The Role of Transurethral BPH Surgeries in Management of Urinary Symptoms in Prostate Cancer Patients, Narrative Review.

PURPOSE OF REVIEW: Prostate cancer and benign prostate hyperplasia (BPH) are two ubiquitous pathologies that may coexist. A significant percentage of patients with different stages of prostate cancer suffer lower urinary tract symptoms (LUTS) due to associated BPH. We aimed to review the literature regarding the role of transurethral surgeries in the management of prostate cancer patients and the different available management options. RECENT FINDINGS: The evidence in literature for the use of BPH surgeries in prostate cancer patients is based mainly on low-quality retrospective studies. In patients on active surveillance, BPH surgeries are beneficial in relieving LUTS without oncological risk and can eliminate the contribution of adenoma to PSA level. In patients with advanced prostate cancer, palliative BPH surgery can relieve LUTS and urinary retention with unclear oncological impact; however some reports depict that the need for BPH surgery in advanced prostate cancer is associated with poorer prognosis. In patients receiving radiotherapy, various studies showed that transurethral resection of prostate (TURP) is associated with increased radiotoxicity despite some recent reports encouraging the use of Holmium Laser Enucleation of the Prostate (HoLEP) to improve urinary symptom scores before radiotherapy. The most commonly reported techniques utilized are TURP, photoselective vaporization of prostate (PVP) and HoLEP. The use of BPH surgery is justified for relieving LUTS in selected prostate cancer patients on active surveillance or in advanced stages, however the use in the pre-radiotherapy settings remains controversial. Future prospective and randomized controlled trials are required for validating the benefits and assessing potential hazards.

Life Expectancy in High-Grade Incidental Prostate Cancer Patients Versus Population-Based Controls According to Treatment Type.

OBJECTIVE: To quantify the differences in 5-year overall survival (OS) between high-grade (Gleason sum 8-10) incidental prostate cancer (IPCa) patients and age-matched male population-based controls, according to treatment type: no active versus active treatment. MATERIALS AND METHODS: We relied on the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015) to identify not actively treated and actively treated high-grade IPCa patients. For each case, we simulated an age-matched male control (Monte Carlo simulation), relying on Social Security Administration Life Tables (2004-2020) with 5 years of follow-up. Additionally, we relied on Kaplan-Meier plots to display OS for each treatment type. Multivariable Cox regression models were fitted to predict overall mortality (OM). RESULTS: Of 564 high-grade IPCa patients, 345 (61%) were not actively treated versus 219 (39%) were actively treated, either with radical prostatectomy or radiotherapy. Median OS was 3 years for not actively treated high-grade IPCa patients, with OS difference at 5 years follow-up of 27% relative to their age-matched male population-based controls (37% vs. 64%). Median OS was 8 years for actively treated high-grade IPCa patients, with OS difference at 5 years follow-up of 6% relative to their age-matched male population-based controls (68% vs. 74%). In the multivariable Cox regression model, active treatment independently predicted lower OM (hazard ratio = 0.6; 95% confidence interval = 0.4-0.8; p < 0.001). CONCLUSION: Relative to Life Tables' derived age-matched male controls, not actively treated high-grade IPCa patients exhibit drastically worse OS than their actively treated counterparts. These observations may encourage clinicians to consider active treatment in newly diagnosed high-grade IPCa patients.

Ejaculation preserving TURP (Ep-TURP): A viable alternative in sexually active males with BOO-a single centre prospective randomized study.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a common urological condition, particularly among middle-aged and elderly men. Trans urethral resection of prostate (TURP) has some drawbacks, particularly concerning ejaculatory function. Ejaculation preserving TURP (Ep-TURP) is one such technique that aims at preserving the tissues that are primarily responsible for antegrade ejaculation. METHODS AND MATERIAL: In this prospective study, patients with bothersome LUTS were randomized into Ep-TURP and standard TURP groups. Supramontal tissue was preserved in Ep-TURP while standard TURP group had resection of the entire prostatic tissue up to the verumontanum. The outcomes with regard to IPSS, Qmax, IIEF(Q9), Ejaculation and PVR were studied. Ejaculation projection score was separately calculated and assessed. RESULTS: About 60 patients were studied, with 30 in each group. At 6 months' follow-up, complication rates were the same in both groups. The IPSS, Qmax, IIEF were similar and comparable. There was no change in erection in all patients (P = 0.559). The ejaculation was well preserved in Ep-TURP (p<0.001). Ejaculation projection score was maintained at 3.77 in the Ep-TURP group while in the standard group it was 0 (P<0.001). CONCLUSIONS: Ep-TURP is a safe and a cost-effective method of preserving ejaculation in patients undergoing TURP. This procedure adds a better quality of life that greatly aids in enhancing the improving his psychological outlook towards life. Ep-TURP has now emerged as the standard procedure of choice in sexually active young males needing TURP, as the degree of ejaculation is largely well preserved in patients undergoing this procedure.

