Prostatectomy in the over 80-year-old

Management of the Spectrum of Hormone Refractory Prostate Cancer

INTRODUCTION

In its advanced stages, hormone refractory prostate cancer (HRPC) is an incurable condition which consists of a spectrum of disease. This requires an integrated multidisciplinary approach by an uro-oncologic team supported by radiologists, skeletal surgeons and palliative care. Aim of this review was to critically evaluate the current and potential approaches to patients affected by HRPC.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1981 to January 2006. Official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

Most men with hormone refractory prostate cancer will die of their disease in the absence of intercurrent illness, and the various conditions arising as a consequence of local and distal cancer progression commonly lead to a spectrum of morbidity requiring treatment. Recent data regarding docetaxel-based chemotherapy have shown small but significant improvements in survival and improvement in quality of life in men receiving treatment. However, this therapy may not be suitable for all patients. New agents used alone or in combination with docetaxel currently are under trial in an attempt to provide much needed improvements in outcome. Bone-targeted treatments, particularly late-generation bisphosphonates, have added to the range of options, reducing the incidence of skeletal complications in some men. Further work is needed to target their use more effectively, to explore their efficacy in combination with existing proven therapies and to develop new approaches to treat bone metastases. Complications arising as a consequence of upper and lower tract dysfunction, haematologic, neurologic and psychologic disorders are common. These complications often are amenable to effective treatment, but interventions may engender difficult clinical and ethical decisions.

CONCLUSIONS

Although HRPC is incurable, it is not untreatable, and that the clinical management embraces not just chemotherapy, but many interventional and supportive therapies. A holistic and supportive approach to patient care is vital for optimal management, and is best provided by a coordinated, multidisciplinary team including urologists and oncologists.

Acute urinary retention: defining the need and timing for pressure-flow studies

OBJECTIVE

To investigate the utility of "late" pressure-flow studies in predicting the outcome of prostatectomy for acute urinary retention.

PATIENTS AND METHODS

Fifty-eight patients with acute urinary retention were prospectively assessed using the International Prostate Symptom Score and pressure-flow studies at a median (range) of 24 (13-60) days after the episode of retention, and before transurethral resection of the prostate. Bladder outlet obstruction and bladder contractility were graded using a modified adaptation of Schäfer's passive urethral linear resistance relation.

RESULTS

Fifty-six (97%) patients generated a voluntary detrusor contraction, with a mean (range) detrusor pressure at maximum flow of 72.7 (5-144) cmH2O, and 43 (75%) patients were deemed to be obstructed. Eight (16%) patients failed to void after prostatectomy and required clean intermittent catheterization. There were statistically significant differences between successful and unsuccessful patients in mean (SD) age, at 66.30 (6.9) vs 78.8 (2.6) years (P = 0.001), detrusor instability (49% vs 0%, P = 0.01), inability to void during pressure study (8% vs 75%, P = 0.001), and maximal detrusor pressure in the voiding phase, at 80 (36.0) vs 19 (11.2) cmH2O (P = 0.001).

CONCLUSIONS

In patients with acute urinary retention, pressure-flow studies undertaken after a period of adequate bladder rest (> 3 weeks) are useful in predicting the surgical outcome. Old age, absence of bladder instability, inability to void during the pressure-flow study and a maximal detrusor pressure of < 20 cmH2O are associated with a poor outcome after prostatectomy.

Urodynamic characterization of nonobstructive voiding dysfunction in symptomatic elderly men

PURPOSE

The pathogenesis of lower urinary tract symptoms in men without bladder outlet obstruction has not been well characterized. Therefore, we defined the urodynamic abnormalities associated with symptomatic nonobstructive voiding dysfunction, and determined the relationship between age and type of dysfunction.

MATERIALS AND METHODS

Video urodynamic studies of symptomatic men without outlet obstruction were examined. The criterion for a normal bladder outlet was a pressure gradient across the prostatic urethra of 5 cm. water or less in the absence of distal stricture. A maximum isometric contraction pressure less than 60 cm. water was regarded as impaired detrusor contractility. Detrusor instability was defined as involuntary detrusor contractions during filling or the inability to suppress a detrusor contraction after initiation of flow. Patients were categorized into 4 groups based on the urodynamic findings.

