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January 2005, Volume 55, Issue 1

Original Article

Benign Prostatic Hyperplasia: mode of presentation and postoperative outcome

Masha Khan  ( Departments of Urology, Bolan Medical College and Sandeman Teaching Hospital, Quetta. )
Abdul Latif Khan  ( Departments of Surgical Unit III, Bolan Medical College and Sandeman Teaching Hospital, Quetta. )
Saadat Khan  ( Departments of Urology, Bolan Medical College and Sandeman Teaching Hospital, Quetta. )
Haq Nawaz  ( Departments of Urology, Bolan Medical College and Sandeman Teaching Hospital, Quetta. )

Abstract

Objective: To find out various modes of benign prostate hyperplasia (BPH) presentation in our region and their relation to postoperative failure to void after transurethral resection of prostate (TURP).
Methods: A study was conducted at Urology Department, Sandeman Teaching Hospital Quetta and Akram Hospital (Private) Quetta from January 2000 to December 2003. All BPH patients in whom the primary mode of presentation was accurately determined and later on underwent TURP were included in the study. Four modes of presentation were defined: (1) lower urinary tract symptoms (LUTS), (2) acute retention, (3) chronic retention and (4) and acute on chronic retention. After relevant investigations all these patients underwent TURP. Postoperatively catheter was removed when the urine was clear, usually within 48 hours of operation. Patients failing to void were recatheterized and given a second trial without catheter (TWOC) at third day of recatheterization. Resumption of spontaneous voiding on either the first or second TWOC was defined as “successful TWOC". Failure to void on second TWOC was defined as "failure to void" and was managed by a six week period of catheterization, followed by an additional TWOC. Statistical analysis was used to see any significant relation of failure to void postoperatively to mode of presentation of BPH, age of the patients and weight of the resected prostatic tissues.
Results: A total of 345 BPH patients were included in the study. Of these 270 (78.3%) patients presented with urinary retention and 75 (21.7%) with lower urinary tract symptoms (LUTS). Patients who presented with retention were acute retention 129 (37.4%), chronic retention 81(23.5%) and acute on chronic retention 60 (17.4%). The proportion of men failing to void after TURP was significantly higher (P <0.05) in those with (I) acute retention as compared to LUTS (ii) chronic retention compared to acute retention and (iii) acute on chronic retention as compared to acute retention. The proportion of men failing to void postoperatively was highly significant (P <0.005) in those with retention of any type as compared to LUTS. Age of the patients and weight of the resected prostatic tissues were found not significant factors in relation to failure to void postoperatively.
Conclusion: BPH patients in our region present very late, most of them (>78%) with complication of urinary retention. Mode of presentation of BPH greatly influences the postoperative outcome of this disease. Patients presenting with complications of chronic and acute on chronic retention have less favourable results regarding postoperative voiding after TURP. Moreover age of the patient and weight of the prostate are not significant factors in relation to failure to void postoperatively (JPMA 55:20;2005).

Introduction

Benign Prostatic Hyperplasia (BPH) and its related signs and symptoms are extremely common among elderly men, suggesting it to be a natural concomitant of aging.1 This is specially true in our region with less health awareness where bothersome lower urinary tract symptoms ( LUTS) in aging men are taken for granted as old age sequelae. Scarce health resources and economic constraints cause further delay in presentation and treatment.
In western world more than 90% patients of BPH are treated based on symptoms severity and the degree to which a patient is bothered by his symptoms.2 In contrast to this 70-80% patients of BPH in developing countries seek medical advice only when they get complications of the disease.3,4
Various complications of long standing untreated BPH include acute and chronic urinary retention, recurrent urinary tract infections, secondary bladder stones and diverticuli, upper urinary tract dilatation and renal insufficiency.5,6 Long standing obstruction due to BPH causes ischemia7, excessive collagen deposition8 and certain changes in neuromuscular tissues of urinary bladder9 which may also affect postoperative outcome of this disease. Impaired detrusor contractility has been reported in men with long standing BPH and patients with this finding achieve a less satisfactory outcome after surgery.10
The aims of the study were to determine the ratio of various modes of BPH presentation in our region and their relation to postoperative failure to void after transurethral resection of prostate.

