Clinical Paper

Eur Urol 1998;33:476–480

Ulrike Zwergel
Bernd Wullich
Long-Term Results following
Ulrike Lindenmeir
Volker Rohde
Transurethral Resection of the
Thomas Zwergel Prostate
Klinik für Urologie und Kinderurologie der
Universität des Saarlandes, Homburg/Saar,
Deutschland
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Abstract
Two subsets of a single-center study population with benign prostatic hyperpla-
sia (n(1) = 232; n(2) = 214) undergoing transurethral resection (TUR) of the
prostate (TURP 1979 and 1995) entered a retrospective study designed to
examine the long-term follow-up. The actual data were assessed with a patient-
addressed questionnaire. Preoperative voiding patterns did not differ signifi-
cantly; postoperative micturition revealed comparable results for both groups.
Mortality and TUR syndrome rates were reduced to very low levels. The most
significant improvement was found in blood transfusions. The postoperative
incidence of urethral stricture (1.7 vs. 1.5%) or bladder neck contracture (2.7
OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO vs. 2.4%) were low and did not alter significantly. Urinary incontinence
Key Words changed for both collectives (11.4 vs. 3.3%). Urodynamic investigations
Transurethral resection of the revealed that all (n = 21) but 1 of the patients with TURP 1979 had the inconti-
prostate nence due to different bladder dysfunctions, but not because of postoperative
Morbidity stress incontinence. The questionnaire about the patient’s actual contentment
Mortality after TURP 1979 showed 79% of the patients still satisfied, 12% neutral and
Patients’ contentment 9% dissatisfied with their micturition. Overall the patients reported a generally
Follow-up, long-term favorable view of TURP outcome in the long-term follow-up.
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Benign prostatic hyperplasia (BPH), one of the most tion about patient’s satisfaction after TURP is also dis-
common conditions associated with aging men, has been cussed [5, 6].
noted at autopsy in approximately 40% of men in their In contrast to other BPH studies after TURP [6–9],
50s and in about 70% in their 60s [1]. Reflecting the high which present the follow-up of patient groups over a short
incidence of BPH, treatment of these patients has a high time, this retrospective study is different, since we have
social and financial value. Transurethral resection of the analyzed the complications and especially the long-term
prostate (TURP) is the major operation most often pre- results for more than 15 years after TURP.
ferred in patients with this diagnosis, done in more than
120,000 men/year in Germany [2, 3]. Since there exist a
number of other and especially new therapeutic options Patients and Methods
for BPH, efficacy of TURP has come into question [2]. Is
TURP still the golden standard? Insurance claim data We report the outcome of two subsets of a single-center study
population (n = 5,766) with symptoms related to BPH. Both groups
indicate patients to have higher rates of reoperation and (I and II) underwent TURP, the first in 1979 (n = 232) and the other
urethral stricture or even higher mortality rates following in 1995 (n = 214). All patients of the nonselected population were
TURP than those treated by open surgery [4]. The ques- evaluated postoperatively and were alive at the time of interrogation.