Effect of Prior Transurethral Prostate Resection (TURP) or Laser Enucleation (ThuLEP) on Radiotherapy-Induced Toxicity and Quality of Life in Prostate Cancer Patients Undergoing Definitive Radiotherapy.

In our study, the post-radiotherapy quality of life of prostate cancer patients who previously underwent transurethral resection of the prostate (TURP) is compared to those who had thulium laser enucleation of the prostate (ThuLEP) and those who had no prior surgery. It also aims to identify and assess risk factors affecting therapy tolerance in this patient group. We analyzed 132 patients with localized prostate cancer treated with definitive radiotherapy (RT), including 23 who had prior TURP and 19 who previously underwent ThuLEP. A total of 62% of patients underwent irradiation within 12 months after surgery. We included only patients treated with radiotherapy using the IMRT technique. Changes in patient-reported urinary toxicity were evaluated using the International Prostate Syndrome Score (IPSS) and the quality of life index of the World Health Organization (QoL/WHO-PSS) over a three-year post-radiotherapy period. Patients with prior TURP experienced significant deterioration in QoL and IPSS immediately after irradiation (p < 0.001), whereas those without previous surgery showed both less significant differences in IPSS and QoL scores. In conclusion, patients with previous TURP/ThuLEP differ from those without previous surgery in urinary quality of life and acute and chronic urinary symptom profiles after RT. The surgical technique (ThuLEP vs. TURP) and the time interval to irradiation are crucial factors affecting RT tolerance in acute and late settings. The previously operated patient group reported a significantly longer period of increased symptom burden.

Quality and Educational Value of YouTube Surgical Videos of Transurethral Resection of the Prostate: A Descriptive Cross-Sectional Study.

Introduction The aim of the study is to evaluate the quality and educational value of surgical videos on YouTube (Alphabet Inc., Mountain View, CA) demonstrating transurethral resection of the prostate (TURP). Methods A thorough YouTube search for "TURP" or "transurethral resection of the prostate" was performed. Each video's uploader, content, duration, date of upload, time since upload, views, comments, likes, and dislikes, and Video Power Index (VPI) scores were recorded and evaluated. Video analysis and rating followed the LAParoscopic Surgery Video Educational Guidelines (LAP-VEGaS) recommendations, which constitute nine items with values from 0 (absence) to 2 (complete presence). The guidelines' overall score can be 0 to 18. A higher score is indicative of a better level of educational value. Results There were a total of 43 videos included, 10 (23.3%) of which were academic publications. The average LAP-VEGaS score was 6.58, with 22 (51.2%), 18 (41.8%), and three (7%) videos classified as having low, medium, and high educational quality, respectively. None of the videos satisfied all the requirements outlined in the checklist. There was no statistically significant positive correlation observed between the educational score and the number of views. Conclusion A significant proportion of transurethral resection of the prostate (TURP) videos available on the YouTube platform exhibit limited educational value. Videos frequently lack comprehensive and in-depth descriptions of surgical operations. Those seeking information on TURP should carefully choose which videos to view. It is recommended that academic institutions establish comprehensive criteria aimed at enhancing the educational value of surgical videos on the YouTube platform.

Comparative Outcomes of Monopolar and Bipolar Transurethral Resection of the Prostate: An Institutional Perspective.

