management of luts after turp and mittheprostate.org/conference/pdf/2007_02/2-03.pdf · turp is...

Management of LUTSafter TURP and MIT

Hong Sup Kim

Konkuk University

TURP & MIT

TURP : Gold standard

MIT

TUIPTUNATUMTHIFULASER – Nd:YAG, ILC, HoLRP, KTP

LUTS after TURP and MIT

Improved : about 70%Persistent LUTS : about 20~35%

Nitti VW, et al. J Urol. 1997;157:600-3

LUTS after TURP & MIT

Symptoms

frequency 20~35%

dysuria 10~23%

poor flow & hesitancy 0.4~10%

others – incontinence (urge) 40%

Nitti VW, et al. J Urol. 1997;157:600-3, Kuo HC. Urol Int. 2002;68:99-104


Causes (urodynamic study)

bladder outlet obstruction 27.3%

low detrusor contractility 18.7%

pure detrusor instability 9.6%

detrusor instability + inadequate detrusor contractility 14.4%

poor relaxation of urethral sphincter 19.3%

incontinence 40.0%

Nitti VW, et al. J Urol. 1997;157:600-3, Kuo HC. Urol Int. 2002;68:99-104

Evaluation of LUTS after TURP & MIT

urine analysis with microscopy

urine culture, sensitivity and colony counts

urine cytology

uroflowmetry and check residual urine

retrograde urethrography

TRUS (due to incomplete resection)

cystourethroscopy

videourodynamic study (persistent LUTS)

Treatment outcomes after TURP & MIT

TURP, TUIP, TUVP : 71% (66~76%) improved

but 29% - not improved

need for another therapy due to LUTS

LUTS

lower prostate volume (<30cc) without BOO

results : not better than with BOO

Madersbacher S, et al. BJU Int. 1999;83:227-37, Tkocz M, et al. Neurourol Urodyn. 2002;21:112-6

Advantage and disadvantage

TURP : Gold standard• Bleeding • Incontinence• TUR syndrome

MITAdvantage

• low morbidity and low mortalityDisadvantage

• possibility of incomplete resection• prolonged irritative symptoms• catheter indwelling times - more longer than TURP• not achieved prostate specimen• need for secondary operation

Tomas AW, et al. BJU Int. 2004;93:745-50

Complication Te AE et al (%) Malek RS et al (%)

Prolonged dysuria (>10d) 9.4 6

Transient (> 10 days) hematuria 8.6 3

Transient urinary urge incontinence 6.5 0

Urinary tract infection 2.2 2

Retrograde ejaculation 26 *

Urinary retention requiring recatheterization 5 1

Bladder neck contracture 1.4 2

Urethral stricture 0.7 0

Epididymitis 0.7 0

* : number of patients retrograde ejaculation varied at different followup points

Malek RS, et al. J Urol 2005;174:1333-8Te AE, et al. J Urol 2004;172:1404-8

Complications of KTP laser

Case

RGU TRUS

Brief History65/Malelocal clinic, KTP laser ablation - 8 month agoPSA : 9.1ng/ml, RGU, TRUSProstate biopsy : nodular hyperplasiaTreatment – endoscopic incision of urethra & secondary TURP

Obstructive symptoms after TURP & MIT

Common causes

incomplete resection of the prostatebladder neck contractureurethral stricture, meatal stenosis

low detrusor contractility (underactive bladder)

Symptoms

hesitancy, weak stream, prolonged voidingD/Dx – low detrusor contractility

Urethral stricture Bladder neck contractureTURP 3.8% 4.0%TUIP 1.7% 0.4%

Wasson JH, et al. N Engl J Med. 1995;332:75-9, Kuntz RM, et al. J Urol. 2002;168:1465-9


Madersbacher S et al. BJU Int 1999;83:227-37


Incomplete resection of prostate

Treatment: α1-blocker, 5α-reductase inhibitorSecondary prostatic operation

Urethral stricture and bladder neck contracture

Diagnosis• retrograde urethrography• uroflowmetry and check residual urine• cystoscopy

