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Intermittent catheterization time required after interstitial laser coagulation of the prostate
ADULT UROLOGY
INTERMITTENT CATHETERIZATION TIME REQUIRED AFTER INTERSTITIAL LASER COAGULATION OF THE PROSTATE KOJI NISHIZAWA, TAKASHI KOBAYASHI, KENJI MITSUMORI, JUN WATANABE,
AND
KEIJI OGURA
ABSTRACT Objectives. To evaluate and minimize the duration of clean intermittent catheterization (CIC) required after interstitial laser coagulation of the prostate in patients with benign prostatic hyperplasia. Methods. Patients who did not show sufficient improvement in lower urinary tract symptoms or voiding dysfunctions with alpha-1 adrenergic blockers, and who agreed to undergo interstitial laser coagulation of the prostate, were enrolled in this study. Postoperatively, the indwelling Foley catheters were removed by the next morning. Patients were then required to undertake CIC with alpha-1 adrenergic blockade therapy until the postvoid residual urine volume decreased to less than 100 mL. Results. Seventy-nine patients underwent interstitial laser coagulation of the prostate, and 70 underwent catheter-free trials by postoperative day 1. The mean age and preoperative prostate volume of these 70 patients was 70.3 years (SD 8.7) and 49.6 cm3 (SD 34.8), respectively. Forty-three patients experienced postoperative urinary retention, and 37 of these underwent CIC. The median postoperative catheterization time was 3 days (range 0 to 31), and all patients eventually became catheter free. Univariate analysis showed that postoperative urinary retention was associated with a preoperative prostate volume of 30 cm3 or larger, a maximal flow rate of less than 6 mL/s, and a postvoid residual urine volume of 100 mL or greater. Multivariate analysis showed that a preoperative prostate volume of 30 cm3 or larger was the most significant predictor of postoperative urinary retention. Conclusions. More than 60% of the patients experienced urinary retention after interstitial laser coagulation of the prostate. However, the results of the present study suggested that CIC and alpha-1 adrenergic blockade therapy could manage post-treatment urinary retention with a relatively short catheterization time. UROLOGY 64: 79–83, 2004. © 2004 Elsevier Inc.
M
inimally invasive therapy is recommended for patients with symptomatic benign prostatic hyperplasia who are poor candidates for transurethral resection of the prostate (TURP), have had limited success with medications, or want to avoid long-term medications.1 Minimally invasive therapy offers patients with benign prostatic hyperplasia an alternative way to achieve substantial improvements in lower urinary tract symptoms and a better quality of life at an acceptable low risk of treatment-associated complications. Among minimally invasive interventions, interstitial laser coagulation of the prostate has been reported to yield From the Department of Urology, Hamamatsu Rosai Hospital, Shizuoka; and Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan Reprint requests: Koji Nishizawa, M.D., Department of Urology, Hamamatsu Rosai Hospital, Shogen-Cho 25, Hamamatsu, Shizuoka 430-8525, Japan Submitted: December 22, 2003, accepted (with revisions): March 5, 2004 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED
statistically significant improvements in both symptoms and voiding parameters with minimal morbidity.2 Interstitial laser coagulation of the prostate can be performed safely and easily under local or sacral anesthesia on an outpatient basis. However, despite these advantages offered, postoperative prostate swelling is still one of the major problems associated with this procedure because the management of post-treatment urinary retention can result in prolonged indwelling catheterization.2 Moreover, long-term catheterization after minimally invasive therapy tends to require more postoperative catheter-free trials compared with TURP. Fulfilling a short catheterization time is essential for obtaining a better postoperative quality of life and a shorter hospital stay, even on an outpatient basis. Although clean intermittent catheterization (CIC) might contribute to a shortened catheter time, to our knowledge, CIC after interstitial laser coagulation has never been studied. We 0090-4295/04/$30.00 doi:10.1016/j.urology.2004.03.009 79
report the results of our experience with interstitial laser coagulation and CIC. MATERIAL AND METHODS PATIENTS From November 2001 to August 2003, those patients who did not show sufficient improvements in lower urinary tract symptoms and voiding dysfunctions with alpha-1 adrenergic blockers, and who agreed to undergo interstitial laser coagulation of the prostate, were enrolled in this study. Patients with acute prostatitis, neurogenic bladder dysfunction, or prostate carcinoma were excluded. To rule out prostate cancer, all patients were screened preoperatively by digital rectal examination and prostate-specific antigen determination. Transrectal ultrasound-guided biopsies were performed in cases of suspected prostate cancer. Pressure flow studies were performed not only to exclude neurogenic bladder dysfunctions and acontractile overdistended bladders but also to assess urodynamic obstruction. All patients with clinical benign prostatic hyperplasia were initially treated with alpha-1 adrenergic blockade therapy. Patients who presented with acute urinary retention were also instructed in CIC. If patients had limited success with this treatment, interstitial laser coagulation was recommended and informed consent obtained after presenting the benefits and risks compared with TURP. The preoperative assessments included prostate volume estimated by transrectal ultrasound measurements, International Prostate Symptom Score (IPSS), disease-specific quality-of-life (QOL) score, maximal urinary flow rate (Qmax), postvoid residual urine volume, detrusor pressure at Qmax, and Schafer grade.
