Experience of 480 cases of benign prostatic hyperplasia treated with transurethral resection of the prostate [Abstract] Objective: to evaluate the efficacy of transurethral resection of the prostate in the treatment of prostatic hyperplasia and the prevention and treatment of common complications. Methods: The clinical data of 480 patients who underwent transurethral resection of the prostate were retrospectively analyzed. RESULTS: There were 2 cases of intraoperative perforation of the prostate peritoneum and 5 cases of electroresection syndrome (TURS). Postoperatively, the patients’ IPSS scores were significantly lower than preoperatively (P=0.032), the mean residual urine volume was significantly lower than preoperatively (P=0.002), and the maximum urinary flow rate was significantly higher than preoperatively (P=0.013). There were 12 cases of postoperative complications of temporary incontinence, 14 cases of dysuria, and 6 cases of urethral stricture. CONCLUSION: TURP is a surgical method with definite efficacy, few complications and high safety. Benign prostatic hyperplasia (BPH) is one of the most common diseases in elderly men, and the lower urinary tract symptoms caused by it seriously affect the patients’ daily life and sleep, and reduce their quality of life. Treatment includes medication and surgery. Medication is not effective for all patients and some patients have to discontinue treatment due to side effects. Among the surgical methods, transurethral resection of the prostate (TURP) is the main treatment modality, which is the “gold standard” for the treatment of BPH. 480 cases of BPH were treated with TURP in our hospital from May 2000 to May 2006, and the results were satisfactory, which are now reported as follows. Materials and Methods Clinical Data The 480 cases in this group were 68.4±5.6 years old on average. They were diagnosed with prostatic hyperplasia by ultrasound, clinical symptoms, rectal fingerprinting and urodynamic examination, and the duration of the disease ranged from 4 months to 18 years. Degree of hyperplasia: 83 cases of degree I, 294 cases of degree II, 103 cases of degree III or above, average IPSS score 19.7 points (13 points to 35 points), average residual urine 113ml (55ml to 375ml), maximum urinary flow rate was 9.6ml/s (7ml/s to 12ml/s). There were 149 cases of combined coronary heart disease, 128 cases of hypertension, 19 cases of diabetes mellitus, 7 cases of bladder tumor, 15 cases of hematuria, 24 cases of inguinal hernia, and 12 cases each of bladder stone and bilateral hydronephrosis. Among them, 17 cases had different degrees of renal function impairment, and the renal function was recovered by indwelling urinary catheterization or cystostomy drainage. Surgical methods Under continuous epidural anesthesia, Shunkang F25.6 electrosurgical scope was applied, and 5% dextrose solution was used as the flushing solution, and low-pressure flushing was performed via suprapubic cystostomy for those who were expected to have a long surgical time. After putting in the electrodesiccope, first observe whether there is any lesion in the bladder and deal with it, observe the important surgical markers such as bilateral ureteral orifices, bladder neck and seminal mound position, and understand the main parts of prostatic hyperplasia. Adjust the power of electrocision 100-120W and the power of electrocoagulation 50-60W, start from the most obvious hyperplasia, excise the gland to reveal the field of view, and take the level of the proximal end of the seminal caruncle as the end point of electrocision. Finally, electrocut the prostate tissue at 10~2 points. After cutting the gland, a pink, fibrous layer of smooth peritoneal structure was seen near the peritoneum. After electrocutting, the bladder was rinsed with ELIK, and the glandular tissue was aspirated, weighed, and sent for pathologic examination. After reelectrocoagulation and hemostasis, F18-22 triple-lumen balloon urinary catheter was placed for continuous irrigation for 3-5d, and the urinary catheter was removed for 6-7d postoperatively. Results: The average operation time was 30-100 min, intraoperative bleeding was 20-120 ml, no blood transfusion was needed, and the weight of the resected prostate tissue was 28.6(12-52) g. Two cases of perforation of the peritoneum of the prostate occurred during the operation, and five cases of the prostate electrocutaneous syndrome (TURS) or its precursor symptoms were relieved by oxygen absorption, intravenous hypertonic saline solution, and diuresis, etc. The postoperative IPSS scores were 9.5 and 9.5, respectively. The mean postoperative IPSS score was 9.7 points (3 to 15 points), which was significantly lower than that of the preoperative period (P=0.032). The mean residual urine volume was 13 ml (0 ml to 35 ml), which was significantly less than preoperative (P=0.002). Maximum urine flow rate was 18.6 ml/ s (13 ml/s to 25 ml/s), which was significantly increased from preoperative period (P=0.013). After ureter removal, all of them had different degrees of bladder irritation symptoms, most of which were relieved after 3-5 d, and lasted for 15-30 d. The irritation symptoms were relieved after administration of flavopiridate and probenecid. Transient urinary incontinence was found in 12 cases, which were cured after 1 week-2 months with ephedrine and detrusor exercise. 