© 1998 S. Karger AG, Basel PD Dr. Ulrike Zwergel

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Patients with concomitant urethral stricture, bladder and/or prostate Table 1. Preoperative data (within 4 weeks) before TURP (col-
cancer at the time of surgery were excluded. All patients underwent lected as documented in the medical records)
an Otis urethrotomy prior to surgery; a 26-French resectoscope was
used (Wolf, Knittlingen, Germany). TURP 1979 TURP 1995
Preoperative micturition troubles (including urological symp- (n = 232) (n = 214)
toms within 30 days prior to surgery) and peri- or immediately post-
operative complications were collected as documented in the medi- Frequency, 1 7/day, % patients 43.9 40.1
cal records. The actual data were assessed in detail with the aid of a Nocturia, 1 2/night, % patients 75.4 77.0
patient-addressed questionnaire, which comprises a symptom index, Complete retention, % patients 17.9 13.2
an adapted International Prostate Symptom Score (IPSS) [10]. We Urinary retention, ml 361B266 184B98
especially asked the patients about their actual voiding problems and BPH dimension1, % patients
their general contentment after TURP. Since postoperative urinary Small 18.0 7.3
incontinence (defined as to be unable to stop urinating or dripping Medium 58.5 62.7
unintentionally) bothers TURP patients most, not only the subjec- Large 23.5 30.0
tive perceptions, but further analyses were necessary to decide on the
incontinence reason. The question whether patients had a true post- 1 Definition for the different sizes of the prostate, according to the
operative stress incontinence has been analyzed by urodynamic estimated volume after rectal digital examination, i.e., small ! 20 mg,
investigations (i.e. the results here include postoperative examina- medium 20–40 mg, large 1 40 mg.
tion only of those patients who reported postsurgical incontinence
symptoms).
For all comparisons of data from both groups statistical signifi-
cance was determined using Student’s t test or the log rank test (p !
Table 2. Postoperative data of micturition troubles and imme-
0.05 as significant). The analyses were performed with a Statistics
diate postoperative complications (within 4 weeks) after TURP
Software Package (SSPS).
(evaluated in 1996)

TURP 1979 TURP 1995

Results (n = 232) (n = 214)

No differences were observed in the mean age of the BPH weight, g 29.3B12.3 28.5B14.3
patients at the time of TURP (67.7 and 68.3 years, respec- Frequency, 1 7/day, % patients 12.5 10.1
Nocturia, 1 2/night, % patients 16.5 13.3
tively). Frequent voiding, nocturia and/or complete is- Urinary retention, % patients 11.4 8.6
churia (urinary retention) did not differ significantly for Mortality, % patients 0.5 0.2
both groups (table 1). Postoperative day- and nighttime TUR syndrome, % patients 1.6 0.8
frequencies of micturition or dysuria revealed compara- Blood transfusion, % patients 21.2 14.6
ble results for both groups (table 2).
Mortality rate and incidence of TUR syndrome were
reduced to very low levels (table 2). TUR syndrome is
Table 3. Results of major long-term complications after TURP
characterized by mental confusion, nausea, vomiting, hy- (evaluated in 1996)
pertension, bradycardia and/or visual disturbances. It is
related to dilutional hyponatremia with possible severe TURP 1979 TURP 1995
consequences like cerebral edema and/or edema of the (n = 232) (n = 214)
lungs. The serum sodium concentrations are !125 mEq/l.
Urethral stricture, % 1.7 1.5
We defined in our study a patient to have this syndrome if
Bladder neck contracture, % 2.7 2.4
at least three items were found and other causes (e.g. car- Urinary incontinence1, % 11.4 3.2
diac shock) were excluded.
The most significant improvement has been found in 1 Subjective data without urodynamic confirmation.
the numbers of blood transfusions, including retransfu-
sions of own blood (24% patients in 1995). The postoper-
ative incidence of urethral stricture (1.7 vs. 1.5%) or blad-
der neck contracture (2.7 vs. 2.4%) did not alter signifi- only 1 patient from the first group to have a severe urinary
cantly during follow-up (p 1 0.05) (table 3). In contrast, stress incontinence. The others have different bladder
urinary incontinence changed for both collectives: it dysfunctions (table 4).
amounted to 11.4% for the first group and 3.3% for the The questionnaire about the patient’s actual content-
second group. But urodynamic investigations revealed ment after surgical treatment showed the following data:

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 Overall, the symptom score distribution changed for
both groups (all patients being alive at the time of inter-
rogation) (fig. 2): the average total score was higher in
group I than in group II, but did not differ significantly
(p 1 0.05).

