Does histological prostatic inflammation during transurethral resection of the prostate for bladder outlet obstruction affect post-operative urinary outcomes?

OBJECTIVE: Benign prostate hyperplasia (BPH) is a common cause for bladder outlet obstruction (BOO) and lower urinary tract symptoms (LUTS) in men. The pathophysiology of BPH is multifactorial and inflammation has been linked with progression of BPH and LUTS. The association between histological prostatitis found at transurethral resection of the prostate (TURP) and adverse post-operative urinary outcomes is not clearly defined. Our aim was to evaluate the association between histological prostatitis and adverse post-operative urinary outcomes following TURP procedure. METHODS: Patients who had undergone TURP for BPH at a single institution between 2014 and 2018 were included. The study population was divided into three cohorts: those with no histological inflammation, those with any form of inflammation and those specifically with prostatic stromal inflammation. Functional outcomes were assessed by defining a series of measurable post-operative "LUTS events" and comparing these to time-to-event profile using a Kaplan-Meier estimator. RESULTS: A total 198 patients were included (no inflammation n = 101; any inflammation n = 97, prostatic stromal inflammation n = 81). All three groups were comparable in terms of baseline characteristics. The any inflammation group had significantly more adverse post-operative outcomes after TURP compared to the no inflammation group, P = 0.0065. The stromal inflammation group had more LUTS events after surgery compared to the no inflammation groups in the first year of follow-up n = 0.011; over a 5-year follow-up period the results were not statistically significant, P = 0.244. CONCLUSION: Histological prostatitis is associated with worse urinary outcomes after TURP compared to no inflammation. These results are useful in improving prognostic discussions with patients after TURP.

Clinical pharmacokinetics of flomoxef in prostate tissue and dosing considerations for prostatitis based on site-specific pharmacodynamic target attainment.

Flomoxef is used to treat bacterial prostatitis; however, its prostatic pharmacokinetics have not been fully clarified. Flomoxef (500 or 1000 mg) was administered to patients with benign prostatic hypertrophy (n = 54). After a 0.5-h infusion, venous blood samples were drawn at time points of 0.5-5 h, and prostate tissue samples were collected at time points of 0.5-1.5 h during transurethral resection of the prostate. The drug concentrations in plasma and prostate tissue were analyzed pharmacokinetically and used for a stochastic simulation to predict the probability of attaining pharmacodynamic target in prostate tissue. Showing dose linearity in the prostatic pharmacokinetics, flomoxef rapidly penetrated into prostate tissue, with a prostate/plasma ratio of 0.48-0.50 (maximum drug concentration) and 0.42-0.55 (area under the drug concentration-time curve). Against the tested populations of Escherichia coli, Klebsiella and Proteus species isolates, 0.5-h infusion of 1000 mg three times daily achieved a ≥90% expected probability of attaining the bactericidal target (70% of the time above the minimum inhibitory concentration [MIC]) in prostate tissue. The site-specific pharmacodynamic-based breakpoint (the highest MIC at which the target-attainment probability in prostate tissue was >90%) values were 0.25 mg/L (MIC for 90th percentile of E. coli and Klebsiella species) for 500 mg four times daily and 0.5 mg/L (MIC90 of Proteus species) for 1000 mg four times daily. These results help to fully characterize the prostatic pharmacokinetics of flomoxef, while also helping to rationalize and optimize the dosing regimens for prostatitis based on site-specific pharmacodynamic target attainment.

Chronic prostatitis effectively managed by transurethral prostatectomy (TURP) in a spinal cord injury male.