RESULTS

Of 193 men (mean age 69.6+/-10.5 years) 40.9% had detrusor instability (group 1), 31.1% had impaired contractility (group 2), 10.8% had detrusor instability and impaired contractility (group 3), and 17.1% were urodynamically normal (group 4). Average patient age was significantly lower in group 4 than all other groups. Bladder capacity was lowest in group 1, and group 3 had the lowest voiding efficiency. Maximum flow rate, bladder compliance and symptom scores were not different among the 4 groups. The prevalence of detrusor instability with and without impaired contractility increased, while the proportion of patients without urodynamic abnormalities decreased with age. Bladder contractility did not correlate with age.

CONCLUSIONS

The nonobstructed patient population comprises several groups that are functionally distinct while symptomatically similar. Thus, treatment of nonobstructed cases based on symptoms may lead to inappropriate pharmacological therapy and unsuccessful clinical outcomes.

Failure to void after transurethral resection of the prostate and mode of presentation

OBJECTIVES

Contemporary audits and reviews of outcome after transurethral resection of the prostate (TURP) make little reference to failure to void following catheter removal after this operation. There have been few reports of the likelihood of a successful trial without a catheter after TURP related to mode of presentation. We report the results of a retrospective review of outcome of TURP related to mode of presentation, age, and prostate histologic findings in a consecutive series of patients in a London Teaching Hospital.

METHODS

A consecutive series of 379 patients (381 TURPs) was reviewed to document the incidence of and risk factors for failure to void following initial trial without a catheter after TURP.

RESULTS

Twelve percent of men failed to void after TURP on the initial trial without a catheter. In those patients presenting with lower urinary tract symptoms, there were no instances of failure to void. Ten percent of patients with acute retention (painful inability to void, urine volume less than 800 mL), 38% with chronic retention (maintenance of spontaneous voiding, bladder volume greater than 500 mL), and 44% with acute on chronic retention (painful retention, urine volume greater than 800 mL) failed to void after TURP. Only 1% of patients required management by long-term catheterization. Failure to void on catheter removal was not related to age or prostate histologic findings.

CONCLUSIONS

Bladder volume at initial presentation in patients with urinary retention provides important information about the likelihood of re-establishing spontaneous voiding catheter removal following TURP. Patients should be warned that there is a significant chance of failure to void after TURP, the exact risk depending on their mode of presentation, but that most will ultimately not require a permanent indwelling catheter.

Outcome of transurethral prostatectomy in men over 80 years

Two-hundred-and-twenty-nine men aged between 80 and 97 years (mean 83 years) underwent transurethral prostatectomy (TUR-P) for lower urinary tract symptoms (LUTS). All case records were reviewed. The follow-up period was 6-16 years. One-hundred-and-seven patients underwent operation because of acute urinary retention, and 122 because of chronic retention. The mean weight of tissue removed was 20 g (1-200 g). The perioperative mortality (< 1 month) was 2% (5 patients). Postoperative complications occurred in 21% (49 patients). Reoperation was performed in 11% (26 cases). The result was considered satisfactory in 196 patients (86%). The present data demonstrate that transurethral resection of the prostate in men over 80 years has a good outcome with an acceptable urological complication rate and mortality, and we therefore advocate surgery instead of watchful waiting in the fit patient.

Il trattamento tradizionale dell'IPB nell'anziano: The traditional treatment of BPH in the elderly

Longer life expectancy and the progress made in anaesthesiology have led to an increase over the last few years in the request for treatment of symptomatic benign prostatic hypertrophy (BPH) in elderly patients. A retrospective analysis on 270 patients aged 75 years who underwent surgery on the cervico-prostatic district between 1989 and 1997 showed a rate of complications (10% overall) comparable with that in patients of any age undergoing the same operation. This reinforces the conviction that both open surgery and endoscopic procedures for treating symptomatic BPH are safe and reliable even in the elderly.

Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable?

PURPOSE

Some patients with acute urinary retention due to benign prostatic hyperplasia do not have successful outcome after prostatectomy and require either a chronic indwelling urethral catheter or clean intermittent catheterization. Urodynamic and clinical parameters were examined preoperatively in 81 men 56 to 93 years old (mean age 72 years) in search of an outcome predictor after prostatectomy.

MATERIALS AND METHODS

International Prostate Symptom Score, prostate volume, retention episodes, retention volume and urodynamic parameters from a multichannel pressure-flow study were analyzed preoperatively and postoperatively. All patients underwent transurethral prostatectomy and were reexamined 2, 4, 12 and 24 weeks after surgery. A multichannel pressure-flow study was performed preoperatively and 12 weeks postoperatively.

RESULTS

At 24 weeks postoperatively 11 patients (13%) were unable to void and therefore classified as treatment failures while the remaining patients voided spontaneously and were classified as treatment successes. There were statistically significant differences (p < 0.005) between treatment failure and treatment success regarding age (83.5 +/- 7 versus 70.1 +/- 8 years), preoperative volume of retention (1,780 versus 1,080 ml.), and maximal detrusor pressure (24.4 versus 73.5 cm. water), but not to International Prostate Symptom Score, episodes of retention and prostate volume. The ability to void during preoperative pressure flow study and the presence of detrusor instability predicted good outcome. In treatment success patients postoperative urodynamic data showed significant decrease in detrusor pressure at maximum flow rate (from 80.8 +/- 33 to 34.6 +/- 10 cm. water). Those with treatment failure had an increase in maximal detrusor pressure (from 26 +/- 12 to 42.6 +/- 13 cm. water), suggesting detrusor recovery.

CONCLUSIONS

Patients with acute urinary retention, age 80 years or older, with retention volume greater than 1,500 ml., no evidence of instability and maximal detrusor pressure less than 28 cm. water are at high risk of treatment failure. However, despite treatment failure the detrusor may recover in patients younger than 80. Therefore, prostatectomy should still be performed in this group (less than 80 years old) even if preoperative urodynamics suggest an unfavorable outcome.

Transvesical prostatectomy in elderly patients

PURPOSE

We assessed the results of transvesical prostatectomy in patients older than 80 years.

MATERIALS AND METHODS

We studied 98 patients 80 to 90 years old who underwent transvesical prostatectomy between 1986 and 1993, including those with a large prostate (preoperative estimated weight more than 80 gm.), numerous or large cystolithiasis and large bladder diverticulum, which are indications for open prostatectomy. Clinical data were obtained by chart review.

RESULTS

The indications for surgery were urinary retention in 53 patients (54%), severe obstructive urinary symptoms in 18 (18.4%), cystolithiasis in 17 (17.3%), prostatic bleeding in 10 (10.2%) and bladder diverticulum in 2 (2%). Accompanying diseases were present in 69 patients (70.6%), including ischemic heart disease in 41 (42%), diabetes mellitus in 17 (17.3%) and arterial hypertension in 14 (14.3%). A total of 59 patients (60.2%) underwent surgery while under general anesthesia and 39 (39.8%) received regional anesthesia. Average operative time was 62 minutes. Of the patients 40 (40.8%) received 1, 14 (14.3%) received 2 and 2 (2%) received 4 units of blood. No postoperative deaths or life threatening complications were noted. The immediate postoperative complications included urinary tract infection in 20 patients (20.5%), wound infection in 3 (3.0%) and orchiepididymitis in 3 (3.0%). Postoperative mild to moderate incontinence was noted in 2 patients (2.0%). Bladder neck constriction and urethral strictures occurred in 4 (4.1%) and 3 (3.0%) patients, respectively.

CONCLUSIONS

Transvesical prostatectomy can be performed safely in elderly patients with a low morbidity rate.

