TURP safest when perfomed under sixty minutes

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From an article in the Urology times.

Transurethral resection of the prostate (TURP) is safest when performed in under 60 minutes and should not be performed for longer than 120 minutes, researchers say.The study supports the conventional wisdom about the procedure, said Christopher B. Riedinger, MD, a fourth-year resident who works with attending surgeon Norm Smith, MD, at the University of Chicago.

“We mostly confirmed what we thought,” Dr. Riedinger said. He presented the research at the AUA annual meeting in San Francisco.

Around the world, 1.2 million men undergo surgery for BPH or lower urinary tract symptoms per year, with TURP the most common procedure, said Dr. Riedinger.

Complication rates are improving with advances in instrumentation and perioperative care, yet a “dogma” persists that the procedure should be done in under an hour, he said. To see whether this tradition is supported by actual complication rates, Dr. Riedinger and his colleagues analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP, as defined by CPT codes 52601 and 52630.

They excluded patients whose cases were classified as an emergency, who were diagnosed with preoperative sepsis, or who underwent a concurrent procedure. That left them with 31,813 TURPs.

They separated these patients into five groups based on operative time: 0 to 30 minutes (8,163 patients), 30.1 to 60 minutes (12,932 patients), 60.1 to 90 minutes (6,790 patients), 90.1 to 120 minutes (2,517 patients), and greater than 120 minutes (1,411 patients).

Longer surgery, more complications

They found an overall complication rate of 9.00%, which increased with longer surgical duration (p<.001).

The odds ratio of having any complication was 1.1 in the 30.1- to 60-minute group, 1.3 in the 60.1- to 90-minute group, 1.6 in the 90.1- to 120-minute group, and 2.1 in the >120-minute group.

Patients whose American Society of Anesthesiologists classification was at least 4 were more likely to have fast procedures.

General anesthesia was used in 62.4% of the procedures in the 0- to 30-minute group. Another 33.8% had spinal anesthesia and 3.8% had some other type of anesthesia. The proportion getting general anesthesia increased with the duration of the procedure, reaching 79.8% in the group whose TURP took more than 2 hours.

The risk of needing a transfusion (p<.001) and reoperation (p<.001) also increased with the operative time in a linear fashion.

The risk of deep vein thrombus or pulmonary embolism was highest in the group whose surgery took longer than 2 hours, and was lowest in the groups whose surgery took 30.1 to 90 minutes (p=.021).

The risk of sepsis or septic shock remained relatively constant, below 1%, for all the duration groups except the group whose TURP took longer than 2 hours, whose risk was 1.8%. Controlling for age, comorbidities, American Society of Anesthesiologists class, race, year of surgery, and type of anesthesia administered did not affect this association.

The risk of transfusion remained significantly increased across all groups, while each of the above complications remained significantly increased for surgeries lasting longer than 120 minutes.

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  • Posted

    Now that this information is made available, is there some way in which it was intended to be helpful to a TURP candidate?

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  • Posted

    It would have been interesting and more informative to know why some take 30 minutes and others take 2 hours or more. It would help to make your mind up whether this procedure was a genuine option, if you knew how long yours might take. Is this Prostate driven or surgeon?

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  • Posted

    Thanks Derek. Interesting. Based on this, and if I was considering a TURP, I would definitely ask the doctor how long on average are his procedures. Besides what is mentioned and the risks of longer exposure to general anesthesia, I wonder how much physician experience plays into the equation. Makes sense that those who have done more procedures may do them faster. It would also be interesting to see more breakdowns like this in procedures other than TURP.

    Jim

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    • Posted

      It must depend mainly on the size of the prostates and if all the lobes are involved. The Uro from earlier tests/examination must have a very good idea.

      My GL for 75 grm prostate in 2004 took 57 lasing minutes and about an hour and a half in total. but I did not think to ask how much he had removed. The lateral lobes were the problem and the median lobe was not too bad they said. It was also a bladder neck sparing version.

      When it regrew to 135 grms and I had Thulium/Holmium laser (Revolix ) in 2013 he told me prior to surgery that I would have to have a general anesthetic as it would take over three hours and too long for a local. He removed 80 grms of which 35 was saved for histology and said it had taken 3 1/2 hours.

      The Urology Times is worth looking at for past and future articles. They may even deal with CIC.

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  • Posted

    Is it simply the case that more complex cases take longer and also come with greater risk of complications? I don't think study really serves any purpose for people who didn't have procedure yet, I would imagine that no doctor can predict in advance how long will TURP take based on preliminary exam only IMO.

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    • Posted

      I would imagine that no doctor can predict in advance how long will TURP take based on preliminary exam only IMO.

      Really? You don't think a surgeon who has done hundreds of TURPs could predict how long it would take based on the size of the prostate and a cystoscopy? I think it would be just the opposite, the more experienced the surgeon, the better he/she will be on estimating the time it will take. My guy told me about an hour and that's about what it took.

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  • Posted

    Thanks, Derek:

    Your post spurred me to look through some Urology Times articles. It looks like Aquablation is receiving a lot of attention. There have been several phases of a WATER (Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue) study. While the mean total operative time was similar between Aquablation and TURP (33 versus 36 minutes), the resection time was markedly lower for Aquablation (4 minutes versus 27 minutes).

