Debating the utility of TURP
Saturday’s debate weighed the benefits and risks of transurethral resection of the prostate surgery, with evidence-based opinions from the panel.
and Ricardo Gonzalez, MD
Detrusor underactivity (DU) and bladder outlet obstruction (BOO) are both common troublesome causes of lower urinary tract symptoms (LUTS) and often simultaneously impact quality of life in men. When should transurethral resection of the prostate (TURP) be recommended to men with DU and BOO?
Saturday’s “Crossfire: Controversies in Urology: Detrusor Underactivity in Men and Retention: To TURP or Not to TURP?” debated the rationale for recommending TURP in an index patient, a 60-year-old man who experienced two to three episodes of prostatitis yearly. The patient required clean intermittent catheterization (CIC) four times per day. He had renal insufficiency and a prostate volume of 65 centimeters. He was currently taking finasteride and tamsulosin. His previous procedure included photoselective vaporization of the prostate in 2019. Now he was in your theoretical office with voiding complaints. Would you recommend TURP so he could void without catheterization?
“To do surgery or not, think about the goals of treatment,” said Nicole Miller, MD, FACS, professor of urology at Vanderbilt University in Nashville, who led the pro-TURP side of the debate. “For patients with DU, the goals include resuming spontaneous voiding, reducing postvoid residual, preventing upper tract deterioration, improving symptoms and quality of life and reducing the risk of complications.”
Dr. Miller cited the literature and the AUA Whitepaper slide to support TURP surgery. “Where we clearly see obstruction, surgery will be beneficial,” she said.
Christopher Tenggardjaja, MD, a urologist with Kaiser Permanente in Los Angeles, disagreed, citing evidence indicating that the risks of TURP outweighed the potential benefit. “Sexual dysfunction is a big risk. How do we counsel patients about it? We don’t do so well,” he said. “The patient already had bladder outflow resistance reduction surgery. Don’t make the patient worse.”
Ricardo Gonzalez, MD, associate professor of medicine at Houston Methodist, circled back to the goals of treatment for DU, including reducing the risk of complications, infections, renal failure, bleeding, stones and catheter use. “Offering surgery is likely to resolve retention, and postponing it risks waiting until the patient has worse dexterity and the inability to perform CIC. Operate!” he said.
Matthew Rutman, MD, associate professor of urology at Columbia University Medical Center in New York City, offered evidence supporting a rationale against TURP, including the fact that the patient didn’t improve with prior surgery, didn’t void between CIC and showed minimal detrusor pressure. “I know we’re surgeons, but this is a guy we’ve got to leave alone,” he said.
Overall, the audience favored TURP surgery. When session moderator Mitchell Humphreys, MD, chair and professor in the department of urology at Mayo Clinic in Arizona, asked: “How many of you would operate on this patient?” and, “If this was you, would you want the opportunity to void without catheterization?” there was a large show of hands both times.
