|Year : 2004 | Volume
| Issue : 2 | Page : 42-46
A study on the correlation between clinical outcome and residual prostatic weight ratio after transurethral resection of the prostate for benign prostatic hyperplasia
MC Songra, Rajiv Kumar
Gandhi Medical College, Bhopal, India
M C Songra
Gandhi Medical College, Bhopal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: A prospective trial to determine the effect of the extent of tissue resection on symptom improvement after transurethral resection of the prostate in men with symptomatic benign prostatic enlargement and to evaluate any potential correlation between prostate size and outcome, a new variable the residual prostatic weight ratio (RPWR)
Patients and Methods: From October 2002 to November 2003, a total of 50 patients (mean age 62.6 yrs., range 50-91) with symptomatic benign prostatic enlargement who underwent TURP participated in this prospective study. Patients were assessed preoperatively with the American Urological Association symptom Score, Urinary flow rate measurements (Qmax and Qavg) as well as prostate volumes by transabdominal ultrasound. The amount of tissue resected was weighted. RPWR was derived by dividing the weight afterTURP by the initial weight. Clinical outcome was evaluated by the difference in AUA score, Qmax and Qavg before and 2 months after Surgery.
Results: There was a significant improvement in AUA score, Qmax and Qavg postoperatively. Maximum numbers of patients undergoing TURP had RPWR in the range of 5160% (mean RPWR 49.9%). Mean overall change in AUA Score (DAUA), D Qmax and D Qavg was 12.04, 8.27 ml/sec and 6.64 ml/sec respectively. Smaller the RPWR larger is the DAUA, DQmax, DQavg and vice versa. There was negative correlation between the RPWR and the DAUA, DQmax and DQavg (r = -0.42, -0.067, and -0.09 respectively).
Conclusion: Symptomatic improvement after TU RP will depend on the amount of tissue removed and the smaller the RPWR after TU RP the better the clinical outcome.
Keywords: Benign prostatic hyperplasia. Transurethral Resection of the prostate. Residual Prostatic Weight Ratio. Clinical outcome.
|How to cite this article:|
Songra M C, Kumar R. A study on the correlation between clinical outcome and residual prostatic weight ratio after transurethral resection of the prostate for benign prostatic hyperplasia. Indian J Urol 2004;20:42-6
|How to cite this URL:|
Songra M C, Kumar R. A study on the correlation between clinical outcome and residual prostatic weight ratio after transurethral resection of the prostate for benign prostatic hyperplasia. Indian J Urol [serial online] 2004 [cited 2019 Jun 27];20:42-6. Available from: http://www.indianjurol.com/text.asp?2004/20/2/42/37167
| Introduction|| |
Benign prostatic Hyperplasia (BPH) is the most common disorder of the prostate gland. It is a major cause of morbidity in the ageing men affecting more and more men with increasing age. 
Transurethral resection of the prostate (TURP) is a safe and effective procedure  and remains the standard surgical treatment of benign prostatic hyperplasia despite a variety of treatment alternatives.  Presently, the outcome of TURP is assessed in terms of symptom improvement as well as improvement in lower urinary tract function measured by u roflowmetry.
While it is well known that there is little correlation between the size of the prostate gland and lower urinary tract symptoms in BPH, it is not entirely clear as to whether and how much outcome after TURP is related to the degree of adenoma removal which is achieved.
We conducted a prospective trial to determine the effect of the extent of tissue resection on symptom improvement after TURP in men with symptomatic benign prostatic enlargement and to evaluate any potential correlation between prostate size and outcome, a new variable the residual prostatic weight ratio (RPWR).
| Material& Methods|| |
The present study was carried out in the Department of Surgery, Gandhi Medical College & Associated Hamidia Hospital, Bhopal between October 2002 & November 2003.
Patients presenting to the surgery OPD of Hamidia Hospital, Bhopal with lower urinary tract symptoms viz, weak urinary stream, frequency, hesitancy, intermittency, urgency, nocturia etc. were included in the study.
Patients were evaluated on basis of the American Urological Association symptom index questionnaire. They were also evaluated by transabdominal ultrasound examination and patients having BPH on USG were further evaluated by Uroflowmetry. Patients with obstructive symptoms and documented obstruction on uroflowmetry were finally included in the study. Patients included were having moderatly enlarged prostate and patients in whom only TU RP was done were excluded from study.