14 patients had difficulty in urination and urinary retention after extubation, which was normalized after indwelling urinary catheter and acupuncture treatment. 358 cases were followed up for 3 months-5 years. 6 cases developed urethral stricture in 2-6 months after surgery, which was passed after sphincterization of the urethra, and the rest of the 352 cases had smooth urination without urethral stricture and contracture of the bladder neck. The remaining 352 patients were able to urinate without complications such as urethral stricture and bladder neck contracture. Discussion Since its application in urology in the 1930s, TURP has remained the “gold standard” of BPH treatment, with the advantages of less trauma, faster recovery, wider indications, and lower mortality than open surgery. In the past 10 years, many other minimally invasive procedures, such as transurethral electrical vaporization of the prostate, transurethral needle ablation, transurethral microwave thermotherapy, etc., have been gradually applied to the treatment of BPH [1], which has wider indications and efficacy close to or equivalent to TURP compared with TURP [2,3]. However none of these methods can replace TURP. Our results also show that TURP can be very effective for the treatment of BPH, with a significant reduction in postoperative IPSS scores, a significant increase in urinary flow rate, improvement of patient symptoms and quality of life, and less trauma, faster recovery, shorter hospitalization, which is easily accepted by patients compared with open prostatectomy. It is more advantageous for patients with medical comorbidities and poor general condition. However, there are some common complications of TURP, and it is important to correctly recognize and prevent these complications. TURS is the most serious complication of TURP, and improper management may jeopardize the patient’s life. Its incidence is about 2%-10% [4, 5], and only 5 out of 480 cases occurred in our group, with an incidence rate of about 1%, which is slightly lower than that reported at home and abroad. 2 out of the 5 cases had an operation time of more than 90 minutes, and 2 cases had cut through the peritoneum of the prostate. We believe that minimizing the operation time, continuous low-pressure perfusion, and avoiding perforation of the prostate peritoneum can effectively prevent the occurrence of TURS. Perforation of the prostate peritoneum can cause hemorrhage, urinary extravasation, and TURS, which can lead to death in severe cases. Perforation occurs mostly due to deep electrocution and overfilling of the bladder [6]. In the literature, the incidence of perforation of the prostate peritoneum and urinary extravasation during TURP is reported to be about 1.6% [7], and two cases of perforation of the prostate peritoneum and consequently TURS occurred in our patients, both of which were early cases due to inexperience and unskillful operation. In subsequent operations, maintaining low-pressure slow perfusion, ensuring the patency of the outlet ducts, and preventing overfilling of the bladder effectively prevented the occurrence of perforation of the peritoneum. The literature reports that the chance of dyspareunia after TURP is 6.5%-12% [8, 9]. The main causes are prostate tissue residue, inflammatory edema, blood clot blockage, bladder forced urethra muscle weakness, and most of the causes of dyspareunia in the long term are urethral stenosis. In our group, there were 14 patients who had difficulty in urination and urinary retention after the first removal of urinary catheter, and 6 cases had urethral stenosis. For this kind of cases, we need to explain patiently to the patients, relieve the ideological burden, on the basis of anti-inflammatory treatment, we can leave the catheter for 3-5 days, or perform 1-2 times of urethral dilatation, consider the existence of bladder forceps muscle contraction weakness, with the traditional Chinese medicine acupuncture and baking treatment, the patients are mostly able to urinate on their own. For patients with residual prostate tissue and clots blockage, another surgery is needed to deal with the problem. Urinary incontinence is one of the common complications after TURP, and its incidence is about 1.7% [10]. Injury to the external urethral sphincter, bladder hyperreflexia, urethral muscle instability, and urinary tract infection are common causes. Mild urinary incontinence can be cured by pelvic floor muscle contraction training and medication, which was applied to 12 cases of temporary urinary incontinence in our group, and good results were obtained. The external urethral sphincter injury is serious conservative treatment is ineffective, some people in foreign countries apply the urethral sphincter around the submucosal injection of collagen, 90% of patients with significant improvement in symptoms [11].