- Email: [email protected]
592How complete should be transurethral resection of the prostate?
589 I N T R A P R O S T A T I C B O T O X - AN I N J E C T I O N IN P A T I E N T S W I T H SEVERE BENIGN PROSTATIC HYPERPLASIA. A MULTICENTER STUDY
590 CATHETER FREE TECHNIQUE
SUPRAPUBIC
PROSTATECTOMY,
A
NOVEL
Djaladat H., Mehrsai A., Pourmand G., Saraji A., Moosavi S., Nasseh H. Ouerciui F?, Giaunantoni A. I , Bard R.L. 2, Brisinda G. 3, Cadeddu F.3, Maria 0. 3, Rosi P?, Paioncini C.~, Porena M. 1 tUniversity of Perugia, Urology, Perugia, Italy, 2University of New York, Radiology, New York, United States, 3Catholic University of Rome, Surgery, Rome, Italy INTRODUCTION & OBJECTIVES: Botulinum toxin (BTX-A) blocks acetylcholine release at the neuromuscular junction and in autonomic neurons. It has been widely used to treat patients with dystania, pelvic floor disorders, and gustatory or axillary sweating. In patients with voiding dysfnnction, weakening of the urethral sphincter muscle by BTX injection is followed by symptoms improvement. BTX-A injection into the rat prostate induces selective denervation and subsequent atrophy. Recently, inta'aprostatic BTX-A has been reported to be efficacious in men with moderate voiding obstruction mad medium sized prostates. Given this background, the present study was designed to determine the effects of BTX-A intraprostatie injection in patients with severe benign prostatic hyperplasia (BPH). MATERIAL & METHODS: 16 Patients were recruited to the study which was approved by the Perugia University Ethics Committee. Inclusion criteria were prostatic volume >80cc and urinary peak flow ranging from 10 to 0 ml/sec (with indwelling catheters). The only exclusion criterion was presence of neurogenic bladder disorders. Patients underwent DRE, TRUS with uroflowetry and PSAt evaluation. Symptoms were assessed by the AUA -IPSS score. Each patient received an intraprostatic ultrasound-guided injection of 150 U of BTX-A in a saline solution into each lobe. Patients underwent the same baseline evaluations after 1, 2 and 6 months' follow-up. Data were analysed using the maalysis ofvarimace for repeated measures. RESULTS: The mean age of patients was 68.8 years (range: 56-90). All patients had BPH except for one who had low grade adenocarcinoma (not considered in PSAt evaluation). At the beginning of the treatment 3 patients had indwelling catheters.
1 month
2 months
6 months
P
IPSS
IBaseline 24
13
11
9
0.002
Prostate weight (gr.)
106
65
53
53
0.000
PSAt (ngr/ml) Flow Max (ml/sec) Residual urine (ml)
9.5 8.2 295
6.8 15.4 106
2.5 17.9 96
2.5 18.1 85
0.05 0.05 0.05
CONCLUSIONS: We consider intraprostatic BTX-A injection as a mutually exclusive alternative to surgery in high grade voiding dysfunction for BPH or cancer, particularly in patients at risk.
Urology Research Center, Tehran University of Medical Sciences, Dept. of Urology, Tehran, Iran I N T R O D U C T I O N & O B J E C T I V E S : To evaluate postoperative morbidity and technical complications of a new procedure, urethral catheter free suprapubic prostatectomy. M A T E R I A L & M E T H O D S : This pilot study composed of 20 patients. Their mean age was 70 years, mean International Prostatic Symptom Score (IPSS) 32 and mean m a x i m u m flow rate (Qmax) 3.7 ml/sec. None of them had significant medical co morbidity. Patients were admitted to' hospital the day before operation and underwent modified suprapubie prostatectomy under spinal anaesthesia without urethral catheter, but a hand made cystostomy. Mean prostate adenoma weight was 48 grams. Postoperatively all the patients were treated like those underwent standard suprapubic prostatectomy. First 24-hr. drain collection, episode of clot retention, irritative symptoms, time elapsed to empty the balloon of catheter, voiding status after cystostomy removal and incontinence were evaluated postoperatively. Three months later, we followed the patients with IPSS, Qmaxand cystoscopic examination (to rule out stricture formation). Data were analyzed with SPSS-10. All the patients were informed and consented regarding the new technique. R E S U L T S : The mean first 24-hr. drain leakage was 162 ml. Postoperatively none of the patients complained of significant irritative urinary symptoms, clot retention and true or stress urinary incontinence, although some had temporary urge incontinence for the first few days. There was no report of urinary tract infection (UTI) or epididymoorchitis. One patient developed urinary retention after cystostomy removal that was treated with intermittent catheterization, as there was no bladder neck or urethral stricture. Three months after operation, mean IPSS and Qmax were 3.8 and 21.5 ml/sec respectively. There was no bladder neck or urethral stricture on cystoscopic examination. C O N C L U S I O N S : Transurethral resection o f prostate (TUR-P) has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia (BPH). However, open adenomectomy has still its own place and being used as a common procedure in some parts of the world. Catheter free suprapubic prostatectomy can be safely applied with low post-operative risk of infection, incontinence or stricture formation.