Introduction: Spinal cord injury (SCI), specifically suprasacral SCI, results in high intravesical pressures, elevated post-void residual and urinary incontinence which are all risk factors for urinary tract infections (UTIs). The management of UTIs usually is conservative medical antibiotic treatment. However, recurrent UTIs in the SCI patient population warrant further investigation. The method of urinary drainage (intermittent or indwelling urinary catheters, urinary diversion) and untreated complications of NLUTD (vesicoureteral reflux, stone formation, chronic incomplete emptying of the bladder) are risk factors for recurrent UTIs (rUTIs). Removal of these UTI risk factors and improving urinary drainage are goals of urologic management; however, when conservative interventions do not succeed, surgery may be a viable solution in select cases of rUTIs. Case presentation: We present a case of complicated persisting rUTIs and associated urethral discharge in a middle-aged SCI male who manages his bladder with intermittent catheterization (IC). We detail the evaluation and management approach that leads to an eventual transurethral prostatectomy (TURP) as a final solution for his rUTIs. Fortunately, the surgical intervention was successful, and the patient is free of UTIs after 4 years of follow-up. Discussion: In SCI male patients with rUTIs and suspected chronic prostatitis, TURP may be a valuable treatment option once all predisposing factors have been remediated.

[Granulomatous Prostatitis : Three Cases Report].

Case 1 : A 65-year-old man visited withfrequent urination and dysuria. Pyuria and bacteriuria were observed and prostate specific antigen (PSA) was elevated to 5.69 ng/ml. Prostate cancer and urinary tract infection were suspected. A antibiotics were administered and prostate magnetic resonance imaging (MRI) was performed. Massive prostate cancer was strongly suspected from the MRI findings and prostate needle biopsy was performed. The pathological examination revealed nonspecific granulomatous prostatitis. Case 2 : A 69-year-old man visited withfrequent urination. Urinalysis was normal and PSA was elevated to 4.52 ng/ml. Diffuse prostate cancer was suspected from the MRI findings and prostate needle biopsy was performed. Pathological findings were similar to those in case 1. Case 3 : A 61-year-old man presented withno urinary symptoms. Urinalysis was normal and PSA was elevated to 11.64 ng/ml. Medical history was renal pelvic cancer and bladder cancer. He had undergone a transurethral resection of the bladder tumor (TURBT) and intravesical Bacillus Calmette-Guérin (BCG) immunotherapy. Prostate cancer was suspected from the MRI findings and prostate needle biopsy was performed. Pathological findings were granulomatous prostatitis. In these three cases, the structure of these prostate capsules was preserved although extensive prostate cancer was suspected from the findings of MRI T2-weighted and diffusion weighted images. Although histopathologic examination is mandatory for differential diagnosis between granulomatous prostatitis and diffuse prostate cancer, prostate MRI may help to distinguish these diseases.

A significant percentage of patients with transrectal biopsy-related infections have positive blood cultures but negative urine cultures. A literature review and meta-analysis.

BACKGROUND: Infectious complications after transrectal prostate biopsy are rare. Nevertheless, since these are frequent procedures, the burden of infectious complications is high. Considering the increasing antimicrobial resistance, microbiological confirmation is important to guide antimicrobial therapy. METHODS: We reviewed PubMed for original studies providing concurrent urine and blood culture data in symptomatic patients with transrectal biopsy-related infectious complications. We performed a proportions meta-analysis (with MedCalc) and calculated the pooled yield of urine and blood cultures and the pooled discordance rate between urine and blood cultures. RESULTS: Our review identified 41 studies, involving 852 patients with infectious complications after transrectal prostate biopsy and sufficient data to calculate discordance. The pooled yield of urine cultures was 64.6% (95% CI: 56.2-72.3%, I2 83%), the pooled yield of blood cultures was 43% (95% CI: 36.5-49.7%, I2 74%) and the pooled discordance rate was 14% (95% CI: 10.6-17.8%, I2 53%). In subgroup analyses the pooled discordance was; 19.6% (95% CI: 11.8-28.9%, I2 31%) in 113 patients presenting within 2 calendar days after the biopsy and 11.2% (95% CI: 4.5-20%, I2 47%) in 143 patients presenting with fever and symptoms of lower urinary tract symptoms. The statistical and methodological heterogeneity of included studies was high. CONCLUSION: Obtaining blood cultures is reasonable in all patients presenting with systemic symptoms suggestive of infection after a transrectal prostate biopsy. Blood cultures can provide additional microbiological data in about 1 of 7 patients with post-biopsy infectious complications. Prospective studies are needed to validate these results.

