Comparison of the Transurethral Resection of the Prostate by Traditional Versus Preserved Urethral Mucosa of the Prostatic Apex

Abstract

Background:

Benign prostatic hyperplasia (BPH) is a common disease in elderly men. Transurethral resection of the prostate (TURP) is still the standard treatment for BPH. However, postoperative urinary incontinence (UI) is still one of the complications.

Objective:

This study aims to evaluate the clinical efficacy and safety of the TURP by traditional compared with preserved urethral mucosa of the prostatic apex (PUMPA).

Materials and Methods:

From July 2015 to June 2016, 80 patients with TURP were included and divided into the two groups: traditional nonpreserved urethral mucosa group (TURP group, n = 40) and the PUMPA group (PUMPA-TURP group, n = 40). This study identified the apex of the prostate and determined the cut position of mucosa. Then, we separated the preserved urethral mucosa, excised the hyperplastic prostate tissue, and trimmed the preserved urethral mucosa.

Results:

The rate of UI after PUMPA-TURP was significantly lower than that traditional TURP (0% vs 22.5%). The operative time was significantly shorter in the PUMPA-TURP group than traditional TURP group (50 ± 16.5 minutes vs 65 ± 18.5 minutes). The intraoperative bleeding loss was lower in the PUMPA-TURP group than traditional TURP group (280 ± 33 mL vs 190 ± 35 mL). International prostate symptom score, quality of life (QoL), and peak uroflowmetry data (Qmax) were similar between two groups.

Conclusions:

When compared with traditional TURP, PUMPA-TURP can reduce the occurrence of UI and intraoperative blood loss. Besides, PUMPA-TURP could shorten the operative time.

Introduction

Benign prostatic hyperplasia (BPH) is a common disease in elderly men and transurethral resection of the prostate (TURP) is still the gold standard for the treatment of BPH.^1
–3 However, postoperative urinary incontinence (UI) is one of the common complications and its incidence is nearly 2%.^4
–6 UI brings great suffering to patients and its unpredictability and uncertainty in the recovery period cause significant pressure to surgeons. External urethral sphincter damage is the main reason for UI after prostatectomy. The treatment of postoperative UI has also become an important issue for many years. Along with the progress of technology, there have been various methods of TURP but no method has been found to adequately avoid the occurrence of UI.

In our hospital, we used preserved urethral mucosa of the prostatic apex (PUMPA), TURP, or traditional TURP for our patients. However, the difference in these treatments remains unclear. Therefore, we conducted this study to investigate the clinical efficacy and safety of TURP by traditional vs PUMPA. Therefore, the hypothesis of this study was that the preserved urethral mucosa of prostatic apex was effective and safe than traditional nonpreserved urethral mucosa by shorting the operative time and reducing intraoperative blood loss.

Materials and Methods

Patients

This study was a prospective trial. The study consisted of 80 cases. The diagnosis was confirmed after a detailed history was taken and a physical examination of the patients was complete, which included a digital rectal examination and a transabdominal ultrasound. The Ethics Committee of the first Hospital of Qinhuangdao approved the trial and the methods were carried out in accordance with the approved guidelines. All patients had signed informed consent.

Inclusion and exclusion criteria

Inclusion criteria were as follows: (1) patients regularly used α -receptor blockers, 5α-reductase inhibitors, and/or M-receptor blockers for more than 6 months but did not achieve a satisfactory international prostate symptom score (IPSS); and (2) they were willing to undergo PUMPA-TURP or traditional TURP and provided written informed consent. Exclusion criteria were as follows: (1) patients with an unstable bladder; (2) patients with a neurogenic bladder; (3) patients with an anterior urethral stricture; (4) patients with detrusor weakness; and (5) patients with preoperative urethral external sphincter injury.

Methods

The patients were divided into two different groups chronologically, each group with 40 cases. The early 40 cases (TURP group) underwent traditional TURP and the mean patient age was 75 + 8.3 years, while the mean prostate volume (PV) was 40 + 10.5 g. The later 40 cases (PUMPA-TURP group) underwent PUMPA-TURP and the mean patient age was 73 + 10.5 years, while the mean PV was 45 + 12.3 g. The age and the PV in the two groups had no statistically significant difference (p > 0.05) (Table 1).

Table 1.

Baseline Characteristics of All the Patients Who Underwent TURP and PUMPA-TURP

Groups	Cases	Age (years)	PV (g)	Operation time (minutes)	Bleeding (mL)	IPSS	QoL	Qmax (mL/s)
TURP	40	75 ± 8.3	40 ± 10.5	65 ± 18.5	280 ± 33	5 ± 1.2	1.3 ± 0.9	22.1 ± 5
PUMPA-TURP	40	73 ± 10.5	45 ± 12.3	50 ± 16.5	190 ± 35	4.9 ± 1.1	1.1 ± 0.5	21.8 ± 4.5
t		1.4997	1.9554	2.5513	11.8329	0.3885	1.2886	0.2821
p		0.1377	0.0541	0.0127	0.000	0.6987	0.2229	0.7786

IPSS = international prostate symptom score; PUMPA = preserved urethral mucosa of the prostatic apex; PV = prostate volume; QoL = quality of life; TURP = transurethral resection of the prostate.

