The prostate (from Greek prostates, literally "one who stands before", "protector", "guardian") is a compound tubuloalveolar exocrine gland of the male reproductive system in most mammals (1). The function of the prostate is to secrete a slightly alkaline fluid, milky or white in appearance, that usually constitutes 20–30% of the volume of the semen along with spermatozoa and seminal vesicle fluid. The prostate, prostatic urethra and the bladder neck play a critical role in the normal delivery of the sperm in the sexual act. It is one of the common sites for infection and benign and malignant neoplasms; so it has become an organ of clinical interest. Benign Enlargement of Prostate (BEP) is one of the most common diseases that affect men beyond their middle age. These patients generally present with the lower urinary tract symptoms. Studies have reported increase in the prevalence of lower urinary tract symptoms (LUTS) with age (2).  As in majority of the patient’s symptoms are gradually progressive over the time, few patient presents with acute symptoms like urinary retention. Treatment aims at alleviation of the LUTS, improvement in the quality of life and patient satisfaction. Treatment options include watchful waiting, medical management and surgical intervention.

Medical management of the BEP has been a recent concept and data on long term efficacy of the drugs is limited. TURP has remained time tested procedure of choice. In spite of technological advances and availability of recent techniques like Trans-Urethral Nuclear Ablation (TUNA) & Holmium LASER evaporation of Prostate (HOLEP); Trans-urethal resection of Prostate (TURP) remains gold standard surgery for BEP. Outcome of these recent procedures are measured in comparison with TURP. Though majority patients report significant relief in the symptoms after TURP; however, some still remain unsatisfied. 

TURP is associated with its own set of risks and complications. Long term complications of TURP are well reported (3)(4). Though there have been few studies on the long term outcome and complications of TURP had been done in the western world; Indian data in this regard is lacking. This inspired us to study the long term outcomes of TURP at a community hospital.

The study was conducted at a community hospital. A retrospective analysis of all the patients of BEP undergone TURP at the BARC hospital between January 2004 and August 2006 was performed. They were enrolled after a valid informed consent. The project was approved by IEC (Institutional Ethical Committee).

Information was collected from the individual patient records maintained in in a computerized hospital management and information system. Ultrasound reports, cystoscopy reports, operative notes and consultation notes were used to gather necessary information.  Detailed history of each patient was taken. Presenting complaints were noted and IPSS score was calculated prior to the surgery. IPSS was divided into mild (0 to 7), moderate (8 to 19) and severe (20 to 35) grades (5). IPSS can also be divided into two groups: Obstructive scores and irritative scores (6). All patients were subjected to DRE (Digital Rectal Examination) and if the prostate was large or nodular then they were investigated by Serum PSA levels and TRUS (Trans-rectal ultrasound) guided biopsy six core biopsy. Otherwise, they were subjected to abdominal ultrasonography to assess full Bladder Capacity (FBC), size of the prostate gland and post void residue of urine (PVR) was also recorded. Prostate size was measured using abdominal ultrasonography. Few patients who had initially undergone trans-rectal ultrasound (TRUS) were followed up with abdominal ultrasonography. We reserve TRUS only for the patients whose DRE findings/PSA levels/Abdominal ultrasound findings suggest the possibility of prostate cancer. Each patient was subjected cystoscopy prior to surgery and findings were recorded in the proforma. Each patient was operated at a community hospital by a single surgeon using a Gyrus plasmakinetic unit with Karl Storz 3 chip video camera for every TURP. 26 F resectoscope was used for every patient. A dorsal internal urethrotomy was done only if required. Average resection time was approximately 60 minutes. Normal saline was used as irrigation fluid for each surgery. Post operatively a per urethral Foley‘s catheter was kept with 30cc balloon under traction. Traction was removed and balloon was deflated by 5 cc after 24 hrs. Duration of per urethral catheter was varying for each patient with average of 5 days.

Post-operatively each patient was clinically followed up at one month, three months and five years and at every follow up visit data was collected with respect to their symptoms based on IPSS. Also complications, if any, were recorded during this duration. Cystoscopy was advised only if clinically indicated. Following complications were considered in the study: Urethral stricture, Re-do TURP, Incontinence, Impotence and Ejaculatory disorders.

Table 1: Timeline IPSS: Age wise

       Age does neither affect IPSS pre-operatively nor affects the outcome of the surgery.

Table 2: SITE OF STRICTURE AND ITS RATE OF OCCURANCE

BMJ (junction of bulbar and membranous urethra) was seen as a most common site of stricture occurrence. However, six patients had strictures at more than one site.

In the above graph, it is seen that there is definite decrease in the obstructive scores and 5 years post TURP surgery. However, the fall is not linear. It is seen that, the degree of fall is more with the higher pre-operative scores. So, it can be said that TURP is more beneficial to the patients who have higher pre-operative obstructive scores.

In the above graph, it is seen that there is definite decrease in the irritative scores pre operatively and 5 years post operatively after the TURP surgery. However, the fall is almost linear. It is seen that patients who were presented with higher pre-operative irritative scores are left with higher 5 year’s post-op scores.

AGE

The mean age of total patients included in the study was 69.77 yrs. The age of patients ranges between 57 to 85 years. Maximum numbers of patients were falling in the age group of 71-75 years. However, age does not seem to have any significant effect on the outcome of TURP surgery even at the end of five years. Even an old man gets benefited equally from TURP provided patients are carefully selected with due precautions (5).

IPSS Score:

From a pragmatic point of view; studies of symptom severity and its frequency are of greatest importance in a disease that is rarely fatal and is characterized by its effect on quality of life (6). 