Experience of hundred cases of transurethral resection of prostate at tertiary care hospital in Karachi.

To share the experience of 100 cases of Transurethral Resection of Prostate (TURP), This cross-sectional study was conducted in the Department of Urology, SMBBMC and Lyari General Hospital, Karachi from 1.1.13 to 30.4.15. One hundred cases were selected through purposive sampling. Patients who underwent TURP were included. Those with two life threatening co-morbidities, positive urine culture and patients on anti coagulant medications were excluded from the study. Mean age of the patients was 66±6.2 years with minimum 60 years and maximum 85 years. Six percent of the cases were residents of Iran, while 30% belonged to Baluchistan and also from remote areas of Sindh. Prostate was found hard in 6%, with immobile mucosa in 1%, tenderness in 22%, upper margin not approachable in 6% and Nodularity in 3% of the cases. Lyari General Hospital is catering the surgical needs, especially endoscopic gold standard option (TURP), of the patients not only from Lyari but also from Baluchistan and Iran along with remote and underdeveloped areas of Sindh.

Surgical therapy of prostatitis: a systematic review.

PURPOSE: The clinical term "prostatitis" refers to a clinical syndrome defined by the following 4 distinct entities: acute bacterial prostatitis (category 1), chronic bacterial prostatitis (category 2), chronic prostatitis/chronic pelvic pain syndrome (category 3), and asymptomatic prostatitis (category 4) The etiology of the chronic forms is still not fully understood and choice of therapy is often debated. The objective of this systematic review is to collect evidence on the surgical treatment of the chronic form of prostatitis and to evaluate its clinical implication. METHODS: We performed a systematic literature search and identified 6683 relevant publications, of which 16 were included in the review. RESULTS: Transurethral prostate resection was performed in 110 patients; 78 patients (70%) were reported as "cured", 16 patients (15%) as improved, and 16 patients (15%) as unchanged. Radical prostatectomy was performed in 21 patients; a full resolution of prostatitis related symptoms was reported for 20 patients (95%). No increased rates of complications or unusual complications were noted. CONCLUSIONS: Surgical therapy of chronic bacterial prostatitis or chronic pelvic pain syndrome might be a viable option; however, since little evidence is currently available and no randomized controlled trials have been conducted, the presently available data does not provide a base for clinical decisions.

[Extracorporeal shock wave therapy in chronic prostatitis].

INTRODUCTION: Chronic prostatitis is a prevalent urologic disease, but treatment outcomes are not always satisfactory. As a rule, chronic prostatitis results in chronic pelvic pain syndrome, significantly reducing the patient's quality of life. MATERIAL AND METHODS: Open pilot prospective non-comparative study was conducted to test the effectiveness of extracorporeal shock wave therapy (ESWT) using Aries (Dornier) machine in patients with chronic prostatitis (CP) of IIIb category. A total of 27 patients underwent ESWL as monotherapy, 2 times a week for a course of 6 sessions. Exposure settings: 5-6 energy level (by sensation), the frequency of 5 Hz, 2000 pulses per session; each patient received a total energy up to 12000 mJ. per procedure. RESULTS: Treatment results were evaluated using NIH-CPSI (National Institute of Health Chronic Prostatitis Symptom Index) upon completing the 3 week course of 6 treatments and at 1 month after ESWT. Immediately after the ESWT course positive trend was not significant: pain index decreased from 9.1 to 7.9, urinary symptom score remained almost unchanged (4.2 at baseline, 4.1 after treatment), quality of life index also showed a slight improvement, dropping from 7.2 points to 6.0. Total NIH-CPSI score decreased from 20.5 to 18.0. One month post-treatment pain significantly decreased to 3.2 points, the urinary symptom score fell to 2.7 points, the average quality of life score was 3.9 points. CONCLUSION: ESWT, performed on Aries (Dornier) machine, is highly effective as monotherapy in patients with category IIIb chronic prostatitis.