PROCEDURES Interstitial laser coagulation was performed with an Indigo 830j. Patients received sacral, spinal, or general anesthesia according to their level of risk. Suprapubic catheterizations were not conducted. All interstitial laser coagulation procedures were performed under direct vision using a cystoscope with warm normal saline irrigation. The right and left prostate lobes were punctured individually at an angle of 30° against the midline of the urethra; the middle lobe was also punctured.2 An interstitial laser light was emitted creating a conical radiation field, and the tissue was heated to 85°C.3 Laser coagulations were produced continuously in 1-cm proximal portions.2 The number of coagulations performed was determined by the prostate volume in cubic centimeters divided by 8. Postoperatively, Foley catheters were placed in patients undergoing interstitial laser coagulation under spinal or general anesthesia until the following morning, and postoperative antibiotics were supplied. A catheter was not placed in patients undergoing interstitial laser coagulation under sacral anesthesia. Patients were required to undertake CIC with alpha-1 adrenergic blockade therapy until the postvoid residual urine volume decreased to less than 100 mL and spontaneous voiding was guaranteed. If patients experienced dysuria or a sensation of residual urine, they were also required to perform CIC to ensure that the residual postvoid volume was less than 100 mL. Voiding diaries, including the postvoid residual urine volume, were used. The total catheterization time was counted until the last day that the residual volume was greater than 100 mL. If patients could not, or were unwilling to, undertake self-CIC, nurses or caregivers performed the procedure.
FOLLOW-UP The IPSS, QOL score, Qmax, and prostate volume were reassessed 3 months after surgery to evaluate the treatment 80
outcomes. The number of patients who received additional treatments was assessed.
STATISTICAL ANALYSIS The paired t test was used to analyze the postoperative improvements in Qmax and prostate volume, and the Wilcoxon matched-pairs signed-ranks test was used to evaluate the differences in the IPSS and QOL score. To evaluate the success of the catheter-free trial, preoperative values were compared for age, prostate volume, IPSS, QOL score, Qmax, postvoid residual urine volume, detrusor pressure at Qmax, and Schafer grade for the catheter-free patients by postoperative day 1 (group 1) and those who failed the catheter-free trial (group 2). The paired t test and Mann-Whitney U test were performed to assess the statistical significance of the observed differences between these two groups, with a significance level of P ⬍0.05. To predict the success of the catheter-free trials by postoperative day 1, univariate analysis using Cox proportional hazards models was performed to estimate the hazards ratios and statistical significance. Multivariate analysis was performed to assess the significance of each predicting factor while adjusting for the others. Each statistical analysis was performed using commercial statistical software.
RESULTS PATIENT CHARACTERISTICS Seventy-nine patients underwent interstitial laser coagulation of the prostate. Of the 79 patients, 70 performed the catheter-free trials, 7 were unwilling to perform CIC, and 2 had severe dementia. Patients who could not, or would not, perform CIC had indwelling Foley catheters for several days and then switched to CIC if necessary. Of the 70 patients, 1 had cerebrovascular disease, 6 myocardial disease, 1 Parkinson’s disease, 6 diabetes mellitus, and 8 had miscellaneous diseases. The mean patient age and preoperative prostate volume was 70.3 years (SD 8.7, range 50 to 88) and 49.6 cm3 (SD 34.8, range 14.7 to 223.1), respectively. The mean preoperative value for Qmax, IPSS, and QOL score was 6.8 mL/s (SD 6.1), 18.7 (SD 6.9), and 4.5 (SD 1.2), respectively. Pressure flow studies were performed in 56 patients. The mean detrusor pressure at Qmax and Schafer grade was 81.6 cm H2O (SD 27.6) and 3.3 (SD 1.2), respectively. PERIOPERATIVE OUTCOMES All patients eventually became catheter free without additional surgery. The median total catheterization time was 3.0 days (mean 4.7, range 0 to 31; Fig. 1). Of the 70 patients who undertook the catheter-free trials, 27 (38.6%) were catheter free at postoperative day 1 (group 1). Of the remaining 43 patients who failed the catheter-free trial (group 2), 6 could not perform self-administered CIC. For 3 patients, nurses or caregivers performed CIC, and for the other 3 patients, a Foley catheter was again placed. In group 1, the preoperative prostate volume and postvoid residual urine volume were significantly smaller and the preoperative Qmax UROLOGY 64 (1), 2004
TABLE II. Preoperative factors independently predictive of successful catheter-free trials until postoperative day 1 Preoperative Characteristic
FIGURE 1. Kaplan-Meier estimates of postoperative catheter time.
