Transurethral Resection Group Research Articles

Bipolar Transurethral Resection in Saline—An Alternative Surgical Treatment for Bladder Outlet Obstruction?

The transurethral resection in saline system uses bipolar energy for transurethral prostate resection, thus, avoiding the need for glycine irrigation and its associated complications. We compared the clinical efficacy and safety of bipolar transurethral resection in saline and of monopolar transurethral prostate resection for symptomatic benign prostate hyperplasia. From January 2005 to June 2006, 238 consecutive patients with symptomatic benign prostate hyperplasia were randomized into a prospective, controlled trial comparing the 2 treatment modalities. Patient demographics, operative time, hospital stay and complications were noted. Serum hemoglobin and electrolytes were determined in all patients immediately before and after the endoscopic procedure. During 18 months 120 patients were randomized to the conventional transurethral prostate resection group and 118 were randomized to the transurethral resection in saline group. Patient profiles, weight of resected prostatic tissue and duration of hospitalization were similar in the 2 groups. The decrease in serum sodium and serum chloride was statistically significantly greater in the transurethral prostate resection group than in the transurethral resection in saline group (each p = 0.05). The transurethral resection in saline procedure required significantly more time (mean 56 vs 44 minutes, p <0.01). There was 1 case (0.8%) of transurethral resection syndrome in the transurethral prostate resection group but none in the transurethral resection in saline group. Postoperative bleeding did not significantly differ between the 2 groups. Clot retention was observed in 6 (5%) and 4 patients (3%) in the transurethral prostate resection and transurethral resection in saline group, respectively. Two repeat interventions were required in the transurethral prostate resection group. The bipolar transurethral resection in saline system is as efficacious as monopolar transurethral prostate resection but it is safer than the latter because of the lesser decrease in postoperative hypernatremia and the smaller risk of transurethral resection syndrome. However, probably due to technical reasons, transurethral resection in saline operative time is significantly longer.

Comparative Diagnostic Value of Urine Cytology, UBC-ELISA, and Fluorescence In Situ Hybridization for Detection of Transitional Cell Carcinoma of Urinary Bladder in Routine Clinical Practice

Fluorescence in situ hybridization (FISH) has been reported to have much better sensitivity for the detection of bladder transitional cell carcinoma (TCC) than urine cytology. We comparatively tested cytology, FISH, and the cytokeratin-detection test of urinary bladder cancer (UBC) in routine clinical practice. In a prospective study, FISH, the urinary bladder cancer test (UBC-enzyme-linked immunosorbent assay [ELISA]), and cytology were used in 166 patients. Of the 166 patients, 62 had primary TCC (group 1), 71 had undergone transurethral resection of primary TCC before routine secondary transurethral resection (group 2), and 33 control had not undergone TCC (group 3). All patients with false-positive test results were followed up for a mean follow-up time of 22 months. The overall sensitivity of FISH, UBC-ELISA, and cytology was 53.2% (95% confidence interval 40% to 66%), 40.3% (95% confidence interval 28% to 53%), and 71.0% (95% confidence interval 59% to 83%), respectively (P <0.05). For grade 3 TCC, both FISH and cytology reached a sensitivity of 93.3%. In the 104 patients without TCC, the specificity of FISH, UBC-ELISA, and cytology was 74.0%, 75.0%, and 83.7%, respectively. During follow-up, 33.3% of patients with a false-positive FISH result developed recurrence, as did 23.1% with false-positive UBC results and 29.4% with false-positive cytology findings (P >0.05). Receiver operating characteristic analysis showed an area under the curve for FISH, UBC, and cytology of 0.636, 0.577, and 0.773, respectively. Only cytology and FISH were significantly predictive of a TCC finding on histologic examination (P <0.001 and P = 0.003, respectively). In routine clinical practice, conventional cytology in experienced hands can be superior to FISH. False-positive results with all three test systems used warrant a high suspicion of subclinical precursor lesions of TCC recurrence.