Discussion

Since increasing attention is directed toward BPH

management and especially new therapeutic options [2,
10], it is inevitable that efficacy and durability of the
TURP has been analyzed [6, 11]. A number of retro-
spective studies have been published about TURP results
[12–16]. Most data concern posttherapeutic mortality and
morbidity. In one part of our retrospective study we also
Fig. 1. Subjective results concerning micturition contentment analyzed the data concerning especially intra- and postop-
after resection of the prostate (comparison of three evaluations). erative complications; furthermore, we reviewed pre- and
postoperative voiding symptoms. Several of our observa-
tions are not particularly new and correlate with other
Table 4. Urodynamic results (evaluated authors [6, 8]. The results showed the expected improve-
in 1997) concerning 21 patients (6 with two ments comparing pre- and postoperative micturition of
and more symptoms) with subjective feeling
each group, regarding ‘frequency, nocturia or urinary
of urinary incontinence after TURP 1979
retention’ (tables 1, 2). On the other hand, with one excep-
Urodynamic results Patients tion (urinary incontinence), the pre- or postoperative
voiding symptoms did not change in the two groups – one
Important urinary retention 4 resected in 1979 and the other in 1995.
Bladder instability 12 As an interesting fact, urinary incontinence was found
Reduced bladder capacity 10
Severe stress incontinence 1
to be different for both collectives. The discrepancies
between the patient reports on urinary incontinence may
probably be the consequence of other incontinence rea-
sons than postoperative urinary stress incontinence [17];
furthermore, they depend on the wording of the questions
Table 5. General contentment concerning micturition after
TURP (comparison of five different evaluations)
used. Since in the questionnaire we have described uri-
nary incontinence as to be unable to stop urinating or
Patients Maximum Content- dripping unintentionally, it is easily understood that most
follow-up, years ment, % patients with these symptoms do not really have postoper-
ative stress incontinence with sphincter dysfunction.
Bruskewitz, 1986 186 3 75
TURP certainly is associated with some risks, for
Lepor, 1990 32 2 84
Doll, 1992 388 1 78 instance mortality or TUR syndrome. The postoperative
Walz, 1995 312 6 87 mortality rate (0.5 vs. 0.2% of our two groups) is similar to
Zwergel, 1997 232 17 79 that reported previously [2, 16]. Only 1.6 vs. 0.8% of the
patients, who underwent TURP, were reported to have
developed TUR syndrome. Although the possibility of
underreporting must be considered, this compares favora-
79% of our patients, who underwent TURP 1979, are still bly with TUR syndrome rates reported in other studies [2,
satisfied, 12% neutral and 9% dissatisfied with their post- 18]. Endoscopic surgery of the prostate certainly is also
operative micturition. These results, which are compared associated with the risk of reoperation, for instance because
with data of other authors, reveal contentment rates of bladder neck contracture or urethral stricture. Using the
between 75 and 87% (fig. 1, table 5). right equipment and technique, this complication may be

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 Fig. 2. Distribution of the total symptom
scores of all patients from both groups after
TURP (i.e. only patients with at least 1 to 17
years of follow-up, since all patients were still
alive at the time of interrogation).