Benign prostatic hyperplasia in elderly men. What are the special issues in treatment?

BPH is an age-related condition that can give rise to urinary symptoms. As the proportion of elderly men in the population rises, the number with symptomatic BPH requiring advice on possible treatments will increase. A range of effective treatments is available, and although there are certain absolute indications for surgery, patients with moderate or severe symptoms require counseling to reach a decision on the treatment modality most appropriate for them. Concomitant age-related disease and use of multiple medications add to the complexity of treating elderly men for BPH. In every case of BPH, the risks of each treatment option should be weighted against the potential benefits and a joint decision reached by physician and patient.

Prostates and profits: the social construction of benign prostatic hyperplasia in American men

Benign prostatic hyperplasia (BPH) is clinically diagnosed in approximately three-fourths of American men, a prevalence two to three times higher than that currently reported in Scotland and Japan. Prostatectomy is the most common operation performed on American men over 65. A critical medical anthropological analysis reveals that American urologists rely on prostatectomy to maintain their practices, and the growth of urology as a specialty is significantly related to the 50% increase in the rate of surgery since 1965. Marketing campaigns and studies funded by pharmaceutical companies promote the perception of urinary difficulties as problematic, encourage men to medicalize their symptoms, and create demand for drug therapy and urologist treatment. The social construction of BPH as a progressive age-related disorder and the profit orientation of American medicine account for the elevated prevalence of BPH.

Effect of age, comorbidity and type of surgery on perioperative complications and mortality of prostatectomy

OBJECTIVE

To study the effect of age, type of surgery and comorbidities (cardiovascular diseases, chronic lung diseases, diabetes mellitus and renal impairment) on the peri-operative complications and mortality of prostatectomy.

PATIENTS AND METHODS

A series of 236 consecutive patients who underwent prostatectomy (171 by transurethral resection, TUR, and 65 by open procedure) were reviewed. Ninety patients at risk with one or more of the comorbidities were grouped together and compared with the remaining 146 fit patients. Also, 148 patients aged < or = 70 years were compared with 88 patients aged > 70 years. The peri-operative morbidity variables compared were haemorrhage, > or = 3 units of blood transfusion, bacteriuria, orchitis, pyrexia, uraemia and bed-stay.

RESULTS

Mean post-operative bed-stay for patients at risk was significantly longer than that for fit patients (12 +/- 7 and 9.7 +/- 6 days, respectively). Mortality and the other morbidity variables, apart from post-operative bacteriuria which was more frequent in diabetics, were not significantly different between the groups. Similarly, comparing age groups revealed no significant differences. However, open surgery was associated with more haemorrhage, blood transfusion, post-operative pyrexia and a longer bed-stay.

CONCLUSION

The comorbidities studied and age did not significantly influence the complications and mortality of prostatectomy. However, comorbidities prolonged post-operative bed-stay. Open surgery was associated with more bleeding and pyrexia and a longer bed-stay than TUR.

Long-term experience utilizing a new balloon expandable prostatic endoprosthesis: the Titan stent. North American Titan Stent Study Group

OBJECTIVES

To determine the long-term safety and efficacy of the Titan endoprosthesis as a therapeutic alternative in the management of men with bladder outlet obstruction.

METHODS

One hundred forty-four patients (mean age, 73.5 years +/- 4.2) had placement of the Titan stent. The stents were inserted under direct vision and expanded to 33 F using a balloon catheter. Of the 144 patients, 59 (41%) were in urinary retention and 85 (59%) presented with moderate to severe symptoms of prostatism. Patients were assessed at baseline and in follow-up at 1, 3, 6, 12, 18, and 24 months. Parameters of evaluation included the Madsen-Iversen symptom questionnaire, peak flow rate (Qmax), postvoid residual urine volume (PVR), and incidence of adverse events.