TABLE I. Patient characteristics Preoperative Variable Age (yr) Prostate volume (cm3) Postvoid residual urine volume (mL) Qmax (mL/s) IPSS QOL Pdet Qmax (cm H2O) Schafer grade
Group 1 (n ⴝ 27)
Group 2 (n ⴝ 43)
P Value*
69.3 (9.2) 70.9 (8.2) 33.8 (16.1) 64.9 (41.5)
0.313 0.0014
45.3 (57.7)
0.006
9.6 20.3 4.6 71.7
146 (114)
(5.6) 3.8 (6.1) (6.9) 18.5 (7.2) (1.1) 4.4 (1.4) (17.3) 82.8 (24.9)
3.0 (1.0)
3.6 (1.2)
0.0006 0.717 0.681 0.188 0.114
KEY: Qmax ⫽ maximal urinary flow rate; IPSS ⫽ International Prostate Symptom Score; QOL ⫽ quality of life; Pdet ⫽ detrusor pressure. Data presented as mean values, with SD in parentheses. Group 1, patients catheter free until postoperative day 1; group 2, patients who failed catheter-free trial. * Two-sample t test and Mann-Whitney U test.
values were significantly greater than in group 2 (Table I). Univariate analysis showed that postoperative urinary retention was associated with a preoperative prostate volume of 30 cm3 or larger, Qmax of less than 6 mL/s, and postvoid residual urine volume of 100 mL or greater. Multivariate analysis showed that the preoperative prostate volume was the most statistically significant predictor of postoperative urinary retention (hazard ratio 2.42, 95% confidence interval 1.21 to 4.82, P ⫽ 0.012), and a postvoid residual urine volume greater than 100 mL and preoperative Qmax of less than 6 mL/s were not statistically significant in the presence of other factors (Table II). POSTOPERATIVE OUTCOMES The mean Qmax increased from 6.4 mL/s (SD 6.1) at baseline to 11.4 mL/s (SD 6.0) after 3 months. A statistically significant improvement occurred in the mean IPSS value from 18.7 (SD 7.0) at UROLOGY 64 (1), 2004
Univariate analysis Prostate volume ⱖ30 cm3 Postvoid residual urine volume ⱖ100 mL Qmax ⬍6 mL/s Multivariate analysis Prostate volume of ⱖ30 cm3 Postvoid residual urine volume ⱖ100 mL Qmax ⬍6 mL/s
Hazard Ratio (95% CI)
P Value
2.54 (1.42–4.54)
0.002
2.54 (1.48–4.37)
0.001
2.00 (1.20–3.33)
0.008
2.37 (1.23–4.57)
0.010
1.91 (0.96–3.81)
0.067
1.39 (0.72–2.68)
0.327
KEY: CI ⫽ confidence interval; Qmax ⫽ maximal urinary flow rate.
baseline to 9.6 (SD 4.9) after 3 months (P ⬍0.001). The QOL scores also improved significantly from 4.5 (SD 1.2) at baseline to 2.3 (SD 1.4) after 3 months (P ⬍0.001). After 6 months, prostate volumes decreased to 75.4% of the preoperative values (mean ⫾ SD 49.6 ⫾ 34.8 to 37.4 ⫾ 20.3 cm3, P ⬍0.001). The median follow-up time was 14 months (range 3 to 24). Eight patients (11.2%) continued alpha-1 adrenergic blockade therapy after interstitial laser coagulation for continued improvement. Only 2 patients (3%) underwent TURP during the follow-up period. Urinary infection was observed in 3 patients within 1 month after interstitial laser coagulation; they were treated with oral antibiotics. Postoperative severe bleeding occurred in 1 patient with an indwelling Foley catheter. Other adverse events, including urethral stricture, bladder neck constriction, and retrograde ejaculation, were not observed. COMMENT One of the problems associated with minimally invasive therapy is postoperative prostate swelling, because a common feature of minimally invasive therapy is the application of energy to the prostate to destroy the prostatic tissue surrounding the urethra in an attempt to reduce obstruction.1 Such prostatic swelling often results in postoperative urinary retention or prolonged indwelling catheter times. Arai et al.4 reported that the prostate volume increased by 25% 2 days after interstitial laser coagulation of the prostate. They also reported that urinary retention was observed after interstitial laser coagulation in 45% of patients and that the mean catheterization duration was 13.0 days (range 2 to 35) using either an indwelling Foley 81
catheter or CIC.4 Because the current catheterization time after TURP is short and most men void soon after catheter removal, the advantages of interstitial laser coagulation in terms of quality of life and cost effectiveness are eroded by prolonged catheterization. The intensive use of CIC could most effectively contribute to shortened catheter times, because catheterization would be finished soon after the postvoid residual urine volume became less than 100 mL. The present study demonstrated a median and mean total catheterization time of 3.0 and 4.7 days (range 0 to 31), respectively. Although the preoperative prostate volumes in this study were relatively large, the total catheter times were much shorter than in other reported series. Eighteen patients, who did not require indwelling catheters after interstitial laser coagulation with sacral anesthesia, were instructed in CIC and discharged on the operative day. Moreover, CIC could prevent the need for patients to return to the hospital because of dysuria or a sensation of postvoid residual urine after catheter removal and discharge. It is possible that CIC contributed to this shortened hospitalization time and, therefore, lowered costs. Alpha-1 adrenergic blockade therapy during postoperative retention might also have contributed to some degree to the shortened catheter times. It has been reported that alpha-1 blockers improve the overall chance of successful catheter withdrawal after acute urinary retention.5 However, because