Association between asymptomatic inflammatory prostatitis NIH category IV and prostatic calcification in patients with obstructive benign prostatic hyperplasia.

BACKGROUND: The aim of this study was to evaluate the incidence of prostatic calcification and prostatitis NIH category IV in patients with obstructive BPH. METHODS: Ninety-six patients with obstructive BPH who had undergone transurethral electroresection of the prostate gland were evaluated. In accordance with a preoperative transrectal ultrasound examination, patients were divided into one group with prostatic calcification (N.=31) and one without (N.=65). Prostatitis NIH category IV was classified according to the grading system by Irani. Correlations between the incidence of prostatic calcification, histological prostatitis, PSA, uric acid, cholesterol, triglycerides, CRP, IPSS, IIEF-25, and NIC-CPSI were analyzed. A stone analysis of prostatic calcification was performed using X-ray powder diffraction. RESULTS: Sixty-nine (71.9%) patients had NIH category IV prostatitis, accounting for 83.9% of those with prostatic calcification versus 66.1% of those without (P<0.04). Significant correlations were found between prostatic calcification and the severity of inflammation (P<0.02) as well as the NIH-CPSI subdomain of urinary symptoms (P<0.02). The only predictor for prostatic calcifications were elevated levels of uric acid. Such patients were 1.4times more likely of having calcifications in the prostate gland (OR=1.4, P<0.047). Stone analysis revealed the following: apatite in 41.7%, whewellite in 29.2%, weddellite and brushite in 8.7% each, whitlockite, apatite/whewellite and organic substances in 4.2%. CONCLUSIONS: On ultrasound examination, one third of patients who were treated with TURP for obstructive BPH had prostatic calcification. These were significantly more common in patients with NIH category IV prostatitis.

Chronic bacterial prostatitis and chronic pelvic pain syndrome.

INTRODUCTION: Chronic prostatitis can cause pain and urinary symptoms, and can occur either with an active infection (chronic bacterial prostatitis [CBP]) or with only pain and no evidence of bacterial causation (chronic pelvic pain syndrome [CPPS]). Bacterial prostatitis is characterised by recurrent urinary tract infections or infection in the prostate with the same bacterial strain, which often results from urinary tract instrumentation. However, the cause and natural history of CPPS are unknown and not associated with active infection. METHODS AND OUTCOMES: We conducted a systematic overview and aimed to answer the following clinical questions: What are the effects of treatments for chronic bacterial prostatitis? What are the effects of treatments for chronic pelvic pain syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 131 studies. After deduplication and removal of conference abstracts, 67 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 51 studies and the further review of 16 full publications. Of the 16 full articles evaluated, three systematic reviews and one RCT were included at this update. We performed a GRADE evaluation for 14 PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for 12 interventions based on information relating to the effectiveness and safety of 5 alpha-reductase inhibitors, allopurinol, alpha-blockers, local injections of antimicrobial drugs, mepartricin, non-steroidal anti-inflammatory drugs (NSAIDs), oral antimicrobial drugs, pentosan polysulfate, quercetin, sitz baths, transurethral microwave thermotherapy (TUMT), and transurethral resection of the prostate (TURP).

Transurethral resection of the prostate in recurrent acute bacterial prostatitis.

