Determinant Of Post-Transurethral Resection of The Prostate Acute Urinary Retention at Tibebe Ghion Specialized Hospital, Northwest Ethiopia: Unmatched Case-Control Study 2023

doi:10.21203/rs.3.rs-6736635/v1

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Determinant Of Post-Transurethral Resection of The Prostate Acute Urinary Retention at Tibebe Ghion Specialized Hospital, Northwest Ethiopia: Unmatched Case-Control Study 2023

https://doi.org/10.21203/rs.3.rs-6736635/v1

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Background: Transurethral resection of the prostate (TURP) is recognized as the gold standard for alleviating bladder outlet obstruction associated with benign prostatic hyperplasia (BPH). Despite its efficacy, TURP can be accompanied by various complications, including acute urinary retention, which undermines the intended outcome. However, there is limited evidence available regarding the factors contributing to post-TURP acute urinary retention.

Methods: A hospital-based unmatched case-control study analyzed data from patients undergoing transurethral resection of the prostate (TURP) using SPSS version 23. Bivariate and multivariable analyses identified determinant factors for post-TURP acute urinary retention, with variables < 0.05 deemed significant.; (3)

Results: Among 143 audited cases, 40 fell into the AUR group, while 103 were non-AUR. Variables like age, rural residency, illness duration, preoperative AUR, prostate volume >80ml, and incidental catheter removal showed increased AUR likelihood but lacked statistical significance. In incompletely resected adenomatous tissue, surgery duration >60 minutes, intraoperative urethral injury, prolonged catheterization (>2 days), and postoperative UTI had significantly higher AUR odds. Multivariate analysis revealed incomplete resection as the sole sustained significant variable (AOR=8.34, 95%CI (2.21-31.65)).; (4)

Conclusions: Incomplete resection emerged as a significant predictor of post-TURP AUR. Vigilance, thorough preoperative assessments, and consideration of specific factors are crucial for optimal outcomes. Further studies are warranted to validate these findings, given the study's limitations.

Determinant factors

acute urinary retention. Transurethral resection of the prostate

benign prostatic hyperplasia

The Transurethral resection of the prostate (TURP) stands as one of the most frequently conducted urological surgeries and represents one of the earliest endourological procedures. It constitutes a vital component of the treatment options available to urologists and patients dealing with obstructive lower urinary tract symptoms (LUTS) resulting from benign prostatic enlargement (BPE)[1], [2]. TURP frequently acts as the primary method for men encountering refractory urinary retention, moderate to severe voiding symptoms linked to BPH unresponsive to medical treatment, repeated UTIs associated with BPH, frequent and substantial gross hematuria, recurrent bladder stones, as well as bilateral hydronephrosis causing renal functional impairment[1]–[4].

Despite being the gold standard for surgical treatment of BPH and demonstrating significant symptom improvement with a reoperation rate of less than 1% over the long term, TURP still carries perioperative morbidity risks[5][4]. Complications of TURP can be short- or long-term. Short-term complications include TURP syndrome, bleeding, clot retention, electrolyte imbalances, failed TOV, urinary tract infections, and permanent incontinence[6], [7]. Long-term complications include urethral strictures, bladder neck contractures, and re-operation due to the remnant adenoma.

Acute urinary retention stands out as one of a complication following TURP, contradicting the intended outcome [5], [6], [8]. Its incidence ranges from 3–9% upon the removal of a Foley catheter[9]. Potential causes encompass local pain, edema, residual adenoma, and bladder failure, among others. Local pain and edema are often linked to spasms of the external sphincter muscle[9], [10]. If a patient is unable to void 3–5 days after catheterization, the presence of an obstructing residual adenoma is considered. Bladder failure, commonly observed in aging individuals, diabetics, and those with prolonged bladder distention, may necessitate weeks for recovery, potentially aided by anticholinergics. Despite the acknowledgment of these causes, the specific determinants of acute urinary retention after TURP remain inconclusive[11], [12].

A case-control study was conducted without matching at Tibebe Gihon Specialized Hospital in Bahir Dar, Ethiopia, which is a federal teaching hospital under Bahir Dar University. The study focused on patients who underwent transurethral resection of the prostate (TURP) during the study period. The source population was all patients undergoing TURP, while the study population was composed of patients experiencing acute urinary retention (AUR) after TURP (AUR group) and those with successful voiding (control group).