Objective This prospective comparative study aimed to highlight and compare two types of transurethral resection of the prostate (TURP), namely M-TURP (monopolar) and B-TURP (bipolar), in the endoscopic management of benign prostatic hyperplasia (BPH). Methods and materials This research was conducted between 2022 and 2023 at a tertiary care health center. Included in the investigation were 100 consenting study participants undergoing M-TURP and B-TURP at our center. All referred patients presenting with clinical, ultrasound, or uroflowmetry features of BPH and those with failed attempts at medical management were included in the study. Patients with carcinoma of the prostate were excluded from the study. Post-operatively, the endpoints for comparison included maximal urinary flow rate (Qmax), prostate volume, duration of hospital stay, duration of catheterization, drop in serum sodium concentration, and drop in hemoglobin levels. Descriptive statistics were computed to delineate the study sample. After the completion of data collection, data analysis was performed using SPSS for Windows, Version 16.0 (Released 2007; SPSS Inc., Chicago, IL, USA), and the correlations sought were achieved using the Chi-square test of significance. Results The peak incidence of BPH was seen in the sixth decade of life: the M-TURP group was 65.16 ± 7.07 years (mean ± standard deviation), while that in the B-TURP group was 62.32 ± 8.16 years (mean ± standard deviation). Nine percent of the study participants did not show any comorbidities. The most frequent symptom of BPH at presentation was a poor urinary stream (78%, n = 100), followed by nocturia (67%, n = 100). In our study, patients undergoing M-TURP had a mean serum prostate-specific antigen (PSA) level of 4.31 ± 1.03 ng/mL, while patients undergoing B-TURP had a mean serum PSA of 4.24 ± 0.99 ng/mL (p = 0.820; p > 0.05). The study found that patients undergoing M-TURP had a mean prostate size of 35.04 ± 3.57 cc, while those undergoing B-TURP had a mean prostate size of 35.72 ± 3.22 cc (p = 0.765). For the B-TURP group, the mean decrease in postoperative serum sodium concentration was 4.3 mEq/L, while for the M-TURP group, it was 6.4 mEq/L (p = 0.903). In the M-TURP group, there were three cases of transurethral resection (TUR) syndrome, while the B-TURP group had only one case. Conclusion BPH is a common problem affecting the quality of life of several male patients. Both M-TURP and B-TURP are comparable in their efficacy in treating BPH, with the exception of a higher incidence of hyponatremia and TUR syndrome in the M-TURP group.

Transurethral resection and other minimally invasive treatment options for BPH: would we treat ourselves as we treat our patients? Results from EAU Section of Uro-Technology (ESUT) decision-making survey among urologists.

Introduction: With the introduction of novel treatment options for benign prostatic hyperplasia (BPH), decision making regarding surgical management has become ever more complex. Factors such as clinical exposure, equipment availability, patient characteristics and hospital setting may affect what treatment is offered and an informed patient choice. The aim of this study was to investigate how urologists help patients make decisions regarding BPH management and whether their practice would differ if they were the patient themselves. Material and methods: A 52-question survey presenting hypothetical clinical scenarios was distributed to European urologists and trainees/residents online and in person. In each scenario, regarding treatment options for BPH, the participant considered themselves firstly as the treating clinician and secondly as the patient themselves. Details regarding the participants' clinical experience, awareness of treatment options and exposure to these options were obtained. Results: There were 139 participants; 69.8% of whom were consultants, with 82.1% of participants having practiced urology for more than 5 years. A total of 59.7% of urologists consider themselves BPH specialists. Furthermore, 93.5% of those surveyed had performed transurethral resection of the prostate (TURP), whilst procedures performed the least by participants were minimally invasive surgical therapy (MIST) options. Only 17.3% had seen and 1.4% had performed all of the treatment options. When considering themselves as a patient within standard practice, there was a preference for HoLEP amongst participants. Conclusions: The majority of urologists surveyed had minimal experience to newer BPH techniques and MIST, suggesting that more exposure is required. A higher rate of HoLEP was chosen as a treatment option for urologists themselves as a patient than what they would choose as an option for their patients.

Comparison of perioperative bleeding risk between direct oral anticoagulants in transurethral resection of prostate.

