Short stay bipolar transurethral enucleation of the prostate with catheter-free discharge – A pilot study

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Authors (including presenting author) :
1. Ka Lun LO, FHKAM (Surg) 1 2. Kevin LIM MBChB 1 3. Chi Fai NG, FHKAM (Surg) 1,2
Affiliation :
1. Division of Urology, North District Hospital, New Territory East Cluster Urology Unit, Prince of Wales Hospital, Shatin, Hong Kong 2. SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong
Introduction :
Benign prostatic obstruction (BPO) may be addressed endoscopically by resection, enucleation, vaporisation, or a combination of these techniques using a wide variety of energy modalities. The current gold standard treatment of moderate-to-severe LUTS in men with moderately enlarged prostates (sizing 30mL to 80mL) is bipolar transurethral resection (TURP). The gold standard treatment of moderate-to-severe LUTS in men with severely enlarged prostates (sizing 80mL or above) is transurethral anatomical enucleation. The key difference between resection and enucleation is that resection transects transitional zone parenchyma and does not follow an anatomical plane. Secondary haemorrhage from the raw prostatic surface in the early postoperative period remains a a distressing problem for both patients and surgeons. There is no consensus on the optimal duration of bladder irrigation and timing of catheter removal after transurethral prostate surgery. With the advent of bipolar resection and improved haemostasis, there is a trend towards earlier catheter removal on postoperative days two to three. Catheter removal on postoperative day one has also been demonstrated to be safe and feasible. Because enucleation follows a relatively bloodless anatomical plane, we hypothesise that early cessation of bladder irrigation and early catheter removal after bipolar transurethral enucleation (BipolEP) is also safe and feasible.
Objectives :
To assess the feasibility and safety of short stay bipolar transurethral enucleation of the prostate (BipolEP) with catheter-free discharge.
Methodology :
Patient recruitment This is a single-centre pilot study conducted in a district general hospital in Hong Kong. Prior approval was obtained from The Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee, which is the institutional review board of this study. Inclusion criteria Patients with BPO who were scheduled to undergo transurethral prostatic surgery within the six-month study period between May 2018 to November 2018 were identified through the operating theatre management system, screened for eligibility, and subsequently recruited in the clinic or the surgical ward. Enrolment was continuous throughout the six-month period. Patients on antiplatelets or anticoagulants and those with coagulopathy were not excluded. There was no upper age limit. A responsible adult guardian must be available on discharge. Exclusion criteria Patients with prior TURP, urethral stricture, prostate cancer, neurogenic bladder, small prostates (preoperative sizing less than 30 grams) and those who cannot give informed consent were excluded. Patients with a large bladder stone burden were also excluded, and a staged operation would be performed instead. Preoperative assessment Demographical characteristics were documented. All eligible patients were evaluated by digital rectal examination, urinalysis, prostate sizing, uroflowmetry, laboratory studies including haemoglobin, sodium and prostate specific antigen (PSA) levels. Patients with an elevated PSA were offered prostate biopsy prior to the operation. Abdominal radiographs, ultrasonography, flexible cystoscopy and cystometrography may be performed at the discretion of the clinician to investigate the underlying cause of LUTS. Post-procedural management A 22-Fr three-way Silicon catheter was inserted for continuous bladder irrigation for at least six hours. Catheter traction was avoided. Termination of bladder irrigation was at the discretion of the attending clinician based on the colour of the effluent. The three-way catheter was removed at 9am the next day. Haemoglobin and sodium levels were rechecked. The patient was encouraged to ambulate and void. Post-void residual urine (PVRU) was monitored. Discharge criteria The patient could be discharged if the PVRU is less than 200mL for two measurements consecutively. If the PVRU is above 200mL, he could still be discharged if the voiding efficiency was equal to or above 50% for two consecutive voids. Voiding efficiency is calculated as the quotient of voided volume and pre-micturition volume, wherein the pre-micturition volume is the sum of the voided volume and PVRU.
Result & Outcome :
Between May 2018 and November 2018, thirty-seven consecutive patients underwent BipolEP at our institution. The average age was 73, ranging from 56 to 84. Over half of all patients were in refractory retention or obstructive uropathy. The duration of bladder irrigation was 466 minutes (SD = 181 minutes). The duration of catheterisation was 1213 minutes (SD = 305 minutes). All but one patient failed voiding trial on postoperative day one. The postoperative day one discharge rate was 75% (n = 27). The most common reasons for prolonged hospital stay were persistent haematuria after cessation of bladder irrigation (8.3%, n = 3) and febrile urinary tract infection (8.3%, n = 3). 13.9% (n = 5) of patients were readmitted within thirty days postoperatively for complications related to BipolEP. The most common reason for readmission was haematuria. None required clot evacuation or blood transfusion. There were no readmissions for acute urinary retention.

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