Bladder outflow tract obstruction and urinary retention from benign prostatic hypertrophy treated by balloon dilatation

Efficacy and safety of transurethral split of prostate for benign prostatic hyperplasia: a meta-analysis

BACKGROUND

Transurethral resection of the prostate (TURP) is the first choice for the treatment of benign prostatic hyperplasia. However, Transurethral split of prostate (TUSP) also seems to have clear clinical efficacy and clinical promotion value. To better clarify the potential and limitations of this treatment of prostate hyperplasia. This study objectively evaluated the clinical efficacy and safety of TUSP.

METHODS

The Pubmed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Database for Chinese Technical Periodicals (VIP), Wanfang (Wanfang data), and SinoMed databases were searched for relevant studies. We then used Revman Manager 5.3 to perform a meta-analysis of all randomized controlled trials that evaluated the efficacy and safety of TUSP versus the classic surgical procedures commonly used in the clinic.

RESULTS

A total of 7 studies involving 592 patients were included. The combined data showed that TUSP can shorten the operation time [MD: -33.68; 95% CI: - 38.45 to - 28.91; P < 0.001], reduce intraoperative blood loss [MD: -56.06; 95% CI: - 62.68 to - 49.43; P < 0.001], shorten the time of indwelling catheter [MD: -1.83; 95% CI: - 1.99 to - 1.67; P < 0.001], shorten the postoperative hospital stay length [MD: -1.61; 95% CI: - 1.90 to - 1.32; P < 0.001] and improved postoperative quality of life score (QOL) [MD: 0.16; 95% CI: 0.02 to 0.29; P = 0.02] compared to traditional surgical approaches. There were no statistically significant differences in international prostate symptom score (IPSS), maximum urinary flow rate (Qmax), residual urine volume (RUV), or complications between TUSP and traditional approached.

CONCLUSION

TUSP can be an effective alternative for clinical treatment of benign prostatic hyperplasia. Given the limitations of the included studies, more high-quality randomized controlled trials are needed in the future to validate or update the results of this analysis.

Randomized clinical trial comparing balloon dilatation to transurethral resection of prostate for benign prostatic hyperplasia

To evaluate the effectiveness and clinical outcome of patients treated by balloon dilatation of the prostate (BDP) compared with transurethral resection of the prostate (TURP) we performed a prospective, randomized clinical trial. Fifty-one men were randomized to either BDP or TURP. Both groups demonstrated a significant decrease in symptom score from preoperative levels (TURP 13.6 to 6.0 [p < 0.05]; BDP 14.1 to 8.1 [p < 0.01] at 1 year). The TURP group improved peak urinary flows; while, after initial improvement, the balloon group returned to pre-procedure levels. At twelve months 14 of 19 BDP patients (74%) and 14 of 18 TURP patients (78%) considered themselves improved. BDP results in symptomatic improvement; however, the effect may not persist. Objective improvement after BDP does not always occur. The morbidity of BDP is low and compares favourably to that of TURP. Thus BDP does not appear to be as effective as TURP and may offer only temporary relief of symptoms.

Transurethral balloon divulsion of prostate

Benign prostatic hypertrophy (BPH) is the most common cause of urinary outflow obstruction. Transurethral resection of the prostate (TURP) is the preferred treatment for symptomatic BPH and is considered the gold standard of treatment. Balloon dilatation of the prostate (TUBD), besides some criticism, represents a nonoperative treatment alternative for treatment of symptomatic BPH which is simple and safe. We describe the technique of TUBD, balloon technology, as well as advantages and disadvantages of balloon dilatation.

Nonsurgical, nonpharmacologic treatment of benign prostatic hyperplasia

New treatment modalities are becoming available for benign prostatic hyperplasia. Permanent or temporary stenting of the prostatic urethra, balloon dilatation of the prostate, and hyperthermia and thermotherapy are in the forefront. None of the methods has found a definite place in the spectrum of indications. Prospective trials are needed to ascertain the safety, efficacy, and durability of results.

