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3-Year Followup of Urinary Symptoms after Transurethral Resection of the Prostate
0022-534 7/86/1363-0613$02.00/0 THE JOURNAL OF UROLOGY
Vol. 136, September
Copyright © 1986 by The Williams & Wilkins Co.
Printed in U.S.A.
3-YEAR FOLLOWUP OF URINARY SYMPTOMS AFTER TRANSURETHRAL RESECTION OF THE PROSTATE R. C. BRUSKEWITZ,* E. H. LARSEN, P. 0. MADSEN AND T. D0RFLINGER From the Urology Section, William S. Midd/,eton Memorial Veterans Hospital and Department of Surgery, University of Wisconsin School of Medicine, Madison, Wisconsin
ABSTRACT
A total of 84 patients underwent detailed symptom analysis and urodynamic study preoperatively, and 3 and 12 months after transurethral resection of the prostate. In addition, 69 patients were contacted 3 years postoperatively for a detailed symptom analysis. These 3-year data then were compared to earlier evaluations. At 3 years 75 per cent of the patients claimed to have improvement, while 13 per cent stated that they were the same symptomatically. At the 1-year evaluation 84 per cent of the patients believed that they were improved and 10 per cent stated that they were unchanged. At 3 years 18 per cent of the patients had urge incontinence (an increase from 6 per cent at 1 year), while none complained of marked nocturia or frequency. Mean total irritative and obstructive symptoms were minimal and unchanged from the 1-year evaluation. Of the patients 33 per cent noticed decreased or absent erections and most blamed the surgery. One patient required another prostatic resection, while stricture developed in 3 and bladder neck contracture occurred in 6. We conclude that prostatic resection results in reasonable 3-year symptomatic improvement but it is hampered by other complications, including bladder neck contracture and, possibly, impotence. When the issue of surgical treatment of benign prostatic hyperplasia is contemplated in the elderly man opposing forces come to bear. The population in the United States is aging as the percentage of senior citizens increases, which means that there is a larger absolute number of men with symptoms of prostatism secondary to benign prostatic hyperplasia. Con versely, we are under increasing constraints to contain health care costs and to reduce unnecessary operations. An additional factor to consider in regard to the future of transurethral prostatic resection is that the age-adjusted rate of transurethral prostatic resection increased by 150 per cent petween 1968 and 1978. 1 Also, the prostatectomy rate further varies widely from one locale to another, and ranges between 200 and 400 per year per 100,000 male patients. 2 This fact suggests that indications for transurethral prostatic resection vary as well. Reports on the natural history of prostatism, that is the fate of untreated individuals, are crucial when the necessity for treatment is decided but such data are sparse. 1 The limited information that exists suggests that stabilization or improvement in symptoms may occur in up to 50 per cent of the patients without surgical treatment. 3 • 4 Equally important is the need for more data detailing the long-term outcome of patients undergoing transurethral prostatic resection. Reported reoperation rates for transurethral prostatic resection vary between 2 and 7 per cent in 1 year. 5 Postoperative surgical complications of stricture, bladder neck contracture, incontinence, impotence and operative morbidity have received considerable attention. Of equal importance is the need for detailed symptom analysis beyond the immediate postoperative period. However, reports on symptom followup more than 1 year after transurethral prostatic resection also are scarce. We discuss our 3-year symptom followup data on 84 patients undergoing transurethral prostatic resection.
Accepted for publication March 31, 1986. Supported in part by the Veterans Administration and the Danish Medical Research Council. *Requests for reprints: Section of Urology, Department of Surgery, University of Wisconsin Clinical Science Center, 600 Highland Ave., Madison, Wisconsin 53792.
