BPH surgical modalities safe; some attributes affect outcomes

Editor's note: This article has been updated since its original publication to include additional study data and commentary from the author/presenter.

Stockholm, Sweden-Analyses of morbidity and mortality after surgery for BPH show that the current major modalities are all safe, but also identify patient attributes associated with an increased risk of complications.

Presented at the European Association of Urology annual congress in Stockholm, Sweden, the research used data from the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database for the years 2006 to 2011. It included information on patient characteristics (demographics, preoperative comorbidities, and preoperative laboratory values), operative time, blood transfusions, length of stay, perioperative complications, re-interventions, and perioperative mortality for 4,794 men who underwent transurethral resection of the prostate (TURP), 2,439 men treated by laser vaporization of the prostate (LVP), and 126 men who underwent laser enucleation of the prostate (LEP).

The study found rates of overall complications and perioperative mortality were not significantly different among surgical groups, but that the risk of these events was influenced by patient age, preoperative albumin, and preoperative hematocrit. Specifically, younger age at surgery, hematocrit >30%, and albumin >2.5 g/dL portended better outcomes, reported first author Briony Varda, MD, on behalf of the multi-institutional study.

“With the aging of our population and advent of new surgical modalities, outcomes of BPH surgery need to be at the forefront of research in urology,” said Dr. Varda, urology resident at Harvard Medical School, Boston, who worked on the study with Quoc-Dien Trinh, MD, and co-authors.

“Our study demonstrates that the historic gold standard, TURP, and the newer laser-based procedures all appear to be generally safe, which is reassuring. However, surgeons should recognize certain patient attributes may affect outcomes so that they can optimize these features in men who need to undergo surgery for BPH.”

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More pulmonary complications with TURP

Although the three procedures were similar with respect to overall complications and perioperative mortality, some significant differences between them emerged in analyses of specific perioperative parameters. LVP and LEP were both associated with decreased risk for prolonged length of stay compared to TURP, and LVP had a shorter operative time, reduced need for transfusion, and a lower 30-day re-intervention rate than TURP. Compared to the other procedures, TURP was associated with a significantly higher rate of pulmonary complications, although that finding was thought to be explained by the increased use of general anesthesia with intubation in men undergoing TURP.

“In general, the comparative morbidity was slightly higher with TURP. However, the morbidity is relatively low, and therefore we consider all three procedures relatively benign,” Dr. Varda said.

The multivariable analysis also identified non-Caucasian race as a risk factor for complications. Dr. Varda noted that detailed information on race is lacking in NSQIP so that men were categorized as either Caucasian or non-Caucasian. The investigators suggested that the association found with race may reflect lower access of non-Caucasian patients to skilled surgeons and to the newer laser procedures.

“Our findings reinforce the need to identify ways to improve access to and education about novel techniques in underserved populations,” Dr. Varda said.

She also noted that although the NSQIP database is a robust resource for outcomes analyses as it includes prospectively collected, multi-institutional, contemporary data on a large number of preoperative, intraoperative, and postoperative variables, it does not provide information on certain disease-specific details that would be important for understanding procedure-related morbidity. For example, it lacks information on prostate size and does not allow determination of why a surgeon would choose a specific BPH procedure for a specific patient.

“The NSQIP database has a lot of strengths, but because the data is lacking in some ways, our study provides more of a bird’s eye view of the problems and benefits associated with the different surgical modalities,” said Dr. Varda.

“Urology databases that include more details specific to urologic diseases and procedures are being planned and will help address these shortcomings.”UT

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