OBJECTIVES: To evaluate the perioperative morbidity and mortality associated with direct oral anticoagulants (DOACs) and warfarin for patients receiving transurethral resection of prostate (TURP). PATIENTS AND METHODS: This was a single-centre, retrospective cohort analysis of patients who underwent TURP for benign prostate hyperplasia from April 2019 to December 2023. The primary objective was to evaluate the perioperative bleeding and thromboembolic risk between anticoagulated (AC) vs no-AC patients. The secondary objective was to evaluate perioperative bleeding and thromboembolic risk between different formulations of DOACs. Patient demographics, prior treatment, prostate size, baseline bleeding risk, and operative details were collected. Bleeding and thromboembolic-related morbidity were captured within a 3-month postoperative period. Perioperative management of AC therapy was recorded, and all patients had their AC therapy withheld. Cohort characteristic between the AC vs no-AC, and DOAC groups were analysed with two-sided t-test, and chi-square test. Further logistic regression analyses were carried out to identified significant variables between the groups. These significant variables were used for adjustment in inverse probability-weighted treatment effect analysis to evaluate bleeding risk. RESULTS: There were 629 patients in the cohort, and 113 (18%) patients were receiving AC therapy. The AC patients were at 1.6 times statistically significant increased risk of acute bleeding, and 11 times increased risk of prolonged haematuria for >14 days. When compared to apixaban, patients on rivaroxaban conferred a statistically significant increased risk of acute bleeding by 2.21 times. Patients receiving AC therapy had a statistically significant increased risk of stroke in the perioperative setting (no-AC vs AC: 0.4% vs 2.7%, P = 0.01). CONCLUSION: This is the first study to evaluate risk of bleeding for TURP patients receiving DOACs. The AC patients are more likely to experience haematuria and stroke in the perioperative period despite withholding therapy. Apixaban appears to cause less bleeding-related complications than rivaroxaban.

Description of Transperineostomal Resection of the Prostate: A Case Report.

We report a case of transperineostomal bipolar resection of the prostate (TPR-P) for lower urinary tract symptoms (LUTS). To our knowledge, this is the first description in the scientific literature. A 67-year-old man with a medical history of multiple penile debridements and formation of a perineostomy due to an episode of severe Fournier's gangrene in 2015, was admitted to the emergency room with acute urinary retention. Consecutively, a suprapubic catheter was inserted. Attempts of catheterization failed due to bulbar stenosis and an obstructive prostatic urethra. After the resolution by dilatation of the bulbar stenosis, post-voiding residual volume persisted at up to 150 ml. The intra- and postoperative course after TPR-P was uneventful. No adverse events occurred. The assessment after six weeks revealed an International Prostate Symptom Score (IPSS) improvement of nearly 50% for the symptoms and >60% for overall satisfaction (preoperative: IPSS: S=24, L=6; postoperative IPSS: S=13, L=2). The average post-voiding residual volume decreased from 150 ml preoperatively to 15 ml (range 0-30 ml) postoperatively. Due to the missing full length of the urethra, the augmented range of motion seemed almost too loose for classic resection techniques in our hands. Therefore, we believe that in such cases it might be advantageous to use enucleation techniques. However, in our case, TPR-P was feasible and safe with a good functional outcome.

Multimodal Approach Combining Thulium Laser Vaporization, Bipolar Transurethral Resection of the Prostate, and Bipolar Plasma Vaporization versus Bipolar Transurethral Resection of the Prostate: A Matched-Pair Analysis.

Background/Objectives: The aim of our study is to compare the perioperative and functional outcomes of a multimodal approach combining thulium laser vaporization, bipolar TURP, and bipolar plasma vaporization (TLP) with bipolar TURP in a matched-pair analysis. Methods: A nonrandomized, observational, retrospective, and matched-pair analysis was performed on two homogeneous groups of 60 patients who underwent TLP versus bipolar TURP at our center between March 2018 and December 2021. The American Society of Anesthesiologists (ASA) score and prostate volume (PV) were the main parameters used to match patients between the two groups. Follow-up was evaluated at 3, 6, 12, and 24 months after surgery. Results: There was a shorter operative time in favor of TLP (42 versus 45 min, p = 0.402). Median hemoglobin drop (-0.3 versus -0.6, p < 0.001) and median sodium drop (-0.3 versus -0.7, p < 0.001) after surgery were statistically significantly lower in TLP compared to bipolar TURP. The International Prostate Symptom Score (IPSS) and Quality of Life (QoL) scores were significantly lower, and the maximum urinary flow rate was higher in the TLP group. The median PSA decrease 2 years after surgery was 73.92% in the TLP group versus 76.17% in the bipolar TURP group (p = 0.578). The complication rate was lower in the TLP group (20% versus 21.67%, p = 1). Conclusions: The results show that both procedures are equally effective and safe in the treatment of symptomatic BPH with some advantages regarding the TLP technique.

Transurethral Resection of the Prostate (TURP) and concomitant inguinal hernioplasty: a single-center experience.