MATERIALS AND METHODS
Methods, definitions and units conformed to the standards proposed by the International Continence Society. 6 All patients enrolled in this study underwent evaluation for prostatism, including complete physical examination, excretory urography, cystoscopy, a detailed and scored symptom analysis, post-void residual urine determination, routine blood chemistry, urinalysis and urine culture. The symptom analysis was comprised of questions presented to the patients regarding hesitancy, intermittency, sensation of complete bladder emptying, abdominal straining, terminal dribbling, urge, nocturia, frequency and quality of urinary stream. Each symptom was graded on a scale of O to 4, and the total symptom score was calculated by combining the irritative and obstructive symptom scores. Patients less than 50 years old, with a history of extensive pelvic surgery, previous transurethral prostatic resection, urethral stricture, prostatic carcinoma of stage A2 or greater and serious psychiatric or neurological disease were excluded. All patients had a negative urine culture at the initial evaluation. In addition, they underwent a detailed urodynamic investigation, including uroflowmetry, post-void residual urine determination, medium-fill water cystometrogram with subtracted intrarectal pressure and a pressure-flow study. All symptomatic and urodynamic evaluations were repeated 3 and 12 months postoperatively, and the patients were asked to give their subjective evaluation of the results of the operation on a scale of 1 to 5. The 3-year postoperative evaluation was conducted by telephone interview and the patients were queried about the same symptoms. In addition, they were asked whether they had required hospitalization for complications related to transurethral prostatic resection or reoperation at any other institution. All Veterans Administration hospital records were reviewed for details of any rehospitalization or a clinic visit pertaining to a complication of transurethral prostatic resection (excluding uncomplicated urinary tract infection up to 3 months postoperatively). To determine whether the 60 interviewed patients were representative of the group of 84 as a whole, the records of these 60 were compared to the 24 patients not included in the
613
614
BRUSKEWITZ AND ASSOCIATES
followup or eliminated from consideration, with selected preoperative parameters analyzed by 1-way analysis of variance. The Mann-Whitney rank sum test was used for the statistical evaluation of the preoperative and postoperative results. P values less than 0.05 were considered significant. RESULTS
A total of 84 patients underwent complete preoperative evaluation, while 67 and 54 patients, respectively, were evaluated (including urodynamic study) 3 and 12 months postoperatively. We contacted 69 patients (or their families in cases of those who died) for the 3-year re-evaluation. An attempt was made to contact every patient but some had moved from the vicinity and left no forwarding address, while others had no telephone and could not be reached. The median followup was 35 months (range 20 to 48 months). An additional 9 patients were excluded from 3-year symptom analysis because 3 died of causes unrelated to prostatic disease, 1 had suffered invasive bladder cancer, 3 had primary carcinoma of the prostate (stage Al noted at the time of transurethral prostatic resection), 1 later suffered stage B cancer of the prostate and 1 had metastases presumed to be secondary to prostatic carcinoma. Table 1 shows the preoperative data that were analyzed for the 60 interviewed patients versus the 24 not included in the analysis. The only significant difference between the groups was the mean age of the patients, the lost to followup group being slightly older than the 3-year followup group. Of the 60 patients evaluated 3 years postoperatively 3 noticed persistent pain following the procedure: 1 had pain in the suprapubic region and 2 had persistent dysuria in the face of negative urine cultures. One patient had a postoperative episode of epididymitis and 1 had an unexplained episode of painless hematuria. Three patients currently were on medication for voiding difficulty, including 1 on bethanechol chloride and 2 on propantheline bromide. One patient (2 per cent) required repeat transurethral resection of the prostate, 3 (5 per cent) had a urethral stricture that required treatment and 6 (10 per cent) had bladder neck contracture. There were 20 patients (33 per cent) who complained of potency problems after the operation: 12 considered themselves to be completely impotent, while 8 had impaired erections. Another 5 patients were impotent preoperatively, 29 had no potency problems before or after the operation and 6 did not answer the question. The incidence of retrograde ejaculation was not recorded. Patients noticed a decrease in total symptom score at the 3month followup, which basically was unchanged at 12 and 35 months (table 2). This finding constitutes a statistically significant improvement of symptoms compared to the preoperative symptom level, and there was no significant difference in symptom score among the 3-year, and 3 and 12-month followups. The frequencies of the individual symptoms preoperatively and during followup are shown in table 3. The most persistent improvement in symptoms was found in quality or force of TABLE 1. Comparison of selected preoperative data between 60 interviewed patients and 24 patients whose records were not included in analysis
Preop. Data Age Duration of symptoms (mos.) Total symptom score Total obstructive score Total irritative score Maximum flow Maximum intravesical pressure Detrusor pressure at maximum flow Residual urine Resected wt.
3-Yr. Followup (60 pts.) 63.9 ± 26.3 ± 15.5 ± 10.6 ± 4.8 ± 10.3 ± 118.8 ± 58.2 ± 78.6 ± 22.5 ±
6.2 39.8 3.7 3.3 1.9 4.3 45.7 45.7 77.6 13.0
Not Included (24 pts.) 67.8 ± 9.9* 47.2 ± 59.3 15.7 ± 3.6 11.1 ± 3.3 4.5 ± 2.0 11.2±6.7 116.1 ± 39.9 58.2 ± 36.5 87.7 ± 85.6 18.8 ± 10.1
1-Way analysis of variance. Significance level p <0.05. Values are reported as mean ± standard deviation. * Only age differed significantly between the groups.
TABLE 2.
Symptom scores preoperatively and during followup Preop.
No. pts. Total symptom score (27 points possible)* Irritative symptom score (9 points possible)* Obstructive symptom score (18 points possible)*
84 16 (9-24) 5 (1-9) 11.5 (2-16)
3 Mos.
12 Mos.
67 54 4 (0-16) 3 (0-14) 2 (1-9)
1 (0-7)
1.5 (0-11)
2 (0-10)
35 Mos. 60 3 (0-20) 1.5 (0-7) 2 (0-16)
* Median value (range). TABLE 3.
Frequency of individual symptoms preoperatively and during followup Frequency ( %)
Quality of stream: Normal Variable Weak Dribbling Straining: No Yes Urge: None Mild Moderate Incontinence Hesitancy: No Yes Intermittency: No Yes Bladder emptying: Normal Variable Incomplete Single retention Multiple retention Nocturia: 0-1 2 3-4 >4 Frequency (hrs.): >3 2-3 1-2 <1 Terminal dribbling: No Yes
Preop. (84 pts.)