the efficacy of alpha-1 blockers before surgery was insufficient for the study patients, we could not determine whether alpha-1 adrenergic blockade therapy helped to achieve a shorter postoperative catheter time. More than 60% of patients in this study developed postoperative urinary retention. Smaller preoperative prostate volumes, smaller postvoid residual urine volumes, and larger preoperative Qmax values were observed in group 1 compared with group 2, and no statistically significant differences were observed in the other preoperative variables (Table I). As noted in Table II, a preoperative prostate volume of 30 cm3 or larger, a postvoid residual urine volume of 100 mL or larger, and a Qmax smaller than 6 mL/s were all associated with successful catheter-free trials. Of these factors, a preoperative prostate volume of 30 cm3 or larger was the most significant predictive factor of postoperative urinary retention. Therefore, patients with a prostate volume of 30 cm3 or larger should be informed about the high possibility of catheterization before interstitial laser coagulation of the prostate. The post-treatment catheterization times after minimally invasive therapy have recently been reported. Transurethral needle ablation can safely 82
treat patients under local anesthesia. Although an indwelling Foley catheter was not routinely used, 40% of patients required catheterization for posttreatment urinary retention.6 In recent reports, biodegradable or bioabsorbable urethral stents were successfully used to avoid post-treatment retention.7–9 However, CIC is preferable, because urethral stents might result in problems such as urinary tract infection, urgency, and discomfort. Therefore, using a common catheter with lower cost is a good way to make the most of interstitial laser coagulation. The major problem associated with instructing patients in CIC is the elderly age of most patients in need of treatment. In the present study, however, only 6 patients (8.6%) could not perform CIC because of a poor general condition (n ⫽ 2), weak vision (n ⫽ 1), or severe postoperative prostate swelling (n ⫽ 3). Biodegradable or bioabsorbable urethral stents would be helpful for such patients in preventing prolonged catheterization.7–9 Thus, the results of this study demonstrate an easy way to manage prostate swelling after interstitial laser coagulation. Because many patients could perform self-CIC without significant trouble, we believe that this postoperative management method will be useful for patients undergoing interstitial laser coagulation on an outpatient basis. However, the limitations of this study were primarily related to the small cohort number and the short follow-up period, because the long-term efficacy of interstitial laser coagulation remains unclear.3 Additional cases and follow-up studies are required to confirm these favorable results. CONCLUSIONS More than 60% of the patients observed in this study developed urinary retention after interstitial laser coagulation of the prostate. A preoperative prostate volume of 30 cm3 or greater was the most significant predictor of post-treatment urinary retention. However, post-treatment urinary retention after interstitial laser coagulation was sufficiently managed by CIC with alpha-1 adrenergic blockade therapy, and all patients who underwent this treatment became catheter free within a relatively short catheterization time. This method of postoperative management should be useful for patients undergoing interstitial laser coagulation on an outpatient basis. REFERENCES 1. Larson TR: Rationale and assessment of minimally invasive approaches to benign prostatic hyperplasia therapy. Urology 59(suppl 1): 12–16, 2002. 2. Arai Y, Okubo K, Okada T, et al: Interstitial laser coagulation for the management of benign prostatic hyperplasia: a Japanese experience. J Urol 159: 1961–1965, 1998. UROLOGY 64 (1), 2004
3. Costello AJ, Agarwal DK, Crowe HR, et al: Evaluation of interstitial diode laser therapy for treatment of benign prostate hyperplasia. Tech Urol 5: 202–206, 1999. 4. Arai Y, Kanba T, Ishitoya S, et al: Interstitial laser coagulation for benign prostatic hyperplasia: preliminary clinical results. Int J Urol 2: 104 –109, 1995. 5. McNeill SA: Does acute urinary retention respond to alpha-blockers alone? Eur Urol 39(suppl 6): 7–12, 2001. 6. Roehrborn CG, Burkhard FC, Bruskewitz RC, et al: The effects of transurethral needle ablation and resection of the prostate on pressure flow urodynamic parameters: analysis of the United States randomized study. J Urol 162: 92–97, 1999.
UROLOGY 64 (1), 2004
7. Laaksovirta S, Talja M, Valimaa T, et al: Expansion and bioabsorption of the self-reinforced lactic and glycolic acid copolymer prostatic spiral stent. J Urol 166: 919 –922, 2001. 8. Petas A, Talja M, Tammela T, et al: A randomized study to compare biodegradable self-reinforced polyglycolic acid spiral stents to suprapubic and indwelling catheters after visual laser ablation of the prostate. J Urol 157: 173–176, 1997. 9. Dahlstrand C, Grundtman S, and Pettersson S: Highenergy transurethral microwave thermotherapy for large severely obstructing prostates and the use of biodegradable stents to avoid catheterization after treatment. Br J Urol 79: 907–909, 1997.
