Transurethral resection of the prostate (TURP) is a widely used surgical treatment for lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). However, the efficacy and safety of TURP in men with detrusor underactivity (DU) or acontractile detrusor (AD) have been a subject of debate (1). DU and AD are common among older men with LUTS, and they are associated with a higher risk of postoperative complications and lower rates of improvement in urinary symptoms after TURP compared to men with normal detrusor function. Moreover, there is a lack of consensus on the long-term effects of TURP in men with DU or AD. Only two studies determined the effect of de-obstructive prostate surgery in men with DU at a long-term follow-up. Thomas et al. invited neurologically intact men with DU (PdetQmax<40cmH20 with Qmax<15mL/s) for a repeat PFS and symptomatic assessment. With a mean follow-up of 72 months, the researchers concluded that there were no long-term symptomatic or urodynamic gains from TURP in men with DUA. However, the studied population is small (18 men) and consists of highly selected symptomatic individuals which has likely influenced the results negatively (2). In a 12-year follow-up after TURP, Masumori et al found that IPSS and IPSS-QoL deteriorate with time for all patients, regardless of detrusor contractility. However, after 12 years the symptoms were still better than at baseline with no significant difference in detrusor contractility (3). Due to this conflicting evidence, urologists are still at awe when dealing with this disease entity. Hence, we investigated the long-term rate of spontaneous voiding in male patients with DU or AD and compared the outcomes to those with normal contractility. Transurethral resection of the prostate (TURP) in men with underactive detrusor (DU) or acontractile detrusor (AD) remains a topic of debate. We suspect that TURP also provides long-term improvement in quality of life and patient-reported outcomes, independent of preoperative bladder contractility.

This is a prospective cross-sectional study of the long-term effects of TURP in men with DU/AD. Men with non-neurogenic LUTS, who underwent a preoperative urodynamic examination and who underwent a TURP between 2010 and 2017, were prospectively approached with questionnaires: the international prostate symptom and quality of life score (IPSS/QoL), the patient global impression of improvement (PGI-I), treatment tolerance scale (TTS), and treatment satisfaction scale(TSS). In addition, patients were asked if they were able to void spontaneously and if additional treatments were offered since TURP (i.e. medication or surgery). Men were divided into three groups based on the bladder contractility index (BCI): normal detrusor contractility (BCI≥100); detrusor underactivity (BCI<100) or acontractile detrusor (inability to void during urodynamics).

In total, 89 of 139 (64%) men responded the questionnaires. Baseline characteristics and preoperative urodynamic parameters are presented in Table 1 for each subgroup (BCI≥100, BCI<100 and acontractile detrusor). There was a significant difference at baseline between BCI≥100 and BCI<100 for the parameters Qmax, PdetQmax, Wmax, BCI, BOOI and VE. PVR differed significantly between BCI≥100 and AD (p=0.000) as well as BCI≥100 and BCI<100 (p=0.000). 
IPSS and IPSS-QoL at baseline did not differ significantly between the groups, however only one patient in the AD group reported IPSS-QoL at baseline (Table 1). There was no significant difference in IPSS and IPSS-QoL at the long-term follow-up amongst the groups. All patients with AD reported that they tolerated their treatment ’good’ and ‘very good’. Overall, there was no significant difference in the PGI-I, TTS and TSS amongst the groups. 
The rate of spontaneous voiding differed significantly for men with AD at baseline and postoperatively compared to those with BCI ≥100 and BCI<100. Men with AD had a lower spontaneous voiding rate at the long-term follow-up (69.2%) compared to men with BCI ≥100 (97.3 %) and BCI<100 (94.6%), this difference was however not statistically significant. No significant differences were seen in complications, need for catheterization, need for medication or redo surgery.

There was no significant difference in IPSS and QoL scores at baseline or after a median follow up of 79 months (range 60.5-105.5) between the three groups. All men, regardless of bladder contractility, were satisfied with their treatment. The number of men that voided spontaneously was lower in men with AD compared to those with weak or normal detrusor contractility, but this difference was not statistically significant.

TURP provides men with DU or AD an improved quality of life and other long-term patient-reported outcomes. In men with AD, careful consideration should be given to surgery because of the lower chance of recovery of spontaneous voiding postoperatively compared to men with DU.

Drake MJ. Is Urodynamics Necessary when Assessing a Patient with Male Lower Urinary Tract Symptoms? Eur Urol Focus. 2018;4(1):54-56. doi:10.1016/j.euf.2018.04.008
Thomas AW, Cannon A, Bartlett E, Ellis-Jones J, Abrams P. The natural history of lower urinary tract dysfunction in men: the influence of detrusor underactivity on the outcome after transurethral resection of the prostate with a minimum 10-year urodynamic follow-up. BJU Int. 2004 Apr;93(6):745-50. doi: 10.1111/j.1464-410X.2003.04719.x. PMID: 15049984.
Masumori N, Furuya R, Tanaka Y, Furuya S, Ogura H, Tsukamoto T. The 12-year symptomatic outcome of transurethral resection of the prostate for patients with lower urinary tract symptoms suggestive of benign prostatic obstruction compared to the urodynamic findings before surgery. BJU Int. 2010 May;105(10):1429-33. doi: 10.1111/j.1464-410X.2009.08978.x. Epub 2009 Oct 26. PMID: 19863522.

Continence 7S1 (2023) 100915
DOI: 10.1016/j.cont.2023.100915