LTCs cause a significant burden on healthcare systems and impact negatively on patient quality of life.1 Complications of LTC include infections, bleeding, stone formation, bladder neck trauma, urethral false passage, traumatic hypospadias, bladder neck incompetence, urethral sphincter erosion, pressure sores, sepsis, shame, reduced sexual function, kidney stone formation and squamous cell carcinoma of the bladder. A cost analysis study showed that in the UK long-term catheters and their complications cost the NHS 45,717 bed days and £54.4 million pounds per year, with an additional £209.4 million loss in economic value due to the impact on quality of life years.2 Any procedure which reduces the need for long-term catheters is therefore likely to be vastly beneficial to both patients and healthcare systems and yet there is a paucity of modern evidence for the surgical management of CUR, particularly in elderly patients.
Our single-centre, retrospective, observational cohort study reviews the surgical outcomes for 147 catheterized men over 80 years who underwent TURP with the primary aim of becoming catheter free. Data was obtained from a comprehensive online database of all operations and follow-ups performed between 2012 and 2020. Included patients were those at least 80 years old at the time of undergoing a primary TURP. Exclusion criteria were men with neurogenic bladder dysfunction, concurrent urethral strictures, bladder cancer, and those undergoing emergency TURP for bleeding or infection. All patients underwent monopolar TURP using a Storz® 30° telescope with 28Fr continuous flow sheath and monopolar loop electrode until April 2017 when our departmental unit switched to the Storz® bipolar resection equipment utilizing a 26Fr sheath. Chi-squared test was used to determine statistical significance for grouped data and logistic regression modeling was used for continuous data, with a p-value of <0.05 defined as being statistically significant. The primary outcome measure was catheter-free rate at 3-month and 12-month follow-up appointments. Secondary outcome measures were rates of minor and major complications according to the Clavien Dindo I-IV classification system.
The results of our study were encouraging. Mean operative time was 51 minutes; length of stay was 3.63 days (including 6 procedures completed as a day case and 25 patients having a prolonged stay of more than 3 days); and the average time from operation to ‘12-month follow-up’ was 334.6 days. 89/147 patients (60.5%) passed initial TWOC following TURP. At the 3-month follow-up, surgical success was achieved in 118/147 (80.3%), with 106/147 (72.1%) voiding freely and a further 12 (8.1%) voiding but requiring ISC for high post-void residuals. Of those who failed, two patients were treated with long-term suprapubic catheters (SPCs) and 27 were treated with long-term urethral catheters. At the 12-month follow-up, 79.6% (n=117) were catheter free.
We identified that post-void residual bladder volumes (PVR)>1500ml (50% success vs 83.5% (p=0.017)); age ≥90 (53.8% success vs 84.3% (p=0.0067)); and WHO performance score ≥3 (44.1% success vs 92.9% (p< 0.00001)); were all independent risk factors for long-term surgical failure after TURP in the elderly population. Excluding this sub-set of patients, i.e. those <90 years, with PVR <1500mls and WHO performance status <3, the overall success rate at 3 months was 88.8% (95% C.I. 82.2% - 92.6%), including 8.2% of patients who required ISC for high post-volume residuals. This shows that a high success rate can be achieved in the elderly population when patients are appropriately selected.
Only 27.9% of our patients underwent pre-operative urodynamic studies (UDS) and their use was not associated with a statistically significant change in outcomes (p=0.46) suggesting that it is not an absolute pre-requisite test before offering all elderly patients bladder outflow obstruction surgery. This is in keeping with a previously published UPSTREAM study, which did not support the routine use of UDS over a detailed history, examination, and basic urinary flow and post-void residual bladder scan assessment.3 Our ongoing practice is to consider UDS only in specific cases such as large PVR >1500mls, presence of neurological disease, high anaesthetic risks, or patient choice.
The results from our study allowed us to propose a decision-making algorithm for the management of chronic urinary retention due to prostatic enlargement, shown below.
Our study is the largest study to date of an elderly cohort of catheterized men undergoing TURP to treat chronic urinary retention. Contemporary equipment was used and specific endpoints, important to this cohort were, chosen - namely the number who can expect to be catheter free post-operatively at 3 months and long-term (≥1 year) follow-up. High PVR (>1500ml), age >90 years and reduced performance status (WHO performance status ≥3) have all been identified as independent risk factors for surgical failure. Moreover, we have demonstrated that if those risk factors are avoided, selected patients over 80 years undergoing TURP for CUR can expect an appreciable 88.8% chance of voiding postoperatively. Finally, we have developed a decision aid flow diagram which we hope will be clinically useful to both doctors and patients in informing them about their expected outcomes after surgery.
Written by: Vaki Antoniou, Faisal Edris, Winnette Akpobire, Jim Voss, Bhaskar K Somani
Southampton General Hospital, Urology, Tremona Road, Southampton, United Kingdom of Great Britain and Northern Ireland, SO16 6YD; Southampton General Hospital, Southampton, United Kingdom of Great Britain and Northern Ireland; Southampton General Hospital, Urology, Southampton, United Kingdom of Great Britain and Northern Ireland; Bristol Royal Infirmary, Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland; University Hospitals Southampton NHS Trust, Urology, Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland, SO16 6YD
References:
- Saint S, Trautner BW, Fowler KE, Colozzi J, Ratz D, Lescinskas E, et al. A multicenter study of patient-reported infectious and noninfectious complications associated with indwelling urethral catheters. JAMA Intern Med. 2018;178(8).
- Smith DRM, Pouwels KB, Hopkins S, Naylor NR, Smieszek T, Robotham J V. Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modeling study. J Hosp Infect. 2019 Sep 1;103(1):44–54.
- Lewis AL, Young GJ, Selman LE, Rice C, Clement C, Ochieng CA, et al. Urodynamics tests for the diagnosis and management of bladder outlet obstruction in men: the UPSTREAM non-inferiority RCT. Health Technol Assess (Rockv) [Internet]. 2020 [cited 2022 May 4];24(42):1–154.