OBJECTIVE: To explore the outcome of transurethral resection of the prostate (TURP) in the treatment of refractory recurrent acute bacterial prostatitis. PATIENTS AND METHODS: From 2004 to 2013, 23 TURP for this indication were performed in 21 patients; two patients underwent it twice. The files of these patients were retrospectively analysed for outcome and side effects. TURP intended to remove as much infected tissue as possible under appropriate antibiotherapy. RESULTS: Twelve patients became free of symptoms during a follow-up of 3-108 months (median 44), two others became disease-free after one and two postoperative attacks, respectively; eight were not cured and had rapid recurrences; three patients had follow-up of a few weeks only. Two failures developed orchiepididymitis shortly after the procedure and one a year later. No incontinence or bladder neck contracture was noted. CONCLUSION: TURP is an acceptable procedure in the treatment of refractory recurrent bacterial prostatitis. It could cure about two thirds of patients.

Lower urinary tract symptom improvement after radical prostatectomy correlates with degree of prostatic inflammation.

OBJECTIVE: To determine if prostatic inflammation at the time of radical prostatectomy (RP) was associated with the International Prostate Symptom Score (IPSS). METHODS: We performed a proof of principle analytic case control study of patients who underwent RP between January 2005 and August 2008 for lower urinary tract symptoms (LUTS). We reviewed pathology slides of those who had a change of 4 points or greater, as measured by the IPSS and correlated inflammation with change in IPSS. Multivariate linear regression analyses were performed to determine the association of IPSS with degree of inflammation based on the number of inflammatory cells. RESULTS: Of 249 patients, 136 had complete data and 47 (18.8%) underwent pathologic review. The median change in IPSS for the study cohort was -7.0 points compared to +1.0 point for the control cohort. On univariate analysis, the average improvement in IPSS in patients with severe inflammation was (r = -6.02, 95% confidence interval [CI] -11.0 to -1.1, P = .018) after RP. On multivariate analysis, adjusting for age, body mass index (BMI), year of surgery, history of prostatitis, Gleason score, prostate-specific antigen (PSA), prostate weight, and nerve sparing status, only patients with severe prostatic inflammation had significant improvement in their IPSS (r = -5.93, 95% CI -10.81 to -1.04, P = .004). CONCLUSION: Prostatic inflammation measured in prostatectomy specimens is associated with worse baseline IPSS than matched cohorts. Specifically, severe inflammation is an independent predictor of IPSS improvement at 1 year after RP.

Epidural anesthesia can block the negative effects of prostaglandin mediators during prostate surgery.

INTRODUCTION: Inflammation plays a key role in the development of benign prostatic hyperplasia. Prostaglandin E2 (PGE2) is an important inflammation factor found in enlarged prostatic tissue that can be the main cause of inflammatory pain. The aim of this study was to investigate whether epidural anesthesia can block the negative effects of prostaglandin mediators during prostate surgery. MATERIALS AND METHODS: The study included 60 patients who underwent open prostatectomy. All patients were randomly allocated to one of two study groups. The first group received general anesthesia and the second group a combination of general and epidural anesthesia. Main outcome measures were plasma concentration of PGE2, adrenaline, noradrenaline, and dopamine, before induction of anesthesia and at the time of enucleation. RESULTS: Preoperative serum concentrations of PGE2 were high in both groups. During enucleation, serum concentrations of adrenaline, noradrenaline, and dopamine increased, followed by a rise of systolic and diastolic blood pressure in the group of patients that received only general anesthesia. Serum concentration of PGE2 was at the same level as before induction of anesthesia in both groups. CONCLUSION: Epidural anesthesia blocks transmission of painful stimulus through the spinal cord caused by prostaglandin release and prevents the rise of catecholamines and blood pressure. Open prostatectomy can become a safer procedure performed under a combination of general and epidural anesthesia. Negative intraoperative effects of inflammatory prostate mediators during other techniques for prostate surgery could also be blocked with epidural anesthesia.

[LUTS in BPH patients with histological prostatitis before and after transurethral resection of the prostate].