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INTERMITTENT CATHETERIZATION TIME REQUIRED AFTER INTERSTITIAL LASER COAGULATION OF THE PROSTATE KOJI NISHIZAWA, TAKASHI KOBAYASHI, KENJI MITSUMORI, JUN WATANABE,
AND
KEIJI OGURA
ABSTRACT Objectives. To evaluate and minimize the duration of clean intermittent catheterization (CIC) required after interstitial laser coagulation of the prostate in patients with benign prostatic hyperplasia. Methods. Patients who did not show sufficient improvement in lower urinary tract symptoms or voiding dysfunctions with alpha-1 adrenergic blockers, and who agreed to undergo interstitial laser coagulation of the prostate, were enrolled in this study. Postoperatively, the indwelling Foley catheters were removed by the next morning. Patients were then required to undertake CIC with alpha-1 adrenergic blockade therapy until the postvoid residual urine volume decreased to less than 100 mL. Results. Seventy-nine patients underwent interstitial laser coagulation of the prostate, and 70 underwent catheter-free trials by postoperative day 1. The mean age and preoperative prostate volume of these 70 patients was 70.3 years (SD 8.7) and 49.6 cm3 (SD 34.8), respectively. Forty-three patients experienced postoperative urinary retention, and 37 of these underwent CIC. The median postoperative catheterization time was 3 days (range 0 to 31), and all patients eventually became catheter free. Univariate analysis showed that postoperative urinary retention was associated with a preoperative prostate volume of 30 cm3 or larger, a maximal flow rate of less than 6 mL/s, and a postvoid residual urine volume of 100 mL or greater. Multivariate analysis showed that a preoperative prostate volume of 30 cm3 or larger was the most significant predictor of postoperative urinary retention. Conclusions. More than 60% of the patients experienced urinary retention after interstitial laser coagulation of the prostate. However, the results of the present study suggested that CIC and alpha-1 adrenergic blockade therapy could manage post-treatment urinary retention with a relatively short catheterization time. UROLOGY 64: 79–83, 2004. © 2004 Elsevier Inc.
M
inimally invasive therapy is recommended for patients with symptomatic benign prostatic hyperplasia who are poor candidates for transurethral resection of the prostate (TURP), have had limited success with medications, or want to avoid long-term medications.1 Minimally invasive therapy offers patients with benign prostatic hyperplasia an alternative way to achieve substantial improvements in lower urinary tract symptoms and a better quality of life at an acceptable low risk of treatment-associated complications. Among minimally invasive interventions, interstitial laser coagulation of the prostate has been reported to yield From the Department of Urology, Hamamatsu Rosai Hospital, Shizuoka; and Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan Reprint requests: Koji Nishizawa, M.D., Department of Urology, Hamamatsu Rosai Hospital, Shogen-Cho 25, Hamamatsu, Shizuoka 430-8525, Japan Submitted: December 22, 2003, accepted (with revisions): March 5, 2004 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED
statistically significant improvements in both symptoms and voiding parameters with minimal morbidity.2 Interstitial laser coagulation of the prostate can be performed safely and easily under local or sacral anesthesia on an outpatient basis. However, despite these advantages offered, postoperative prostate swelling is still one of the major problems associated with this procedure because the management of post-treatment urinary retention can result in prolonged indwelling catheterization.2 Moreover, long-term catheterization after minimally invasive therapy tends to require more postoperative catheter-free trials compared with TURP. Fulfilling a short catheterization time is essential for obtaining a better postoperative quality of life and a shorter hospital stay, even on an outpatient basis. Although clean intermittent catheterization (CIC) might contribute to a shortened catheter time, to our knowledge, CIC after interstitial laser coagulation has never been studied. We 0090-4295/04/$30.00 doi:10.1016/j.urology.2004.03.009 79
report the results of our experience with interstitial laser coagulation and CIC. MATERIAL AND METHODS PATIENTS From November 2001 to August 2003, those patients who did not show sufficient improvements in lower urinary tract symptoms and voiding dysfunctions with alpha-1 adrenergic blockers, and who agreed to undergo interstitial laser coagulation of the prostate, were enrolled in this study. Patients with acute prostatitis, neurogenic bladder dysfunction, or prostate carcinoma were excluded. To rule out prostate cancer, all patients were screened preoperatively by digital rectal examination and prostate-specific antigen determination. Transrectal ultrasound-guided biopsies were performed in cases of suspected prostate cancer. Pressure flow studies were performed not only to exclude neurogenic bladder dysfunctions and acontractile overdistended bladders but also to assess urodynamic obstruction. All patients with clinical benign prostatic hyperplasia were initially treated with alpha-1 adrenergic blockade therapy. Patients who presented with acute urinary retention were also instructed in CIC. If patients had limited success with this treatment, interstitial laser coagulation was recommended and informed consent obtained after presenting the benefits and risks compared with TURP. The preoperative assessments included prostate volume estimated by transrectal ultrasound measurements, International Prostate Symptom Score (IPSS), disease-specific quality-of-life (QOL) score, maximal urinary flow rate (Qmax), postvoid residual urine volume, detrusor pressure at Qmax, and Schafer grade.