591
592
IS E A R L Y C A T H E T E R R E M O V A L A N D H O S P I T A L D I S C H A R G E S A F E A N D F E A S I B L E IN A L L C A S E S O F TURP?
HOW COMPLETE THE PROSTATE?
Saeed !,, Saw N., DowneyE
Milonas D., Jievaltas M., Trumbeckas D.
South ManchesterUniversityHospitalTrust, Departmentof MinimallyInvasiveand LaparoscopicUrology, Manchester,UnitedKingdom
University of Medicine, Urology, Kaanas, Lithuania
INTRODUCTION & OBJECTIVES: To determinethe safety and feasibilityof earlycatheterremovaland hospitaldischargein an unselectedgroupof patientsundergoingTURE
INTRODUCTION & OBJECTIVES: The aim of this study was to establish prognostic value of operative parameters as resected tissue weight (RTW), residual prostate weight (RPW) and residual prostatic weight ratio (RPWR) for predicting efficacy after transurethral resection of the prostate (TURP) due to BPH.
MATERIAL & METHODS: We performeda prospectivestudy on an unselectedgroup of 52 consecutive patients undergoingTURP for all indicationsunder the care of one ConsultantUrologist (PD) between October 2003 and August2004. Indicationsfor surgerywere failed medicaltherapy (n 12) or retentionof urine, [acute (~11), chronic (n-18) or acute on-chronic (n=ll)]. TURP was performed with adequate removalof apicaland bladderneck tissue.The catheterwas removedon the first post,operativeday.Patients were dischargedwhen two flow rates and post void residualscanshad been performed. [Flowrate/residuala_ 2] and followedup 1 and 3 months post-operativelywith IPSS/QOLscoring, flow rate and residualvolume assessment[Flowrate/residual3j. RESULTS: 45 of the 52 patientswere dischargedon day 1 post TURP without a catheter. One patientrequiredreadmissionto hospitalprior to plannedreviewwith clot retentionof urine. Assessmentat 1 and 3 monthspost operativelyshowedgood outcomesfollowingsurgery. Failed medicalRx
Acute retention
Chronic retention
SuccessfulTWOC Median flow rate 1 Medianvolumepassed 1 Medianresidual 1
N=I 1 10 140 77
N=10 14 I63 206
N=14 12 216 311
Acute onchronic retention N=10 17 286 170
Median flow rate 2 Medianvolumepassed2 Medianresidual2
16 221 123
11
249 191
11 270 283
21 304 87
1/12 IPSS/QOL Median flow rate 3 Medianvolumepassed 3 Median residual 3
22 234 0
I4 212 55
254 5O
204 19
30 I81
19 249
3 16 235 34
235 44
3/t2 IPSS/QOL Medianflow rate 4 Medianvolumepassed4 Medianresidual4
CONCLUSIONS: Removalof catheterand dischargeon the first day followingTURF'is safe and feasible and may be consideredfor patientsundergoingTURP in the modern era.