The sample size was determined from records of TURP procedures conducted between July 2021 and June 2023. Patients were identified through operative records and card numbers. The dependent variable was the occurrence of AUR following TURP, and independent variables included demographic data, preoperative factors, intraoperative variables, and postoperative outcomes.

A checklist was used to collect data from operation logbooks and patient cards. Trained data collectors ensured compliance with inclusion and exclusion criteria. Data were analyzed to identify factors associated with post-TURP AUR. Bivariate and multivariable analyses were conducted using SPSS version 25, considering variables with a p-value of less than 0.05 as statistically significant.

The study obtained ethical approval, and confidentiality of patient information was maintained. Since the study was retrospective, patient consent was not required.

3.1. Demographic and clinical characteristics of the study participants

The study reviewed 173 men who underwent Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia (BPH) between July 1, 2021, and June 30, 2023. After exclusions, 143 cases were analyzed, with 40 categorized as Acute Urinary Retention (AUR) and 103 as non-AUR. The AUR group averaged 69 years, compared to 67 years in the control group. Among the AUR group, 77.5% were aged 75 or below, with 72.5% residing in rural areas. Moreover, the AUR group exhibited fewer comorbidities than the non-AUR group. While average duration symptom was comparable between two groups, the AUR group had a higher mean preoperative prostate volume (58.2 ml versus 47.4 ml). Preoperative AUR was noted in 71 men, with 46 belonging to in AUR group, with a higher incidence of Urinary Tract Infections (UTI) in the non-AUR group. History of preoperative BPH treatment was rare, particularly in the AUR group. Renal insufficiency was less common in the AUR group compared to the non-AUR group as shown in Fig. 1.

3.2. Intraoperative and postoperative characteristics of the study participants

The study examined intraoperative and postoperative characteristics of participants. Spinal Anesthesia (SA) was administered to 97.9% of participants, with minimal use of General Anesthesia (GA). Resection adequacy varied between groups, with a higher incidence of incomplete resection in the AUR + group. Intraoperative urethral injury was rare in both groups. The mean surgery duration was longer in the AUR group (56 ± 26 minutes versus 46 ± 18minutes), with a higher prevalence of postoperative UTIs and clot retention. Postoperative catheterization duration was also longer in the AUR group compared to the non-AUR group (5 ± 3 days versus 2 ± 0 days) as shown in Fig. 2.

3.3. Factors associated with Post-TURP Acute Urinary Retention (AUR)

Factors influencing Post-TURP Acute Urinary Retention (AUR) were examined using binary logistic regressions, assessing both Crude and Adjusted Odds Ratios (OR) with Confidence Intervals (CI) and P-values for significance verification. Results indicate that age, rural residence, illness duration, preoperative AUR, preoperative prostate volume, anesthesia type, and incidental catheter removal did not significantly affect AUR risk. However, incompletely resected adenomatous tissue, surgery duration exceeding 60 minutes, intraoperative urethral injury, prolonged postoperative catheterization, and postoperative urinary tract infection were associated with increased AUR risk during bivariate analysis. Multivariate regression identified incomplete resection as the sole significant factor, indicating patients with incomplete resection were 8.34 times more likely to develop post-TURP AUR. Other variables showed no significant impact in multivariate analysis as shown in Table 1.

3.2. Figures, and Tables

Table 1
The bivariate and multivariable logistic analysis among selected factors associated with post-TURP AUR at Tibebe Gihon Specialized Hospital, Amhara region, Ethiopia, 2023.
Variables	Category	COR (95%CI)	P = value	AOR (95%CI)
Age (in years)	-	1.02 (0.95–1.09)	0.18	-
Age	Age > 65	1.70 (0.68–4.28)	0.26	-
	Age ≤ 65	1		-
Residency	Rural	1.30 (0.58–2.91)	0.53	-
	Town	1		-
Comorbidity	No	2.01 (0.71–5.73)	0.19	-
	Yes	1		-
Duration of symptoms (in months)	≥ 12months	1.21 (0.58–2.55)	0.61	-
	< 12months	1		-
Preoperative AUR	Yes	2.07 (0.98–4.37)	0.06	-
	No	1		-
Preoperative UTI	Yes	0.55 (0.25–1.22)	0.14	-
	No	1		-
Preoperative prostate volume	> 80ml	2.85 (0.86–9.45)	0.09	-
	< 80ml	1		-
Preoperative medical Rx	Yes	0.49 (0.10–2.34)	0.37	-
	No	1		-
Renal insufficiency	Yes	0.49 (0.16–1.55)	0.22	-
	No	1		-
Type of anesthesia	General anesthesia	5.37 (0.47–60.93)	0.18	-
	Spinal anesthesia	1		-
Resection completeness	Incomplete	18.86 (6.10–58.30)	0.00	8.34 (2.21–31.65)
	complete	1		1
Duration of surgery	> 60 minutes	2.34 (1.053–5.21)	0.04	1.57 (0.40–6.19)
	≤ 60 minutes	1		1
Presence of urethral injury	Yes	4.84 (1.10-21.42)	0.04	4.72 (0.17-130.17)
	No	1		1
post-operative catheterization	> 2days	23.85 (9.29–61.22)	0.00	0.058 (0.02–0.20)
	≤ 2days	1		1
Incidental catheter removal	Yes	8.27 (0.83–82.01)	0.07	-
	No	1		-
Post-operative UTI	Yes	4.15 (1.75–9.86)	0.001	2.95 (0.66–13.16)
	No	1		1