TURP was performed using 26 French standard loop resectoscope (Karl Storz Germany). All the resections were performed by same resectionist Tissue resected was weighed in the operation theater immediately after the completion of TURP 24 French Folley's catheter inserted and balloon placed in the prostatic fossa with a volume corresponding to the amount of tissue removed. Irrigation was maintained until the next morning. The catheters were removed routinely on the 3rd day following TURR Patients were usually discharged 1 day after catheter removal.
The RPWR was derived as the weight after TURP divided by the initial weight where the weight after TURP was calculated as the initial weight minus the weight of the TURP specimen.
Clinical outcome was evaluated by the difference in AUA score, Qmax and Qavg before and 2 months after surgery.
| Results|| |
The mean age of the patients were 62.6 years (range 50 years to 91 years). Berry et al. (1984) reported that 50% of men aged 51-60 years had histological evidence of BPH although clinical evidence of disease occurs less commonly. However our study showed 51-60 year age group to be the most common.
The above findings may be due to the fact that in Indian circumstances, with life expectancy about 65 years for males, patients above 60 years are less in number.
A study of the overall pre-operative AUA symptom score revealed that the most common symptom score range was 11-20 which included 76% (n=38) of patients with mean pre-operative AUA score of 19.08 (range 14-26). Maximum No. of patients post-operatively had a score < 10 (n=49, i.e. 98%) with a mean score of 6.84. The above findings correlate well with those of Derret S. et al. (2001).` Their mean AUA score before surgery was 22.2 while postoperatively it was 7.3.
Thus TURP done for BPH symptoms resulted in symptomatic improvement post-operatively as evident from the decrease in post-operative AUA score.
Pre-operative prostatic weight, as determined by Trasabdominal USG examination ranged from 20 to 81 gms, with a resultant mean weight of 41.15 gms. The pre-operative prostatic weight although did not always correlate with symptom severity. Even small prostates may cause severe symptoms and large prostates may remain relatively asymptomatic.
Post operatively a maximum of 44% patients had prostatic weight in the range of 21-25 gms. Mean post operative prostatic weight was 22.21 gms. Post operative prostatic weight also correlated well with improvement in Qmax post-operatively. This may be explained by the fact that more the tissue that was resected the better was bladder outflow tract and hence the urinary flow. Chen SS, Hong JG, Hsiao YJ, Chang L.S.  (2000) too had the same results.
Analysis of the maximum urinary flow rates also showed significant improvement post-operatively. The mean pre-operative Qmax was 9.59. Post-operatively mean (Qmax) improved to 17.33 ml/sec.
Our findings again correlated well with those of other investigators notably RH. Abrams et al. (1977)  . They found that the mean Qmax had increased from 8.0 to 17.2 ml/sec. Similar were the findings of Roehrborn et al  (1986) who found a highly significant difference between the pre-operative and post-operative flow rates.
On studying the pre-operative average flow rates (Qav) maximum no. of patients had Qavg. rates in the range of 610 ml/sec (52%) followed by <5 ml/sec (48%). The mean pre-operative Qavg was 5.18 ml/sec. Post-operatively there was significant improvement in the Qavg and 86% of the patient had Qavg > 10 ml/sec/The mean post-operative Qavg. Improved to 11.92 mI/sec.
Of all patients undergoing TURP, maximum number of patients had RPWR in the range of 51-60 (38%) followed by 41-50 (32%). The mean RPWR was found to be 49.9%.
On analysis the correlation coefficient between mean DRPWR and mean DAUA score was r = -0.42 which is statistically significant..
This suggests that there is negative correlation between mean DRPWR and mean DAUA score i.e. the lesser is the RPWR, the greater is the improvement in the symptoms in terms of AUA symptom score.
The correlation coefficient between mean DRPWR and mean DQmax was r = -0.067. The correlation coefficient between mean DRPWR and mean DQavg was r = -0.09.
This suggest that there is negative correlation between mean DRPWR and mean DAUA, mean DQmax and mean DQavg.
| Discussion|| |
The conventional technique of transurethral resection aims at complete adenoma removal.  However, individual variations exist regarding the extent of tissue removal. There have been few studies analyzing the effect of resected tissue and completeness of transurethral resection on outcome in BPH. For the patient, the most important outcome parameter is symptomatic improvement as assessed by symptom and bother scores ,,
In our study group, we found a negative correlation between mean DRPWR and mean DAUA score (r=-0.42) i.e. lesser is the RPWR greater is the improvement in the symptoms in terms of AUA symptom score.