BACKGROUND: Benign prostatic hyperplasia (BPH) is a prevalent condition in aging males, leading to bladder outlet obstruction (BOO) and associated urinary symptoms. With increasing life expectancy, the incidence of BPH and its co-morbidities, like inguinal hernia, has risen. This study explores the efficacy of combining transurethral resection of the prostate (TURP) and inguinal hernioplasty in a single surgical session to address both conditions, potentially reducing the need for multiple hospitalizations and surgical interventions. METHODS: This retrospective study at Chi Mei Medical Center included patients from 2014 to 2023 who underwent concurrent TURP and inguinal hernioplasty. A total of 85 patients met the criteria defined for this study. Preoperative, intraoperative, and postoperative characteristics were meticulously documented. Outcomes evaluated included the duration of the surgery, incidence of intraoperative and postoperative complications, duration of Foley catheterization, length of hospital stay, and treatment efficacy. Additionally, we conducted a comparative assessment of the surgical outcomes between two distinct techniques for inguinal hernia repair: open hernioplasty and laparoscopic hernioplasty (LH). RESULTS: In 85 patients who met the criteria, the mean age was 71.1 ± 7.8 years. The study reported no significant intraoperative complications, and postoperative care was focused on monitoring for blood loss, infection, and managing pain. The average postoperative hospital stay was 2.9 ± 1.0 days and the mean duration of catheterization was 51.6 ± 16.7 h, with a minimal complication rate observed during the one-year follow-up. A significant reduction in both operative duration and catheterization interval was observed in patients undergoing LH as opposed to those receiving open hernioplasty. CONCLUSION: Concurrent TURP and inguinal hernioplasty effectively manage BOO due to BPH and inguinal hernias with minimal complications, suggesting a viable approach to reducing hospital stays and surgical interventions. Laparoscopic techniques, in particular, offer benefits in operative efficiency and recovery time, making combined surgery a feasible option for selected patients.

Emergency department visits following transurethral resection of prostate in the elderly: Does duration of postoperative catheterization count?

Background: Elderly patients with benign prostatic hyperplasia are increasingly having minimally invasive surgeries due to their safety. There is also a drive to minimize the duration of postoperative catheterization following transurethral resection of the prostate to reduce hospital stay and encourage early ambulation. These are desirable in the elderly to improve outcomes. Can early catheter removal be done safely in the geriatrics without an increase in presentation to the emergency department with complications? We compare the emergency presentation of elderly patients who had early and delayed catheter removal following transurethral resection of the prostate. Materials and Methods: This was a retrospective review of transurethral resection of the prostate in the elderly (≥70 years) within 2 years in a single hospital. All the patients had monopolar transurethral resection of the prostate and were categorized based on the duration of postoperative catheterization as either early (third postoperative day) or delayed (> third postoperative day). The duration of catheterization was based on surgeon preference. Patients with intraoperative complications were excluded. Data on clinical presentation, comorbidities, and presentation at the emergency department were retrieved and analysed. Results: Forty-one patients were studied with the mean age of patients being 76 ± 4 years. Twenty patients had early catheter removal and 21 had delayed catheter removal. A total of nine patients presented to the emergency department within the 30-day postoperative period with either bleeding urinary retention or incontinence requiring re-catheterization, six had early catheter removal, and three had delayed catheter removal. The catheter duration, preoperative ASA status prostate volume, and preoperative indwelling catheter were not statistically significant determinants of presentation to the emergency department in these elderly men. The presence of comorbidities assessed using the Charlson Comorbidity Index was a statistically significant variable to presentation at the emergency department after surgery P = 0.006. Conclusion: Early catheter removal is safe in elderly patients following transurethral resection of the prostate, however, there is a risk of presentation to the emergency department with complications, especially in patients with comorbidities.

Incidence and Determinants of Catheter-Related Bladder Spasms Following Transurethral Resection of the Prostate; A Prospective Review of 80 Cases.