Variable(s) entered on step 1: age, residency, comorbidity, duration of symptoms, IPSS score, preoperative AUR, preoperative UTI, preoperative prostate volume, history of medical Rx for BPH, renal insufficiency, resection completeness, duration of surgery, urethral injury, duration of postoperative catheterization, incidental catheter removal, postoperative UTI.

predictors (constant): duration of surgery, preoperative prostate volume, age, duration of illness

Benign Prostatic Hyperplasia (BPH) stands as one of the most prevalent slowly progressing diseases among older men. Statistics indicate a lifetime treatment probability of 40% for BPH in men over 50 years old [13]. Despite Transurethral Resection of the Prostate (TURP) being associated with numerous complications, a failed voiding trial post-procedure is a rare occurrence, opposing the intended outcome [5].

This study marks the first hospital-based case-control investigation in Ethiopia dedicated to comparing Acute Urinary Retention (AUR) complications after TURP. To minimize confounding factors, patients with diagnoses other than BPH, such as prostatic cancer or Parkinsonism, were deliberately excluded. The study exclusively enrolled males meeting specific inclusion criteria. Various factors including age, residency, illness duration, comorbidity, preoperative AUR, prostate volume, renal insufficiency, preoperative UTI, medical treatment history, intraoperative urethral injury, resection completeness, surgery duration, anesthesia type, postoperative UTI, clot retention, catheterization duration, and incidental catheter removal were meticulously investigated and analyzed using descriptive statistics and binary logistic regression. The findings suggest that the success of TURP, as measured by the trial of voiding without a catheter (TOVWOC), seems to be influenced by multiple factors.

In this investigation, a significant 28% of patients experienced AUR following TURP. This prevalence stands out, notably differing from studies conducted in Pakistan, Korea, and Taiwan which is 13.3%, 12.2%,13.8%, and 8.9% respectively [14]–[17] but close to research conducted in Australia, and India which is 15.4%, and 26.8% respectively [9], [18]. These variations underscore AUR as a persistent TURP complication, emphasizing the importance of urologists' awareness and vigilant monitoring.

The mean age of patients in the AUR group was higher than that in the control group(69 ± 10 versus 67 ± 9), consistent with findings from Korea(70.5 ± 7.2 versus 69.1 ± 7.7) [15]. Each additional year in age was associated with a higher probability of encountering AUR, reflecting observations in New Zealand[6]. However, patients over 65 years old were more likely to develop AUR compared to the control group, although statistically insignificant (COR = 1.70,95% CI = 0.68–4.28).

Patients from rural areas showed a higher likelihood of developing AUR, albeit statistically insignificant (COR = 1.3, CI = 0.58–2.91), possibly due to delayed presentation and concurrent detrusor failure. Preoperative AUR significantly increased the likelihood of post-TURP AUR (COR = 2.07, 95%CI = 0.98–4.37), aligning with a similar study in Taiwan[16], suggesting detrusor contractile function impairment. Severe International Prostate Symptom Score (IPSS) was associated with a greater likelihood of detrusor impairment, potentially leading to post-TURP AUR (COR = 2.07,95%CI = 0.98–4.37)which is comparable finding with the study done in Korea[15].

Regarding illness duration, no substantial differences were observed between the AUR + and AUR- groups, though symptoms persisting for over 12 months increased the likelihood of post-TURP AUR. Patients with preoperative prostate volumes exceeding 80 ml had 2.85 times the likelihood of post-TURP AUR, possibly due to inadequate resection. This observation aligns with findings from a study conducted by McMkinnon et al [9].

