve percent of men failed to void after TURP on the initial trial without a catheter. In those patients presenting with lower urinary tract symptoms, there were no instances of failure to void. Ten percent of patients with acute retention (painful inability to void, urine volume less than 800 mL), 38% with chronic retention (maintenance of spontaneous voiding, bladder volume greater than 500 mL), and 44% with acute on chronic retention (painful retention, urine volume greater than 800 mL) failed to void after TURP. Only 1% of patients required management by long-term catheterization. Failure to void on catheter removal was not related to age or prostate histologic findings. CONCLUSIONS: Bladder volume at initial presentation in patients with urinary retention provides important information about the likelihood of re-establishing spontaneous voiding catheter removal following TURP. Patients should be warned that there is a significant chance of failure to void after TURP, the exact risk depending on their mode of presentation, but that most will ultimately not require a permanent indwelling catheter.     

Transurethral needle ablation of the prostate: a minimally invasive treatment for symptomatic benign prostatic hyperplasia

Transurethral needle ablation of the prostate, a relatively new minimally invasive treatment modality for patients with bladder outlet obstruction attributable to an enlarged prostate gland, has undergone extensive evaluation by numerous investigators worldwide. The results to date indicate that needle ablation is safe and effective for relieving symptoms in patients with benign prostatic hyperplasia, and the effect has been demonstrated to be durable for at least 2 years. Nevertheless, additional investigations with longer follow-up data are needed to address the important issues of extended durability (5 to 10 years) and biophysiologic mechanism of action. Comparisons between transurethral needle ablation of the prostate and transurethral resection of the prostate (TURP) have revealed that the subjective and objective measures of response are comparable, although TURP has consistently displayed a slight advantage over needle ablation for most variables analyzed, except quality of life score. The advantages of needle ablation over TURP are (1) performance in the office as an outpatient procedure, (2) no need for general or spinal anesthesia, (3) rapid recovery, (4) minimal side effects, and (5) one-time intervention. The following disadvantages exist with needle ablation: (1) it may not be indicated or effective in patients with large prostate glands (75 g or more); (2) no prostate tissue is available for histologic evaluation; and (3) no long-term efficacy or re-treatment rate data have been published. Overall, the available information indicates that transurethral needle ablation is a viable minimally invasive treatment that may be applicable in men with moderate to severe bladder outlet obstruction as a result of an enlarged prostate gland.     

Autologous blood retransfusion in transurethral resection of prostate (TURP)]

Blood collected from the irrigation fluid used during TURP was retransfused in 17 patients. Of the 17 patients, 8 cases were also transfused preoperatively reserved blood. The weight of resected adenoma (g), resection time (minutes), the volume of salvaged blood (ml) of 9 cases who were transfused only salvaged autologous blood were 30.6 g, 63 min. and 355 ml, respectively, and those of 8 patients who were given both salvaged and preoperatively reserved autologous blood were 46.1 g, 78 min. and 703 ml, respectively. No patient was transfused homologous blood. Preoperative urine cultures showed contamination of bacteria in 12 cases (70.6%), and the blood concentrated from irrigated fluid was positive for bacteria in 2 cases (11.8%). Blood count (RBC, Hb, Ht) just after TURP, after blood retransfusion, at the next and the 7th day after the operation were compared to those of just before TURP (Blood Count Ratio). The ratio of the 9 cases who received only salvaged blood were 83.5%, 96.8%, 90.9%, 85.2% each and the ratio of the 8 cases who were transfused both salvaged and preserved blood were 86.9%, 102.6%, 101.4%, 97.5% each. There were no adverse effects due to the autologous blood retransfusion. Conclusion: Retransfusion of salvaged autologous blood from the irrigating fluid of TURP was clinically safe and effective. No homologous blood was transfused in TURP when salvaged autologous blood with or without preserved blood was retransfused to the patient.     

Objective and subjective comparison of transurethral resection, transurethral incision and balloon dilatation of the prostate. A prospective study

Anastrozole is a comparatively simple, achiral benzyltriazole derivative, 2,2'-[5-(1H-1,2,4-triazol-1-ylmethyl)-1,3-phenylene]bis(2-++ +methylpropiononitrile), that inhibits human placental aromatase with an IC50 of 15 nM and elicits maximal activity in vivo in rats (inhibition of ovulation and androstenedione-induced uterine hypertrophy) and monkeys (lowering of plasma oestradiol) at 0.1 mg/kg p.o. At 30 times this dose, anastrozole does not elevate plasma 11-deoxycorticosterone in monkeys, and at 100 times this dose, does not affect plasma aldosterone levels or Na+/K+ excretion in rats, plasma K+ concentrations in dogs, or cause adrenal hypertrophy in rats or dogs. It therefore has no discernible effect on adrenocorticoid hormone synthesis in vivo at very large multiples of its maximally effective aromatase-inhibiting dose. At similar large multiples in rats it displays no oestrogenic, anti-oestrogenic, androgenic, anti-androgenic, progestogenic, glucocorticoid, antiglucocorticoid or mineralocorticoid activity. Anastrozole is thus a potent and highly selective aromatase inhibitor, with no intrinsic hormonal activities--a pharmacological profile particularly suitable for the treatment of breast cancer.     

A comparison of transurethral resection of the prostate and medical treatment for the patient with moderate symptoms of benign prostatic hyperplasia

Transurethral resection of the prostate is the most common surgical treatment for benign prostatic hyperplasia. We conducted a prospective randomized clinical trial to compare this surgery with medical treatment in men with moderate symptoms of benign prostatic hyperplasia. Of 98 men over the age of 54 years who were screened between June 1993 and June 1995, 53 were studied (25 in the surgery group and 28 in the medication group). Patients' symptoms and the degree to which they were bothered by urinary difficulties were measured with standardized questionnaires and medical evaluations. The men randomly assigned to the surgery group underwent surgery within 2 weeks after the assignment. Surgery was not associated with an impotence or urinary incontinence. The follow-up period was 1 year. Surgery was significantly associated with improvement in residual urinary volume and peak flow rate; and also in the scores for urinary difficulties, sexual performance and interference with activities of daily living (P < 0.001 for all comparisons). We concluded that for patients with moderate symptoms of benign prostatic hyperplasia, surgery is more effective than medication in improving genitourinary symptoms and enhancing the quality of life. Thus, medication as treatment should be reserved for patients who are less bothered by urinary difficulty or who wish to delay surgery.     

Evaluation of blood loss and absorption of irrigating fluid in transurethral resection of the prostate

A questionnaire was sent to all Danish departments performing transurethral resection of the prostate (TUR-P) concerning the use of irrigating fluids and methods to estimate peroperative blood loss and absorption of irrigating fluid. Fifty-six of 60 departments used glycine as an irrigant. Seventeen percent of the departments measured blood loss peroperatively (HemoCue). Only two departments (3%) measured absorption of irrigating fluid quantitatively by the expired breath ethanol method. The other departments estimated blood loss and absorption of irrigant from the colour of the irrigating fluid. From studies of the literature we suggest the use of sorbitol/mannitol as irrigating fluid instead of glycine, as this may have fewer adverse effects, and we recommend quantitative measurements of blood loss and absorption of irrigating fluid to minimise the potentially dangerous consequences of TUR-P.