Abstract
Introduction: To evaluate the effect of ageing on the efficacy of transurethral vaporization resection of the prostate (TUVRP). Methods: The clinical outcomes of 285 patients treated by TUVRP were retrospectively analyzed. Patients were divided into three groups by age, Group A with 91 patients less than ≤70 years of age, Group B with 127 patients from 71 to 79 years of age, and Group C with 67 patients greater than ≥80 years of age. Results: Prostate volume was 53.1 ± 24.1 ml in Group A, 67.8 ± 39.7 ml in Group B and 60.0 ± 43.9 ml in Group C (p < 0.001). More co-existent systemic diseases were identified in Group C than in the other two groups (p < 0.001). American Society of Anesthesiologists (ASA) grade increased with age (p < 0.001). Urological comorbidities associated with BPH, operating time, IPSS score, and QOL index were not different among the three groups. A significant difference was observed in before and after surgery IPSS score, QOL index, and maximum urinary flow rate (Qmax), in all three groups (p < 0.05). Post-operative Qmax decreased with age (p < 0.05). Conclusion: TUVRP was safe and effective for the patients greater than 80 years of age, similarly to younger patients. Advanced aged was not a contraindication for surgery, and did not increase the difficulty of the procedure.
Introduction
BPH is a common disease of aged men. Its frequency and associated morbidity increases as men age. Since the advent of medical therapy for symptomatic prostatic hypertrophy, the need for immediate surgical intervention in symptomatic prostatic obstruction has been reduced substantially. Surgery is reserved for patients with serious obstructive symptoms or urological comorbidities in which medical management or less-invasive prostatic procedures have failed.
The age of the surgical patient with BPH is increasing. The increased surgical risks associated with age can make the decision to operate more difficult. We retrospectively evaluated the effect of age on prostate volume, clinical features, surgical indications, operative procedure, and clinical efficacy of TUVRP, in elderly patients with BPH.
Patients and methods
Patients
Between January 2003 and December 2007, 285 patients with BPH were treated. Their mean age was 75.7 years (range: 60–97 years). The Chinese Urology Association guideline on diagnosis and treatment to BPH was followed to select patients for surgery. Patients with ASA score β and χ also underwent surgery after the life-threatening systemic disease was effectively treated.
Operative technique
Surgery was performed using spinal anesthesia. A standard 26F continuous-flow Storz resectoscope with a wing loop was used. The electrosurgical generator (Bircher Type-4400, USA) was set to 280–290 W of pure cutting current for the incision and 80–90 W for coagulation. All procedures were performed by two consultant urologists with equivalent experience. No significant difference in surgical outcome was found between the two surgeons. Prostate tissue was resected to the surgical capsule of the prostate during the operating procedure. All patients signed an informed consent.
Outcome variables
Measured outcomes included pre-operative prostate volume, IPSS score, QOL index, Qmax, Urological Comorbidities associated with BPH, other urological comorbidities, co-existent systemic diseases, and ASA grade. Surgical outcome of TUVRP was evaluated using operating time, hemoglobin (Hgb) level one day after operation, use of continuous bladder irrigation, irrigating time, perioperative blood transfusions, and surgical complications. Follow-up was obtained 36–48 months (average: 42 months) after surgery. IPSS score, QOL index, and Qmax were determined. Transabdominal ultrasonography was performed to assess the prostate volume and the urinary system. The urine flow rate was measured in all patients without a urinary catheter ().
Table I. Patient characteristics grouped by age.
Statistical analysis
Differences of measurement data were evaluated using a Student’s t-test. Pre- and post-operative outcomes for each patient were compared using a paired t-test. Multi-sample measurements were compared using ANOVA. Enumeration data were compared using χ2 test and Ridit Analysis. p values <0.05 were considered significant. Values were reported as the mean ± SD.
Results
A total of 285 patients were enrolled in the study, in three groups. Group A consisted of 91 patients with a mean age of 66.8 ± 4.8 years (range: 60–70 years). Group B consisted of 127 patients with a mean age of 73.3 ± 2.2 years (range: 71–79 years). Group C consisted of 67 patients with a mean age of 84.5 ± 4.2 years (range: 80–97 years).
The mean prostate volume in Group B was 14.7 ml larger than that of Group A (p < 0.05), but was not significantly different from that of Group C (Group C, 7.8 ml smaller, p > 0.05). Mean prostate volume in Group C was not different from that of Group A (Group C, 6.9 ml larger, p > 0.05). No group difference was seen in pre-operative IPSS score, QOL index, Qmax, or incidence of urological comorbidities associated with BPH. Diabetes mellitus and pre-operative Hgb level did vary between groups (p < 0.05; p < 0.01). The number of co-existent systemic diseases varied significantly between groups (p < 0.001) and more frequently found in Group C (p < 0.001). A significant difference in ASA grade was observed among the three groups (p < 0.01). Group C patients had a higher ASA grade than the other groups (p < 0.001) ().
Table II. Surgical outcome of TUVRP.
A significant difference in post-operative Hgb level was observed among the three groups (p < 0.01). There was no group difference in operating time, use of post-operative continuous bladder irrigation, irrigating time, post-operative IPSS score, or post-operative QOL index (p > 0.05). Compared with pre-operative Hgb level, post-operative Hgb level was decreased by 2.2 g/l in Group A (p > 0.05), 4.6 g/l in Group B (p > 0.05), and 8.6 g/l in Group C (p < 0.01). Group C had a significantly lower post-operative Qmax than Group A (p < 0.05). A significant difference was observed in pre- and post-surgery IPSS score (p < 0.001) and QOL index (p < 0.001) in all of the three groups. A significant difference was observed in pre- and post-surgery Qmax in Group A (p < 0.001), Group B (p < 0.001) and Group C (p < 0.05). No significant difference was observed in post-operative decrease in Hgb level, IPSS score and QOL index and post-operative increase in Qmax between groups.