PROCEDURES Interstitial laser coagulation was performed with an Indigo 830j. Patients received sacral, spinal, or general anesthesia according to their level of risk. Suprapubic catheterizations were not conducted. All interstitial laser coagulation procedures were performed under direct vision using a cystoscope with warm normal saline irrigation. The right and left prostate lobes were punctured individually at an angle of 30° against the midline of the urethra; the middle lobe was also punctured.2 An interstitial laser light was emitted creating a conical radiation field, and the tissue was heated to 85°C.3 Laser coagulations were produced continuously in 1-cm proximal portions.2 The number of coagulations performed was determined by the prostate volume in cubic centimeters divided by 8. Postoperatively, Foley catheters were placed in patients undergoing interstitial laser coagulation under spinal or general anesthesia until the following morning, and postoperative antibiotics were supplied. A catheter was not placed in patients undergoing interstitial laser coagulation under sacral anesthesia. Patients were required to undertake CIC with alpha-1 adrenergic blockade therapy until the postvoid residual urine volume decreased to less than 100 mL and spontaneous voiding was guaranteed. If patients experienced dysuria or a sensation of residual urine, they were also required to perform CIC to ensure that the residual postvoid volume was less than 100 mL. Voiding diaries, including the postvoid residual urine volume, were used. The total catheterization time was counted until the last day that the residual volume was greater than 100 mL. If patients could not, or were unwilling to, undertake self-CIC, nurses or caregivers performed the procedure.
FOLLOW-UP The IPSS, QOL score, Qmax, and prostate volume were reassessed 3 months after surgery to evaluate the treatment 80
outcomes. The number of patients who received additional treatments was assessed.
STATISTICAL ANALYSIS The paired t test was used to analyze the postoperative improvements in Qmax and prostate volume, and the Wilcoxon matched-pairs signed-ranks test was used to evaluate the differences in the IPSS and QOL score. To evaluate the success of the catheter-free trial, preoperative values were compared for age, prostate volume, IPSS, QOL score, Qmax, postvoid residual urine volume, detrusor pressure at Qmax, and Schafer grade for the catheter-free patients by postoperative day 1 (group 1) and those who failed the catheter-free trial (group 2). The paired t test and Mann-Whitney U test were performed to assess the statistical significance of the observed differences between these two groups, with a significance level of P ⬍0.05. To predict the success of the catheter-free trials by postoperative day 1, univariate analysis using Cox proportional hazards models was performed to estimate the hazards ratios and statistical significance. Multivariate analysis was performed to assess the significance of each predicting factor while adjusting for the others. Each statistical analysis was performed using commercial statistical software.
RESULTS PATIENT CHARACTERISTICS Seventy-nine patients underwent interstitial laser coagulation of the prostate. Of the 79 patients, 70 performed the catheter-free trials, 7 were unwilling to perform CIC, and 2 had severe dementia. Patients who could not, or would not, perform CIC had indwelling Foley catheters for several days and then switched to CIC if necessary. Of the 70 patients, 1 had cerebrovascular disease, 6 myocardial disease, 1 Parkinson’s disease, 6 diabetes mellitus, and 8 had miscellaneous diseases. The mean patient age and preoperative prostate volume was 70.3 years (SD 8.7, range 50 to 88) and 49.6 cm3 (SD 34.8, range 14.7 to 223.1), respectively. The mean preoperative value for Qmax, IPSS, and QOL score was 6.8 mL/s (SD 6.1), 18.7 (SD 6.9), and 4.5 (SD 1.2), respectively. Pressure flow studies were performed in 56 patients. The mean detrusor pressure at Qmax and Schafer grade was 81.6 cm H2O (SD 27.6) and 3.3 (SD 1.2), respectively. PERIOPERATIVE OUTCOMES All patients eventually became catheter free without additional surgery. The median total catheterization time was 3.0 days (mean 4.7, range 0 to 31; Fig. 1). Of the 70 patients who undertook the catheter-free trials, 27 (38.6%) were catheter free at postoperative day 1 (group 1). Of the remaining 43 patients who failed the catheter-free trial (group 2), 6 could not perform self-administered CIC. For 3 patients, nurses or caregivers performed CIC, and for the other 3 patients, a Foley catheter was again placed. In group 1, the preoperative prostate volume and postvoid residual urine volume were significantly smaller and the preoperative Qmax UROLOGY 64 (1), 2004
TABLE II. Preoperative factors independently predictive of successful catheter-free trials until postoperative day 1 Preoperative Characteristic
FIGURE 1. Kaplan-Meier estimates of postoperative catheter time.