RESULTS

At 24 months, for the retention cohort, symptoms, Qmax, and PVR were 5.21 +/- 0.81, 11.34 +/- 1.12 mL/s, and 31.00 +/- 12.8 mL, respectively (P < 0.002). For patients with symptoms of bladder outlet obstruction, the results were as follows at 24 months: (1) symptoms decreased from 15.89 +/- 0.47 to 9.33 +/- 0.86 (P < 0.001); (2) Qmax increased from 8.59 +/- 0.41 mL/s to 11.43 +/- 1.12 mL/s (P < 0.001); and (3) PVR decreased from 116.94 +/- 19.95 mL to 74.4 +/- 36.2 mL (P < 0.03). There were minimal complications; stents were removed from 28 patients (19%) because of migration, 10 of which were placed by one investigator.

CONCLUSIONS

When properly placed, the Titan stent was an effective therapeutic alternative to prostatectomy or long-term catheterization in high-risk obstructed patients or those in urinary retention.

Deaths and complications following prostatectomy in 1400 men in the northern region of England. Northern Regional Prostate Audit Group

OBJECTIVE

To determine the degree of variation in mortality and major morbidity following transurethral resection of the prostate (TURP), and to assess intersite variation for mortality and morbidity over 12 sites within the Northern Region. Further, to determine whether the previously observed effects on morbidity of unit size, patient through-put and emergency admission were borne out in contemporary urological practice in the Northern Region.

PATIENTS AND METHODS

For an 8 month period, 1 April 1991-31 November 1991, an independent audit of TURP was performed on 12 different hospital sites throughout the Northern Region. A constant data set was designed which was collected on each patient before and 3 months after operation by two independent clinical co-ordinators who travelled to each of the sites. All case notes were reviewed at 3 months after operation by the co-ordinators using a standard proforma, rather than depending upon self reporting by medical staff. Data on factors potentially affecting mortality and morbidity were collected, including emergency admission, diagnosis of prostate cancer, American Society of Anesthesiologists' co-morbidity scores, and age and differences in throughput in the 12 sites. The effect of through-put or 'volume' on mortality and morbidity was assessed by comparing morbidity and the number of cases performed.

RESULTS

The early mean death rate was 13 of 1396 patients (0.9%), with an inter-site variation ranging from 0% to 3.8%. A mean of 2.0% of men were returned to theatre after TURP, 2.4% of patients received a blood transfusion (> 2 units) after operation, and 8.0% of patients developed post-operative sepsis; these complications varied sixfold, sevenfold and 17-fold across the different sites respectively. Those units performing < or = 100 operations over the audit period (equivalent to < 150 operation per year) had a significantly increased rate of deaths and complications which was not related to population differences, though some low volume units had good results. Elderly men who were admitted as emergencies or with prostate cancer were particularly vulnerable to complications.

CONCLUSIONS

The overall early mortality rate after TURP for benign prostatic hyperplasia across the Region compares well with other reported large series. The significant variation in morbidity rates found in this study suggests that careful attention needs to be paid by Urologists, Purchasers and Providers to morbidity rates after prostatectomy.

ECG and cardiac enzymes after glycine absorption in transurethral prostatic resection

The electrocardiogram (ECG) was recorded and the serum levels of creatine kinase (CK), aspartate transaminase (ASAT) and prostatic acid phosphatase (PAP) was measured in 22 patients undergoing transurethral resection of the prostate (TURP) under spinal or epidural anaesthesia. The irrigating fluid consisted of 1.5% glycine and 1% ethanol, and absorption of the fluid was monitored by detection of alcohol in the expired breath. The results show that nine of the 11 patients (82%) who absorbed more than 1,000 ml of irrigating fluid had developed ECG changes 24 h after the operations. The most common alteration was depression of the T wave. This sign was only seen in one (9%) of the patients who absorbed none or very small amounts of irrigating fluid (P < 0.001). The serum activity of CK and ASAT increased in five patients who also developed ECG changes, and the highest values were recorded 24 h after TURP. The CK-MB isoenzyme was detected in 85% of the samples with elevated total CK, but the criteria for myocardial infarction were never fulfilled. In contrast, PAP increased in all patients and the highest level occurred at the end of TURP. The activity-time profiles suggest that CK and ASAT entered the circulation by a mechanism different from that of PAP. We conclude that absorption of glycine solution during TURP is frequently followed by nonspecific ECG signs of altered cardiac function and also that the serum activities of CK and ASAT increase in some of these patients.