European Urology Supplements 4 (2005) No. 3, pp. 150
SHOULD BE TRANSURETHRAL RESECTION OF
M A T E R I A L & METHODS: 102 were involved in this prospective study in Jan 2002 - May 2003. Local ethical committee approved the study. IPSS, QoL, Qmax, total prostate volume (TPV), transition zone volume (TZV), transition zone index (TZI), PSA, postvoid residual volume (PER) were evaluated preoperatively. Inclusion criteria were: written informed consent, age 45-80 years, IPSS >13, Qmax < 15 ml/s, PSA <4 or 4-10ng/ml after negative biopsy of the prostate, PER <300ml. RTW, RPW and RPWR were investigated as operative factors. Follow-up was performed at 6 month after TURP. Efficacy of the surgery was evaluated as changes of post/pre operative IPSS, QoL, Qmax, and TPV. Results were divided into two groups: effective (good + excellent results) treatment and not effective (fair + none results) treatment. Statistical analysis was done by comparison of means with t test. Logistic regression analysis was used for finding valuable operative parameters that could predict treatment efficacy. Differences were considered statistically significant at p<0.05. RESULTS: Final analysis was done using data 90 (of 102) patients. Treatment was effective in 85.6% (excellent - 65.6% and good - 20%) of cases, not effective - in 14.4% (poor - 11.1% and none - 3,3%) of cases. Differences between operative parameters according treatment efficacy (effective vs. not effective) groups were significant (p <0.05) for mean RTW - 24.95 (SD 14.38) vs. 14.85 (SD 12.64), mean RPW - 20.32 (SD 7.42) vs. 27.92 (SD 14.I1) and mean RPWR - 0.49 (SD 0.17) vs. 0.72 (SD 0.11). RPWR with cut off value 0.71, (62% sensitivity, 96% specificity and OR 39.47 (95% CI 7.92-196.76)) had the strongest impact on treatment efficacy as individual parameter. Logistic regression analysis was performed to detect the influence of all operative parameters on treatment efficacy. RPW (cut off 26.6, OR 9.97, p=0.013) and RPWR (cut off 0.71, OR 62.2, p=0.001) had strong prediction when used together. Prognostic power of these factors was 96.1% for predicting positive results and 61.5% for predicting of negative results. Overall prognostic power for detecting correct results was 91.1%. CONCLUSIONS: Resected tissue weight as alone factor had no significant impact on efficacy of the TURP. The most important operative parameter that can predict TURP efficacy was RPWR with cut off value 0.71. At least 29% of total prostate volume should be resected during the TURP in anticipation of effective outcome.
590 CATHETER FREE TECHNIQUE
SUPRAPUBIC
PROSTATECTOMY,
A
NOVEL
Djaladat H., Mehrsai A., Pourmand G., Saraji A., Moosavi S., Nasseh H. Ouerciui F?, Giaunantoni A. I , Bard R.L. 2, Brisinda G. 3, Cadeddu F.3, Maria 0. 3, Rosi P?, Paioncini C.~, Porena M. 1 tUniversity of Perugia, Urology, Perugia, Italy, 2University of New York, Radiology, New York, United States, 3Catholic University of Rome, Surgery, Rome, Italy INTRODUCTION & OBJECTIVES: Botulinum toxin (BTX-A) blocks acetylcholine release at the neuromuscular junction and in autonomic neurons. It has been widely used to treat patients with dystania, pelvic floor disorders, and gustatory or axillary sweating. In patients with voiding dysfnnction, weakening of the urethral sphincter muscle by BTX injection is followed by symptoms improvement. BTX-A injection into the rat prostate induces selective denervation and subsequent atrophy. Recently, inta'aprostatic BTX-A has been reported to be efficacious in men with moderate voiding obstruction mad medium sized prostates. Given this background, the present study was designed to determine the effects of BTX-A intraprostatie injection in patients with severe benign prostatic hyperplasia (BPH). MATERIAL & METHODS: 16 Patients were recruited to the study which was approved by the Perugia University Ethics Committee. Inclusion criteria were prostatic volume >80cc and urinary peak flow ranging from 10 to 0 ml/sec (with indwelling catheters). The only exclusion criterion was presence of neurogenic bladder disorders. Patients underwent DRE, TRUS with uroflowetry and PSAt evaluation. Symptoms were assessed by the AUA -IPSS score. Each patient received an intraprostatic ultrasound-guided injection of 150 U of BTX-A in a saline solution into each lobe. Patients underwent the same baseline evaluations after 1, 2 and 6 months' follow-up. Data were analysed using the maalysis ofvarimace for repeated measures. RESULTS: The mean age of patients was 68.8 years (range: 56-90). All patients had BPH except for one who had low grade adenocarcinoma (not considered in PSAt evaluation). At the beginning of the treatment 3 patients had indwelling catheters.