TABLE I. Patient characteristics Preoperative Variable Age (yr) Prostate volume (cm3) Postvoid residual urine volume (mL) Qmax (mL/s) IPSS QOL Pdet Qmax (cm H2O) Schafer grade
Group 1 (n ⴝ 27)
Group 2 (n ⴝ 43)
P Value*
69.3 (9.2) 70.9 (8.2) 33.8 (16.1) 64.9 (41.5)
0.313 0.0014
45.3 (57.7)
0.006
9.6 20.3 4.6 71.7
146 (114)
(5.6) 3.8 (6.1) (6.9) 18.5 (7.2) (1.1) 4.4 (1.4) (17.3) 82.8 (24.9)
3.0 (1.0)
3.6 (1.2)
0.0006 0.717 0.681 0.188 0.114
KEY: Qmax ⫽ maximal urinary flow rate; IPSS ⫽ International Prostate Symptom Score; QOL ⫽ quality of life; Pdet ⫽ detrusor pressure. Data presented as mean values, with SD in parentheses. Group 1, patients catheter free until postoperative day 1; group 2, patients who failed catheter-free trial. * Two-sample t test and Mann-Whitney U test.
values were significantly greater than in group 2 (Table I). Univariate analysis showed that postoperative urinary retention was associated with a preoperative prostate volume of 30 cm3 or larger, Qmax of less than 6 mL/s, and postvoid residual urine volume of 100 mL or greater. Multivariate analysis showed that the preoperative prostate volume was the most statistically significant predictor of postoperative urinary retention (hazard ratio 2.42, 95% confidence interval 1.21 to 4.82, P ⫽ 0.012), and a postvoid residual urine volume greater than 100 mL and preoperative Qmax of less than 6 mL/s were not statistically significant in the presence of other factors (Table II). POSTOPERATIVE OUTCOMES The mean Qmax increased from 6.4 mL/s (SD 6.1) at baseline to 11.4 mL/s (SD 6.0) after 3 months. A statistically significant improvement occurred in the mean IPSS value from 18.7 (SD 7.0) at UROLOGY 64 (1), 2004
Univariate analysis Prostate volume ⱖ30 cm3 Postvoid residual urine volume ⱖ100 mL Qmax ⬍6 mL/s Multivariate analysis Prostate volume of ⱖ30 cm3 Postvoid residual urine volume ⱖ100 mL Qmax ⬍6 mL/s
Hazard Ratio (95% CI)
P Value
2.54 (1.42–4.54)
0.002
2.54 (1.48–4.37)
0.001
2.00 (1.20–3.33)
0.008
2.37 (1.23–4.57)
0.010
1.91 (0.96–3.81)
0.067
1.39 (0.72–2.68)
0.327
KEY: CI ⫽ confidence interval; Qmax ⫽ maximal urinary flow rate.
baseline to 9.6 (SD 4.9) after 3 months (P ⬍0.001). The QOL scores also improved significantly from 4.5 (SD 1.2) at baseline to 2.3 (SD 1.4) after 3 months (P ⬍0.001). After 6 months, prostate volumes decreased to 75.4% of the preoperative values (mean ⫾ SD 49.6 ⫾ 34.8 to 37.4 ⫾ 20.3 cm3, P ⬍0.001). The median follow-up time was 14 months (range 3 to 24). Eight patients (11.2%) continued alpha-1 adrenergic blockade therapy after interstitial laser coagulation for continued improvement. Only 2 patients (3%) underwent TURP during the follow-up period. Urinary infection was observed in 3 patients within 1 month after interstitial laser coagulation; they were treated with oral antibiotics. Postoperative severe bleeding occurred in 1 patient with an indwelling Foley catheter. Other adverse events, including urethral stricture, bladder neck constriction, and retrograde ejaculation, were not observed. COMMENT One of the problems associated with minimally invasive therapy is postoperative prostate swelling, because a common feature of minimally invasive therapy is the application of energy to the prostate to destroy the prostatic tissue surrounding the urethra in an attempt to reduce obstruction.1 Such prostatic swelling often results in postoperative urinary retention or prolonged indwelling catheter times. Arai et al.4 reported that the prostate volume increased by 25% 2 days after interstitial laser coagulation of the prostate. They also reported that urinary retention was observed after interstitial laser coagulation in 45% of patients and that the mean catheterization duration was 13.0 days (range 2 to 35) using either an indwelling Foley 81
catheter or CIC.4 Because the current catheterization time after TURP is short and most men void soon after catheter removal, the advantages of interstitial laser coagulation in terms of quality of life and cost effectiveness are eroded by prolonged catheterization. The intensive use of CIC could most effectively contribute to shortened catheter times, because catheterization would be finished soon after the postvoid residual urine volume became less than 100 mL. The present study demonstrated a median and mean total catheterization time of 3.0 and 4.7 days (range 0 to 31), respectively. Although the preoperative prostate volumes in this study were relatively large, the total catheter times were much shorter than in other reported series. Eighteen patients, who did not require indwelling catheters after interstitial laser coagulation with sacral anesthesia, were instructed in CIC and discharged on the operative day. Moreover, CIC could prevent the need for patients to return to the hospital because of dysuria or a sensation of postvoid residual urine after catheter removal and discharge. It is possible that CIC contributed to this shortened hospitalization time and, therefore, lowered costs. Alpha-1 adrenergic blockade therapy during postoperative retention might also have contributed to some degree to the shortened catheter times. It has been reported that alpha-1 blockers improve the overall chance of successful catheter withdrawal after acute urinary retention.5 However, because the efficacy of alpha-1 blockers