One patient was treated with blood transfusion (400 ml) in Group A (1.1%) and Group B (0.8%). No patient in Group C was transfused.
Discussion
Effect of ageing on surgical indication
People aged 60–69 years are considered younger aged, 70–79 years, medium aged, and over 80 years, advanced. BPH is a common problem that affects the quality of life in approximately one third of men older than 50 years. In autopsy studies of 60-year-old men, about 50% demonstrate BPH. This number increases to 90% by age 85 years. Thus, increasing gland volume is considered a normal part of the ageing process [Citation1,Citation2]. The incidence of co-existent systemic disease also increases with age. With new advances in medical management, and the increasing age of patients, the indications for performing TUVRP are becoming stricter.
In our study, the incidence of urological comorbidities associated with BPH did not differ by age. Co-existent systemic diseases were more common and systemic conditions were worse in advanced aged patients. The decline in post-operative Hgb levels with age was noteworthy. ASA grade also increased with increasing age. These observations reflect the decline in overall health associated with aging. The advanced aged patient can, however, safely undergo surgery after careful pre-operative evaluation. Close patient evaluation and treatment of co-existent systemic disease in the perioperative period is needed.
Effect of ageing on surgical procedure
Continuing improvements in instrumentation and technique allow safer performance of TUVRP. Post-operative continuous bladder irrigation is uncommonly used with this procedure, only for significant bleeding or a blocked catheter. Prostate volume is the most important factor in TUVRP surgery. Larger prostate volume is associated with extended operating time and increased surgical and post-operative bleeding [Citation3–9]. In this study, mean prostate volume of medium aged patients (71–79 years) was significantly larger than that of younger aged patients (≤70 years). Mean prostate volume of advanced aged patients (≥80 years), however, was not increased. The mean prostate volume of advanced aged patients (≥80 years) was smaller than that of medium aged patients (71–79 years). These differences in prostate volume could represent a simple bias, and will be evaluated in a future study.
Operative time, frequency of blood transfusion, use of post-operative continuous bladder irrigation, and the maintained time were not different in the three age groups. Advanced aged did not increase the operative difficulty, which may be more related to prostate volume. We feel that smaller glands would require shorter resection times. The operative time of Group C was not different from that of other groups, however. We feel that advanced aged does not negatively impact surgery, as long as adequate pre-operative preparation has been made.
Effect of ageing on surgical outcome
Transurethral resection of the prostate (TURP) remains the standard therapy for obstructive prostatic hypertrophy. It is treatment of choice and standard of care when other methods fail. TUVRP is a modification of TURP using one of the novel band resection election electrodes. The advantages of TUVRP include instantaneous bulky tissue removal, greater visibility, better hemostasis, and less bleeding [Citation8,Citation9].
In our study, all patients did well after TUVRP surgery. Post-operative surgical complications, IPSS score, and QOL index were not different among the three groups. Post-operative Qmax was found to decrease with increasing age. In these elderly patients, bladder detrusor function must be evaluated when assessing clinical symptoms [Citation3–8].
TUVRP can improve clinical symptoms in all aged patients. However, because of an increased incidence of bladder detrusor dysfunction, clinical outcome in advanced aged patients may not be as good as in younger aged patients [Citation10].
Conclusion
TUVRP is safe and effective for patients older than 80 years, similar to younger patients. However, close attention to bladder detrusor function is required when evaluating the clinical symptoms of these aged patients. Advanced age is not a contraindication to surgery in patients with obvious surgical indications. It was not associated with any increased difficulty in performing the procedure. However, the advanced aged is associated with reduced health, and health-associated risks. Careful pre-operative evaluation is required.
Declaration of Interest: The authors declare no conflicts of interest.
References
- Safarinejad MR. Prevalence of benign prostatic hyperplasia in a population-based study in Iranian men 40 years old or older. Int Urol Nephrol 2008;40:921–931.
- Vesely S, Knutson T, Damber JE, Dicuio M, Dahlstrand C. Relationship between age, prostate volume, prostate-specific antigen, symptom score and uroflowmetry in men with lower urinary tract symptoms. Scand J Urol Nephrol 2003;37:322–328.
- Berry SJ, Coffey DS, Ewing LL. Effects of aging on prostate growth in beagles. Am J Physiol 1986;250:R1039–R1046.
- Lepor H. Pathophysiology of lower urinary tract symptoms in the aging male population. Rev Urol 2005;7 Suppl 7:S3–S11.
- Kuo HC. Videourodynamic analysis of pathophysiology of men with both storage and voiding lower urinary tract symptoms. Urology 2007;70:272–276.
- Soga N, Sugimura Y. [Analysis of changes in lower urinary tract symptoms with aging]. Nippon Hinyokika Gakkai Zasshi 2004;95:766–772.
- Hsieh K, Taylor JA, Albertsen PC. Lower urinary tract symptoms in the older male. Conn Med 2003;67:487–490.
- Nuhoglu B, Ayyildiz A, Fidan V, Ersoy E, Huri E, Germiyanogu C. Transurethral electrovaporization of the prostate: is it any better than standard transurethral prostatectomy? 5-year follow-up. J Endourol 2005;19:79–82.
- Gupta NP, Singh A, Kumar R. Transurethral vapor resection of prostate is a good alternative for prostates >70 g. J Endourol 2007;21:1543–1546.
- Kojima M, Hayakawa T, Saito T, Mitsuya H, Hayase Y. [Age-related changes in lower urinary tract symptoms and urodynamic parameters in patients with benign prostatic hyperplasia treated by transurethral resection of the prostate]. Nippon Hinyokika Gakkai Zasshi 2001;92:513–519.