prevented. Urethral strictures can be mostly avoided by patients received no heterologous, but autologous blood;
doing initially Otis urethrotomy before TURP [18]. the 24% are included in the overall percentage of blood
In several series [14, 16] the incidence of bleeding, transfusion in group II, also reducing the autologous
defined as patients requiring blood transfusion, was 2.5% transfusion rate of the population of 1995 again.
intraoperatively and 3.7% postoperatively. Koshiba et al. Little knowledge is available about satisfaction of the
[15] reported that the incidence of the patients requiring BPH patients after surgery [6]. We found that 80% of
blood transfusion had decreased dramatically to 3.6% severely symptomatic men experienced improvement af-
and less during the last 3 years of their observation period. ter TURP, while only 9% were unsatisfied in the long-
Our results are not compatible with those cited before. We term follow-up. Since we did not examine the patients
reported 21 and 14% patients, who received blood trans- again, we cannot distinguish between the dissatisfaction
fusions. These data are similar to observations by Chute due to persisting outflow obstruction or regrowth of pros-
et al. [3] and Doll et al. [8], who reported to have needed tatic tissue. Overall, these findings confirm the experi-
14 or 16% blood transfusions after surgery. The higher ences of other authors [6–9]. On the other hand, there still
percentage of TURP patients who required blood transfu- exists the question of whether a patient’s opinion is
sions is considered due to several negative circumstances important for decision in treatment and follow-up. Beier-
in the own selected population. As well known, bleeding is Holgerson and Bruun [19] described that urologists rely
related to gland size and operative time, and especially to upon patient self-reports of difficult bladder emptying as
surgeons’ experience. The probability of bleeding in- one of the criteria to decide when to accept surgical treat-
creases in high-risk patients with concomitant cardiovas- ment of the BPH-related symptoms. A recent review of
cular and pulmonary diseases, larger prostates (145 g), the natural history of the BPH patients suggests that the
procedures lasting 90 min and more, and resections done subjective criteria are the major deciding factors for surgi-
by less experienced surgeons [14, 16]. Since TURP of our cal intervention [17, 19, 20]. However, despite this strong
patients was performed by trainees as well as by residents, reliance on symptoms of voiding, we again ask how useful
this fact may especially be responsible for the higher these observations are. Black et al. [5], for instance, sus-
transfusion rate (and also for the difference found for both pected patients with TURP not to be able to decide on
groups) compared to other data. Overall, all the negative their therapeutic success, since they do not know enough
factors mentioned above are mostly found in our hospital, about their illness and the treatment options and risks.
since we have a large number of multimorbid patients They may also give false answers to please their surgeons.
with larger prostates and we have many younger surgeons Nevertheless, we think that patients’ opinions are not only
on training. Nevertheless, the number of blood transfu- advantageous, but necessary to capture the symptom lev-
sions has been reduced from 1979 to 1995 and the indica- els of men with BPH-related voiding troubles [2, 10, 11].
tions have also changed in our hospital; furthermore, out By using symptom score indexes (Boyarsky, AUA or
of the group II (i.e. resections 1995) 24% of the 214 International Prostatic Symptom Score – IPSS), quantifi-

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cation of subjective data has been improved. A disadvan- presented evidence not only for increased rates of reoper-
tage that should be mentioned is that the indexes show ation, but especially for decreased survival after the endo-
differences [1] and are hard to be compared. A further scopic procedure. Compared with open prostatectomy,
criticism is that we studied a preselected population, these findings raised significant concern in the urological
which may just be the reason why the results are so ‘excel- community. In contrast, Koshiba et al. [15] found that
lent’ [21]: our patients indicated for surgery were carefully both procedures (TURP and open BPH surgery) are safe
selected. We especially excluded patients with smaller for the symptomatic relief of urinary obstruction due to
glands and urinary irritative symptoms, which cannot be BPH and that transurethral prostatectomy does not jeop-
corrected by TURP alone. In general, patients with the ardize long-term survival of the patients. Nevertheless,
irritative micturition symptoms initially have an exact there are still no unique criteria for the choice of BPH
examination including urodynamic investigation. Thus treatment, either for TURP or for other therapeutic
we exclude those patients having urinary urge as the main options. In the authors’ opinion TURP remains the first
reason for their voiding problems. Therefore, TURP choice in surgical therapy of patients with BPH-related
works best for those who need it most and works poorest symptoms [11, 18].
for those who need it least. To summarize, we report a generally favorable view of
TURP is the major operation most often preferred in the TURP outcome in the long-term follow-up of about
patients with BPH [2, 14, 18]. The endosopic operation 16 years. Most patients experience improvement in pros-
has gradually replaced open surgery as the choice for BPH tatic symptoms and about 80% report satisfaction after
treatment. Why do we prefer TURP? Indication for trans- resection of the prostate. Overall, surgical complications
abdominal surgery is usually limited to extraordinary are limited and have not changed much for both groups.
large glands, which are found less often. With TURP, This type of outcome research takes into account the
mortality and morbidity could be reduced [2, 10, 18]. On patient’s perception of the treatment results, which is
the other hand there has been great discussion about the needed to establish therapeutic priorities among the rap-
advantages of TURP based on insurance claim data from idly changing options that are available for the treatment
patients after endoscopic surgery; Roos and Ramsey [4] of BPH.