3Mos. (67 pts.)
12 Mos. (54 pts.)
3 Yrs. (60 pts.)
1 19 73 7
76 15 7 1
70 26 4 0
75 5 18 2
57 43
97 3
93 7
80 20
15 27 43 14
49 22 16 13
67 17 11 6
49 18 15 18
26 74
93 7
91 9
83 17
21 79
85 15
91 9
83 17
24 24 48 2 2
75 18 7 0 0
78 15 7 0 0
78 5 17 0 0
10 25 40 25
57 28 12 3
67 24 7 2
62 29 7 2
11 44 35 11
50 19 26 4
57 31 11 0
67 21 12 0
27 73
65 35
61 39
50 50
stream, bladder emptying, nocturia and frequency. A larger percentage of patients noticed some degree of urge incontinence (18 per cent at 3 years versus 6 per cent at 1 year) and 50 per cent noticed terminal dribbling. Over-all, 75 per cent of the patients claim that they are better or much better. This figure has decreased from the 87 and 84 per cent of the patients who claimed to have improvement at 3 and 12 months. Of the patients 12 per cent now claim that they are worse or much worse following the procedure, as opposed to 3 and 6 per cent at 3 and 12 months, respectively. The median resected prostatic weight among the 6 patients who had bladder neck contracture was 11 gm. (range 10 to 15.6 gm.). For 54 patients who did not experience bladder neck contracture the median prostatic weight was 28 gm. (range 4.2 to 80 gm.). This difference is statistically significant (p <0.01). There was no difference in the size of the prostatic resection in patients claiming benefit for transurethral prostatic resection compared to those who did not benefit. DISCUSSION
Surprisingly, little has been reported regarding detailed longterm followup of patients after transurethral prostatic resection from a urodynamic and symptomatic standpoint. As refinements in surgical technique and patient selection develop, more
URINARY SYMPTOMS AFTER TRANSURETHRAL RESECTION OF PROSTATE
detailed long-term followup of the postoperative results, as well as observation of nonoperated control groups will be necessary to assess results from standard transurethral prostatic resection as currently practiced, and to compare results with advances in technique and patient selection. Our observation on the increased chance for postoperative bladder neck contracture with a small prostate has been reported previously by others. 7• 8 One approach has been to avoid selection of this group of patients for transurethral prostatic resection. We do note that patients with a smaller prostate were more symptomatic preoperatively. 9 They had a most favorable postoperative result as far as symptoms were concerned until and unless troubled by recurrent bladder neck contracture. The 33 per cent incidence of impotence in our study is in accordance with the 4 to 40 per cent incidence reported in the literature. 10• 11 Unfortunately, we have no preoperative data for comparison and relied solely on the memory of the patient. Although the maintenance of potency is dependent on age, the availability of a willing partner and the level of patient anxiety12- 14 it is a disturbingly high percentage, since several reports have confirmed that aging men are vitally interested in sexual potency. 15- 17 In addition, it is our impression that some of the deterioration in patient satisfaction between 1 and 3 years is related to this potency issue rather than the voiding situation. It has been estimated that 1.3 per cent of all patients who have a prostatectomy will die postoperatively while in the hospital and that men within 1 year following prostatectomy have a much higher risk of death than age-matched male medicare recipients. 18 The 3 deaths that occurred in our study group were unrelated to the surgical procedure but obviously this claim of increased mortality following prostatic surgery needs further investigation. Our experiences have led us to embark on a trial of simple incision of the bladder neck with local anesthesia in patients with prostatism and in whom the amount of resectable tissue is estimated to be less than 20 gm. We hope that prostatic incision will address the bladder neck contracture problem and perhaps the impotence issue as well. This will form the basis of a future report. In addition, we plan to reassess and report the progress of these patients at 5 and 10 years afte;r transurethral prostatic resection. REFERENCES
1. Birkhoff, J. D.: Natural history of benign prostatic hypertrophy.
2.
3. 4. 5.
6.
7. 8.
9. 10.