Data collection and follow-up

The following data were collected before the surgery: (1) age and (2) PV. The following data were obtained after the surgery: (1) operation time and (2) intraoperative blood loss (using the HM hemoglobin meter cyanide high iron method).^7,8 The following data were immediately obtained after the removal of the catheter: UI. IPSS, and quality of life (QoL), and peak uroflowmetry data (Qmax) were obtained 1 month after the surgery.

Surgical technique

The operation was completed with the patient in the lithotomy position under subarachnoid anesthesia in all cases. The same surgeon completed all the surgeries (Q.L.L.) with a 24F resectoscope (Richard Wolf GmbH, Knittlingen, Germany) using monopolar energy. The TURP group underwent traditional antegrade TURP described as Nesbit¹ and urethral mucosa of the prostate was not preserved. Another group was treated with PUMPA-TURP and the procedures were divided into five steps.

Step 1. Identify the apex of the prostate: the general position of the apex of the prostate could be easily identified when the resectoscope retreated from the obvious site of the prostatic hyperplasia (Fig. 1A).

FIG. 1.

(A) Apex of prostate (arrow-head). (B) The mucosal incision line (loop). (C) The preserved urethral mucosa (double arrows). (D) The soft preserved urethral mucosa of the prostatic apex (double arrows). The external urethral sphincter is well protected (arrow).

Step 2. Determine the cut position of mucosa: the mucosal incision line was positioned at the mucosa around 0.5 cm proximal from the tip of the prostate (Fig. 1B). A near circle could mark the line by electric coagulation (except six points). The distal urethral mucosa was the preserved part.

Step 3. Separate the preserved urethral mucosa: the urethral mucosa was cut along the determined incision line, and then, the distal preserved urethral mucosa was gently pulled away from the prostatic tissue with a resectoscope loop. The hyperplastic prostate tissue can be pushed tenderly to the opposite direction with the resectoscope sheath (Fig. 1C). Urethral mucosa was gradually cut and separated nearly one circle along the mucosal incision line. The soft urethral mucosa of the prostatic apex has been isolated for preservation and the proximal hyperplastic prostate tissue was the part that was going to be removed.

Step 4. Excise the hyperplastic prostate tissue: the prostatic tissue was directly excised according to medical conventions. Since the distal terminal line has been determined, the prostate tissue can be removed rapidly with less anxiety. Since the preserved urethral mucosa had been separated, it was easy to avoid the removal of the preserved urethral mucosa.

Step 5. Trim the preserved urethral mucosa: after the resection of the prostate, the soft preserved urethral mucosa should be trimmed slightly so that irregular portions and a little prostate tissue remaining on the mucosa can be removed. At this time, we are able to observe that the external urethral sphincter at the distal end of the urethral mucosa was intact (Fig. 1D). The chips were then evacuated using an Ellik evacuator. A 20F three-way Foley catheter was inserted when the surgery was completed. The catheter would be removed after 5 days.

Statistical method

We used the software program SPSS 21.0 (SPSS, Inc., Chicago, IL) to conduct the statistical analysis. Continuous variables were expressed as mean ± standard deviation. Discontinuous variables were expressed as a percentage (%). For the two comparisons, each value was compared by a t-test when each datum conformed to a normal distribution, while the non-normally distributed continuous data were compared using nonparametric tests. Discontinuous variables were compared by a chi-square test. A value of p < 0.05 was considered statistically significant.

Results

The general data

A total of 80 patients were included in this study. These 80 patients were divided into the TURP group and the PUMPA-TURP group. In the TURP group, the mean patient age was 75 + 8.3 years and the mean PV was 40 + 10.5 g. In the PUMPA-TURP group, the mean patient age was 73 + 10.5 years and the mean PV was 45 + 12.3 g. The age and the PV in the two groups had no statistically significant difference (p > 0.05) (Table 1). When the patients in the PUMPA-TURP group were compared with those in the TURP group, no significant differences were found in age, PV, IPSS, QoL, and Qmax.

The surgery outcomes

The operative time and the intraoperative blood loss were significantly lower for the patients who underwent PUMPA-TURP than for those who underwent TURP (65 ± 18.5 minutes vs 50 ± 16.5 minutes and 190 ± 35 mL vs 280 ± 33 mL, respectively). The differences were statistically significant (p < 0.05).

In the TURP group, there were nine cases of UI after the removal of the catheter. Among them, seven cases recovered within 1 week and two cases recovered within 3 months. The incidence of UI was 22.5%. In the PUMPA-TURP group, all patients achieved immediate continence (after the removal of the catheter with no need to use the urine diapers), the incidence rate of UI was 0. Comparing the two groups χ ² = 10.141, p = 0.001, the differences were statistically significant (p < 0.05) (Table 1).