Rotoresection Versus Transurethral Resection of the Prostate: Short-Term Evaluation of a Prospective Randomized Study

We compared in a prospective fashion the short-term outcome of rotoresection to transurethral resection of the prostate. A total of 50 patients with bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized into 2 groups, rotoresection and transurethral resection of the prostate. Mean+/-SD patient age was 60.76+/-5.85 years in the rotoresection and 64.24+/-6.84 in the transurethral resection groups. All patients had an International Prostate Symptom Score of 8 or more, maximum free flow rate less than 15 ml per second, prostate volume 20 to 100 ml and prostate specific antigen 1 to 4 ng/ml. Pressure flow study revealed bladder outlet obstruction (Schafer's grade 3 or more). Patients were assessed at 1, 3 and 6 months by International Prostate Symptom Score, maximum free flow rate, transrectal ultrasound, pressure flow study, hemoglobin and urinalysis. At 6 months International Prostate Symptom Score decreased from 26.2+/-4.06 to 5.32+/-1.52 in the rotoresection group and from 22.84+/-4.56 to 7+/-1.4 in the transurethral resection group. Maximum free flow rate increased from 7.87+/-2.24 to 25.29+/-10.39 ml per second in the rotoresection group and from 9.44+/-2.29 to 25.2+/-5.8 ml per second in the transurethral group. Prostate volume decreased from 41.2+/-16.58 to 17.24+/-7.61 ml in the rotoresection group and from 40.6+/-16.93 to 18.28+/-8.75 ml in the transurethral group. Detrusor pressure at maximum flow and Schafer grade decreased from 79.84+/-26.8 cm H2O and 4.24+/-0.97 to 38.8+/-18.8 cm H2O and 1.24+/-0.93 in the rotoresection group, and from 63.04+/-21.08 cm H2O and 3.48+/-0.65 to 34.16+/-12.7 cm H2O and 1+/-0.7 in the transurethral group. Dilutional hyponatremia was higher with transurethral resection of the prostate (p=0.005) but no patient showed manifestations of the transurethral syndrome. Mild stress urinary incontinence was noted in 4 patients in the rotoresection group and in 3 in the transurethral group. Rotoresection is a safe and effective method of treating bladder outlet obstruction resulting from benign prostatic hyperplasia, and its efficacy is comparable to transurethral resection of the prostate.

Finasteride effects on hypoxia and angiogenetic markers in benign prostatic hyperplasia

Objectives To assess the effects of finasteride on angiogenetic and hypoxia markers in benign prostatic hyperplasia. Methods A total of 178 patients aged 51 to 85 years (mean 68.7) with benign prostatic hyperplasia and awaiting transurethral prostate resection were prospectively randomized into a group of patients receiving finasteride (group 1; 88 patients) and a group of patients who received no medication until transurethral prostate resection (group 2; 90 patients). Tissue specimens were immunohistochemically stained with monoclonal antibodies against CD34 for microvessel density (MVD), vascular endothelial growth factor (VEGF), and hypoxia inducible factor-1alpha (HIF-1α). Results Blood loss during transurethral prostate resection was significantly higher in group 2 compared with group 1 ( P <0.001). The distribution of CD34 immunostaining was mainly at the suburethral prostate. MVD, VEGF, and HIF-1α values were significantly lower statistically ( P <0.001) in group 1 compared with group 2. In the finasteride group (group 1), the positive correlation of the immunoreactivity of CD34 and HIF-1α, VEGF and HIF-1α, and VEGF and CD34 was statistically significant ( P <0.001). In the same group, MVD and VEGF and HIF-1α expression correlated statistically with the treatment duration. Conclusions Finasteride administration in benign prostatic hyperplasia results in statistically significant suppression of MVD, VEGF, and HIF-1α in a time-dependent manner.

Overexpression of laminin-5 γ2 chain and its prognostic significance in urothelial carcinoma of urinary bladder: association with expression of cyclooxygenase 2, epidermal growth factor, and human epidermal growth factor 2