In: Benign Prostatic Hypertrophy. Edited by F. Hinman, Jr. New York: Springer-Verlag, sect. I, chapt. 1, pp. 5-9, 1983. McPherson, K., Wennberg, J. E., Hovind, 0. B. and Clifford, P.: Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. New Engl. J. Med., 307: 1310, 1982. Jensen, K. M.-E. and Madsen, P. 0.: Candicidin treatment of prostatism: a prospective double-blind placebo-controlled study. Urol. Res., 11: 7, 1983. Ball, A. J., Feneley, R. C. L. and Abrams, P.H.: The natural history of untreated 'prostatism'. Brit. J. Urol., 53: 613, 1981. Grayhack, J. T. and Sadlowski, R. W.: Results of surgical therapy. In: Benign Prostatic Hyperplasia. Edited by J. T. Grayhack, J. D. Wilson, and M. J. Scherbenske. Washington, D. C.: Department of Health, Education and Welfare Publication No. (NIH) 76-1113,pp. 125-135, 1975. Bates, P., Bradley, W. E., Glen, E., Griffiths, D., Melchior, H., Rowan, D., Sterling, A., Zinner, N. and Hald, T.: The standardization of terminology of lower urinary tract function. J. Urol., 121: 551, 1979. Hohenfellner, R. and Jonas, U.: Results following prostatectomy. Urol. Int., 33: 187, 1978. Turner Warwick, R., Whiteside, C. G., Arnold, E. P., Bates, C. P., Worth, P.H. L., Milroy, E.G. J., Webster, J. R. and Weir, J.: A urodynamic view of prostatic obstruction and the results of prostatectomy. Brit. J. Urol., 45: 631, 1973. Jensen, K. M.-E., Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Significance ofprostatic weight in prostatism. Urol. Int., 38: 173, 1983. Hargreave, T. B. and Stephenson, T. P.: Potency and prostatec-
615
tomy. Brit. J. Urol., 49: 683, 1977. 11. Holtgrewe, H. L. and Valk, W. L.: Late results of transurethral prostatectomy. J. Urol., 92: 51, 1964. 12. Gold, F. M. and Hotchkiss, R. S.: Sexual potency following simple prostatectomy. N. Y. State J. Med., 69: 2987, 1969. 13. Finkle, A. L. and Prian, D. V.: Sexual potency in elderly men before and after prostatectomy. J.A.M.A., 196: 139, 1969. 14. Zohar, J., Meiraz, D., Maoz, B. and Durst, N.: Factors influencing sexual activity after prostatectomy: a prospective study. J. Urol., 116: 332, 1976. 15. Bowers, L. M., Cross, R. R., Jr. and Lloyd, F. A.: Sexual function and urologic disease in the elderly male. J. Amer. Geriatr. Soc., 11: 647, 1963. 16. Freeman, J. T.: Sexual capacities in the aging male. Geriatrics, 16: 37, 1961. 17. Newman, G. and Nichols, C.R.: Sexual activities and attitudes in older persons. J.A.M.A., 173: 33, 1969. 18. Wennberg, J. and Gittelsohn, A.: Variations in medical care among small areas. Sci. Amer., 246: 120, 1982. EDITORIAL COMMENT The authors attempted to quantitate the symptoms before and after transurethral prostatectomy to determine if the operation results in symptomatic improvement. An attempt to quantitate symptoms primarily is subjective and open to criticism. It is particularly difficult to obtain an objective evaluation of a patient who is interviewed 3 years later by telephone. This is especially true of patients with urinary urgency and bladder outlet obstructive symptoms, which could reflect urethral stricture, postoperative bladder neck contracture or regrowth of tissue. Nevertheless, the authors have made a reasonable attempt to be as objective as possible. The frequency of postoperative complications that they list, such as vesical neck contracture and urethral stricture, is similar to those of previous reports. Their relatively high incidence of impaired sexual function after transurethral resection probably represents the extreme difficulty of obtaining objective data. The authors noted that potency is dependent upon age, availability of a willing partner, patient anxiety and misunderstanding of retrograde ejaculation. In a small study in which penile tumescence monitoring was measured preoperatively and postoperatively, and compared to the symptoms So and associates found little correlation. 1 Therefore, the urologist must rely on his own personal experience as well as what data are available, and he must explain to the patient the risk of impotence following transurethral resection. It is my educated guess that the incidence as a direct effect of a transurethral prostatectomy is 10 per cent or less. The authors referred to the use ofurodynamic studies preoperatively and postoperatively, and included some data in table 1. However, they did not include the data noted 3 and 12 months after transurethral prostatectomy, and we would hope that this information would be forthcoming in the near future. Winston K. Mebust Department of Urology Kansas University Medical Center Kansas City, Kansas 1. So, E. P., Ho, P. C., Bodenstab, W. and Parsons, C. L.: Erectile impotence associated with transurethral prostatectomy. Urology, 19: 259, 1982. REPLY BY AUTHORS The urodynamic findings in this group of patients have been reported previously. i-B 1. Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Value ofpostvoid
2. 3. 4. 5. 6.
residual urine determination in evaluation of prostatism. Urology, 20: 602, 1982. Bruskewitz, R., Jensen, K. M.-E., Iversen, P. and Madsen, P. 0.: The relevance of minimum urethral resistance in prostatism. J. Urol., 129: 769, 1983. Iversen, P., Bruskewitz, R. C., Jensen, K. M.-E. and Madsen, P. 0.: Transurethral prostatic resection in the treatment of prostatism with high urinary flow. J. Urol., 129: 995, 1983. Jensen, K. M.-E., Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Predictive value of voiding pressure in benign prostatic hyperplasia. Neurourol. Urodynam., 2: 117, 1983. Jensen, K. M.-E., Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Spontaneous uroflowmetry in prostatism. Urology, 24: 403, 1984. D0rflinger, T., Frimodt-M0ller, P. C., Bruskewitz, R. C., Jensen, K. M.-E., Iversen P. and Madsen, P. 0.: The significance of uninhibited detrusor contractions in prostatism. J. Urol., 133: 819, 1985.