Patients and Methods

This study was conducted at Urology Department Sandeman Provincial Teaching Hospital, Quetta and Akram Hospital, Quetta from January 2000 to December 2003. All BPH patients in whom the primary mode of presentation was accurately determined and later on underwent transurethral resection of prostate (TURP) were included in the study.
In addition to mode of presentation of BPH, age of the patients, weight of resected prostatic tissues and results after trial without catheter (TWOC) were recorded. Four modes of presentation of BPH were defined: lower urinary tract symptoms (LUTS), acute retention, chronic retention and acute on chronic retention. Routine ultrasound examination of kidneys and bladder to assess postvoid residual urine volume was obtained in patients presenting with lower urinary tract symptoms (LUTS) and all patients in this diagnostic category had a postvoid residual urine less than 500ml. The definitions for retention of urine were based on those used by Hamm & Speakman11 and the residual urine volumes recorded were those drained by catheterization at initial presentation. Acute retention was defined as a painful inability to void with a urine volume on catheterization of less than 1000ml. Chronic retention was defined as the presence of postvoid residual urine volume greater than 500ml (estimated on bladder ultrasound scan ) with or with out upper tract dilatation on ultrasound and / or renal function deterioration occurring in a patient who was still able to void spontaneously (frequent small quantity and even continuos dribbling due to over flow incontinence) and acute on chronic retention was defined as painful inability to void with a urine volume on catheterization of greater than 1000ml.
Complete medical history was taken for all patients and International Prostate Symptoms Score (I-PSS) questionnaire was filled for those presenting with lower urinary tract symptoms (LUTS). Physical examination including digital rectal examination (DRE) done in each patient. Ultrasonography of kidneys, bladder and prostate was carried out for all patients and for postvoid residual urine for those presenting with LUTS. Intravenous urography and urethrography was performed in selected patients where it was indicated. Uroflometry in patients with LUTS could not be performed due to unavailability of a uroflowmeter.
All patients were operated on by one of three consultant urologists and one consultant general surgeon highly experienced in endoscopic urological procedures. The prostatic tissues resected were sent to histopathological department for determining the total weight of the tissues and histopathological findings. Patients who had Ca prostate, neurological deficits, complicated diabetes mellitus or associated stricture urethra were excluded from the study.
TURP was done usually on the next available operating list in all those patients who had normal renal functions but for those with an elevated serum creatinine, TURP was performed when the creatinine had stabilized. Postoperatively catheters were removed when the urine was clear, usually within 48 hours of operation. Patients failing to void were recatheterized and given a second trial without catheter (TWOC) at third day of recatheterization. Resumption of spontaneous voiding on either the first or second TWOC was defined as a "successful TWOC". Failure to void on second TWOC was defined as "failure to void" and was managed by a six week period of catheterization followed by an additional TWOC.
In postoperative follow up all patients were interviewed, physically examined and ultrasound examination for postvoid residual urine were carried out at the end of the 2nd week of their successful TWOC.
Statistical analysis: Data analysis was performed using computer package, "GraphPad Instat" version 3.05. Student\'s t-test was used for comparing the means of quantitative variables {age & weight of resected prostatic tissues} between the two groups i.e. those who voided successfully and those who failed to void after TWOC. Fisher\'s exact test was used for comparing the proportions of qualitative variables (Outcomes related to modes of presentation). In all statistical analysis only P-values < 0.05 were considered significant.

Results

A total of 345 BPH patients were included in the study, of which 270 (78.3%) presented with urinary retention and 75 (21.7%) with lower urinary tract symptoms (LUTS). All patients who presented with LUTS had severe lower urinary tract symptoms (I-PSS >20). Patients who presented with urinary retention had acute retention 129 (37.4%), chronic retention 81 (23.5%) and acute on chronic retention 60 (17.4%).
One patient, who initially presented with acute retention, underwent revision TURP at 10th day of the initial TURP procedure. In this patient the initial procedure was terminated incompletely because of perforation of prostatic capsule and opening of large venous sinuses early in the procedure. However this patient voided successfully following TWOC 48 hours after the second TURP. So for the purpose of subsequent analysis he was included in the "successful TWOC" group.
All patients presenting with LUTS voided successfully following TURP. Seven (5.4%) out of 129 patients with acute retention, 11 (13.6 %) of 81 patients with chronic retention and 9 (15.0%) of 60 patients with acute on chronic retention failed to void on catheter removal.
The proportion of men failing to void after TURP was significantly higher (P<0.05) in those with acute retention as compared to LUTS. Similarly the proportion of men failing to void after TURP was significantly higher (P<0.05) in those with chronic retention and acute on chronic retention compared to acute retention. The proportion of men failing to void after TURP was highly significant (P<0.005) in those with retention of any type compared to those with LUTS as shown in Table 1.