Laminin-5 (LN-5) and cyclooxygenase 2 (COX-2) play important roles in many kinds of cancers. Recently, it has been reported that epidermal growth factor receptor [corrected] (EGFR) and/or human epidermal growth factor receptor [corrected] 2 (HER2) expressions are associated with LN-5 and/or COX-2 expressions in a few carcinoma cell lines and human tumor tissue. LN-5, COX-2, EGFR, and HER2 expressions were examined immunohistochemically in 67 patients with urothelial carcinomas (UCs), and associations among these 4 biomarkers and clinicopathologic characteristics were investigated. Patients were classified into transurethral resection group and cystectomy group based on clinical end points, and prognostic significances of increased expressions were evaluated. Overexpression of LN-5, COX-2, EGFR, and HER2 was observed in 16 (23.9%), 34 (50.7%), 42 (62.7%), and 15 (22.4%) of 67 patients, respectively. LN-5 overexpression was associated high-grade (P = .002), invasive (pTa+1 versus pT2-4, P = .011), and nonpapillary (P = .027) UCs. Concerning EGFR and HER2, high-grade (EGFR, P = .0009; HER2, P = .003) and nonpapillary (EGFR, P = .016; HER2, P = .0002) UCs had a significantly higher overexpression rate. UCs penetrating basal membrane (pT1-4) showed significantly higher overexpression rates than pTa UCs on all biomarkers. In transurethral resection group, LN-5 overexpression could be proved as an independent prognostic parameter for intravesical recurrence (P = .007), whereas in cystectomy group, nodal involvement was an independent prognostic parameter for cause-specific survival (P = .025). The current study showed that the 4 biomarkers were associated with aggressive behaviors of UCs. Above all, LN-5 overexpression was considered to play an important role in intravesical recurrence of superficial UCs.

Qualitative and quantitative assessment of urinary cytokeratin 8 and 18 fragments compared with voided urine cytology in diagnosis of bladder carcinoma

Objectives To evaluate the value of urine tests based on the detection of cytokeratins 8 and 18 for the diagnosis of bladder cancer compared with urine cytology. Methods Samples from 112 patients before transurethral resection (group 1), 40 patients before secondary surgical treatment (group 2), 29 healthy control subjects (group 3, controls), and 10 women with acute urinary tract infection (group 4, controls) were examined with the UBC Rapid and UBC II enzyme-linked immunosorbent assay (ELISA) tests and voided urine cytology. Results Of the 112 patients in group 1, 90 had transitional cell carcinoma. For the UBC Rapid, UBC ELISA, and cytology, the sensitivity and specificity was 64.4%, 46.6%, and 70.5% and 63.6%, 86.3%, and 79.5%, respectively. The cytology had the greatest accuracy (72.3%) compared with both cytokeratin tests (54.4% and 64.2%). For all three tests, sensitivity increased with tumor grade and stage. In group 2, 16 of 40 patients had residual carcinoma. The sensitivity was similar for all three tests, and the specificity of cytology was lower compared with its specificity in group 1 (47.9% versus 70.5% in group 1). In the controls with or without urinary tract infection, the specificity of cytology was greater than that of both other tests. The combination of the UBC ELISA test with cytology increased the sensitivity to 83% (specificity 68%). Conclusions Both cytokeratin tests detected patients with transitional cell carcinoma, but were inferior to voided urine cytology in test quality.

A Randomized Controlled Trial of Short-Term Versus Long-Term Prophylactic Intravesical Instillation Chemotherapy for Recurrence After Transurethral Resection of Ta/T1 Transitional Cell Carcinoma of the Bladder

In a prospective randomized controlled study, we investigated the optimal schedule for intravesical instillation of epirubicin for maximizing its effect on prophylaxis and disease progression after transurethral resection of newly diagnosed Ta/T1 bladder cancer. The patients were instilled with epirubicin (30 mg/30 ml in normal saline) within 24 hours after transurethral resection and then randomized into 2 groups after a definite histopathological diagnosis of Ta/T1 bladder cancer. One group of 77 patients received 19 intravesical instillations of epirubicin in the year after transurethral resection (group 1). The second group of 73 patients received 9 intravesical instillations of epirubicin during the 3 months after transurethral resection (group 2). Nonrecurrence rates and toxicity were compared. In the followup period, 10 group 1 patients (13.0%) and 23 group 2 patients (31.5%) had recurrent disease. The 3-year nonrecurrence rate was 85.2% in group 1, whereas it was 63.9% in group 2. The nonrecurrence rate of group 1 was significantly higher than that of group 2 throughout the observation period (p = 0.005). The incidence and severity of toxicity were not significantly different between the 2 groups. Our study indicates that long-term instillation of epirubicin is more effective than short-term instillation in preventing recurrence after transurethral resection of Ta/T1 bladder cancer.

