Transurethral resection of the prostate: studies on efficacy, morbidity and costs

Abstract

Lower urinary tract symptoms (LUTS), based on benign prostatic enlargement (BPE), are increasingly common, in ageing men. A considerable amount of men will ultimately progress with deteriorating symptoms or with the occurrence of complications secondary to obstruction of the bladder outlet, for example, urinary retention (UR). These subjects need surgery. Transurethral resection of the prostate (TURP) is the gold standard surgical intervention for symptoms associated with BPE. Over time, the TURP procedure has evolved due to manifold technical improvements and these progresses, coupled with improved surgical skill, are thought to have led to additional improvements regarding voiding outcomes, coupled with a decreased morbidity and mortality. The aims of this thesis were to explore and elucidate the effects of TURP, in a non-academic setting, including functional outcomes, complications and healthcare costs. All consecutive men subjected to a TURP procedure due to BPE at Skaraborgs Hospital during the periods 2010-2012 and 2017-2019 were identified and data retrieved from the hospital records. All men were followed-up for 3 months postoperatively and more if deemed necessary. Responders were defined according to criteria set up by de Wildt. Complications were graded in accordance with the Clavien-Dindo system. In Paper I, men with bothersome LUTS and men in UR reported response rates of 95% and 83% respectively indicating that TURP is a successful procedure in both these patient categories. In Paper II, the incidence of major complications was low, during hospital stay (2.3%) and between hospital discharge and follow-up (3.4%). Late complications, requiring endourological re-intervention occurred in 9.7%. In Paper III, we followed the fate of the 35 non-responders and found that 11 men were finally judged to have satisfactory voiding parameters, 16 men utilized clean intermittent self-catheterisation to varying degrees, 7 men had to use an indwelling catheter indefinitely, and only one man still suffered from bothersome LUTS. In Paper IV, we analysed all in-hospital expenses of 122 men subjected to TURP and found that the median cost for this procedure was 37343 SEK (IQR 29852-44260). The main drivers of total cost were length of hospital stay, the surgical procedure and anaesthesia related costs. The main factor that increased total cost per patient was the occurrence of complications. In summary, transurethral resection of the prostate is a rewarding operation in men with UR or with bothersome LUTS. Men with preoperative UR constituted most of non-responders. There was a low use of invasive urodynamic investigations after surgery. In the end, nearly one in three non-responders had a fair outcome with or without redo-surgery. TURP in routine clinical care was linked with a low incidence of serious complications. TUR syndrome was very rare. A small amount of patients needed the endourological treatment to be repeated. The main factor affecting total cost for a TURP procedure was the occurrence of postoperative complications.