1 month
2 months
6 months
P
IPSS
IBaseline 24
13
11
9
0.002
Prostate weight (gr.)
106
65
53
53
0.000
PSAt (ngr/ml) Flow Max (ml/sec) Residual urine (ml)
9.5 8.2 295
6.8 15.4 106
2.5 17.9 96
2.5 18.1 85
0.05 0.05 0.05
CONCLUSIONS: We consider intraprostatic BTX-A injection as a mutually exclusive alternative to surgery in high grade voiding dysfunction for BPH or cancer, particularly in patients at risk.
Urology Research Center, Tehran University of Medical Sciences, Dept. of Urology, Tehran, Iran I N T R O D U C T I O N & O B J E C T I V E S : To evaluate postoperative morbidity and technical complications of a new procedure, urethral catheter free suprapubic prostatectomy. M A T E R I A L & M E T H O D S : This pilot study composed of 20 patients. Their mean age was 70 years, mean International Prostatic Symptom Score (IPSS) 32 and mean m a x i m u m flow rate (Qmax) 3.7 ml/sec. None of them had significant medical co morbidity. Patients were admitted to' hospital the day before operation and underwent modified suprapubie prostatectomy under spinal anaesthesia without urethral catheter, but a hand made cystostomy. Mean prostate adenoma weight was 48 grams. Postoperatively all the patients were treated like those underwent standard suprapubic prostatectomy. First 24-hr. drain collection, episode of clot retention, irritative symptoms, time elapsed to empty the balloon of catheter, voiding status after cystostomy removal and incontinence were evaluated postoperatively. Three months later, we followed the patients with IPSS, Qmaxand cystoscopic examination (to rule out stricture formation). Data were analyzed with SPSS-10. All the patients were informed and consented regarding the new technique. R E S U L T S : The mean first 24-hr. drain leakage was 162 ml. Postoperatively none of the patients complained of significant irritative urinary symptoms, clot retention and true or stress urinary incontinence, although some had temporary urge incontinence for the first few days. There was no report of urinary tract infection (UTI) or epididymoorchitis. One patient developed urinary retention after cystostomy removal that was treated with intermittent catheterization, as there was no bladder neck or urethral stricture. Three months after operation, mean IPSS and Qmax were 3.8 and 21.5 ml/sec respectively. There was no bladder neck or urethral stricture on cystoscopic examination. C O N C L U S I O N S : Transurethral resection o f prostate (TUR-P) has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia (BPH). However, open adenomectomy has still its own place and being used as a common procedure in some parts of the world. Catheter free suprapubic prostatectomy can be safely applied with low post-operative risk of infection, incontinence or stricture formation.
591
592
IS E A R L Y C A T H E T E R R E M O V A L A N D H O S P I T A L D I S C H A R G E S A F E A N D F E A S I B L E IN A L L C A S E S O F TURP?
HOW COMPLETE THE PROSTATE?
Saeed !,, Saw N., DowneyE
Milonas D., Jievaltas M., Trumbeckas D.
South ManchesterUniversityHospitalTrust, Departmentof MinimallyInvasiveand LaparoscopicUrology, Manchester,UnitedKingdom
University of Medicine, Urology, Kaanas, Lithuania
INTRODUCTION & OBJECTIVES: To determinethe safety and feasibilityof earlycatheterremovaland hospitaldischargein an unselectedgroupof patientsundergoingTURE
INTRODUCTION & OBJECTIVES: The aim of this study was to establish prognostic value of operative parameters as resected tissue weight (RTW), residual prostate weight (RPW) and residual prostatic weight ratio (RPWR) for predicting efficacy after transurethral resection of the prostate (TURP) due to BPH.