Prior transurethral resection (TUR) of the prostate reduces post-operative urinary morbidity associated with transperineal interstitial permanent prostate brachytherapy (PB)

Purpose: Early prostate brachytherapy (PB) techniques used uniform source loading patterns that delivered an excessive urethral dose, resulting in high rates of necrosis, urinary retention and incontinence if performed following TUR. Although many aspects of dosimetry, imaging and intraoperative technique has evolved, prior TUR is still frequently cited as a contraindication to PB based on the earlier adverse experience. We reviewed our experience with PB following TUR to assess both urinary morbidity and prostatic dose coverage using more contemporary techniques. Materials and Methods: 300 consecutive patients undergoing PB as primary treatment for T1-T2 prostate cancer from 9/98-1/01 were followed prospectively. All were treated by the same two physicians and physicist using a modified peripheral loading technique and pre-plan dosimetry. Treatments included PB alone (Pd-103 or I-125) or with 45 Gy EBT boost, with selected patients receiving androgen ablation (AA). PB was performed using a B&K Leopard ultrasound with placement of pre-loaded needles on transverse imaging, and source deposition on longitudinal imaging. Dosimetric coverage was evaluated using an in-house treatment planning system which included CT-based dose-volume histogram analysis approximately 3-4 weeks post implant. Data analysis included details of the implant and dosimetry, size of TUR defect, number of sources retrieved at cystoscopy after PB, V100, V80, and urinary retention (defined as any need for a catheter after post-op day 1. Results: 33 of 300 (11%) had undergone prior TUR 0.25-24 years before PB. Follow-up ranges from 3-33 months. TUR defects were noted in 23 on pre-implant planning ultrasonography. Other than older age (60-84, m=75 vs. 42-84, m=66) and less urinary retention after PB (3% vs. 22%), prior TUR patients were well matched to those with no prior TUR for Gleason Score, PSA, target volume, gland size, I-PSS, numbers of needles and sources, and treatment delivered. Specific treatments in the prior TUR group included implant alone in 19, while 14 received 45 Gy EBT boost (8 prior to implant, 6 after implant); 12 received I-125, 21 received Pd-103, and 18 received AA. Sources were retrieved at cystoscopy immediately after implant in 10 patients (30.3%). This included a single source in 7 patients, 4 sources in 2 patients, and 5 sources in a single patient. V100 ranged 93.6-100% (m=98.1%) and there was no underdosage (defined as any volume < 80% prescribed dose) identified around the TUR defect or elsewhere in the prostate. There were no cases of urethral necrosis and none are incontinent. Conclusion: Using contemporary techniques of PB including a modified peripheral loading pattern, bi-planar imaging, and pre-loaded needles, prior TUR should not be a contraindication to PB. In fact, our experience suggests that patients who have previously undergone TUR may tolerate PB even better in terms of reduced urinary retention. This more contemporary philosophy allows for the inclusion of many patients previously thought not to be candidates for PB. Planned TUR for relief of voiding symptoms in selected patients prior to PB should now be evaluated.

SCORING THE SHORT FORM ICSmaleSF QUESTIONNAIRE

The International Continence Society (ICS) ICSmale questionnaire was devised to provide a thorough evaluation of the occurrence and bothersomeness of lower urinary tract symptoms and their impact on the lives of men with benign prostatic disease. This report completes the developmental work on the questionnaire, producing the concise short form instrument, ICSmaleSF, with a valid, reliable and scientifically justified scoring system. Two data sets were used. The short form version of the questionnaire was devised and initially evaluated using data on men with uncomplicated lower urinary tract symptoms who were involved in the CLasP randomized controlled trial comparing laser therapy with transurethral prostatic resection and conservative management or monitoring without active intervention. External validation of the scoring system was undertaken using data from phase II of the ICS benign prostatic hyperplasia (BPH) study, an observational study of outcome in men with lower urinary tract symptoms related to benign prostatic enlargement. All patients completed the developmental version of the ICSmale questionnaire. Parallel analysis on the CLasP data set identified items that were responsive to change or highly problematic, allowing other redundant and overlapping items to be eliminated. Factor analysis and Cronbach's alpha coefficients were used to examine the clustering of items. Regression models were used to investigate the validity of followup scores within and across treatment groups in the CLasP and ICS/BPH studies. The questionnaire, which originally comprised 22 items, was shortened to 11 items in the 2 distinct factors of voiding (ICSmaleVS) and incontinence (ICSmaleIS) symptoms. Cronbach's alpha coefficients were high at 0.76 for ICSmaleVS and 0.78 for ICSmaleIS. A simple additive score was calculated by adding the 5 items in ICSmaleVS and 6 in ICSmaleIS. ICSmaleVS and ICSmaleIS detected expected improvement in the laser therapy and transurethral prostatic resection groups, and stability in the conservative management group within CLasP. Similarly each subscore but particularly ICSmaleVS was sensitive to differences in the outcome of the range of treatments in the ICS/BPH study. While frequency and nocturia were highly problematic and sensitive to change individually, they did not load into the other main factors or correlate with each other. It is suggested that these symptoms should be evaluated separately with the additional inclusion of a single item measure of the impact of lower urinary tract symptoms on daily life. The ICSmaleSF represents a comprehensive, concise, valid and reliable instrument for evaluating men with lower urinary tract symptoms. Unlike other questionnaires in the field it contains subscores for the domains of voiding and incontinent symptoms as well as the separate consideration of frequency, nocturia and impact on daily life. We hope that it will become the tool of choice for the comprehensive evaluation of treatment of men with lower urinary tract symptoms associated with benign prostatic disease.