OBJECTIVE: To investigate the effects of transurethral resection of the prostate (TURP) on lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH) complicated by histological prostatitis. METHODS: This study included 432 cases of BPH pathologically confirmed after TURP. Excluding those with LUTS-related factors before and after surgery and based on the international prostatitis histological classification of diagnostic criteria, the remaining 144 cases were divided into groups A (pure BPH, n = 30), B (mild inflammation, n = 55), C (moderate inflammation, n = 31), and D (severe inflammation, n = 28). Each group was evaluated for LUTS by IPSS before and a month after surgery. RESULTS: A total of 399 cases (92.4%) were diagnosed as BPH with histological prostatitis, 269 (67.4%) mild, 86 (21.6%) moderate and 44 (11.0%) severe. The preoperative IPSS was 21.43 +/- 6.09 in group A, 21.75 +/- 5.97 in B, 27.84 +/- 4.18 in C and 31.00 +/- 2.92 in D, with statistically significant differences among different groups (P < 0.001) except between A and B (P = 1.000); the postoperative IPSS was 5.60 +/- 2.16 in A, 7.36 +/- 2.77 in B, 11.55 +/- 3.39 in C and 16.89 +/- 3.37 in D, with statistically significant differences among different groups (P < 0.01), and remarkably lower than the preoperative one (P < 0.001). Almost all the infiltrating inflammatory cells in BPH with histological prostatitis were lymphocytes. CONCLUSION: BPH is mostly complicated with histological chronic prostatitis. The severity of LUTS is higher in BPH patients with histological prostatitis than in those without before and after TURP, and positively correlated with the grade of inflammation. Those complicated with moderate or severe histological prostatitis should take medication for the management of LUTS.

Do the medical treatment reduces the rate of surgical treatment in suspected cases of chronic prostatitis before prostatectomy?

AIM: Our aim is to investigate how the chronic intraprostatic inflammation affect the course of the BPH (benign prostatic hyperplasia). PATIENTS AND METHODS: Between the dates of 2007-2011, the files of the patients who had TUR-P (transurethral resection of the prostate) and underwent open surgery were retrospectively reviewed because of BPH, and the patients were divided into two groups who were operated due to AUR (acute urinary retention) or LUTS (lower urinary tract symptoms) and the clinical data and pathology results of the two groups were compared in terms of chronic intraprostatic inflammation. RESULTS: There were evaluable data of 130 of 150 patients. The age range of the patients was 50-88. 52 of the 130 patients due to AUR and 78 of them due to LUTS underwent surgery. While there was chronic inflammation in 59 of the 130 patients, there was not in 71. The volume of the prostate and the average age of those who had chronic prostatitis with the combination of AUR were greater compared to the LUTS. CONCLUSIONS: It seems that chronic prostatitis is a factor which is often accompanied by BPH and affects the progression and pathology of the disease. The risk of acute urinary retention is more frequent in patients with chronic inflammation than in those who lack. In the future, related clinical trials with the relationship between the intraprostatic inflammation and BPH treatment are necessary and should include more cases and longer period of follow-up for these studies.

Transrectal US-guided seminal vesicle aspiration in the diagnosis of partial ejaculatory duct obstruction.

There has been recent interest in techniques for diagnosing ejaculatory duct obstruction (EDO), especially when the partial form of the disease is suspected clinically. Currently, there is no gold standard technique for diagnosing EDO. Transrectal ultrasonography (TRUS), which is the technique used most widely, can overdiagnose EDO. As adjunctive diagnostic techniques, duct chromotubation and seminal vesiculography cannot distinguish patients with partial obstruction from those without EDO. TRUS-guided seminal vesicle aspiration can be used in conjunction with TRUS to confirm the diagnosis pre-operatively, especially in patients with seminal vesicle dilation and a prostatic midline/ejaculatory duct cyst on TRUS. In patients with findings of chronic inflammation, such as ejaculatory duct calcifications and seminal vesicle atrophy/ hypoplasia on TRUS, proximal vasal obstruction or functional EDO should be excluded.