The titanium intraprostatic stent: the United States experience

This multicenter, cooperative study represents the initial United States experience using an expandable, titanium intraprostatic stent in 68 patients (60 to 93 years old). The stents were inserted under direct vision and expanded to 33F using a balloon catheter. All patients had a symptom score analysis, and underwent measurement of peak urine flow and rate and post-void residual urine volume as part of the initial evaluation. Patients were seen at approximately 1, 3, 6 and 18 months after stent insertion (mean followup 16 months). Of the 68 patients 38 presented in urinary retention. The type of anesthesia used included general anesthesia in 6 patients, spinal or epidural anesthesia in 24, intravenous sedation in 20 and intraurethral lidocaine only in 18. All patients were able to void spontaneously within 36 hours after stent insertion. Symptom scores decreased from 16.8 to 3.9, 6.3, 5.0, 5.7 and 3.2 at approximately 1, 3, 6, 12 and 18 months, respectively. Peak urine flow rate increased from 3.9 to 13.8, 11.5, 11.2, 12.4 and 14.4 ml. per second at approximately 1, 3, 6, 12 and 18 months, respectively. Post-void residual urine volume decreased from 74.4 to 30.1, 29.2, 19.8 and 40.2 ml. at approximately 1, 3, 6 and 12 months, respectively. Of the initial 68 patients 5 died of the underlying disorder (all voiding satisfactorily with the stent in place) and 17 underwent uneventful stent removal (10 for technical failure and 7 for treatment failure). Technical failures were secondary to either inaccurate positioning or improper stent sizing. Of the 58 patients with proper placement of the stent and no technical failures 46 (79%) had improvement in symptom scores and urine flow rate. Transient hematuria was noted in 43 patients (63%) and usually resolved within 48 hours. None of the 6 urinary tract infections (9%) was recurrent. In conclusion, the titanium intraprostatic stent, when properly placed, is a promising therapeutic alternative to prostatectomy or long-term catheterization in high risk obstructed patients or those in urinary retention. Studies are currently in progress to determine the long-term efficacy of this therapeutic modality.

The Prostakath stent: four years' experience

The Prostakath stent is recommended as an option in the treatment of acute urinary retention in the patient at high risk from a transurethral resection of the prostate. In 57 of 64 patients with acute retention, voiding was re-established. A stent-related problem developed in 16 patients and further treatment was usually required. Patients with satisfactorily functioning stents have been followed up for 12.0 +/- 9.9 months. The most frequent complication was displacement of the stent. Infection and stone formation were uncommon. Our results do not support the use of the Prostakath in patients with symptoms of outflow obstruction or chronic retention.

Age as a prognostic variable in patients undergoing transurethral prostatectomy

In a retrospective study the outcome of transurethral prostatectomy (TURP) for benign prostatic hyperplasia (BPH) in patients more than 80 years old was compared to a control group of patients with a mean age ten years younger. The elderly had significantly more tissue resected and presented with a higher rate of preoperative urinary tract infection. More urological complications were seen among the elderly but these were generally short lived and had no influence on the morbidity, mortality and symptomatic outcome. The perioperative mortality was 3.2% among elderly and 0% in the younger age group. A cardiorespiratory risk score could not predict patients at risk. In conclusion the age per se had no major influence on the outcome of TURP.

Prostatectomy in the very aged

The number of very aged men who demand prostatectomy for benign disease is increasing. We have assessed surgery results in 79 patients operated during the last four years. Sixty-two underwent endoscopic and 17 open procedure. Mortality rate was 3.7%. Two patients died in the first week and one patient three weeks after surgery. Morbidity rate was 61% but did not significantly affect the final operative outcome. Operative success rate six weeks postoperatively was 87%, satisfactory for this age group. After detailed preoperative evaluation and postoperative care by specialized age care team, prostatectomy is safe, effective and involves low-cost treatment.

