Early outcome of transurethral enucleation and resection of the prostate versus transurethral resection of the prostate

<p><b>INTRODUCTION</b>Recurrent prostate adenoma is a long-term complication following transurethral resection of the prostate (TURP). Transurethral enucleation and resection of the prostate (TUERP) is more appealing, since the nodular adenoma can be completely removed through endoscopy. TUERP is also hypothesised to result in a lower frequency of recurrent adenoma. This study aimed to compare the early outcomes of TUERP and TURP, and assess the feasibility and safety of TUERP.</p><p><b>METHODS</b>We compared the outcome of 81 patients who underwent TUERP with that of 85 patients who underwent TURP. International prostate symptom score, quality of life score, prostate volume, degree of intravesical prostatic protrusion, maximum flow rate, post-void residual volume and prostate-specific antigen (PSA) level were obtained pre- and postoperatively. Complications (e.g. transfusion rate, incontinence, infection and urethral stricture) were analysed.</p><p><b>RESULTS</b>Operative time was significantly longer in the TUERP group compared to the TURP group (85.3 minutes vs. 51.6 minutes). After TUERP, the maximum flow rate was significantly higher (21.1 mL/s vs. 17.1 mL/s) and PSA level was significantly lower (1.2 ng/mL vs. 1.9 ng/mL) than after TURP. The rates of infection, transfusion and urethral stricture were similar for both groups, but the TUERP group had a higher rate of temporary incontinence (13.6% vs. 4.7%).</p><p><b>CONCLUSION</b>The lower PSA level and better maximum flow rate achieved following TUERP suggest that prostate adenoma removal was more complete with TUERP. Long-term follow-up is required to establish whether TUERP results in fewer resections for recurrent adenoma.</p>

Relationships between Prostatic Volume and Intravesical Prostatic Protrusion on Transabdominal Ultrasound and Benign Prostatic Obstruction in Patients with Lower Urinary Tract Symptoms

<p><b>INTRODUCTION</b>The objective of this study is to determine the relationships between prostatic volume (PV) and intravesical prostatic protrusion (IPP) with benign prostatic obstruction (BPO).</p><p><b>MATERIALS AND METHODS</b>A total of 408 males (aged 50 years and above) who presented with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) were recruited. All had International Prostate Symptoms Score (IPSS), quality of life (QOL) index, uroflowmetry (Qmax) and postvoid residual urine (PVR) measured by transabdominal ultrasonography (TAUS). The PV and the degree of IPP were also measured by TAUS in the transverse and sagittal planes respectively. The PV is classified as Grade a, (20 ml or less), Grade b, (more than 20 ml to 40 ml) and Grade c, (more than 40 ml), while the IPP is graded as Grade 1 (5 mm or less), Grade 2 (more than 5 mm to 10 mm) and Grade 3 (more than 10 mm).</p><p><b>RESULTS</b>There was a fair positive correlation between the PV and IPP (Spearman, r(s) = 0.62, P <0.001) with important clinical exceptions. There was negative correlation between the PV and Qmax (rs = -0.20, P = 0.022), IPP and Qmax (r(s) = -0.30, P <0.001). PV and IPP were good predictors of BPO. However, IPP was slightly better (r(s) of -0.30 vs -0.20) than PV.</p><p><b>CONCLUSION</b>PV is related to IPP with important clinical exceptions. IPP is a better predictor of BPO than PV.</p>

Diagnosis of prostate adenoma and the relationship between the site of prostate adenoma and bladder outlet obstruction

<p><b>INTRODUCTION</b>The objective of this study was to evaluate the accuracy of using intravesical prostatic protrusion (IPP) as a parameter for the diagnosis of prostate adenoma (PA), as well as to determine the relationship between the site of PA and bladder outlet obstruction. IPP was determined with the use of transabdominal ultrasonography (TAUS).</p><p><b>METHODS</b>A total of 77 consecutive adult men aged 30-85 years with haematuria or undergoing checkup for bladder tumour were enrolled. International Prostate Symptom Score (IPSS), and the results of uroflowmetry, TAUS and cystourethroscopy were assessed. All cases of IPP were classified into grades 0 (no IPP), 1 (1-5 mm), 2 (6-10 mm) or 3 (> 10 mm). PA diagnosis was confirmed using flexible cystourethroscopy. The sites of PA were classified as U0 (no adenoma), U1 (lateral lobes), U2 (middle lobe) or U3 (lateral and middle lobes).</p><p><b>RESULTS</b>Of the 77 patients, 11 (14.3%) had no IPP. PA was confirmed using cystourethroscopy for all patients with IPP and for 7 of the 11 patients without IPP. Of the 37 patients with prostate volume < 20 g, 29 (78.4%) had IPP. Sensitivity, specificity, as well as positive and negative predictive values for diagnosing PA using only IPP were 90.4%, 100.0%, 100.0% and 36.4%, respectively. Higher sensitivity (95.9%) and negative predictive value (50.0%) were obtained when PA was used together with peak urinary flow rate (Qmax) < 20.0 mL/s. The mean Qmax of patients classified as U1 (n = 39) was 16.0 mL/s, while the mean Qmax in those classified as U2 (n = 12) and U3 (n = 22) was 11.9 mL/s and 8.9 mL/s, respectively.</p><p><b>CONCLUSION</b>All patients with IPP had PA, and PA in the middle lobe was more obstructive than those in lateral lobes. Patients without IPP may still have PA.</p>