Value of balloon dilation in treatment of youthful patients with prostatism

Forty-three youthful patients with uncomplicated prostatism were prospectively evaluated to test the safety and efficacy of transurethral balloon dilation (TUDP). Treatment consisted of cystoscopic placement of an intraprostatic balloon inflated to 25 mm diameter at 3 atm pressure for ten minutes. At longest follow-up (9.8 months, average; 3-24 months, range), 88 percent of patients were satisfied with overall treatment results. The average improvements in voiding symptom score and peak uroflow were 77 percent and 73 percent, respectively. Mean improvements over pretreatment levels were statistically significant at one month (p less than 0.01) and remained so for the entire follow-up period. No incontinence, impotency, retrograde ejaculation, sepsis, or serious bleeding developed. An intraprostatic fissure, which spared the bladder neck, was a uniform finding and the most likely mechanism of lasting action of TUDP. In the relief of uncomplicated prostatism in youthful patients, TUDP compares favorably with other treatment alternatives.

Transurethral resection of prostate under sedation and local anesthesia (sedoanalgesia). Experience in 100 patients

One hundred male patients (average age 68.2 yrs) with acute retention (n = 20) or with symptoms of outflow obstruction (n = 80) underwent transurethral resection of the prostate (TURP) under sedation (midazolam) and local anesthesia (lidocaine)--referred to as sedoanalgesia technique. Procedures lasted twenty-four minutes on average (range 15-35 min), and the weight of prostatic tissue resected ranged from 2-35 g (average 11.1 g). There were no complications related to the use of midazolam or lidocaine. The technique of sedoanalgesia proved safe and acceptable to all patients regardless of their pre-existing medical condition. Where the weight of prostate to be resected is estimated to be less than 40 g, TURP under sedoanalgesia proves an effective alternative to general or regional anesthesia.

Dilatation of the prostatic urethra with 35 mm balloon

A series of 54 men, 25 with acute urinary retention and 29 with cytometrically proven bladder outflow obstruction (BOO), underwent dilatation of the prostatic urethra using a 35 mm fixed diameter, low compliance balloon. In 42 patients this was performed under cystoscopic guidance and in 12 patients under fluoroscopic control. Three months following dilatation, 13/27 patients (48%) with BOO who returned for review were rendered unobstructed and 19/27 (70%) were symptomatically improved. By 6 months only 3 remained unobstructed but 15 remained symptomatically improved. Nine months after dilatation 14 patients retained symptomatic improvement but only 2 remained unobstructed. Of the 25 patients treated for acute retention only 6 voided spontaneously, 1 of these relapsing into retention at 2 months and another at 4 months. No patient was rendered unobstructed but 2 patients (who declined prostatectomy) noted an improvement in their obstructive symptoms at both 3 and 6 months. No patient developed retrograde ejaculation following dilatation. Balloon dilatation to 35 mm has no role in acute urinary retention but may have a role in younger men with BOO who wish to avoid prostatectomy and the risk of retrograde ejaculation. In these patients careful follow-up is required.

Wallstent endoprostheses for the relief of prostatic urethral obstruction in high risk patients

Twenty-one patients with prostatic urethral obstruction who were unfit for surgery were treated with self-expandable stainless steel endoprostheses inserted under fluoroscopic guidance. The procedure was technically successful in all patients, although in one case a second stent was required 2 months later. One patient developed a urethral stricture in the 12-16 month follow up period. One case of epididymoorchitis and one case of septicaemia after stenting were treated successfully with antibiotics. Endoprostheses represent a satisfactory alternative to prostatectomy in high-risk patients.

Alternatives to prostatectomy

The danger of the treatments described are that patients may be treated without referral to a urologist. Investigations to determine whether genuine obstruction is the cause of their symptoms may not be performed and follow-up to exclude the side effects of their outflow obstruction or indeed their treatment may not be carried out. In addition, in cases where digital palpation does not alert the clinician to the possibility of prostatic malignancy, the loss of specimens for histological interpretation may lead to missed diagnoses. In summary, the alternatives to prostatectomy are still limited. Hormonal manipulation, hyperthermia and prostatic dilatation using the smaller balloons have no role at present in symptomatic patients. The role of larger balloons has still to be determined. Alpha blockade, while achieving relief in the short-term, still requires long-term objective follow-up studies in patients with urodynamically proven obstruction to assess patient compliance and the effects of treatment before it can be recommended as a long-term alternative. Similar information is also required before the efficacy of hyperthermia in patients with retention can be determined. For high risk patients with a limited life expectancy who present with retention of urine, prostatic stents may have a role, but once again long-term follow-up data are required before this treatment can be advocated in fitter or symptomatic patients.