Intravesical Bacillus Calmette-Guerin in Ta and T1 Bladder Cancer.

Intravesical therapy with Bacillus Calmette-Guerin (BCG) aims to reduce the incidence of tumour recurrence following transurethral resection (TUR) for patients with superficial bladder cancer. The objective of this review was to compare the incidence of tumour recurrence after the standard therapy of transurethral resection versus transurethral resection plus intravesical Bacillus Calmette-Guerin. We searched the Cochrane Controlled Trials Register (March 2000), Medline (February, 2000), EMBASE (February, 2000), Cancerlit (February, 2000), Healthstar (February, 2000), Database of Abstracts of Reviews of Effectiveness (February, 2000) and the Bath Information Data Service. The Proceedings of the American Society Clinical Oncology was hand searched (1996 - 1999). Randomised or quasi-randomised trials of transurethral resection alone versus transurethral resection plus intravesical Bacillus Calmette-Guerin. Patients with Ta and T1 bladder cancer of medium or high risk of tumour recurrence, were eligible for inclusion. Four reviewers assessed trial quality and two abstracted the data independently. The Peto odds ratios and log hazard ratios were determined to compare the number of patients with disease recurrence at 12 months and the rate of recurrence, respectively. Six randomised trials were included involving 585 eligible patients. There were significantly fewer patients with disease recurrence at 12 months in the BCG plus TUR group compared to those that received TUR alone (odds ratio 0.30, CI 0.21, 0.43). The overall log hazard ratio for recurrence (-0.83, variance 0.02) indicated a significant benefit of BCG treatment in reducing tumour recurrence. Toxicities associated with BCG consisted mainly of cystitis (67%), haematuria (23%), fever (25%) and urinary frequency (71%). No BCG-induced deaths were reported. In patients with medium/high risk Ta or T1 bladder cancer, immunotherapy with intravesical BCG following TUR appears to provide a significant advantage over TUR alone in delaying tumour recurrence.

IMPACT OF INTERVENTIONAL THERAPY FOR BENIGN PROSTATIC HYPERPLASIA ON QUALITY OF LIFE AND SEXUAL FUNCTION: A PROSPECTIVE STUDY

Treatment for benign prostatic hyperplasia (BPH), including minimally invasive therapy, can impair the quality of life. We prospectively determined the impact of 4 different interventional therapies on quality of life and sexual function. A total of 173 patients were prospectively evaluated between February 1995 and August 1997. Treatment modalities consisted of standard transurethral resection of the prostate in 55 cases, transurethral microwave thermotherapy in 34, interstitial laser coagulation of the prostate in 42 and transurethral needle ablation in 42. Disease specific quality of life was assessed using the International Prostate Symptom Score quality of life assessment index and BPH impact index. In addition, a self-reporting questionnaire was completed before and 3 months after treatment to determine the impact on sexual function. All 4 treatment groups showed significant improvement in the symptom score, International Prostate Symptom Score quality of life assessment score and BPH impact index score. Satisfaction with treatment was highest in patients treated with transurethral resection or laser coagulation. A mild to moderate decrease in erectile function was noted in 26.5%, 18.2%, 18.4% and 20.0% of the transurethral resection, microwave thermotherapy, laser coagulation and needle ablation groups, respectively, but there was no significant difference of mean pretreatment and posttreatment erectile function or libido scores in any group. Ejaculation loss or severe decrease in ejaculate volume was reported by 48.6%, 28.1%, 21.6% and 24.3% of the patients, respectively. Interestingly, 20 of the 44 patients (45. 5%) with loss of ejaculation or severe decrease in ejaculate reported deterioration of the sex life, while only 2 (3.6%) of the 56 without any change in ejaculate volume reported such deterioration. The association of ejaculatory dysfunction with an adverse impact on sexual activity was highly significant (p <0.0001). Significant improvement in quality of life could be achieved with the present assessed interventional therapies. There was no significant change in sexual desire or erectile function with these therapies. Posttreatment sexual dysfunction appears to be mainly related to impaired ejaculatory function. Urologists should provide proper counseling regarding the possibility of this complication even in patients receiving minimally invasive treatment.

