Impact of medical therapy on transurethral resection of the prostate: two decades of change

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Over the last several decades, medical therapy has usurped transurethral resection of the prostate (TURP) as the standard first line therapy for benign prostatic hyperplasia (BPH). The effect of this dramatic shift on the patients now presenting for TURP is generally unknown. Failure of medical therapy has now become one of the most important indications for TURP while those undergoing the procedure experience more progression events (e.g. acute or chronic urinary retention), poorer immediate short‐term results and higher rates of postoperative complications than those who had the operation two decades previously. OBJECTIVE • To examine how the introduction of medical therapy for symptomatic benign prostatic hyperplasia (BPH) might have changed the indications, patient characteristics and outcomes in men undergoing transurethral resection of the prostate (TURP) over two decades (1988–2008). PATIENTS AND METHODS • All patients who underwent TURP for symptomatic BPH in a geographically defined area at our institution in 1988 (before the introduction of medical therapy for BPH), 1998 (when medical therapy was becoming an important therapy for BPH), and 2008 (when medical therapy was the primary first line therapy for BPH) were reviewed. • We assessed the total number of TURPs, indications for surgery, patient age, health status, weight of resected tissue, and pre‐ and postoperative events/complications. RESULTS • There was a 60% decrease in TURPs from 1988 to 1998 with a moderate increase in number in 2008. • Failure of medical therapy was not an indication for TURP in 1988, but was at least one of the indications in 36% and 87% of patients in 1998 and 2008, respectively. • There was a substantial rise in the percentage of patients (but not total number or percentage of men at risk for BPH) presenting with acute or chronic urinary retention (AUR or CUR) at the time of their TURP (from 22.9% in 1988 to 42.9% in 2008, and from 14.6% in 1988 to 39.3% in 2008 for AUR and CUR, respectively). There was also a rise in the percentage of patients presenting with preoperative hydronephrosis (1.3% in 1988, 12.5% in 1998, 7.1% in 2008). • Inpatient stays decreased (from 4.1 day in 1988 to 2.7 days in 1998, and to 2.1 day in 2008), but the number of patients discharged with a catheter increased over the two decades (from 3.2% in 1988 to 12.5% in 1998, and to 28.6% in 2008). CONCLUSIONS • The increasing use of medical therapy as a first line treatment for BPH has resulted in a dramatic decrease in TURPs which, in turn, has been associated with an apparent increase in risk of poor pre‐ and postoperative outcomes. However, the actual number (either the total number or as a percentage of men at risk for BPH) who have experienced these progression events has not changed and the postoperative outcomes are probably related to earlier catheter removal and hospital discharge. • It appears that we are performing TURP on the right patients.

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