6th College of Surgeons lecture: the philosophy of balance: the art of healing

With the rise of high tech medicine, and emphasis on the scientific aspects of medicine, there is danger that we may lose the balanced approach to healing, and lose the benefit of the traditional medical wisdom and emotional support, to improve the care of our patients. Allopathic or the mainstream medicine (Western medicine) is not the only way. With over-emphasis on the anatomy and pathology, the biochemistry and the molecular biology, we tend to treat the disease, and somehow neglect the patient. That is one of the reasons why many patients still turn to alternative medicine to relieve their ailments.We need to remember that the patient is a person, consisting of not just the body, but also the mind and the spirit. We therefore need to treat not just the body but also the mind and to heal the spirit. That would be the balanced approach in the management of patients. To treat our patients optimally, we need to understand the natural history of diseases, and not make our treatment worse than the disease itself, carefully balancing the risks and benefits in our treatment for that individual patient. The mind has more influence over the body in health and diseases than we used to think. We need to be optimistic and give patients hope through counseling, and help to minimise the harmful effects of stress and anxiety on the body. It is as important to improve the immunity of the body to diseases (infection as well as cancer) as to get rid of every bacteria or cancer cell. It may not be possible to get rid of all the cancer cells in the body, but it may be possible to keep them under control. The most important factor in improving the immunity is for the patient to have a relaxed mind. He would need emotional support from family and friends. Exercise, proper diet with plenty of fresh fruits and vegetables would help to improve immunity and speed up the healing process. The art of healing is the art of balancing the Science and the Art of Medicine, treating the disease and the patient as a whole, incorporating the best in allopathic (Western) medicine as well as complementary medical practices. With this, we hope to provide the best care to our patients.

Staging of benign prostate hyperplasia is helpful in patients with lower urinary tract symptoms suggestive of benign prostate hyperplasia

<p><b>INTRODUCTION</b>We prospectively evaluated the staging of benign prostate hyperplasia (BPH) to decide transurethral resection of prostate (TURP) therapeutic modality and the final outcomes in patients with lower urinary tract symptoms (LUTS) suggestive of BPH.</p><p><b>MATERIALS AND METHODS</b>Male patients above 50 years old presented with LUTS suggestive of BPH were included in this study. The initial assessment included the International Prostatic Symptoms Score (IPSS) and the Quality of Life (QOL) index, digital rectal examination (DRE). Transabdominal ultrasound was done to measure the prostate volume, intravesical prostatic protrusion (IPP) and the post void residual (PVR) urine. BPH was classified according to the degree of IPP using grades 1 to 3. The staging of BPH was performed according to the presence or absence of bothersome symptoms (QOL ≥3) and significant obstruction (PVR >100ml). Patients with stage I BPH with no bothersome symptoms and no significant obstruction were generally observed. Those with stage II BPH, bothersome symptoms but no significant obstruction, received pharmacotherapy in the first instance, and were offered TURP if symptoms persisted or worsened. Patients with significant obstruction, persistent PVR >100ml, irrespective of symptoms would be classified as stage III, and were advised to undergo TURP as an option. Lastly, those with stage IV (complications of BPH) were strongly recommended to undergo TURP.</p><p><b>RESULTS</b>A total of 408 patients were recruited in this study and after a mean follow-up of 30 months (range, 6 to 84), 96 (24%) eventually had TURP. Sixteen (13%), 50 (21%), 28 (64%) and 2 (100%) patients who underwent TURP were initially diagnosed as stage I, II, III and IV, respectively. Eighty-seven (91%) of the 96 patients significantly improved to stage I BPH post TURP.</p><p><b>CONCLUSIONS</b>These results showed that the staging of BPH can assist in the tailoring of treatment for patients with LUTS suggestive of BPH, with good outcome in 91% post TURP.</p>