Open or transurethral surgery for the large prostate gland

A comparative study of transurethral (TUR) and open prostatectomy for the large prostate gland has been carried out. Over a 5-year period 94 transurethral resections and 73 open procedures were performed for prostate glands weighing more than 50 g. There was a single death in each group, giving relative mortality rates of 1.1% TUR and 1.4% open. The post-operative hospital stay was significantly shorter in the TUR group. The open group suffered significantly more complications in the first week but the TUR patients, although having fewer immediate postoperative complications, had significantly more in the first year, so that overall complication rates were similar (35% vs 36%). Patient satisfaction was equal in both groups.

Ethics, logistics and a trial of transurethral versus open prostatectomy

An increased long-term morbidity rate after transurethral compared with open prostatectomy has recently been claimed on the basis of retrospective studies of operations done up to 20 years ago. These studies have led to a demand for a prospective trial. Most reports show that peri-operative mortality following prostatectomy is virtually confined to unfit men over 80 years old. Before agreeing to participate in a trial we examined our operative mortality in this group of patients. Between 1981 and 1987, 123 octogenarians underwent transurethral prostatectomy: 64 operations were elective and 59 were performed for retention. There were 2 operative deaths (1.6%), both from gram-negative septicaemia despite prophylactic antibiotics. There were no additional deaths in the first 12 months following surgery. Few of these patients would have been considered fit to undergo an open prostatectomy. Any proposed randomised trial would have to exclude such high risk patients until it can be shown that open prostatectomy is equally safe.

A prostatectomy audit: phase I--insights and questions

A local prostatectomy audit is being undertaken to gain some insight into the pre- and peri-operative factors that influence post-operative outcome and length of post-operative stay. The aims of the first phase of the audit, involving 150 prostatectomy patients, have been to attempt to define the minimum data set required to meet the study's objectives, and to devise a data-collecting tool that can be completed by the medical and nursing staff as part of the routine work. A tentative model has been devised to forecast post-operative stay. The audit has raised a number of questions which will form the basis of further studies.

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.

Comorbidities and perioperative complications among patients with surgically treated benign prostatic hyperplasia

We address the question of whether or not age and comorbidity are related to intra- and postoperative complications after a transurethral resection. The data are derived from a retrospective, population-based study conducted in Hagen, Germany, which included all patients with an initial prostatectomy for benign prostatic hyperplasia (N = 621) during the five-year period 1984-1988. Seventy-seven percent of the patients had at least one of the following preoperative risk factors: heart disease, hypertension, smoking, chronic obstructive lung disease, and diabetes. There was no intraoperative death. The risk of intraoperative circulatory complications was found to be related to age only for patients without a history of heart diseases or hypertension. The incidence of major complications was 3.1 percent and was significantly higher in the oldest age group. Three patients (0.54%) died postoperatively in the hospital. Infections were the most frequent postoperative complications. The relationship of age and overall postoperative complications was not statistically significant either for patients with (p = 0.121) or without any comorbidity (p = 0.651). Based on this study it seems reasonable to conclude that age is not a clinically relevant risk factor for perioperative complications in patients who have a transurethral resection for benign prostatic hyperplasia.

Management of acute retention of urine: a reappraisal

Our standard policy for the management of retention of urine due to prostatic hypertrophy is that the patient is catheterised and sent home, later to be seen and assessed in the Out-patient Department where he is given an admission date for operation. A detailed audit of 166 patients cared for in this way is presented and the results compared with those in 25 patients who remained in hospital in the interval between catheterisation and operation and in 402 patients not previously catheterised. Although the mortality rate was significantly higher in the retention group (3.3 vs 0.25%), we feel that this is a reflection of the fitness of the patients with retention rather than a consequence of the management policy. The advantages of the "catheterise and send home" policy are discussed.