The changing practice of transurethral resection of the prostate MJ Young, M Elmussareh, T Morrison, JR Wilson York Teaching Hospital NHS Foundation Trust, UK ABSTRACT INTRODUCTION Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower uri- nary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. The number of TURPs performed has declined signifi- cantly over the last three decades owing to pharmaceutical therapy. TURP data from a single institution for the years 1990, 2000 and 2010 were compared to assess the difference in performance. METHODS A retrospective analysis was undertaken of all patients who underwent TURP between January and December 2010. These findings were compared with historical data for the years 1990 and 2000: 100 sets of case notes were selected ran- domly from each of these years. RESULTS The number of TURPs performed fell from 326 in 1990 to 113 in 2010. The mean age of patients increased from 70.6 years to 74.0 years. There was also a significant increase in the mean ASA grade from 1.9 to 2.3. The most common indi- cation for TURP shifted from LUTS to acute urinary retention. No significant change in operating time was observed. The mean resection weight remained constant (22.95g in 1990, 22.55g in 2000, 20.76g in 2010). A reduction in transfusion rates was observed but there were higher rates of secondary haematuria and bladder neck stenosis. There was an increase from 2% to 11.5% of patients with long-term failure to void following TURP. CONCLUSIONS The number of TURPs performed continues to decline, which could lead to potential training issues. Urinary retention is still by far the most common indication. However, there has been a significant rise in the percentage of men pre- senting for TURP with high pressure chronic retention. The number of patients with bladder dysfunction who either have persis- tent storage LUTS or eventually require long-term catheterisation or intermittent self-catheterisation has increased markedly, which raises the question of what the long-term real life impact of medical therapy is on men with LUTS secondary to benign prostatic hyperplasia who eventually require surgery. KEYWORDS Lower urinary tract symptoms – Benign prostatic hyperplasia – Transurethral resection of the pros- tate – Simulation – Training Accepted 16 October 2017 CORRESPONDENCE TO Matthew Young, E: [email protected] Transurethral resection of the prostate (TURP) has long been the ‘gold standard’ for the management of male patients with lower urinary tract symptoms (LUTS) secon- dary to benign prostatic hyperplasia (BPH). It also has a role in the management of patients with LUTS caused by advanced prostatic malignancy. Despite being considered by many as a ‘bread and but- ter’ urological procedure, TURP may be associated with significant morbidity. Bleeding remains the main complica- tion of the procedure, with transfusion rates ranging from 2.9% to 3.9%. 1,2 Contemporary papers still report bleeding following surgery to be as high as 4.8% for monopolar TURP. 3 Interestingly, a Chinese group discovered an increasing rate of returns to theatre to control bleeding (from 0.4% to 2.7% over a 15-year period). 4 Transurethral resection syndrome is also a well recog- nised complication, some theorists noting an incidence of 1–2.4%. 1,3,5 Overall failure to void (which is likely to be secondary to detrusor failure) is reported to occur in 5.8– 6.5% of cases. 1,2 Historically, procedural mortality has been quoted as 0.23% 2 but over the last two decades, large scale series have had mortality rates of 0–0.1%. 1,6,7 The technol- ogy used in TURP has improved, with bipolar technology being increasingly advocated owing to a reduction in com- plications and similar efficacy to monopolar surgery. 8 In an attempt to delay or avoid TURP surgery and its complications, alternative pharmacological treatments (eg 5a-reductase inhibitors and a 1 -adrenergic receptor antago- nists) have become increasingly popular over the last 20– 30 years. The development of less invasive surgical proce- dures such as transurethral needle ablation, transurethral microwave thermotherapy and high intensity focused ultra- sonography failed to replace the classic monopolar TURP owing to poorer patient outcomes. 9,10 During the last 326 Ann R Coll Surg Engl 2018; 100: 326–329 UROLOGY Ann R Coll Surg Engl 2018; 100: 326–329 doi 10.1308/rcsann.2018.0054
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