Background: Bladder spasms due to involuntary contraction of the bladder occur frequently following Transurethral resection of the prostate (TURP). They may be aggravated by the presence of a catheter, blood clots, preoperative overactive bladder, or preoperative ingestion of bladder stimulants like caffeine. These bladder spams are painful, associated with peri-catheter leakage of urine, increased post-operative bleeding, and often refractory to postoperative analgesia. The incidence and risk factors for the occurrence of bladder spasms following TURP need to be reviewed and validated to ensure adequate patient counseling and possible lifestyle modification before surgery. We conducted a prospective review of the determinants of bladder spasms in our patients following TURP. Methodology: The study population was patients with benign prostatic obstruction scheduled for TURP between March 2022 and April 2023. Monopolar transurethral resection of the prostate was done using a continuous flow resectoscope. The primary endpoint of the study was occurrences of bladder spasms postoperatively before the trial without a catheter. Pain perception during the spasms was assessed using a visual analog scale. Clinical data were collected and analyzed to determine their association with the occurrence of bladder spasms postoperatively using regression analysis. Sub-group analysis was also done to correlate significant variables with the severity of pain in patients with spasms. Results: The mean age of the 80 patients reviewed was 66.9 ±8 years. Bladder spasms were seen in 41(51.2%) of the patients. The presence of overactive bladder (OAB) symptoms and the use of bladder stimulants were statistically significant determinants with a p-value of 0.003 and 0.026 respectively. The age of the patient, preoperative indwelling catheter, prostate volume, and resection time were not statistically determinant variables in the occurrence of bladder spasms post-operatively. 61% had severe pains and 39% had mild pains. There was no significant correlation between the presence of OAB or the use of bladder stimulants with the severity of pains in patients with bladder spasms after TURP. Conclusions: Half of the patients are likely to have bladder spasms after TURP. The risk of having these spasms is higher in patients with preoperative OAB or patients who are exposed to bladder stimulants. The severity of spasms is however independent of these risk factors.

Non-Surgical Bleeding and Transurethral Resection of the Prostate (TURP) Syndrome after TURP Surgery: A Case Report and Literature Review.

Patients undergoing transurethral resection of the prostate (TURP) surgery can develop TURP syndrome and post-TURP bleeding. Post-TURP bleeding can be surgical, from arteries or venous sinuses, or non-surgical, due to coagulopathy preventing clot formation. Non-surgical post-TURP bleeding may be due to high concentrations of urokinase and tissue plasminogen activator (tPA) in the urine that cause fibrinolytic changes and increase bleeding risk. Urine urokinase and tPA may have both local and systemic fibrinolytic effects that may prevent blood clot formation locally at the site of surgery, and cause fibrinolytic changes systemically through leaking into the blood stream. Another post-TURP complication that may happen is TURP syndrome, due to absorption of hypotonic glycine fluid through the prostatic venous plexus. TURP syndrome may present with hyponatremia, bradycardia, and hypotension, which may be preceded by hypertension. In this case report, we had a patient with benign prostatic hyperplasia (BPH) who developed both TURP syndrome and non-surgical post-TURP bleeding. These complications were transient for one day after surgery. The local effect of urine urokinase and tPA explains the non-surgical bleeding after TURP by preventing clot formation and inducing bleeding. Coagulation studies showed fibrinolytic changes that may be explained by urokinase and tPA leakage into the blood stream. In conclusion, non-surgical bleeding after TURP can be explained by the presence of fibrinolytic agents in the urine, including urokinase and tPA. There is a deficiency in existing studies explaining the pathophysiology of the fibrinolytic changes and risk of bleeding after TURP. Herein, we discuss the possible pathophysiology of developing fibrinolytic changes after TURP. More research effort should be directed to explore this area to investigate the appropriate medications to treat and prevent post-TURP bleeding. We suggest monitoring patients' coagulation profiles and electrolytes after TURP because of the risk of developing severe acute hyponatremia, TURP syndrome, fibrinolytic changes, and non-surgical bleeding. In our review of the literature, we discuss current clinical trials testing the use of an antifibrinolytic agent, Tranexamic acid, locally in the irrigation fluid or systemically to prevent post-TURP bleeding by antagonizing the fibrinolytic activity of urine urokinase and tPA.

Sudden cardiac arrest in low-risk patient during transurethral resection of the prostate under spinal anesthesia: Acute myocardial infraction a possible cause? Case report.