Similarly we found negative correlation between mean DRPWR and mean DQmax (r=-0.067), and mean DQavg (r=-0.09).
Although relationship is weak and affected by several other factors. A possible explantation is that better clinical result after TURP correlates significantly with the completeness of resection of the obstructing adenoma.
Chen S.S., et. al.  studied 40 patients of TURP (2000). Their findings were compared with our study.
They have described significant correlations between the improvement in American urological association symptom score and the calculated RPWR 4 months after TURP
Oliver W. Hakenberg et al.  found that patients with larger prostates and hence larger absolute RTWs benefit more from a TURP in terms of symptom improvement than patients with smaller prostates.
Possible methodological limitations of our study are that prostate weight was measured by transabdominal rather than transrectal ultrasound, residual prostatic weight was calculated rather than measured and follow up of patients were short as most of our patients were from rural areas.
In our study one patient died of acute myocardial infarction after 3 days of TURP Other than that we didn't encounter any complication. In our study we didn't perform pre-operative pressure flow study in any patient.
| Conclusion|| |
AUA score, Qmax and Qavg show improvement after TURP The greater is the improvement if more is the amount of tissue resected during TURP The smaller the RPWR the larger is the DAUA, DQmax, & DQavg. Although correlation between DRPWR and DQmax, DQavg is small.
Thus we can conclude that symptoms improvement after TURP will depend on the amount of tissue removal and the smaller the RPWR after TURP the better the clinical outcome in moderately enlarged prostate.
| Acknowledgement|| |
We are grateful to the Dean, Gandhi Medical College and Hamidia Hospital Bhopal for allowing as to publish this paper. We are also thankful to OT Staff of Kamla Nehru
| References|| |
|1.||Berry S.J., Coffey D.S., Walsh PC., Ewing L.L. The development of human benign prostatic hypertrophy with age. J. Urol 1984: 132:474-9. |
|2.||Emberton M, Neal D.E., Black N, Harrison M, Fordham M., McBrien M.P, et al. : The National prostectomy Audit : The clinical management of patients during hospital admission. Br. J. Urol 1995, 75: 301-316. |
|3.||Speakman M.J. : Who should be treated and bow? Evidence based medicine in symptomatic BPH. Eur. Urol. 1999; 36 (Suppl 3) : 21-27. |
|4.||Derrett S, Paul C, Herbison P : Prospective evaluation of the effects of prostatectomy on symptoms and quality of life NZ Med J 2001 Jun 22; 114 (1134): 276-9. |
|5.||S.S.Chan, J.G.Hong, Y.J.Hsiao and L.S.Chag : The correlation between clinical outcome and residual prostatic weight ratio after transurethral resection of the prostate for benign prostate hyperplasia, BJU International (2000) 85, 79-89. |
|6.||Abrams PH, Farrar DJ, Turner Warwick R T et al : The results of prostatectomy : a symptomatic and urodymanic analysis of 152 patients. J Urol 1979;, 121:640-642. |
|7.||Roehrborn C.G., Chinn H.K., Fulgham PF, Simpkins K.L. and Peters PG. : The role of transabdominal ultrasound in the pre-operative evaluation of patients with benign prostatic hypertrophy. J. Urol. 1986 : 135 (6) 1190-3. |
|8.||Nesbit R.M. Transurethral prostatic resection in Compbell L. Harrison J. (eds) : Urology Philadeinhia, Sounders 1970, P 2479. |
|9.||Barry M.J., Fowler F.J. O'Leary M. Bruskewitz R.J. Holtgrewe H.L., Mebust W.K. Cocket A.T. : The American Urological Association symptom index for benign prostatic hyperplasia. The measurement committee of the American Urological Association. J. U rol . 1992: 148: 1549-1555. |
|10.||Hakenberg OW, Pinnock CB, Morshall VR : Does evaluation with the International prostate symptom score predict the outcome of transurethral resection of the prostate? J. Urol. 1997; 158: 94-99. |
|11.||Barry MJ, Fowler FJ, O'Leary MP : Measuring disease specific health status in men with benign prostatic hyperplasia. Med. Care 1995: 33 : 145-155. |
|12.||Oliver W. Hakenberg, Christian Helke, Andreas Mansect,. Manfred, P Wirth : is there a relationship between the amount of tissue removed of transurentral resection of the prostate and clinical improvement in Benign Prostatic hyperplasia. Eur Urol. 2001 : 39 412-417. |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]