HOLMIUM LASER VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: A RANDOMIZED PROSPECTIVE TRIAL WITH 1-YEAR FOLLOWUP

The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.

High Energy Thermotherapy Versus Transurethral Resection in the Treatment of Benign Prostatic Hyperplasia: Results of a Prospective Randomized Study With 1 Year of Followup

Purpose We compared the outcome of transurethral resection of the prostate and high energy microwave thermotherapy in patients with benign prostatic hyperplasia. Materials and Methods Of 52 patients with symptomatic benign prostatic hyperplasia 21 (mean age plus or minus standard deviation 69.6 +/− 8.5 years) were treated with transurethral resection of the prostate and 31 (mean age 69.3 +/− 5.9 years) were treated with high energy microwave thermotherapy. Patients were assessed using the Madsen symptom score, measurements of voiding parameters, transrectal ultrasound and cystometry, including pressure-flow analyses. Examinations were repeated at fixed intervals for up to 12 months after treatment. Results After transurethral resection and thermotherapy there was significant improvement in all clinical parameters. At 1 year of followup symptomatic improvement was 78% in the transurethral resection group versus 68% in the thermotherapy group, with improvements in free flow rate of 100 and 69%, respectively. Both groups had significant relief of bladder outlet symptoms. No serious complications occurred in either group, while 1 patient in each group required repeat treatment. Conclusions Satisfactory results were obtained after both treatments, with improvements following high energy microwave thermotherapy being in the same range as those after transurethral resection of the prostate.

Does Transurethral Resection of the Prostate Pose a Risk to Life? 22-Year Outcome

The clinical outcomes of 717 patients who underwent transurethral resection for benign prostatic hyperplasia between 1971 and 1981, and of 48 who underwent open prostatectomy during the same period were evaluated. All living patients could be followed for a minimum of 12 years postoperatively. The cumulative percentage of patients undergoing a secondary operation was substantially greater after transurethral resection of the prostate than after open prostatectomy. The volume of resected tissue, operating time, requirement for blood transfusion and hyponatremia during or after the procedure did not affect long-term outcome of patients in the transurethral resection group. Abnormal preoperative electrocardiography and azotemia appeared to be associated with increased risk of postoperative mortality after controlling for other variables (p less than 0.05). Actuarial survival rates did not differ substantially for patients who underwent transurethral resection and open prostatectomy, and exceeded the expected survival rates in the general male population in the same age group in Japan. Both procedures are safe for the symptomatic relief of urinary obstruction due to benign prostatic hyperplasia. Prostatectomy does not jeopardize long-term survival of the patients.

Total cystectomy after intravesical bacillus Calmette-Guérin (Tokyo strain) therapy for superficial bladder cancer: Experience in Japan

To clarify which patients might most require total cystectomy after intravesical bacillus Calmette-Guérin (BCG) therapy, we reviewed data for 111 individuals with superficial bladder cancer. Of the 111 patients, 73 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection (group 1), 24 therapeutically for Ta or T1 tumours (group 2), and 14 for eradicating carcinomas in situ (CIS, group 3). Although the BCG therapy significantly reduced frequencies of recurrence in group 1, 27 patients (37%) did develop tumours again. Tumours disappeared in 18 of 24 patients (75%) in group 2, and in 11 of 14 (79%) in group 3. The rate of disease progression was 6% for all 111 patients: 3% (2/73) for group 1, 17% (4/24) for group 2, and 7% (1/14) for group 3. A total of 16 of the 111 patients (14%) underwent total cystectomy, the respective figures being 7% in group 1, 29% in group 2, and 29% in group 3. Indications for total cystectomy were progression in 7, recurrent multiple tumours in 5, persistent CIS in 2, a contracted bladder in 1, and occurrence of bilateral renal pelvic cancer in 1. Thus, 4 of 6 patients (67%) who had tumours unresponsive to BCG therapy in group 2 demonstrated progression and necessitated total cystectomy. Because tumours persisting after BCG therapy are frequently of the muscle-invasive type, such cases should be regarded as candidates for immediate total cystectomy.