Treatment• urethral dilation• endoscopic incision of urethra or bladder neck

Kuntz RM, et al. J Urol. 2002;168:1465-9


Low detrusor contractility (underactive bladder)

with LUTS

decreased clinical outcomes : LUTS after TURP and MIT

treatment• medication : α-blocker, bethanechol, cholinesterase inhibitor• Double voiding trial• CIC• suprapubic cystostomy



Group A; unobstructed and underactive detrusor functionGroup B; obstructed and/or normal detrusor contractility

Irritative symptoms after TURP & MIT

Common causes

preoperative misdiagnosis

idiopathic detrusor overactivity

• 66% improved after TURP and MIT• but about 30% persistent LUTS

increased vascular resistance of the bladderhypoxia of the detrusor musclesdenervation of the detrusor muscles

treatment• anticholinergic drugs: propiverin, tolterodine, darifenacin, oxybutinin, trospium


Drug Grade of recommendation

Antimuscarinics

Tolterodine A

Trospium A

Solifenacin A

Darifenacin A

Propantheline B

Drugs with mixed action

Oxybutinin A

Propiverine A

Flavoxate C

Antidepressant

Imipramine C

Drug Grade of recommendation

Alpha-AR antagonist

Alfuzosin C

Doxazosin C

Prazosin C

Terazosin C

Tamsulosin C

Other drugs

Estrogen C

* A – highly recommendedB – recommendedC – recommended with reservation

OAB guideline 배뇨장애요실금학회 2007


Dysuria

Nd:YAG laser, ILC, HoLRP, KTPcommon incidence rather than TURPprolonged dysuria rather than TURP

treatmentanti-inflammatory regimens – diclofenac, etc.

Kabalin JN, et al. J Urol. 1997;158:1923


Incontinencedecreased Quality of Life

incidence of urge incontinence : upto 40%

causessphincter incompetence : 30%detrusor instability : 20% Medical treatmentmixed incontinence : 30%

residual adenoma : 5%bladder neck contracture : 5% Surgical treatmentUrethral stricture : 5%

Kuo HC. Urol Int. 2002;68:99-104, Price DA et al. J Urol. 1982;52:529-31


Incontinence

incidence of stress incontinence : TURP (2.2%), TUIP (1.8%)

cause external sphincter injury

management & medical treatmentpad apply, external device applypelvic floor exercise, biofeedbackanticholinergic drugs, duloxetineelectrostimulation

surgical treatmentperiurethral injection therapy, artificial sphincter implantationinflatable paraurethral balloons

Hubner WA, et al. BJU Int. 2005;96:587-94

Secondary TURP after MIT

Secondary prostatic operation following surgical treatment

TURP approximately 1~2% per year

Laser Nd:YAG approximately 2% per year

ILC approximately 2% per year in the first year,

rising to 9.6% thereafter

HoLRP 1.4% per year during the 6-year study group

HIFU 43.8% during the 4-year study group

TUNA 20% during the 3-year study group

TUMT 7% during the 2-year study group

*ILC- interstitial laser coagulation, HoLRP – Holuim laser resection of the prostate, TUNA – transurethralneedle ablation of the prostate, TUMT – high-energy transurethral microwave thermotherapy

European Association of Urology. Guidelies. 2007 edit.

Intractable LTUS after TURP & MIT

Treatment of intractable LUTS after TURP and MITSecondary therapy

botulinum toxin injection (??)

sacral neuromodulation (??)

need for further studies and future developments

Intractable LTUS after TURP & MIT

Conclusion

The indication for surgical management is refractory LUTS to medical management.

TURP is widely recognized as an efficacious procedure for the relief of symptomatic BOO due to BPH.

TURP have been associated with significant morbidity.

The efficacy of MIT in relief of BOO was observed to be less than TURP.

need for secondary prostatic operationdysuria (laser ablation of the prostate)

Conclusion

Symptoms alone are unreliable in predicting urodynamicfindings with respect to BOO and detrusor instability after TURP and MIT.

low detrusor contractilityidiopathic detrusor overactivityinadequate detrusor contractiltiypoor relaxation of the urethral sphincter

The treatment of persistent LUTS after TURP and MIT are important in improving QoL.

management of luts after turp and mittheprostate.org/conference/pdf/2007_02/2-03.pdf · turp is...

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