before surgery was insufficient for the study patients, we could not determine whether alpha-1 adrenergic blockade therapy helped to achieve a shorter postoperative catheter time. More than 60% of patients in this study developed postoperative urinary retention. Smaller preoperative prostate volumes, smaller postvoid residual urine volumes, and larger preoperative Qmax values were observed in group 1 compared with group 2, and no statistically significant differences were observed in the other preoperative variables (Table I). As noted in Table II, a preoperative prostate volume of 30 cm3 or larger, a postvoid residual urine volume of 100 mL or larger, and a Qmax smaller than 6 mL/s were all associated with successful catheter-free trials. Of these factors, a preoperative prostate volume of 30 cm3 or larger was the most significant predictive factor of postoperative urinary retention. Therefore, patients with a prostate volume of 30 cm3 or larger should be informed about the high possibility of catheterization before interstitial laser coagulation of the prostate. The post-treatment catheterization times after minimally invasive therapy have recently been reported. Transurethral needle ablation can safely 82
treat patients under local anesthesia. Although an indwelling Foley catheter was not routinely used, 40% of patients required catheterization for posttreatment urinary retention.6 In recent reports, biodegradable or bioabsorbable urethral stents were successfully used to avoid post-treatment retention.7–9 However, CIC is preferable, because urethral stents might result in problems such as urinary tract infection, urgency, and discomfort. Therefore, using a common catheter with lower cost is a good way to make the most of interstitial laser coagulation. The major problem associated with instructing patients in CIC is the elderly age of most patients in need of treatment. In the present study, however, only 6 patients (8.6%) could not perform CIC because of a poor general condition (n ⫽ 2), weak vision (n ⫽ 1), or severe postoperative prostate swelling (n ⫽ 3). Biodegradable or bioabsorbable urethral stents would be helpful for such patients in preventing prolonged catheterization.7–9 Thus, the results of this study demonstrate an easy way to manage prostate swelling after interstitial laser coagulation. Because many patients could perform self-CIC without significant trouble, we believe that this postoperative management method will be useful for patients undergoing interstitial laser coagulation on an outpatient basis. However, the limitations of this study were primarily related to the small cohort number and the short follow-up period, because the long-term efficacy of interstitial laser coagulation remains unclear.3 Additional cases and follow-up studies are required to confirm these favorable results. CONCLUSIONS More than 60% of the patients observed in this study developed urinary retention after interstitial laser coagulation of the prostate. A preoperative prostate volume of 30 cm3 or greater was the most significant predictor of post-treatment urinary retention. However, post-treatment urinary retention after interstitial laser coagulation was sufficiently managed by CIC with alpha-1 adrenergic blockade therapy, and all patients who underwent this treatment became catheter free within a relatively short catheterization time. This method of postoperative management should be useful for patients undergoing interstitial laser coagulation on an outpatient basis. REFERENCES 1. Larson TR: Rationale and assessment of minimally invasive approaches to benign prostatic hyperplasia therapy. Urology 59(suppl 1): 12–16, 2002. 2. Arai Y, Okubo K, Okada T, et al: Interstitial laser coagulation for the management of benign prostatic hyperplasia: a Japanese experience. J Urol 159: 1961–1965, 1998. UROLOGY 64 (1), 2004
3. Costello AJ, Agarwal DK, Crowe HR, et al: Evaluation of interstitial diode laser therapy for treatment of benign prostate hyperplasia. Tech Urol 5: 202–206, 1999. 4. Arai Y, Kanba T, Ishitoya S, et al: Interstitial laser coagulation for benign prostatic hyperplasia: preliminary clinical results. Int J Urol 2: 104 –109, 1995. 5. McNeill SA: Does acute urinary retention respond to alpha-blockers alone? Eur Urol 39(suppl 6): 7–12, 2001. 6. Roehrborn CG, Burkhard FC, Bruskewitz RC, et al: The effects of transurethral needle ablation and resection of the prostate on pressure flow urodynamic parameters: analysis of the United States randomized study. J Urol 162: 92–97, 1999.
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7. Laaksovirta S, Talja M, Valimaa T, et al: Expansion and bioabsorption of the self-reinforced lactic and glycolic acid copolymer prostatic spiral stent. J Urol 166: 919 –922, 2001. 8. Petas A, Talja M, Tammela T, et al: A randomized study to compare biodegradable self-reinforced polyglycolic acid spiral stents to suprapubic and indwelling catheters after visual laser ablation of the prostate. J Urol 157: 173–176, 1997. 9. Dahlstrand C, Grundtman S, and Pettersson S: Highenergy transurethral microwave thermotherapy for large severely obstructing prostates and the use of biodegradable stents to avoid catheterization after treatment. Br J Urol 79: 907–909, 1997.
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