INTRODUCTION AND IMPORTANCY: A patient experienced a sudden cardiac arrest (CA) during a transurethral resection of the prostate (TURP) under spinal anesthesia (SA), despite no conventional risk factors. The incident, which occurred during TURP without significant changes in vital signs or electrocardiogram (ECG), this report, contributes to accidents during SA for TURP in healthy patients. PRESENTATION OF CASE: A 53-year-old man with BMI 24.1 underwent TURP. SA was administered using bupivacaine 15 mg and fentanyl 10 µg. The patient had normal vital signs & sinus rhythm. However, around a hr. into the procedure, he experienced fatigue, severe chest pain, sweating, & nausea, leading to unconsciousness & CA. The anesthesia and surgical teams initiated cardiopulmonary resuscitation according to American Heart Association guidelines, but CA could not be reversed. CLINICAL DISCUSSION: The patient showed symptoms of acute MI while undergoing TURP but didn't exhibit typical changes on ECG. Early detection using a 5­lead ECG or troponin level may not be possible so make it challenging to get definitive diagnosis of MI to start managements. It's highlighted that some individuals might not meet standard MI diagnostic criteria. CONCLUSION: Diagnosing MI using only a 5-lead ECG can be challenging, as some patients may not exhibit MI findings. Modern monitors that numerically display ST segment depression, along with the availability of continuous 12­lead ECG in the operating theater, can improve emergency detection. In resource-limited countries, adopting new protocols for MI management is crucial. These protocols should include initiating MI treatments even without a confirmed diagnosis.

Robotic bladder diverticulectomy with concurrent management of bladder outlet obstruction: A choice to consider.

INTRODUCTION: Acquired bladder diverticula (BD) are associated with bladder outlet obstruction. The aim of our study is to analyse the improvement in lower urinary tract symptoms (LUTS) in patients who underwent robot-assisted bladder diverticulectomy (RABD) combined with transurethral prostatectomy (TURP). MATERIAL AND METHODS: A prospectively single-centre, single surgeon cohort of four patients with posterolateral BD due to bladder outlet obstruction (BOO) undergoing RABD combined with TURP between 2018 and 2023 was analysed. RESULTS: Median age and maximum BD diameter were 73.5 years and 16 cm, respectively. All patients had severe LUTS and elevated postvoid residual (PVR). Preliminary uroflowmetry revealed bladder outlet obstruction with a median of maximum urine flow rate of 8.5 ml/s. The median operative time and blood loss were 212 min and 100 ml, respectively. No intraoperative complications were recorded. The median length of stay was 4 days. The International Prostate Symptom Score (IPSS) and PVR were compared between baseline, 1 month and 6 months after surgery. IPSS significantly decreased from 24 (IQR 24-25) preoperatively compared to the postoperative, at 1 month follow up 7 (IQR 6-8) (p < 0.0001). PVR significantly decreased too from 165 (IQR 150-187) to 35 ml (IQR 25-42) (p < 0.0001). In transitioning from the 1-month follow-up to the 6-month follow-up, no substantial statistical improvement was observed. CONCLUSION: Concomitant performance of TURP with RABD is feasible and safe. Diverticulectomy in addiction at the endoscopic procedure should be discussed with patients who have obstructive lower urinary tract symptoms as viable alternative to single procedure individually performed.

Perioperative Dyselectrolytemia in Patients Undergoing Transurethral Resection of the Prostate Using 0.9% Normal Saline Irrigation.

BACKGROUND: The choice of irrigation fluid used in transurethral resection of the prostate (TURP) has a significant impact on serum electrolyte levels. Among the many available options, 0.9% normal saline (NS) is considered to be more physiological. MATERIAL AND METHODS: This observational study was conducted on 60 adult males aged 50-70 years, classified as American Society of Anesthesiologists grade 1 and 2, undergoing TURP with 0.9% NS irrigation under spinal anesthesia achieved with a mixture of 0.5% heavy bupivacaine. The patients' hematocrit and serum electrolyte levels were obtained after six hours and compared with preoperative values. RESULTS: Hematocrit reduced from 40.32 ± 6.27 to 31.07 ± 5.40 (p < 0.001). Both serum sodium and potassium decreased from 136.77 ± 3.27 to 128.31 ± 5.91 and from 4.02 ± 0.26 to 3.81 ± 0.36, respectively (p < 0.001). However, serum chloride showed only a minimal increase from 101.58 ± 2.88 to 102.25 ± 1.66 (p < 0.12). CONCLUSION: Although the changes in serum sodium and potassium were statistically significant, they did not have any physiological consequences in our study. However, this emphasizes the importance of vigilant electrolyte monitoring to identify and mitigate the risk of electrolyte disturbances during TURP surgeries.

Development of the UroARC Surgical Calculator: A Novel Risk Calculator for Older Adults Undergoing Surgery for Bladder Outlet Obstruction.

PURPOSE: Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist. MATERIALS AND METHODS: Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications. RESULTS: In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit. CONCLUSIONS: This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

Survival benefit of radical prostatectomy in patients with advanced TURP-diagnosed prostate cancer: a population-based real-world study.