All except 3 (0.9%) patients voided successfully after 6 week period of catheterization. These 3 patients who failed to void even after 6 weeks of catheterization were treated with a permanent indwelling catheter and all these patients initially had presented with chronic retention.
The mean age of the patients who voided successfully was 64.7 + 9.2 years and those who did not was 66.4 + 8.6 years. So the difference in age between the two groups was not statistically significant (P>0.05). Similarly there was no significant difference (P>0.05) in weight of resected prostatic tissues in the successful voiders (mean 28.6 + 15.8grams) versus the unsuccessful group (mean 31.2 + 18.4 grams) as shown in Table 2.


Although some patients initially developed transient urinary incontinence after removal of catheter but the condition subsided in few days postoperatively and no patient had permanent incontinence. Two patients died in this series less than 30 days postoperatively, resulting in overall mortality rate of 0.6%.

Discussion

Contrary to the western world where more than 90% of BPH patients are treated based on symptoms severity2, majority of our patients presented with complications of BPH. More than 78% patients presented with urinary retention either acute, chronic or acute on chronic retention. Only 21.7% patients came with lower urinary tract symptoms (LUTS) and all of them had severe symptoms (I-PSS>20). These findings are although contrary to the findings in the developed world2 but correlate well with those in the developing countries where 70-80% of BPH patients seek medical advice only when they get complications of the disease.3,4
Urinary retention both acute and chronic are the complications of long standing untreated BPH which also influence/ affect the postoperative outcome of this disease. In our series 5.4% patients with acute retention, 13.6% patients with chronic retention and 15.0% patients with acute on chronic retention failed to void after removal of catheter postoperatively. So a significantly higher (P<0.05) number of patients with chronic retention and acute on chronic retention failed to void after trial without catheter (TWOC) as compared to acute retention. A highly significant (P<0.005) number of patients with retention of any type failed to void after TWOC as compared to those with LUTS. Our these findings correlate well with those described by Reynard and Shearer12 and can be explained by the changes in neuromuscular tissues of urinary bladder induced by long standing obstruction due to BPH.9
Wyatt et al13 reported failure to void after TURP on initial TWOC in 27% patients. Most patients in this series had either acute, chronic or acute on chronic retention. Pickard et al14 reported failure to void in 9.2% of men with acute retention compared with only 2.3% of those undergoing TURP for LUTS. In contrast to this in our series 5.4% patients with acute retention and no single patient with LUTS failed to void after TURP. Various studies12,15 suggest that some recovery of detrusor function does occur with time after relieving obstruction in that initially unsuccessful voiders. Manikandan et al16 have found that increasing the period of drainage of the bladder before a TWOC improves the chances of voiding. The same was the case in our study in which all except 3 (0.9%) patients were able to void after 6 weeks of catheterization.
Contrary to the findings of Djavan et al15, in our series the difference of age between those who voided successfully and those who did not, was not statistically significant (P>0.05). These findings are in agreement with those described by Reynard and Shearer.12
We did not find weight of the resected prostatic tissues to be a significant predictive factor for postoperative outcome. The difference in weight of resected prostatic tissues between the two groups was not statistically significant (P>0.05). These findings again correlate well with Reynard and Shearer.12
The results of our study suggest that mode of presentation of BPH greatly influences the postoperative outcome of this disease. Patients presenting with symptoms have a favourable outcome while those presenting with complications, specially chronic retention and acute on chronic retention have a less favourable result in respect to voiding after removal of catheter postoperatively. Moreover the results suggest that age of the patient and weight of the prostate are not significant factors regarding failure to void postoperatively.
From the results of our study it can be concluded that BPH patients in our region present very late, most of them (>78%) with complication of urinary retention.
Mode of presentation of BPH greatly influences the postoperative outcome of this disease. Patients presenting with complications of chronic and acute on chronic retention have less favourable results regarding postoperative voiding after TURP. Moreover, age of the patients and weight of the prostate are not significant factors in relation to failure to void postoperatively.

References

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