Impact of Transurethral Resection on the Long-Term Outcome of Patients with Prostatic Carcinoma

Between March 1970 and December 1987, 1,078 patients with adenocarcinoma of the prostate were treated with pelvic lymph node dissection and permanent 125iodine implantation. Before implantation, 257 patients (27%) underwent transurethral resection of the prostate, while 702 (73%) did not and their diagnosis was established by needle biopsy. A total of 119 patients (10%) underwent hormonal therapy before implantation and they were excluded from the present analysis. Clinical stage and pathological grade were similar in both groups. A higher percentage of patients in the transurethral resection group had nodal metastases at implantation. Positive lymph nodes were found in 121 patients (47%) in the transurethral resection group versus 199 (26%) who did not undergo resection (p < 0.001).The actuarial 5, 10 and 15-year distant metastasis-free survival rates among the patients who underwent transurethral resection of the prostate were 79%, 42% and 16%, respectively, compared to 86%, 52% and 27%, respectively, in the group without transurethral resection (p <0.0001). Similarly, the actuarial disease-free and local relapse-free survival rates were significantly inferior in the transurethral resection group. A negative impact of transurethral resection of the prostate could be demonstrated among patients with grade I/II tumors. However, when stratified for nodal status, no difference in outcome in any clinical parameter was noted between the groups with and without transurethral resection of the prostate. Specifically, distant metastasis-free survival among transurethral resection group patients with negative nodes was 78%, 57% and 47% at 5, 10 and 15 years, respectively, compared to 80%, 59% and 47%, respectively, among the patients with negative nodes who did not undergo transurethral resection of the prostate (p = 0.38). Similarly, the differences between the 2 groups among patients with positive lymph nodes were not significant. When stratified by the clinical stage, grade and nodal status, the negative impact of transurethral resection of the prostate could not be demonstrated in any combination. A multivariate analysis failed to demonstrate transurethral resection of the prostate to be an independent variable in predicting the metastatic, local control or disease-free survival outcome.In conclusion, the long-term results in these pathologically staged cases indicate that transurethral resection of the prostate does not impact negatively on the clinical outcome.

Androgen receptor assays in specimens of prostatic tissue obtained by transurethral resection and transvesical adenomectomy

The main goal of this study was to ascertain whether routine transurethral resection (TUR) of prostate may provide useful material for the evaluation of androgen receptor (AR) status. At the same time, either intracellular distribution of binding affinity and capacity of receptor molecules were particularly taken into account. Based on our previous findings in breast and endometrial cancer, we suggest that a "functional" receptor status may correspond to the presence of type I (high affinity, low capacity) AR in both soluble and nuclear fractions. However, the precise significance of type II (lower affinity, higher capacity) binding sites remains to be clarified. Ten samples of large prostatic adenomas, obtained by transvesical adenomectomy (TVA), were compared with ten parallel specimens obtained by an in vitro TUR, whereby a pure cutting current was used. The AR assay was carried out with a standard competition method using tritiated mibolerone as the radioligand and Scatchard analysis for data processing. No significant difference between the TUR and TVA groups emerged concerning type I AR content of soluble, nuclear or soluble together with nuclear fractions; this was also true when the results were expressed either as fmol/ml homogenate or as fmol/mg DNA. Similarly, concentrations of type II AR in TVA and TUR samples did not differ significantly in either cell compartment, although they were widely scattered, especially in the soluble fraction. In the light of our findings, it is suggested that TUR specimens represent suitable material for receptor studies, provided that only cutting current is employed and that the use of coagulation current, to control bleeding from the prostatic bed, is confined to the final step of the TUR procedure.

