Management of LUTS after TURP and MIT

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1 Management of LUTS after TURP and MIT Hong Sup Kim Konkuk University

2 TURP & MIT TURP : Gold standard MIT TUIP TUNA TUMT HIFU LASER 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

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

4 LUTS after TURP & MIT 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

5 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)

6 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

7 Advantage and disadvantage TURP : Gold standard Bleeding Incontinence TUR syndrome MIT Advantage low morbidity and low mortality Disadvantage 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

8 Complications of KTP laser Complication Te AE et al (%) Malek RS et al (%) Prolonged dysuria (>10d) Transient (> 10 days) hematuria Transient urinary urge incontinence Urinary tract infection Retrograde ejaculation 26 * Urinary retention requiring recatheterization 5 1 Bladder neck contracture Urethral stricture Epididymitis * : number of patients retrograde ejaculation varied at different followup points Malek RS, et al. J Urol 2005;174: Te AE, et al. J Urol 2004;172:1404-8

9 Case Brief History 65/Male local clinic, KTP laser ablation - 8 month ago PSA : 9.1ng/ml, RGU, TRUS Prostate biopsy : nodular hyperplasia Treatment endoscopic incision of urethra & secondary TURP RGU TRUS

10 Obstructive symptoms after TURP & MIT Common causes incomplete resection of the prostate bladder neck contracture urethral stricture, meatal stenosis Urethral stricture Bladder neck contracture TURP 3.8% 4.0% TUIP 1.7% 0.4% low detrusor contractility (underactive bladder) Symptoms hesitancy, weak stream, prolonged voiding D/Dx low detrusor contractility Wasson JH, et al. N Engl J Med. 1995;332:75-9, Kuntz RM, et al. J Urol. 2002;168:1465-9

11 Obstructive symptoms after TURP & MIT Madersbacher S et al. BJU Int 1999;83:227-37

12 Obstructive symptoms after TURP & MIT Incomplete resection of prostate Treatment: α1-blocker, 5α-reductase inhibitor Secondary 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

13 Obstructive symptoms after TURP & MIT 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 Tomas AW, et al. BJU Int. 2004;93:745-50

14 LUTS after TURP & MIT Tomas AW, et al. BJU Int. 2004;93:745-50

15 Obstructive symptoms after TURP & MIT Group A; unobstructed and underactive detrusor function Group B; obstructed and/or normal detrusor contractility

16 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 bladder hypoxia of the detrusor muscles denervation of the detrusor muscles treatment anticholinergic drugs : propiverin, tolterodine, darifenacin, oxybutinin, trospium

17 Irritative symptoms after TURP & MIT Drug Grade of recommendation Drug Grade of recommendation Antimuscarinics Alpha-AR antagonist Tolterodine A Alfuzosin C Trospium A Doxazosin C Solifenacin A Prazosin C Darifenacin A Terazosin C Propantheline B Tamsulosin C Drugs with mixed action Oxybutinin Propiverine Flavoxate Antidepressant Imipramine A A C C Other drugs Estrogen * A highly recommended B recommended C recommended with reservation C OAB guideline 배뇨장애요실금학회 2007

18 Irritative symptoms after TURP & MIT Dysuria Nd:YAG laser, ILC, HoLRP, KTP common incidence rather than TURP prolonged dysuria rather than TURP treatment anti-inflammatory regimens diclofenac, etc. Kabalin JN, et al. J Urol. 1997;158:1923

19 Irritative symptoms after TURP & MIT Incontinence decreased Quality of Life incidence of urge incontinence : upto 40% causes sphincter incompetence : 30% detrusor instability : 20% Medical treatment mixed incontinence : 30% residual adenoma : 5% bladder neck contracture : 5% Surgical treatment Urethral stricture : 5% Kuo HC. Urol Int. 2002;68:99-104, Price DA et al. J Urol. 1982;52:529-31

20 Irritative symptoms after TURP & MIT Incontinence incidence of stress incontinence : TURP (2.2%), TUIP (1.8%) cause external sphincter injury management & medical treatment pad apply, external device apply pelvic floor exercise, biofeedback anticholinergic drugs, duloxetine electrostimulation surgical treatment periurethral injection therapy, artificial sphincter implantation inflatable paraurethral balloons Hubner WA, et al. BJU Int. 2005;96:587-94

21 Irritative symptoms after TURP & MIT

22 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 TUNA TUMT 43.8% during the 4-year study group 20% during the 3-year study group 7% during the 2-year study group *ILC- interstitial laser coagulation, HoLRP Holuim laser resection of the prostate, TUNA transurethral needle ablation of the prostate, TUMT high-energy transurethral microwave thermotherapy European Association of Urology. Guidelies edit.

23 Intractable LTUS after TURP & MIT Treatment of intractable LUTS after TURP and MIT Secondary therapy botulinum toxin injection (??) sacral neuromodulation (??) need for further studies and future developments

24 Intractable LTUS after TURP & MIT

25 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 operation dysuria (laser ablation of the prostate)

26 Conclusion Symptoms alone are unreliable in predicting urodynamic findings with respect to BOO and detrusor instability after TURP and MIT. low detrusor contractility idiopathic detrusor overactivity inadequate detrusor contractiltiy poor relaxation of the urethral sphincter The treatment of persistent LUTS after TURP and MIT are important in improving QoL.

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