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References
1 Berry SJ, Coofey DS, Walsh PC: The develop- 8 Doll HA, Black NA, McPherson K, Flood AB, 15 Koshiba K, Egawa S, Ohori M, Uchida T,
ment of human benign prostatic hyperplasia Williams GB, Smith JC: Mortality, morbidity Yokoyama E, Shoji K: Does transurethral re-
with age. J Urol 1984;132:474–479. and complications following transurethral re- section of the prostate pose a risk to life? 22-
2 Almer FM, Altwein JE: Transurethrale Prosta- section of the prostate for benign prostatic hy- year outcome. J Urol 1995;153:1506–1509.
taresektion: Steht ein Wandel in der Therapie pertrophy. J Urol 1992;147:1566–1573. 16 Mebust WK, Holtgrewe HL, Cockett ATK,
der benignen Prostatahyperplasie bevor? Akt 9 Lepor H, Rigaud G: The efficacy of transure- Peters PC: Transurethral prostatectomy: Im-
Urol 1994;25:143–153. thral resection of the prostate in men with mod- mediate and postoperative complications. A
3 Chute CG, Stephenson WP, Guess HA, Lieber erate symptoms of prostatism. J Urol 1990; cooperative study of 13 participating institu-
M: Benign prostatic hyperplasia: A population- 143:533–537. tions evaluating 3,885 patients. J Urol 1989;
based study. Eur Urol 1991;20(suppl):11–17. 10 Melchior HJ, Schulze H, Seibert J, Sökeland J: 141:243–247.
4 Roos NP, Ramsey EW: A population-based Neue Perspektiven in der Behandlung der 17 Diokno AC, Brown MB, Goldstein N, Herzog
study of prostatectomy: Outcome associated Prostatahyperplasie. Dtsch Ärztebl 1994;91: AR: Epidemiology of bladder emptying symp-
with different surgical approaches. J Urol 792–797. toms in elderly men. J Urol 1992;148:1817–
1987;137:1184–1188. 11 Zwergel Th, Wullich B, Lindenmeir U, Zwergel 1821.
5 Black N, Ginzler M, Petticrew M, Flood A, U: Complications and results following trans- 18 Zwergel U, Zwergel Th: Benigne Prostatahy-
Smith J, Williams G, Davies J, Doll H, urethral resection of the prostate 1979 and perplasie: Was bringen neue Therapieformen?
McPherson K: Do doctors and patients agree? 1995. J Urol 1997;157(suppl):329. Med Welt 1993;44:64–68.
Views of the outcome of transurethral resection 12 Engelmann UH, Olschewski R, Herberhold D, 19 Beier-Holgerson R, Bruun J: Voiding pattern of
of the prostate. Int J Assess Health Care 1991; Senge T: Der Einfluss von TUR und tranvesika- men 60 to 70 years old: Population study in an
7:533–544. ler Prostatektomie auf Symptomatologie und urban population. J Urol 1990;143:531–532.
6 Walz PH, Nies A: Würden Sie sich erneut für Lebensqualität. Urologe A 1991;31:43–47. 20 Sagnier PP, MacFarlane G, Teillac P, Botto H,
eine TUR-P entscheiden? Eine Patientenbefra- 13 Hannappel J, Krieger S: Subjective and clinical Richard F, Boyle P: Impact of symptoms of
gung zu den subjektiven Ergebnissen der trans- results after transurethral resection and supra- prostatism on level of bother and quality of life
urethralen Prostataresektion. Akt Urol 1995; pubic prostatectomy in benign prostatic hyper- of man in the French community. J Urol 1995;
26:228–234. trophy. Eur Urol 1991;20:272–276. 153:669–673.
7 Bruskewitz RC, Christensen MM: Critical eva- 14 Holtgrewe HL, Mebust WK, Dowd JB, Cockett 21 Watanabe H: Diagnosis of benign prostatic hy-
luation of transurethral resection and incision ATK, Peters PC, Proctor C: Transurethral pertrophy by ultrasound and outcome from
of the prostate. Prostate 1990;3(suppl):27–38. prostatectomy: Practice aspects of the domi- surgery. Akt Urol 1993;24(suppl):127–130.
nant operation in American urology. J Urol
1989;141:248–253.

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