Comparison of Transurethral Resection to Radical Therapies for Stage B Bladder Tumors

We evaluated the survival rate and time to recurrence for 114 patients in whom an initial histological diagnosis of stage B1 or B2 bladder tumor was made between 1974 and 1983. The 5-year survival rates for stages B1 and B2 disease, respectively, were 63 and 38 per cent in 43 patients treated by transurethral resection alone, 48 and 54 per cent in 40 treated by preoperative radiation and radical cystectomy, 33 and 25 per cent in 15 treated by radical cystectomy alone, and 53 and 11 per cent in 16 treated by definitive radiation therapy alone. Similar results were found among the groups with regard to time to development of metastases. The distribution of stage, grade and number of tumors was not significantly different among the treatment groups. Patients in the transurethral resection group were older, and had smaller tumors and more medical problems. Comparing transurethral resection of muscle invasive bladder tumors to standard radical surgery with or without radiotherapy yielded comparable long-term survival and time to distant recurrence. (J. Urol., 140: 964–967, 1988)

Microwave Surgical Treatment of the Prostate: Clinical Application of Microwave Surgery as a Tool for Improved Prostatic Electroresection

Microwave surgery as a tool for improved prostatic electroresection is introduced. Prior to electroresection the prostate was coagulated with 2,450 MHz of microwave which was emitted from the bipolar electrode of a specially designed probe. We conducted a comparative study of 35 patients with bladder neck obstruction. There was a microwave coagulation group treated with subsequent transurethral resection (TUR) and a conventional TUR group. Both groups were analyzed for the amount of blood loss, irrigant absorption and the frequency of complications. Both during and following surgery, the former group had a significant reduction in blood loss and had no complications. We conclude that the combination procedure of microwave coagulation and TUR can minimize the disadvantage of formal TUR and may be of value in the treatment of patients with both prostatic obstruction and of hemorrhagic diathesis as well as in high risk patients.

Le propofol en endoscopie urologique chez le sujet âgé. Comparaison avec le méthohexital

Twenty patients undergoing cytoscopy (group A) and forty patients undergoing transurethral resection (group B), aged more than 65 years, were anaesthetized. Duration of anaesthesia was less than 15 min for cytoscopy, and more than 30 min for transurethral resection. No premedication was given. The patients were ASA I or ASA II. Group A patients were allocated randomly to receive either 1.5 mg · kg −1 propofol (n=10) or 2 mg · kg −1 methohexitone (n=10) for induction of anaesthesia. Anaesthesia was maintained using incremental doses of propofol or methohexitone and 60% N 2O with a face-mask. Forty group B patients undergoing transurethral resection were randomly assigned to four equal groups (P B : propofol 1.5 mg · kg −1; M B : methohexitone 2 mg · kg −1; P F : propofol and 1.5 μg · kg −1 fentanyl; P FV : propofol, 2 μg · kg −1 fentanyl and 0.1 mg · kg −1 vecuronium). Suxamethonium (1 mg · kg −1; groups P B, M B and P F) and vecuronium (0.1 mg · kg −1; groupe P FV) were given to facilitate endotracheal intubation. Anaesthesia was maintained by infusion of propofol or methohexitone, using a calibrated pump started immediately after intubation. Ventilation was controlled only in group P FV. Induction with 1.5 mg · kg −1 propofol resulted in stopping counting after 62 s and loss of the eye-lash reflex after 84 s versus 47 and 67 s respectively with methohexitone. The anaesthesist's assessment was favourable for cytoscopy with propofol and methohexitone; recovery times were similar for the two drugs in cytoscopy lasting less than 30 min. For transurethral resection, the anaesthesist's assessment was favourable for P B and M B groups (only propofol or methohexitone). Rates of propofol infusion were 147±40 μg · kg −1 · min −1 for P B, 110±37 for P F and 69±9 μg · kg −1 · min −1 for P FV. The anaesthesist's and surgeon's assessments were favourable for the propofol, fentanyl and vecuronium association (P FV). Postanaesthetic recovery was superior after propofol than after methohexitone. In group P FV, mean recovery time, measured from the end of infusion of propofol until eye opening on command and questions answered correctly, were 8 min and 11 min, respectively. Propofol gave significant falls in systolic arterial pressure; end-tidal P co 2 was raised equally with propofol or methohexitone in spontaneously breathing patients. Propofol with fentanyl and vecuronium gave a satisfactory alternative when extradural or spinal anaesthesia was unadvisable for the patient, or refused by him.