Vol. 136, September
Copyright © 1986 by The Williams & Wilkins Co.
Printed in U.S.A.
3-YEAR FOLLOWUP OF URINARY SYMPTOMS AFTER TRANSURETHRAL RESECTION OF THE PROSTATE R. C. BRUSKEWITZ,* E. H. LARSEN, P. 0. MADSEN AND T. D0RFLINGER From the Urology Section, William S. Midd/,eton Memorial Veterans Hospital and Department of Surgery, University of Wisconsin School of Medicine, Madison, Wisconsin
ABSTRACT
A total of 84 patients underwent detailed symptom analysis and urodynamic study preoperatively, and 3 and 12 months after transurethral resection of the prostate. In addition, 69 patients were contacted 3 years postoperatively for a detailed symptom analysis. These 3-year data then were compared to earlier evaluations. At 3 years 75 per cent of the patients claimed to have improvement, while 13 per cent stated that they were the same symptomatically. At the 1-year evaluation 84 per cent of the patients believed that they were improved and 10 per cent stated that they were unchanged. At 3 years 18 per cent of the patients had urge incontinence (an increase from 6 per cent at 1 year), while none complained of marked nocturia or frequency. Mean total irritative and obstructive symptoms were minimal and unchanged from the 1-year evaluation. Of the patients 33 per cent noticed decreased or absent erections and most blamed the surgery. One patient required another prostatic resection, while stricture developed in 3 and bladder neck contracture occurred in 6. We conclude that prostatic resection results in reasonable 3-year symptomatic improvement but it is hampered by other complications, including bladder neck contracture and, possibly, impotence. When the issue of surgical treatment of benign prostatic hyperplasia is contemplated in the elderly man opposing forces come to bear. The population in the United States is aging as the percentage of senior citizens increases, which means that there is a larger absolute number of men with symptoms of prostatism secondary to benign prostatic hyperplasia. Con versely, we are under increasing constraints to contain health care costs and to reduce unnecessary operations. An additional factor to consider in regard to the future of transurethral prostatic resection is that the age-adjusted rate of transurethral prostatic resection increased by 150 per cent petween 1968 and 1978. 1 Also, the prostatectomy rate further varies widely from one locale to another, and ranges between 200 and 400 per year per 100,000 male patients. 2 This fact suggests that indications for transurethral prostatic resection vary as well. Reports on the natural history of prostatism, that is the fate of untreated individuals, are crucial when the necessity for treatment is decided but such data are sparse. 1 The limited information that exists suggests that stabilization or improvement in symptoms may occur in up to 50 per cent of the patients without surgical treatment. 3 • 4 Equally important is the need for more data detailing the long-term outcome of patients undergoing transurethral prostatic resection. Reported reoperation rates for transurethral prostatic resection vary between 2 and 7 per cent in 1 year. 5 Postoperative surgical complications of stricture, bladder neck contracture, incontinence, impotence and operative morbidity have received considerable attention. Of equal importance is the need for detailed symptom analysis beyond the immediate postoperative period. However, reports on symptom followup more than 1 year after transurethral prostatic resection also are scarce. We discuss our 3-year symptom followup data on 84 patients undergoing transurethral prostatic resection.
Accepted for publication March 31, 1986. Supported in part by the Veterans Administration and the Danish Medical Research Council. *Requests for reprints: Section of Urology, Department of Surgery, University of Wisconsin Clinical Science Center, 600 Highland Ave., Madison, Wisconsin 53792.