The development, validation, translation with cultural and linguistic validation of standardized, self-administered seven-item American Urological Association (AUA) symptom index (also known as the International Prostate Symptom Score [IPSS]) has been a pivotal event in the research of LUTS and BEP. (7) (8)

Socioeconomic factors do not seem to influence response to the questionnaire (Moon et al 1994) and fundamentally similar responses were obtained when the questionnaire is self-administered, read to the patient, mailed in or administered in some other way (9) (10). 

We were aware of the fact that the subtle differences in the comprehension as well as different perception of the symptoms and willingness to admit to symptoms do exist.  Hence each questionnaire was surgeon administered. However, there is generally no significant difference between self-administered and surgeon administered IPSS scores. (11) (12)  

The mean IPSS score of all patients included in the study pre-operatively was 18.01. Post operatively the average scores have come down to 8.97, 6.88 and 8.1 at one month, three months and five years respectively.  Although the improved IPSS 3 months gradually deteriorated as time passed, those at 5 years were still significantly better than those at baseline. The IPSS in patients without predominant obstructive component deteriorated faster than in those with it. Similar findings were observed in other studies (13). At Korean medical center it was found that degree of improvement in Q-max and IPSS was statistically significantly greater in definite bladder outlet obstruction group. Though the benefit was more in the group of patients with predominant obstructive scores; (14) regardless of the predominance of obstructive or irritative preoperative scores, the IPSS remained improved for 5 years as also seen in other studies. (15)

 It is observed that patients with a greater preoperative IPSS gained the most symptomatic benefit. Similar results were obtained by study conducted at Mersin University School of Medicine, Mersin, Turkey which predicted a symptomatic improvement of more than 7 points with high sensitivity (16).  22 out of 70 patients had presented with acute urinary retention preoperatively. There was no significant difference in the outcome of the TURP surgery at the end of 5 years in this group. Similar results were observed in the study conducted by Roger S Kirby(17).

COMPLICATIONS

The major complication of the TURP was urethral stricture formation. Site of the stricture was varying. Despite improvements in surgical techniques, lubricants, instruments, and electrical technology, the incidence of urethral strictures did not change significantly. Theoretically, bipolar technology or laser minimizes the risk of a urethral stricture (18).

Varkarakis et al. has done a 10 year follow up study on morbidity and mortality of TURP. Study included 1221 patients operated between January 1988 and July 1991with the patient‘s age varying from 41-91 years (Mean 70.4). Patients with prostate or bladder cancer were excluded. Each patient received prophylactic antibiotic and surgery was done with 24 F resectoscope. Sorbitol+ Mannitol were used as irrigation fluid and post operatively patients were put on 18-20 F Foley‘s catheter. 541 patients were lost to follow up in 10 years and only 577 patients could be followed. Out of 577, 35(6%) patients required repeat TURP surgery, 14(2.4%) developed bladder neck stenosis and10 (1.7%) needed surgery for urethral strictures. Unlike other authors who carry out minimal resection of the prostate; complete resection was performed in all patients (19). Some studies have reported even reoperation rates of 15.5% are reported (20).

Borboroglu et al. has done a study on immediate and postoperative complications of TURP in the 1990s. A retrospective analysis was done of 520 patients undergoing TURP at a single institute between 1991 and 1998. Average age was 67 (range 44-89) years. Pre-op antibiotic prophylaxis was administered. 24-26 F resectoscopes were used. Late postoperative complications were observed in 8.5% patients.  Out of them, bladder neck contractures were seen in 11 patients (2.1%) and urethral stricture in 5 (1.0%). Re-do TURP was needed for 13(2.5%) patients (21)

In a study by Wasson et al 242 patients were operated for TURP with mean age of 66 years. Within three years after surgery, nine men had a contracture of the bladder neck requiring endoscopic surgery (3.72%), nine had a urethral stricture that required dilation (3.72%), and eight underwent a second transurethral resection (3.31), four because of adenocarcinoma. No man underwent more than one dilation or more than two transurethral resections (22).

Second commonest complication encountered was ejaculatory disturbances. However, far less people have actually reported with this complication. Most of the patients have agreed during the interview that they have developed some kind of ejaculatory disturbance post op. Social and cultural inhibitions could be playing a role in inhibiting such patients to report these problems to the hospital.  Out of 70 patients included in the study only 38 were sexually active (54.29%). Out of them 14 people have developed ejaculatory disturbances (retrograde ejaculation). Similar findings were seen by Michael Muntener and Sonja Aellig in their study where they have confirmed this well-known effect of TURP (23).

Re-do TURP was also seen as an important complication. However, age or the pre-op prostate volume was not seen to be affecting the incidence of this complication. However, in a study done by Rehmatullah Soomro; Javed Rajput; Ghulam Akbar Arain, it is seen that resection speed is much higher (four times) with the hands of experienced surgeon and also chance of need of a re-do TURP is significantly lesser (24).

TURP remains the gold standard procedure in the treatment of BEP and TURP operated patients remain benefited even at the end of 5 years after surgery. TURP benefits more to the patients with moderate to severe symptoms compared to those patients with milder symptoms. TURP benefits more to the patients in the group with predominant obstructive symptoms. Age and Prostate volume did not correlate with severity of symptoms or long term outcome of surgery. Stricture, Incontinence, Retrograde ejaculation (Ejaculatory disturbances) and Re-do TURP were most commonly observed complications. Stricture formation rates and Re-do TURP rates were not dependent on age or prostate volume.

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