OBJECTIVES: A considerable number of patients are diagnosed with prostate cancer (PCa) by transurethral resection of the prostate (TURP). We aimed to evaluate whether radical prostatectomy (RP) brings survival benefits for these patients, especially in the elderly with advanced PCa. PATIENTS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database to obtain PCa cases diagnosed with TURP. After the propensity matching score (PSM) for case matching, univariate, multivariate, and subgroup analyses were performed to investigate whether RP impacts the survival benefit. RESULTS: 4,677 cases diagnosed with PCa by TURP from 2010 to 2019 were obtained, including 1,313 RP patients and 3,364 patients with no RP (nRP). 9.6% of RP patients had advanced PCa. With or without PSM, cancer-specific mortality (CSM) and overall mortality (OM) were significantly reduced in the RP patients compared to the nRP patients, even for older (> 75 ys.) patients with advanced stages (all p < 0.05). Except for RP, younger age (≤ 75 ys.), being married, and earlier stage (localized) contributed to a significant reduction of CSM risk (all p < 0.05). These survival benefits had no significant differences among patients of different ages, married or single, and at different stages (all p for interaction > 0.05). CONCLUSIONS: Based on this retrospective population-matched study, we first found that in patients diagnosed with PCa by TURP, RP treatment may lead to a survival benefit, especially a reduction in CSM, even in old aged patients (> 75 ys.) with advanced PCa.

The Impact of SARS-CoV-2 on Patients With Lower Urinary Tract Symptoms (LUTS).

INTRODUCTION: During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the management of patients with lower urinary tract symptoms (LUTS) underwent dynamic adjustments in response to an evolving understanding of the virus's impact on different patient populations. Healthcare practitioners reevaluated therapeutic approaches for conditions like benign prostatic hyperplasia (BPH), considering the potential implications of this condition on the severity and progression of coronavirus disease 2019 (COVID-19). This study aims to investigate potential correlations between SARS-CoV-2 infection severity, exacerbation of LUTS, and BPH progression. MATERIAL AND METHODS: This retrospective study includes patients hospitalized in our Urology Department between January 2021 and January 2023, presenting with both SARS-CoV-2 and BPH. Their ages ranged from 57 to 88 years, with a mean age of 65.4 years. The diagnosis of BPH relied on a diagnostic triad consisting of digital rectal examination, biological markers (including prostate-specific antigen (PSA) and free PSA, and ultrasound examination, with both conditions confirmed based on test results. Transurethral resection of the prostate (TURP) procedures utilized monopolar Karl Storz resection equipment, using sorbitol and bipolar Olympus devices for transurethral resection of the prostate in saline (TURPis). Haemostasia was performed using roller balls. Anticoagulation followed a prescribed scheme by cardiologists and infectious disease specialists. Statistical analysis was conducted using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. RESULTS: Among the 138 hospitalized patients affected by both BPH and COVID-19, 18 required emergency endoscopic procedures (specifically TURP or TURPis) to achieve hemostasis (Figures 1, 2). These individuals presented persistent hematuria despite conservative treatments. The mean duration of surgery was 57.9 minutes. Patients who underwent surgery had a longer average hospital stay compared to those who did not, with durations of 10.5 days versus 7.5 days, respectively. Additionally, urethrovesical catheter insertion was necessary in 29 cases due to acute urinary retention or worsening voiding symptoms during hospitalization. These patients are scheduled for further urological evaluation following the resolution of the COVID-19 episode. In a cohort of 53 patients for whom data were accessible, comparisons were made between the pre-COVID status and the levels of the International Prostate Symptom Score (IPSS), post-voiding residue (PVR), and quality of life (QoL). The findings revealed a mean pre-COVID IPSS value of 11.6 and a COVID-related value of 14.2, with a statistically significant difference noted (p < 0.05). The mean pre-COVID PVR was 42.3 cm2, whereas during the COVID-19 period, it measured 62.5 cm2, also exhibiting a significant difference (p < 0.05). Additionally, the QoL showed a mean pre-COVID-19 score of 2.4 and a COVID-19-associated score of 2.9, again demonstrating statistical significance (p < 0.05). CONCLUSION: The onset of the SARS-CoV-2 pandemic posed novel challenges in the medical realm, impacting the approach to BPH management. A common practice was delaying treatment for chronic BPH until viral infection remission to reduce associated risks. Additionally, our study revealed a worse evolution in LUTS among individuals with severe COVID-19 symptoms.