MATERIALS AND METHODS
Methods, definitions and units conformed to the standards proposed by the International Continence Society. 6 All patients enrolled in this study underwent evaluation for prostatism, including complete physical examination, excretory urography, cystoscopy, a detailed and scored symptom analysis, post-void residual urine determination, routine blood chemistry, urinalysis and urine culture. The symptom analysis was comprised of questions presented to the patients regarding hesitancy, intermittency, sensation of complete bladder emptying, abdominal straining, terminal dribbling, urge, nocturia, frequency and quality of urinary stream. Each symptom was graded on a scale of O to 4, and the total symptom score was calculated by combining the irritative and obstructive symptom scores. Patients less than 50 years old, with a history of extensive pelvic surgery, previous transurethral prostatic resection, urethral stricture, prostatic carcinoma of stage A2 or greater and serious psychiatric or neurological disease were excluded. All patients had a negative urine culture at the initial evaluation. In addition, they underwent a detailed urodynamic investigation, including uroflowmetry, post-void residual urine determination, medium-fill water cystometrogram with subtracted intrarectal pressure and a pressure-flow study. All symptomatic and urodynamic evaluations were repeated 3 and 12 months postoperatively, and the patients were asked to give their subjective evaluation of the results of the operation on a scale of 1 to 5. The 3-year postoperative evaluation was conducted by telephone interview and the patients were queried about the same symptoms. In addition, they were asked whether they had required hospitalization for complications related to transurethral prostatic resection or reoperation at any other institution. All Veterans Administration hospital records were reviewed for details of any rehospitalization or a clinic visit pertaining to a complication of transurethral prostatic resection (excluding uncomplicated urinary tract infection up to 3 months postoperatively). To determine whether the 60 interviewed patients were representative of the group of 84 as a whole, the records of these 60 were compared to the 24 patients not included in the
613
614
BRUSKEWITZ AND ASSOCIATES
followup or eliminated from consideration, with selected preoperative parameters analyzed by 1-way analysis of variance. The Mann-Whitney rank sum test was used for the statistical evaluation of the preoperative and postoperative results. P values less than 0.05 were considered significant. RESULTS
A total of 84 patients underwent complete preoperative evaluation, while 67 and 54 patients, respectively, were evaluated (including urodynamic study) 3 and 12 months postoperatively. We contacted 69 patients (or their families in cases of those who died) for the 3-year re-evaluation. An attempt was made to contact every patient but some had moved from the vicinity and left no forwarding address, while others had no telephone and could not be reached. The median followup was 35 months (range 20 to 48 months). An additional 9 patients were excluded from 3-year symptom analysis because 3 died of causes unrelated to prostatic disease, 1 had suffered invasive bladder cancer, 3 had primary carcinoma of the prostate (stage Al noted at the time of transurethral prostatic resection), 1 later suffered stage B cancer of the prostate and 1 had metastases presumed to be secondary to prostatic carcinoma. Table 1 shows the preoperative data that were analyzed for the 60 interviewed patients versus the 24 not included in the analysis. The only significant difference between the groups was the mean age of the patients, the lost to followup group being slightly older than the 3-year followup group. Of the 60 patients evaluated 3 years postoperatively 3 noticed persistent pain following the procedure: 1 had pain in the suprapubic region and 2 had persistent dysuria in the face of negative urine cultures. One patient had a postoperative episode of epididymitis and 1 had an unexplained episode of painless hematuria. Three patients currently were on medication for voiding difficulty, including 1 on bethanechol chloride and 2 on propantheline bromide. One patient (2 per cent) required repeat transurethral resection of the prostate, 3 (5 per cent) had a urethral stricture that required treatment and 6 (10 per cent) had bladder neck contracture. There were 20 patients (33 per cent) who complained of potency problems after the operation: 12 considered themselves to be completely impotent, while 8 had impaired erections. Another 5 patients were impotent preoperatively, 29 had no potency problems before or after the operation and 6 did not answer the question. The incidence of retrograde ejaculation was not recorded. Patients noticed a decrease in total symptom score at the 3month followup, which basically was unchanged at 12 and 35 months (table 2). This finding constitutes a statistically significant improvement of symptoms compared to the preoperative symptom level, and there was no significant difference in symptom score among the 3-year, and 3 and 12-month followups. The frequencies of the individual symptoms preoperatively and during followup are shown in table 3. The most persistent improvement in symptoms was found in quality or force of TABLE 1. Comparison of selected preoperative data between 60 interviewed patients and 24 patients whose records were not included in analysis
Preop. Data Age Duration of symptoms (mos.) Total symptom score Total obstructive score Total irritative score Maximum flow Maximum intravesical pressure Detrusor pressure at maximum flow Residual urine Resected wt.
3-Yr. Followup (60 pts.) 63.9 ± 26.3 ± 15.5 ± 10.6 ± 4.8 ± 10.3 ± 118.8 ± 58.2 ± 78.6 ± 22.5 ±
6.2 39.8 3.7 3.3 1.9 4.3 45.7 45.7 77.6 13.0
Not Included (24 pts.) 67.8 ± 9.9* 47.2 ± 59.3 15.7 ± 3.6 11.1 ± 3.3 4.5 ± 2.0 11.2±6.7 116.1 ± 39.9 58.2 ± 36.5 87.7 ± 85.6 18.8 ± 10.1
1-Way analysis of variance. Significance level p <0.05. Values are reported as mean ± standard deviation. * Only age differed significantly between the groups.
TABLE 2.
Symptom scores preoperatively and during followup Preop.
No. pts. Total symptom score (27 points possible)* Irritative symptom score (9 points possible)* Obstructive symptom score (18 points possible)*
84 16 (9-24) 5 (1-9) 11.5 (2-16)
3 Mos.
12 Mos.
67 54 4 (0-16) 3 (0-14) 2 (1-9)
1 (0-7)
1.5 (0-11)
2 (0-10)
35 Mos. 60 3 (0-20) 1.5 (0-7) 2 (0-16)
* Median value (range). TABLE 3.
Frequency of individual symptoms preoperatively and during followup Frequency ( %)
Quality of stream: Normal Variable Weak Dribbling Straining: No Yes Urge: None Mild Moderate Incontinence Hesitancy: No Yes Intermittency: No Yes Bladder emptying: Normal Variable Incomplete Single retention Multiple retention Nocturia: 0-1 2 3-4 >4 Frequency (hrs.): >3 2-3 1-2 <1 Terminal dribbling: No Yes
Preop. (84 pts.)