MATERIAL & METHODS: We performeda prospectivestudy on an unselectedgroup of 52 consecutive patients undergoingTURP for all indicationsunder the care of one ConsultantUrologist (PD) between October 2003 and August2004. Indicationsfor surgerywere failed medicaltherapy (n 12) or retentionof urine, [acute (~11), chronic (n-18) or acute on-chronic (n=ll)]. TURP was performed with adequate removalof apicaland bladderneck tissue.The catheterwas removedon the first post,operativeday.Patients were dischargedwhen two flow rates and post void residualscanshad been performed. [Flowrate/residuala_ 2] and followedup 1 and 3 months post-operativelywith IPSS/QOLscoring, flow rate and residualvolume assessment[Flowrate/residual3j. RESULTS: 45 of the 52 patientswere dischargedon day 1 post TURP without a catheter. One patientrequiredreadmissionto hospitalprior to plannedreviewwith clot retentionof urine. Assessmentat 1 and 3 monthspost operativelyshowedgood outcomesfollowingsurgery. Failed medicalRx
Acute retention
Chronic retention
SuccessfulTWOC Median flow rate 1 Medianvolumepassed 1 Medianresidual 1
N=I 1 10 140 77
N=10 14 I63 206
N=14 12 216 311
Acute onchronic retention N=10 17 286 170
Median flow rate 2 Medianvolumepassed2 Medianresidual2
16 221 123
11
249 191
11 270 283
21 304 87
1/12 IPSS/QOL Median flow rate 3 Medianvolumepassed 3 Median residual 3
22 234 0
I4 212 55
254 5O
204 19
30 I81
19 249
3 16 235 34
235 44
3/t2 IPSS/QOL Medianflow rate 4 Medianvolumepassed4 Medianresidual4
CONCLUSIONS: Removalof catheterand dischargeon the first day followingTURF'is safe and feasible and may be consideredfor patientsundergoingTURP in the modern era.
European Urology Supplements 4 (2005) No. 3, pp. 150
SHOULD BE TRANSURETHRAL RESECTION OF
M A T E R I A L & METHODS: 102 were involved in this prospective study in Jan 2002 - May 2003. Local ethical committee approved the study. IPSS, QoL, Qmax, total prostate volume (TPV), transition zone volume (TZV), transition zone index (TZI), PSA, postvoid residual volume (PER) were evaluated preoperatively. Inclusion criteria were: written informed consent, age 45-80 years, IPSS >13, Qmax < 15 ml/s, PSA <4 or 4-10ng/ml after negative biopsy of the prostate, PER <300ml. RTW, RPW and RPWR were investigated as operative factors. Follow-up was performed at 6 month after TURP. Efficacy of the surgery was evaluated as changes of post/pre operative IPSS, QoL, Qmax, and TPV. Results were divided into two groups: effective (good + excellent results) treatment and not effective (fair + none results) treatment. Statistical analysis was done by comparison of means with t test. Logistic regression analysis was used for finding valuable operative parameters that could predict treatment efficacy. Differences were considered statistically significant at p<0.05. RESULTS: Final analysis was done using data 90 (of 102) patients. Treatment was effective in 85.6% (excellent - 65.6% and good - 20%) of cases, not effective - in 14.4% (poor - 11.1% and none - 3,3%) of cases. Differences between operative parameters according treatment efficacy (effective vs. not effective) groups were significant (p <0.05) for mean RTW - 24.95 (SD 14.38) vs. 14.85 (SD 12.64), mean RPW - 20.32 (SD 7.42) vs. 27.92 (SD 14.I1) and mean RPWR - 0.49 (SD 0.17) vs. 0.72 (SD 0.11). RPWR with cut off value 0.71, (62% sensitivity, 96% specificity and OR 39.47 (95% CI 7.92-196.76)) had the strongest impact on treatment efficacy as individual parameter. Logistic regression analysis was performed to detect the influence of all operative parameters on treatment efficacy. RPW (cut off 26.6, OR 9.97, p=0.013) and RPWR (cut off 0.71, OR 62.2, p=0.001) had strong prediction when used together. Prognostic power of these factors was 96.1% for predicting positive results and 61.5% for predicting of negative results. Overall prognostic power for detecting correct results was 91.1%. CONCLUSIONS: Resected tissue weight as alone factor had no significant impact on efficacy of the TURP. The most important operative parameter that can predict TURP efficacy was RPWR with cut off value 0.71. At least 29% of total prostate volume should be resected during the TURP in anticipation of effective outcome.