Contrary to assumptions, comorbidity, preoperative medical treatment, renal insufficiency, and preoperative UTI did not significantly contribute to AUR. This contrasts with a study conducted in Australia, which indicated that having a preoperative UTI resulted in a 4.315 times higher likelihood of experiencing post-TURP AUR as mentioned by McMkinnon et al [9].

Intraoperative factors significantly influencing post-TURP AUR included general anesthesia 5.37 times, intraoperative urethral injury 8.27 times, and resection time exceeding 60 minutes 2.34 times likely to experience AUR compared to control. According to the surgeon's judgment, patients with incomplete adenoma resection were at a significantly higher risk, being 18.86 times more likely to develop post-TURP AUR which aligns with the research conducted by Shin et al.[19], but contrary to the study by Kumar[20]. This could be related to inadequate supplies of cutting loops in low resource-limiting setups.

Prolonged postoperative catheterization for more than 2 days was 23.85 times more likely to develop post-TURP AUR compared to individuals with catheterization periods equal to or less than 2 days. This discovery contrasts with a study conducted in Pakistan, where there was no distinction in the duration of post-operative catheterization between AUR + and AUR- groups[14]. Those who experienced incidental catheter removal were 8.27 times more likely to develop post-TURP AUR than those who did not experience such incidents. Additionally, individuals who experienced post-operative urinary tract infections (UTI) exhibited a 4.15 times higher probability of developing post-TURP AUR compared to those without UTI, a finding consistent with a study conducted in India [21]. However, factors showing significant associations with post-TURP AUR in bivariate logistic regression did not remain significant in multivariate logistic regression, except for incomplete resection of adenomatous tissue.

This study illuminates key factors influencing post-TURP AUR, emphasizing the importance of thorough preoperative assessments and careful surgical considerations for optimal outcomes.

This study delved into the demographic and clinical characteristics, along with intraoperative and postoperative factors, impacting post-TURP Acute Urinary Retention (AUR) among 143 men with Benign Prostatic Hyperplasia (BPH). Remarkably, 28% encountered AUR, with rural residency, extended illness duration, preoperative AUR, larger prostate volume, general anesthesia, and inadvertent catheter removal exhibiting heightened risks, albeit statistical significance varied. In multivariate analysis, incomplete resection emerged as the singular statistically significant predictor, accentuating its pivotal role. The findings underscore the imperative of comprehensive preoperative evaluations and surgical considerations for favorable outcomes in TURP patients. Nonetheless, prudence is warranted given limitations such as modest sample sizes and retrospective design, necessitating future large-scale prospective investigations for validation.

Ethics approval:

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Bahir Dar University, College of Medicine and Health science, protocol code 774/2023 and date of approval: September 01, 2023.

Consent to participate:

Not applicable.

Consent for publication:

Not applicable.

Funding:

This research received no external funding

Author Contribution

AF conceived and designed the study, contributed to data collection, performed the statistical analysis, interpreted the findings, and led the writing and revision of the manuscript. GT contributed to the study design, supervised data collection, participated in the interpretation of clinical data, and reviewed the manuscript for intellectual content. NF assisted with the study methodology, data analysis, and drafting of the manuscript, while also providing critical revisions and coordinating during the submission process. All authors reviewed the manuscript.

Acknowledgement

The authors would like to sincerely thank the staff of the Urology Unit and the Medical Records Department at Tibebe Ghion Specialized Hospital for their invaluable assistance during the data collection process. We also extend our gratitude to Bahir Dar University, College of Medicine and Health Sciences, for providing the necessary institutional support to carry out this research.

Data Availability

The datasets supporting the findings of this study are available from the corresponding author upon reasonable request.

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No competing interests reported.

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You are reading this latest preprint version

Determinant Of Post-Transurethral Resection of The Prostate Acute Urinary Retention at Tibebe Ghion Specialized Hospital, Northwest Ethiopia: Unmatched Case-Control Study 2023

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Abstract

Figures

1. Introduction

2. Materials and Methods

3. Results

3.1. Demographic and clinical characteristics of the study participants

3.2. Intraoperative and postoperative characteristics of the study participants

3.3. Factors associated with Post-TURP Acute Urinary Retention (AUR)

3.2. Figures, and Tables

4. Discussion

5. Conclusions

Declarations

Consent to participate:

Funding:

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

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