    The Conclusion section of an article written by Ali Kasraeian titled "Waterjet ablation offers minimally invasive option for BPH" states that:*

    *"Aquablation has a short learning curve, and the planning strategy and technique can be easily reproduced regardless of the prostate size or shape. Initial published data have demonstrated very strong efficacy outcomes comparable to TURP and simple prostatectomy with a superior safety profile, including a reduction in sexual side effects regardless of prostate size. One-year follow-up data confirmed a sustained reduced rate of sexual side effects, durability in symptom reduction, improved flow rates, and a very low rate of re-treatment.

    In prostates larger than 50 cc, the Centers for Medicare & Medicaid Services found Aquablation therapy to represent a “substantial clinical improvement” to both TURP and simple prostatectomy. The AUA recently joined the Canadian Urological Association in adding Aquablation therapy to treatment guidelines for men suffering from LUTS due to BPH. The benefit of Aquablation’s minimal invasiveness is especially true for men with very large prostates for whom the simple prostatectomy had previously been among the few options to consider."

    However, it appears that a number of these Aquablation articles involve urologists that have some connection with the company that manufactures the equipment (I'm not sure about the WATER study). Secondly, I've seen it mentioned several times that the average length of hospital stay is 1.6 days. This seems puzzling since a number of posters on this site have gone home after having a TURP within 6 hours or less.

    Unfortunately, I can't seem to find a full text of the WATER study without having to pay for it.

    But if total time of resection is a concern, particularly for larger prostates, it would appear that Aquablation is definitely a procedure to consider since it seems to have a much shorter resection time.

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  • Posted

    The longer procedures almost surely, on average require more work and that would translate to higher complication rates. Overall, they are quite low and from this it would seem that side effects are a bigger concern than post surgical complications.

    I'd love to see a comparison with Rezum, PAE and FLA that addressed post procedure complications, side effects and outcomes.

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  • Posted

    Not surprising but it would have been helpful if they would have identified the rates of complication occurrence by all types of complications; whether they were peri- or post-operative; by type of surgical instrument used, and % of tissue removed in addition to size of prostate and experience of surgeon as others mentioned.

    I've been told by urologists that TURP with a loop is more efficient (less time) than plasma button TURP or Green Light, so I would guess some of the differing complication rates could be due to the effects of monopolar TURP where used on the larger prostates with PBT likely being the least prone to be associated with complications. Obviously Aquablation will be the fastest by far since it's essentially a CNC machine cutting precisely at speeds that a surgeon cannot.

    I was recently told by a urologist that he anticipated 30 minutes of actual surgical time for my prostate (~80 gm with moderate median) using a new STORZ bipolar loop electrode that he likes better than the button electrodes. I didn't think to ask whether that was from first cut to last cut or if it included "clean-up" at the end.

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    • Posted

      If he's like my GL one he doesn't stay for the clean up. When he came round a little later to tell me how well it had went he had to lift my sheet when I asked if I had a catheter.

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    • Posted

      So you could say he was a "slash and dash" surgeon. 😉

      I really don't know that much about the details but I have seen videos where the pieces of tissue that went into the bladder are flushed out into a specimen jar, then I suppose the catheter is set up.

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    • Posted

      No not at all he was really good but with a theatre team there is no need for the skilled one to stay.

      Another Uro I saw when my prostate had regrown said of early GL procedures, we thought that they were easy to do but later realised that we needed to give them more time. He was one of the top three UK Uro's.

      I don't expect the surgeon who replaced my heart valve stayed to wire up my chest.

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    • Posted

      Derek, my comment was just meant to add some levity to what is otherwise a very somber topic of discussion. Glad to hear you had the best.

      That raises the question -- how many people are in the operating "theater" or room? When I've had cystoscopies and Urolift with anesthesia it's been my urologist, the anesthesiologist and an OR nurse as well as I can remember. Might have been one more nurse who preps the area and helps get the patient into that wonderfully dignified position.

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    • Posted

      When I had my two laser procedures I was give the pro op in an outer area so did not see how many were involved in the theatre (UK spelling )

      When I had an Amplatzer amulet (filter in the left atrial appendage to stop blood clots getting to my heart) fitted I was amazed to count ten people in the cardiac lab..

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  • Posted

    I've never asked this question directly. Do you or anyone know if typically, a "pre-op" appointment scheduled a week before surgery is for cystoscopy, urodynamics, or other testing? I never found out what that was for because two years ago this is where I decided to wait. I think I forgot to ask my Uro what that appointment was for, anyway I don't recall his answer. I've stated that they were going to do GL on me the next week and I didn't think they had done enough investigation into my case. Now they want to do a TURP. So I just wondered if I should have at least gone through the pre-op appointment.

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    • Posted

      The other testing should have been done as part of your initial, diagnosis.

      The pro op at least in the UK is an appointment on your general health and to make you aware of how the procedure works. For my first one they were not happy with the ECG or EKG they did and I had to have an echo cardiogram as they did not want me dying on them 😃

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