Introduction to DSTURP

Transurethral resection of the prostate (TURP) using electrocautery has long been regarded as the gold standard for the surgical management of bladder outlet obstruction, by which all others treatment methods should be compared. Sometimes an enlarged prostate can press against the urethra, causing the passage of urine to be partially or wholly blocked. TURP involves using a thin tube, passed up through the urethra, to see and remove the blockage. As the technique has improved over the years, the length of time an individual spends in the hospital after the operation has been considerably reduced, and recent attention has been given to TURP performed as day surgery.

Enlarged prostate restricting urine flow


Patients and methods

All the patients considered for DSTURP are private referrals from their General Practitioners with symptoms of difficulty passing urine, failed management with medications or the sudden development of retention of urine on a background of obstructive bladder symptoms and failure to pass urine. All patients were seen in consulting rooms prior to being admitted for the procedure. They were all assessed by history and examination. A scoring system called the AUA (American Urological Association) symptom index and urine analysis formed part of this assessment. Urine was only sent for analysis if indicated by being positive in two out of three of the following: nitrites (an indication of urinary tract infection), leucocytes (white blood cells) and blood. The patients all had blood tests including: Full Blood Examination, Urea, Electrolytes, Creatinine estimations (related to kidney function) and Prostate Specific Antigen (PSA).

All patients also underwent imaging of the upper urinary tract by ultrasound and patients with no bladder catheter (thin, sterile tube inserted into the bladder to drain urine) had bladder volumes measured. The patients’ whose bladder volume was estimated at greater than or equal to 200ml after passing urine, (before the operation), were informed that they would be discharged home with a catheter in place for 3-4 weeks. This would be set on free drainage to assist the bladder to regain its tone. Patients with a catheter in place were then subsequently admitted to Day Surgery for removal of the catheter. An ultrasound was performed after passing urine to estimate the amount of residual urine. Patients who were on aspirin continued taking the medication throughout the operative period and the study did not show any adverse consequences. Patients on anticoagulants (medications used to thin the blood, such as Warfarin – coumarin derivatives) had the medication ceased prior to the operation and re-commenced three to five days after the operation. The factors used to help determine whether patients would have a day surgery were based on the patients’ general medical conditions and fitness for general anaesthesia. . All patients were assessed by their Anaesthetist (a doctor who uses medications to reduce bodily sensations and pain, with or without loss of consciousness) before the operation. Consent to carry out the procedure was obtained after a full discussion of the procedure and likely events that would occur after the operation.

The patient was also informed of the likely costs and provided with a brochure covering topics such as post-operative advice on self-care in the immediate period after discharge. The patients fasted for 6 hours prior to the anticipated time of surgery. They were not given any medications to take prior to the procedure and most procedures were carried out under General Anaesthesia (i.e. patients were put to sleep using a combination of medications). All patients were given one dose of antibiotics (Gentamicin 240mg IV stat) before the procedure, to help prevent any infection. The decision to remove the catheter from the bladder was based on factors including: the degree of mental alertness, adequacy of pain relief and fluid intake and the colour of the drainage of bladder contents. The patients who underwent spinal anaesthesia were required to be able to weight bear on their legs and walk unassisted. The catheter was usually removed 2-3 hours after the operation, the intravenous fluids running into the veins stopped (after 1-2 litres) and the patients encouraged to consume fluids orally, through the mouth. They were then further monitored, being allowed to get dressed and sit in recliner chairs and eat solid food in the form of sandwiches. Monitoring of their fluid status continued and bladder volumes after passing urine were measured using the Bard Bladder Scan 2500TM.


Results

Day surgery transurethral resection of the prostate (DSTURP)The results are shown in Table 1. Before the operation, it had been decided to discharge patients (44) with greater than 200ml in the bladder after passing urine, with a catheter inserted. This was to help promote a regain of tone in the bladder. All of these patients were successfully passing urine normally after the four weeks. Of the remaining 215, 64 (30%) of patients required another catheter to be inserted into the bladder. Six of those catheters were removed the same day. The patients passed urine successfully and were discharged without a catheter. In 26 patients the catheter remained in place and the patient was discharged home overnight. The patients were then readmitted the following morning for removal of their catheter. Catheter re-insertion was not required for these patients. Five patients’ catheters were removed within 72 hours and the remaining 27 (12.6% of those in whom we had hoped to send home catheter-free) patients were deemed to have bladders which had low tone (i.e. the muscles were more relaxed) and were discharged home with the catheter for four weeks. All passed urine successfully upon the removal of the catheter. After the operation four repeat procedures in addition to 11 (4.2%) Bladder Neck Incisions for Bladder Neck Stenosis (tightening / narrowing of the bladder neck) were performed.

There was also 23 (8.8%) incisions of the urethra (tube carrying urine from the kidneys to the bladder), for narrowing of the urethra after the operation. In all cases, there was a significant amount of inflammation found in the bladder, which may have contributed. No patients developed any complications requiring admission to hospital and no patients required blood transfusion or developed infection in the bloodstream. There were no cases of retention of clots.


Discussion

While there have been a number of papers produced to demonstrate to the efficacy of alternative surgical treatments in the treatment of obstruction of the bladder, none of the work has been carried out in a Day-Surgery setting. The time that a bladder catheter needs to remain in place is the key factor related to the length of stay after any procedure to remove part of the prostate gland. This is determined by the amount and duration of bleeding that occurs after the operation, which is considered acceptable before the catheter is removed. DSTURP performed in the conventional manner has significant advantages. These include the cost of set up (including building usage and space for alternative procedures) and costs per case. All the newer modalities which have been reported to cost less per case than conventional TURP have been done so based only on a shorter length of stay in hospital. When the conventional procedure can be carried out as a day case with a documented length of mean stay 10.6 hours, there does not appear to be an advantage when compared to the more expensive newer procedures. A significant number of patients are electing to have surgical procedures which they pay for out of pocket, with no health insurance cover. The ability to carry out surgical procedures safely and effectively in the day-surgery setting makes that a reality. By having procedures done in this manner, it reduces the waiting time for the procedure (usually 1-2 weeks after the initial consultation). It also takes the "pressure" off the public waiting list, which sometimes may require patients to be transported to the state capital for procedures. This can be for a period of up to 4 weeks, often with the requirement that a "carer" accompany the patient.


Table 1: Results of patients undergoing DSTURP 

Number of patients 259
Age (years) 69 (48–87)
AUA score 22 (3–35)
G.A. 205
S.A. 54
Resection weight (g) 14 (3–80)
Blood loss estimated (mL) 80 (10–200)
Length of catheterisation (hours) 2.9
Post-micturition residual (mL) 38
Re-insertion of catheter 64 (30%)
Patients discharged electively with catheter 44 (17%)
Average length of stay at day surgery (hours) 10.6


(Article kindly contributed by Dr Neil S.I. Gordon, MBBS (Melb.) FRCS (Glasg.) FRCSEd. FRACS FICS, Urologist, Cairns Urology and Cairns Day Surgery, Editorial Advisory Board member of the Virtual Cancer Centre.)

More information

Prostate cancer  For more information on prostate cancer, including diagnoses, types of treatments, and some useful tools, videos and animations, see Prostate Cancer.

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