Early and late complications of TURP
Artykuł opublikowany w Urologii Polskiej 2006/59/1.

autorzy

Imre Romics: Department of Urology
Semmelweis University, Budapest, Hungary

słowa kluczowe

przezcewkowa elektroresekcja stercza (TURP), powikłania

streszczenie

In this article based on review of literature and own experience of the author the most frequent early and late complications of transurethral resection of the prostate (TURP) and their incidence are presented. Moreover, the paper contains some prophylactic measures to avoid or prevent complications.

TURP is one of the most often procedures performed in urology. However it is not free of the complication risk. Intraoperative and early postoperative bleeding is one of the most frequent complications. It can be minimalized with proper technique of resection and use of modern equipment with coagulating-intermittent-cutting. Administration of finasteride for several months before TURP may cause lower bleeding during the procedure. TUR-syndrome, being the result of intravenous flow of irrigation with subsequent dilutional hyponatremia is the most serious intraoperative complication. Fortunately, in recent years it occurs in small proportion of the patients. It can be prevented with low intravesical pressure resection and with use of isoosmotic irrigation fluids.

Urethral stricture located mainly in bulbar urethra is one of the most frequent late complications. The risk of postoperative stricture can be lowered by prophylactic urethrotomy. Urine incontinence occurs very rarely, however it is terrible for the patient. One way to avoid the damage to the external urethral sphincter is to perform TURP with care in distal part of prostatic adenoma.

Early complications
The most frequent early complications are the bleeding requiring transfusion or not, and TUR syndrome. Horninger et al. [4] analysed 1.211 consecutive patients who underwent TURP: the mortality rate was 0.0%, intraoperative and early postoperative (within 4 weeks after the procedure) complications listed in tables 1 and 2 occured in 8.9% and in 15,8% of patients respectively.
What are the risk factors of these complications?
The most important factor is age of patients. The rate of postoperative complications rises by age (table III) [5]. Patients less than 65 years have early complication in 0.09%, whereas older in 0.33%. The rate of patients discharged with catheter are also different by age: less than 65 years 0.8%, more than 65 year 3.0% (p=0.005). However, there are no differences in the two age groups in relation to renal insufficiency, urinary tract infection, cardiovascular or pulmonary complications.
In our department between 1998. and 2004. 49 patients more than 90 years old underwent transurethral resection due to benign prostate hyperplasia, prostate cancer or bladder cancer and no one of them died postoperatively. The medical history is also important: cardiac failure has no impact whereas pulmonary diseases have a high impact on the rate of complication. Acute urinary retention (AUR) in the urological past history is an important risk factor. Patients with AUR had a postoperative UTI rate of 4.3 %, compared to 1.5 % among those without retention. There was no difference in the comparative time of catheter removal after TURP. Among the patients with and without retention the over-all rate of postoperative complications was 24% and 15.7%, while the rate of failure to void was 11% and 3.6 %, and the incidence of hypotonic bladder was 8.4% and 1.7% respectively.
The preoperative serum creatinine level also influences the rate of postoperative complications. If it is elevated the mean rate of complications is 4.1%, whereas in patients with serum creatinine in normal range only 0.7%. The risk of complications is also influenced by postoperative care of patients underwent TURP. The rate of complications in patients with elevated creatinine level operated on in 1962 and in 1999 was 2.5% and only 0.25% respectively.
The prostate volume and resection time are important risk factors of complications (table IV and V) [6].
Late complications
The patients are mostly bothered after TURP by incontinence. Wasson et al. [7] analysed 7.055 patients and found that 1.0% of them had total urinary incontinence attributed mostly to technical failures, 2.2% of patients claimed about stress incontinence which could be attributed to any operative technical failures or to other causes as infection, stone, incoplete TURP (residual prostatic adenoma tissue), and chronic prostatitis.
The urethral stricture and the bladder neck contracture are one of the most frequent postoperative complications. Lentz [8] collected data from 12.003 patients has been published in various journals. Among those patients the urethral stricture was proven in 3.1% (0.5-9.7), bladder neck contracture 1,7% (1.3-2.1), and both complications in 3.7% (0.7-10.1). The most frequent localisation of urethral stricture is bulbar part of the urethra (table VI). Typical stricture of the urethra is demonstrated by urethrography (Fig. 1).
Horninger et al. [4] analysing their series of 775 men submitted to TURP found urethral stricture in 3.7%, UTI 3,9%, bladder neck contracture 1.9% and late postoperative bleeding 1.7% of patients.
The potency after TURP has been studied by the number of authors and there is no evidence of correlation between TURP and impotence. The retrograde ejaculation is mostly associated to TURP in 60-80% of the cases. It cannot be avoided but the patient should be informed on the risk of the complication before operation.
The technique of TURP is well established but depends on the skill and experience of urologist, therefore some of the patient has to undergo to repeated operation. Roos and Ramsey [9] reviewed the fates of 1.885 patients. Within one year 2,3-4,3% of them were re-operated. The repeated TURP performed 5 years after primary one was carried out in 8,9-9,7%, whereas after 8 years in 12.0-15.5% of the patients. The mean re-operation rate in different publications is defined as 5-10% in consecutive 5-years periods.
Final remarks
Some of many different causes of complications after TURP are listed below:
n transurethral insertion of the resectoscope without optical control,
n not enough lubricant injected into the urethra,
n improper technique used,
n decreased body temperature,
n high intravesical pressure,
n infection during TURP,
n no antibacterial prophylaxis i perioperative period.
Almost all of them are discussed widely but body temperature is not in front.
How decreasing of body temperature during the procedure could be avoided? There are some rules to prevent it:
n draping should not be wet,
n intravenous infusion fluids must be at body temperature,
n optimal room temperature in the operation theatre,
n irrigation fluids temperature must be 41-42oC,
n Warning! The thermometer measures the temperature of the irrigation fluid at the level of the reservoir, whereas temperature of fluid going to the bladder is lower!

To prevent TUR-syndrome we have to take care on the pressure and flow of the irrigation fluid (constant flow, maximum 30 cm H2O). In order to prevent high irrigation fluid pressure Iglesias type of resectoscope with constant outflow should be used or suprapubic percutaneous cystostomy in selected cases should be performed.
The incontinence is the most terrible complication. Respect to the resection border line at the verumontanum level is important. For beginners to mark this border with resectoscope loop is advised.
To prevent urethral stricture a prophylactic meatotomy and urethrotomy in selected cases should be advised. Bladder neck contracture is mostly associated to resected volume less than 10 g. The use of resectoscope with rotation tube prevents any lesion of the urethral urothelium.
Some factors can reduce the indication of TURP resulting in less complication (table VII). The most important factor to decrease the complications is the experience. Some new methods, as for instance transurethral vaporisation-resection of the prostate [10] or coagulating-intermittent-cutting reduce the intraoperative and postoperative blood loss [11,12,13]. Sandfeldt et al. [14] and Donohue et al. [15] et al. advise preoperative 3 month finasteride treatment to reduce bleeding and blood loss.

piśmiennictwo

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