3Mos. (67 pts.)
12 Mos. (54 pts.)
3 Yrs. (60 pts.)
1 19 73 7
76 15 7 1
70 26 4 0
75 5 18 2
57 43
97 3
93 7
80 20
15 27 43 14
49 22 16 13
67 17 11 6
49 18 15 18
26 74
93 7
91 9
83 17
21 79
85 15
91 9
83 17
24 24 48 2 2
75 18 7 0 0
78 15 7 0 0
78 5 17 0 0
10 25 40 25
57 28 12 3
67 24 7 2
62 29 7 2
11 44 35 11
50 19 26 4
57 31 11 0
67 21 12 0
27 73
65 35
61 39
50 50
stream, bladder emptying, nocturia and frequency. A larger percentage of patients noticed some degree of urge incontinence (18 per cent at 3 years versus 6 per cent at 1 year) and 50 per cent noticed terminal dribbling. Over-all, 75 per cent of the patients claim that they are better or much better. This figure has decreased from the 87 and 84 per cent of the patients who claimed to have improvement at 3 and 12 months. Of the patients 12 per cent now claim that they are worse or much worse following the procedure, as opposed to 3 and 6 per cent at 3 and 12 months, respectively. The median resected prostatic weight among the 6 patients who had bladder neck contracture was 11 gm. (range 10 to 15.6 gm.). For 54 patients who did not experience bladder neck contracture the median prostatic weight was 28 gm. (range 4.2 to 80 gm.). This difference is statistically significant (p <0.01). There was no difference in the size of the prostatic resection in patients claiming benefit for transurethral prostatic resection compared to those who did not benefit. DISCUSSION
Surprisingly, little has been reported regarding detailed longterm followup of patients after transurethral prostatic resection from a urodynamic and symptomatic standpoint. As refinements in surgical technique and patient selection develop, more
URINARY SYMPTOMS AFTER TRANSURETHRAL RESECTION OF PROSTATE
detailed long-term followup of the postoperative results, as well as observation of nonoperated control groups will be necessary to assess results from standard transurethral prostatic resection as currently practiced, and to compare results with advances in technique and patient selection. Our observation on the increased chance for postoperative bladder neck contracture with a small prostate has been reported previously by others. 7• 8 One approach has been to avoid selection of this group of patients for transurethral prostatic resection. We do note that patients with a smaller prostate were more symptomatic preoperatively. 9 They had a most favorable postoperative result as far as symptoms were concerned until and unless troubled by recurrent bladder neck contracture. The 33 per cent incidence of impotence in our study is in accordance with the 4 to 40 per cent incidence reported in the literature. 10• 11 Unfortunately, we have no preoperative data for comparison and relied solely on the memory of the patient. Although the maintenance of potency is dependent on age, the availability of a willing partner and the level of patient anxiety12- 14 it is a disturbingly high percentage, since several reports have confirmed that aging men are vitally interested in sexual potency. 15- 17 In addition, it is our impression that some of the deterioration in patient satisfaction between 1 and 3 years is related to this potency issue rather than the voiding situation. It has been estimated that 1.3 per cent of all patients who have a prostatectomy will die postoperatively while in the hospital and that men within 1 year following prostatectomy have a much higher risk of death than age-matched male medicare recipients. 18 The 3 deaths that occurred in our study group were unrelated to the surgical procedure but obviously this claim of increased mortality following prostatic surgery needs further investigation. Our experiences have led us to embark on a trial of simple incision of the bladder neck with local anesthesia in patients with prostatism and in whom the amount of resectable tissue is estimated to be less than 20 gm. We hope that prostatic incision will address the bladder neck contracture problem and perhaps the impotence issue as well. This will form the basis of a future report. In addition, we plan to reassess and report the progress of these patients at 5 and 10 years afte;r transurethral prostatic resection. REFERENCES