Discussion

The outcomes of this study presented that the rate of UI after PUMPA-TURP was significantly lower than that after traditional TURP. The operative time was significantly shorter in the PUMPA-TURP group than in the traditional TURP group. The intraoperative bleeding loss was lower in the PUMPA-TURP group than in the traditional TURP group. IPSS, QoL, and Qmax were similar in both groups. The study limitations include small sample size and a short period of follow-up sessions.

BPH is a common disease in elderly men and TURP is still the gold standard for the treatment of BPH.⁹ However, postoperative UI is one of the common complications and its incidence is still high. As reported in previous literature, the rates of early incontinence can be as high as 48.7% and 26.7%^10,11; some patients take a long time to restore continence.^12
–14 In this study, UI in the TURP group occurred in 9 of the 40 patients after the removal of the catheter. The incidence of UI was 22.5%. Among them, seven cases recovered within 1 week and two cases recovered within 3 months.

After a long exploration, we have invented a surgical procedure that preserved the urethral mucous of the prostatic apex in about 0.5 cm in length for the transurethral prostate surgery. In this study, 40 patients in the PUMPA-TURP group treated with this operation all reached immediate control of urine; the incidence of UI was 0. Compared with the TURP group, the effect was significant (p < 0.01) and the operative time and intraoperative blood loss were significantly reduced (p < 0.05). Compared with the traditional surgical methods, this procedure has the following characteristics: (1) the endpoint of traditional surgery is the medial margin of the external urethral sphincter, which increases the chance of injury of the sphincter by the loop. The external sphincter is located outside the urethral mucosa, which cannot be observed directly.

At the initial stage of the operation, sometimes even toward the end of the surgery, some patient's external urethral sphincter is still difficult to be identified. These factors increase the chance of urethral sphincter injury, which leads to UI. The endpoint of PUMPA-TURP is already separated so it can be instantly recognized. In this condition, a resectoscope loop has no chance in causing injury to the external sphincter and is therefore completely protected. (2) Because of the possible injury of the urethral sphincter, the treatment of the prostatic apex is important and requires great patience. The traditional surgical procedure deals with the apex of the prostate in the later stage of the operation. At this time, the surgeon's attention declines and the accuracy is therefore likely to decline.

In our method, the external urethral sphincter has been protected since the beginning when the operator is likely to be more accurate so that the sphincter is less likely to be injured. (3) The normal urethral mucosa has a function like a sealing gasket, which can prevent the leakage of urine. Damage of the urethral mucous membrane can lead to the loss of the sealing function.⁷ In the traditional TURP, the prostatic urethral mucosa is removed, resulting in the disappearance of the sealing effect and leaving patients prone to the leakage of urine. The urethral mucous of the prostatic apex is preserved in PUMPA-TURP. It contributes not only to avoid the leakage of urine but also to completely protect the external urethral sphincter. (4)

In traditional TURP, the prostatic apex needs to be resected repeatedly to avoid damage to the external sphincter; this procedure slows down the progress of the operation. In the course of PUMPA-TURP, however, the preserved urethral mucosa as the end of the resection has been separated; so prostate tissue can be boldly and rapidly resected. Therefore, the operative time is shortened, the intraoperative blood loss is decreased, and the surgeon's fatigue is reduced. Besides, in our study, catheters were left in for 5 days, which may help us to calculate the exact amount of urine.

In this research, all patients in the PUMPA-TURP group had good voiding, compared with the TURP group. IPSS, QoL, and Qmax had no significant differences (p > 0.05). The results showed that the PUMPA did not impede the flow of urine. The condition of preserving the urethral mucosa is similar to that of open surgery. Some surgeons who have the experience of open prostatectomy sometimes find that there is a long residual urethral mucosa that needs to be partially subtracted with scissors,^15
–17 while the remaining urethral mucosa does not affect voiding. Similarly, urethral mucosa often cannot be retained wholly during a Madigan prostate resection. This lack of continuity of the urethral mucosa does not affect the efficacy of the operation either.^18,19

Limitations

First, this trial was not a randomized-controlled trial. Second, this study was only a single-center trial and the sample size was limited. Third, the clinical follow-up was short and it was necessary to observe the clinical long-term prognosis. Fourth, in a recent study, there were not enough data about the uroflowmetry performed before the surgery, which should be further researched. Fifthly, there were no postoperative ejaculation disorder was observed in the study which should be further research. Sixth, the aim of this study is to compare the clinical efficacy and safety of TURP by traditional vs PUMPA. Therefore, we mainly evaluate the postoperative UI between these two kinds of surgery. There were not enough data for evaluating postoperative UI compared with baseline.

Conclusions

Compared with traditional TURP, PUMPA-TURP can avoid the occurrence of UI, shorten the operative time, and reduce intraoperative blood loss, and therefore should be popularized in clinical practice.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

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