Long Term Complications

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Long-term complications following TURP primarily include urinary tract infection, obstruction, incontinence, and erectile dysfunction, although there is debate about whether the latter is truly associated with the procedure. Interestingly, despite the use of prophylactic and perioperative antibiotics, delayed genitourinary infection is still a significant problem after TURP, accounting for nearly half of long-term complications (4%) (21). This is probably not a result of persistent bacteriuria from the procedure but is more likely the result of some of the complications discussed below, including obstruction and incontinence.

Bladder Neck Contracture/Urethral Stricture

Recurrent obstruction can occur at the level of the bladder neck and urethra following TURP. In either case, patients return with symptoms similar to their original ones, in particular the obstructive symptoms such as retention, hesitancy, and weak stream. Bladder neck contracture (BNC) has been reported to occur in approx 2% of patients (21). Methods thought to help prevent this complication include avoiding aggressive resection of the bladder neck, limiting cauterization at this site, and decreasing the duration of catheter traction in the postoperative period. BNC can be treated using a variety of techniques. Although not generally successful in the long term, soft dilation can sometimes be effective. More often, however, some type of incision or resection of the fibrous tissue is necessary to achieve a durable response. Bladder neck incision with either electrocautery or the laser is thought to be preferable because it theoretically reduces the likelihood of recurrence as the result of less tissue being damaged by the procedure. Urethral strictures following TURP are relatively uncommon (1%), however, they can be problematic when they develop (21). Often they occur in the bulbous urethra and fossa navicularis. Preventative strategies include adequate calibration and lubrication of the urethra during TURP. Similar to BNC, the occurrence of urethral strictures following TURP can be treated with urethral dilation, but they generally require visual urethrotomy. In situations where these treatments are unsuccessful and recurrence is frequent, open urethroplasty may be required, although insertion of urethral stents represents another possibility.

Bleeding

Bleeding requiring return to the hospital occurs in 1.4% of patients (21). This can usually be avoided by controlling the initial bleeding during hospitalization as described above and discharging the patient only when the urine is essentially clear. Patients are counseled to restrict heavy lifting for 4-6 wk and to avoid constipation by maintaining adequate fluid intake and taking stool softeners. However, the inherent increase in activity with departure from the hospital inevitably puts patients at risk for recurrent hematuria. When hematuria does recur, it generally can be managed conservatively by restricting activity and increasing fluid intake. If hematuria is more significant, clot formation can occur, with a strong potential for obstruction and urinary retention. In this situation, all clots should be removed with a large irrigating catheter, after which continued bleeding can be managed with continuous bladder irrigation and catheter traction. Continued bleeding usually requires repeat transurethral fulguration, although the use of clot-promoting drugs such as aminocaproic acid can be considered. Recurrent hematuria not requiring surgical intervention can sometimes be successfully managed with 5a-reductase inhibitors (25).

Incontinence

Because TURP includes the removal of tissue at the bladder neck that encompasses smooth muscle of the internal sphincter, stress urinary incontinence can result if care is not taken to protect the external urethral sphincter complex. As described earlier, critical in avoiding injury to this sphincteric complex is the identification of the verumontanum and the resection of prostate tissue only proximal to this landmark. Stress urinary incontinence should be uncommon after TURP when the procedure is performed correctly, with an incidence well below 1%. Risk factors for postoperative stress incontinence include prostatic scarring from prior prostate surgery, radiation, and prostate cancer, all of which have the potential to obscure the verumontanum, making resection more difficult and increasing the likelihood of injury to the external sphincter. In fact, patients with a history of advanced prostate cancer who require TURP for relief of obstructive symptoms have an approx 20% risk for the development of postprostatectomy stress incontinence (26). Management of this complication generally requires insertion of an artificial urinary sphincter, although newer techniques such as the male sling procedure may provide a suitable alternative. Transurethral injection therapy with collagen and other agents has not demonstrated similar efficacy or durability. Finally, when addressing the issue of incontinence after TURP, it is important to recognize that detrusor abnormalities (i.e., detrusor instability and/or poor compliance) related to the original bladder outlet obstruction may be the cause. For this reason, urodynamic studies should play an important role in the evaluation of postoperative incontinence in these patients, certainly before any surgical intervention.

Sexual Dysfunction

Sexual dysfunction, in particular erectile and ejaculatory disturbances, has been reported with varying incidences after TURP, occurring in approx 13% and 75% of patients, respectively, according to recent systematic reviews (2,27). The risk of retrograde ejaculation is substantial because the muscle of the bladder neck/internal sphincter is frequently disrupted, allowing entrance of ejaculate into the bladder, thereby interfering with emission. The cavernous nerves run in the neurovascular bundles at approximately the 4 and 8 o'clock positions posterior to the prostate. These nerves are potentially susceptible to injury from the electrocautery current during the resection. Therefore, it has been suggested that maintaining an appropriate depth of resection is important, particularly posteriorly, to prevent this complication. Men with relatively small prostates have in some instances been shown to be at greater risk for perforation of the capsule and thus may be more susceptible to problems with erection (28). Rates of new-onset erectile dysfunction are debatable, ranging from 5 to 33% depending on the study and risk factors of the patient (28,29). Wasson et al. found no differences in the incidence between men with BPH managed with either watchful waiting or with TURP (30). Interestingly, a most recent study found that erectile function actually worsened with conservative management in men with LUTS and improved in men who underwent TURP (31). Furthermore, following TURP, pain and discomfort on ejaculation improved compared with baseline. Clearly, there are conflicting data regarding the incidence of erectile dysfunction after TURP; however, if it does occur, it is probably uncommon.

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