This original work done in patients with Benign Prostatic Obstruction aims to find out the impact of duration of medication therapy on the outcomes of TURP. Medical management of BPO is recommended as the first line of treatment and surgery is usually reserved for those who have failure of medical management and/or complications of BPO (refractory retention, vesical calculus, recurrent UTI or hematuria). However, there is some pointing evidence that delay in the surgery may affect the overall outcomes of transurethral resection of prostate (TURP) [1,2] Presently, there is a lacuna on the impact of delay in surgery owing to prolonged duration of preoperative medical therapy on the outcomes of surgery. We aimed to find this impact with the hypothesis that patients who are on long term medication therapy have less improvement in their subjective symptoms and objective bladder function parameters compared to patients who undergo surgery earlier.

An observational prospective cohort study was conducted to evaluate the outcomes after TURP with respect to prior duration of pre operative medical management as <3, 3-12 and >12 months. Based on the existing literature [3], the expected mean IPSS reduction was 10 points from baseline. A sample size of 72 (24 in each group) would have 90% power to detect a significant difference in the three groups at 5% significance level. With an expected dropout rate of 10%, we aimed to recruit 90 patients in our study. Sample size calculation was done using G Power 3.1.9.7
Baseline characteristics (age, co-morbidities, ASA grade, duration and type of medical therapy, indication of surgery, serum PSA, IPSS, Ultrasound imaging with post-void residual urine {PVR}, UDS storage and voiding pressures) were collected for all patients undergoing TURP. Operative details (surgical time, resected prostate weight) and post-operative outcomes (post-operative stay, catheter duration and Clavien-Dindo grade of complications) were noted. Follow up was done at 6 weeks, 3 months and 6 months with IPSS, PVR and UDS storage/voiding pressures. Primary outcome was PROM (IPSS based improvement of symptoms) at 3 months. Secondary outcome measures included PROM at 6 weeks and 6 months, complete emptying of bladder (as measured by Ultrasound based PVR), Urodynamics Storage and Voiding pressures and comparison between patients who received only alpha blockers and those who also received 5-alpha reductase inhibitors. One way ANOVA was used for testing of mean between three independent groups whereas Repeat measure ANOVA was used for repeated observations. A p-value of <0.05 was considered statistically significant. All analysis was done using SPSS software, version 25.0

87 men undergoing TURP from Jan 2022-Dec 2023 were divided into three groups based on duration of preoperative medical therapy - <3 months (n=24), 3-12 months (n=27) and >12 months (n=36). Baseline parameters including age, co-morbidities, prostate size, ASA grade, serum PSA, resection time, resected prostate weight, post-operative stay, catheter duration and post-operative complications were found to be similar across all three groups. However, the patients in >12 months group had poorer percent reduction in IPSS [30±14.3 vs. 42.4±10.3 vs. 39.1±15.9, p=0.002], PVR [40.8±16.6 vs. 48.9±20.6 vs. 63.3±14, p<0.001], and UDS storage [14.8 ± 12.4 vs. 16.7 ± 18.1 vs. 32.1 ± 21, p=0.002] and voiding pressures [9.2 ± 11.4 vs. 19.7 ± 12.6 vs. 18.8 ± 13.1, p=0.005] compared to the other group of patients. This difference in outcomes was consistent irrespective of the type of medication therapy (alpha blockers vs. combination therapy). There was a significant negative correlation between duration of medical therapy and IPSS reduction [r(86):-0.25, p=0.008].

The patients who were on prolonged medication therapy prior to undergoing TURP despite being similar to other group of patients in terms of their baseline characteristics and operative parameters had significantly lesser improvement in terms of PROM and objective parameters (reduction in PVR, and Urodynamic storage and voiding pressures).

The delay in surgery due to prolonged pre-operative medical therapy is associated with poorer IPSS, PVR, Urodynamic storage and voiding pressure improvements.

Izard, J.; Nickel, J.C. Impact of medical therapy on transurethral resection of the prostate: Two decades of change. BJU Int. 2011, 108, 89–93.
Mayer EK, Kroeze SG, Chopra S, Bottle A, Patel A. Examining the 'gold standard': a comparative critical analysis of three consecutive decades of monopolar transurethral resection of the prostate (TURP) outcomes. BJU Int. 2012 Dec;110(11):1595-601.
Martin Marszalek; Anton Ponholzer; Marlies Pusman; Ingrid Berger; Stephan Madersbacher (2009). Transurethral Resection of the Prostate. , 8(6), 504– 512.

Continence 12S (2024) 101606
DOI: 10.1016/j.cont.2024.101606