1. Birkhoff, J. D.: Natural history of benign prostatic hypertrophy.
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In: Benign Prostatic Hypertrophy. Edited by F. Hinman, Jr. New York: Springer-Verlag, sect. I, chapt. 1, pp. 5-9, 1983. McPherson, K., Wennberg, J. E., Hovind, 0. B. and Clifford, P.: Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. New Engl. J. Med., 307: 1310, 1982. Jensen, K. M.-E. and Madsen, P. 0.: Candicidin treatment of prostatism: a prospective double-blind placebo-controlled study. Urol. Res., 11: 7, 1983. Ball, A. J., Feneley, R. C. L. and Abrams, P.H.: The natural history of untreated 'prostatism'. Brit. J. Urol., 53: 613, 1981. Grayhack, J. T. and Sadlowski, R. W.: Results of surgical therapy. In: Benign Prostatic Hyperplasia. Edited by J. T. Grayhack, J. D. Wilson, and M. J. Scherbenske. Washington, D. C.: Department of Health, Education and Welfare Publication No. (NIH) 76-1113,pp. 125-135, 1975. Bates, P., Bradley, W. E., Glen, E., Griffiths, D., Melchior, H., Rowan, D., Sterling, A., Zinner, N. and Hald, T.: The standardization of terminology of lower urinary tract function. J. Urol., 121: 551, 1979. Hohenfellner, R. and Jonas, U.: Results following prostatectomy. Urol. Int., 33: 187, 1978. Turner Warwick, R., Whiteside, C. G., Arnold, E. P., Bates, C. P., Worth, P.H. L., Milroy, E.G. J., Webster, J. R. and Weir, J.: A urodynamic view of prostatic obstruction and the results of prostatectomy. Brit. J. Urol., 45: 631, 1973. Jensen, K. M.-E., Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Significance ofprostatic weight in prostatism. Urol. Int., 38: 173, 1983. Hargreave, T. B. and Stephenson, T. P.: Potency and prostatec-
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tomy. Brit. J. Urol., 49: 683, 1977. 11. Holtgrewe, H. L. and Valk, W. L.: Late results of transurethral prostatectomy. J. Urol., 92: 51, 1964. 12. Gold, F. M. and Hotchkiss, R. S.: Sexual potency following simple prostatectomy. N. Y. State J. Med., 69: 2987, 1969. 13. Finkle, A. L. and Prian, D. V.: Sexual potency in elderly men before and after prostatectomy. J.A.M.A., 196: 139, 1969. 14. Zohar, J., Meiraz, D., Maoz, B. and Durst, N.: Factors influencing sexual activity after prostatectomy: a prospective study. J. Urol., 116: 332, 1976. 15. Bowers, L. M., Cross, R. R., Jr. and Lloyd, F. A.: Sexual function and urologic disease in the elderly male. J. Amer. Geriatr. Soc., 11: 647, 1963. 16. Freeman, J. T.: Sexual capacities in the aging male. Geriatrics, 16: 37, 1961. 17. Newman, G. and Nichols, C.R.: Sexual activities and attitudes in older persons. J.A.M.A., 173: 33, 1969. 18. Wennberg, J. and Gittelsohn, A.: Variations in medical care among small areas. Sci. Amer., 246: 120, 1982. EDITORIAL COMMENT The authors attempted to quantitate the symptoms before and after transurethral prostatectomy to determine if the operation results in symptomatic improvement. An attempt to quantitate symptoms primarily is subjective and open to criticism. It is particularly difficult to obtain an objective evaluation of a patient who is interviewed 3 years later by telephone. This is especially true of patients with urinary urgency and bladder outlet obstructive symptoms, which could reflect urethral stricture, postoperative bladder neck contracture or regrowth of tissue. Nevertheless, the authors have made a reasonable attempt to be as objective as possible. The frequency of postoperative complications that they list, such as vesical neck contracture and urethral stricture, is similar to those of previous reports. Their relatively high incidence of impaired sexual function after transurethral resection probably represents the extreme difficulty of obtaining objective data. The authors noted that potency is dependent upon age, availability of a willing partner, patient anxiety and misunderstanding of retrograde ejaculation. In a small study in which penile tumescence monitoring was measured preoperatively and postoperatively, and compared to the symptoms So and associates found little correlation. 1 Therefore, the urologist must rely on his own personal experience as well as what data are available, and he must explain to the patient the risk of impotence following transurethral resection. It is my educated guess that the incidence as a direct effect of a transurethral prostatectomy is 10 per cent or less. The authors referred to the use ofurodynamic studies preoperatively and postoperatively, and included some data in table 1. However, they did not include the data noted 3 and 12 months after transurethral prostatectomy, and we would hope that this information would be forthcoming in the near future. Winston K. Mebust Department of Urology Kansas University Medical Center Kansas City, Kansas 1. So, E. P., Ho, P. C., Bodenstab, W. and Parsons, C. L.: Erectile impotence associated with transurethral prostatectomy. Urology, 19: 259, 1982. REPLY BY AUTHORS The urodynamic findings in this group of patients have been reported previously. i-B 1. Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Value ofpostvoid
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residual urine determination in evaluation of prostatism. Urology, 20: 602, 1982. Bruskewitz, R., Jensen, K. M.-E., Iversen, P. and Madsen, P. 0.: The relevance of minimum urethral resistance in prostatism. J. Urol., 129: 769, 1983. Iversen, P., Bruskewitz, R. C., Jensen, K. M.-E. and Madsen, P. 0.: Transurethral prostatic resection in the treatment of prostatism with high urinary flow. J. Urol., 129: 995, 1983. Jensen, K. M.-E., Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Predictive value of voiding pressure in benign prostatic hyperplasia. Neurourol. Urodynam., 2: 117, 1983. Jensen, K. M.-E., Bruskewitz, R. C., Iversen, P. and Madsen, P. 0.: Spontaneous uroflowmetry in prostatism. Urology, 24: 403, 1984. D0rflinger, T., Frimodt-M0ller, P. C., Bruskewitz, R. C., Jensen, K. M.-E., Iversen P. and Madsen, P. 0.: The significance of uninhibited detrusor contractions in prostatism. J. Urol., 133: 819, 1985.