End the TURP

Not a Gold Standard
     
      The transurethral resection of the prostate (TURP or TUR) has been declared the "Gold Standard" therapy for benign prostatic hyperplasia (BPH) and acute urinary retention for over three decades,[1] but there are many reasons why the TURP is imperfect, starting with the risk of death from surgery and anesthesia,[2] which was recently reported to be .37%.[3]

Damages Sexual Function
      The TURP is sexually harmful. In one study, 67 percent of the men were damaged sexually,[4] and in another study satisfaction with sex decreased in 44 percent of men after a TURP.[5]

Post-TURP Syndrome
     The TURP can cause fluid and electrolyte imbalance results, which has been dubbed the post-TURP syndrome.[6]

Infected Prostates

     The risk of urinary tract infection after TURP is 15.5 percent according to a study of 10,000 men.[7] Why the astonishingly high rate of infection after a TURP. Many believe that it’s due to operating on infected prostates. And, many believe that is was the infection that was causing all the symptoms, not the benign enlargement of the prostate. So, the question is, why not treat the infection, and clear the symptoms that way, instead of doing surgery. Other studies suggest that up to 98 percent of TURP specimens are infected, or inflamed.
      Preoperative antibiotics are often given for TURP, but since urologists seldom do pre-operative work-ups for prostatitis and infection before doing the operation, it’s unclear if the antibiotics they give have the potential to clear any prostatic infection. The prostate may remain infected, while antibiotics seemly lower the risk of the infection passing to the bladder.
      Certainly, if Chlamydia is the prevalent organism, as some studies suggest, typical pre-op antibiotics will not adequately cover the organism.

TURP Causes Delayed Death

     In 1988, the TURP was found to have an elevated death rate compared to open prostatectomy.[8] Another study was done which also found an elevated death rate for the TURP.[9] And yet another study found an increased risk of dying compared to the open prostatectomy and a high re-operation rate.[10] A report in 1994 concluded that it is unclear whether the TURP causes increased delayed mortality.[11] After the hundreds of thousands of TURPs that have been done by now, we should know if the operation actually kills men in delayed fashion, but we don’t. The science behind the TURP is terrible.

Side Effects

     In addition to death, there are many other problems with the TURP. TURP can cause urethral strictures in 4%, bladder neck strictures in 4%, impotence in 11%, and retrograde ejaculation in 89%.[12] A repeat operation is needed in up to 17 percent of cases.[13]

Symptoms Don’t Respond

     Not all symptoms uniformly respond to TURP, therefore, it is hard to define when it is indicated to perform one, and there are large geographical differences in how often the operation is performed.[14],[15] Some urologists are 2.2 times more likely to do TURP than others.[16] Such geographic differences are typically seen in treatments that are not truly or consistently efficacious.

New Procedures Based on Flawed Science

     New procedures such as laser prostatectomy and transurethral microwave thermotherapy (TUMT) are being compared to the TURP, despite the fact that the efficacy of the TURP is unclear. Many or all of these new procedures are marketed under the 510K pathway for the Food and Drug Administration, which means that they do not have to undergo randomized controlled studies, so it remains unclear whether they are safer or more efficacious. It is generally felt that laser prostatectomy is not as efficacious[17] as TURP, and one randomized controlled study showed no benefit from transurethral microwave thermotherapy (TUMT).[18]

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[1] Ravery V.Transurethral microwave thermotherapy v transurethral resection of prostate.J Endourol. 2000 Oct;14(8):693-6.

[2] McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8. AHCPR Publication No. 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. February 1994, p. 121.

[3] Lertakyamanee J, Ruksamanee EO, Tantiwong A, Boonsuk K, Nilpradab I, Vorakijpokatorn P, Soontrapa S.The risk and effectiveness of transurethral resection of prostate. J Med Assoc Thai. 2002 Dec;85(12):1288-95.

[4] Peter J. Gilling MB, ChB, Urology Registrar; William L. Wright FRACS, Urologists; James M Gray FRCS, FRACS, Urologists, Waikato Hospital, Hamilton; Factors associated with sexual dysfunction following transurethral resection of the prostate. N Z Med J. 1988 Jul 27; 101(850): 484-485

[5] Petsch MJ and Schulze H: Quality of Erection Does Change After TURP - Results of a Prospective Clinical Study. Abstract presented at the 1999 American Urological Association Meeting.

[6] Coppinger SWV, and Hudd C: Risk factor for myocardial infarction in transurethral resection of the prostate? Letter to the Editor. Lancet 1989;2:859.

[7] McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8. AHCPR Publication No. 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. February 1994, p. 98.

[8] John E. Wennberg, MD, Albert G. Mulley, Jr. MD, Daniel Hanley, MD. Robert P. Timothy, MD. Floyd J. Fowler, Jr. Ph.D, Noralou P. Roos, PhD, Michael J. Barry, MD, Klim McPherson, PhD, E. Robert Greenberg, MD, David Soule, Thomas Bubolz, PhD, Elliott Fisher, MD., David Malenka, MD: An Assessment of Prostatectomy for Benign Urinary Tract Obstruction: Geographic variations and the evaluation of medical care outcomes. JAMA 259(20):3027-3030, 1988, May 27.

[9] Roos NP, Wennberg JE, Malenka DJ, Fisher ES, McPherson K, Andersen TF, Cohen MM, and Ramsey E: Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. NEJM April 27, 1989:320:1120-1124.

[10] Malenka DJ, Roos N, Fisher ES, McLerran D, Whaley FS, Barry MJ, Bruskewitz R, and Wennberg JE: Further study of the increased mortality following transurethral prostatectomy: a chart based review. The Journal of Urology August 1990;144:224-228.

[11] McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8. AHCPR Publication No. 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. February 1994, p. 125.

[12] Hammadeh MY, Madaan S, Hines J, Philp T. 5-year outcome of a prospective randomized trial to compare transurethral electrovaporization of the prostate and standard transurethral resection. Urology. 2003 Jun;61(6):1166-71.

[13] McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8. AHCPR Publication No. 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. February 1994.

[14] Peder H. Graversen, Thomas C. Gasser, John H. Wasson, Frank Hinman, Jr., and Reginald C. Bruskewitz; Controversies about indications for transurethral resection of the prostate, The Journal of Urology, Copyright 1989 by The William and Wilkins Co., Vol. 141, March.

[15] Peder H. Graversen, Thomas C. Gasser, John H. Wasson, Frank Hinman, Jr., and Reginald C. Bruskewitz; Controversies about indications for transurethral resection of the prostate, The Journal of Urology, Copyright 1989 by The William and Wilkins Co., Vol. 141, March.

[16] Stoevelaar HJ, Van De Beek C, Casparie AF, McDonnel J, and Nijs HGT: Treatment Choice for Benign Prostatic Hyperplasia: A Matter of Urologist Preference? The Journal of Urology 1999;161:133-138.

[17] Seki N, Naito S, Oshima S, Hirao Y, Higashihara E. Prevalence and preference with regard to various surgical treatments for benign prostatic hypertrophy: a survey for the Japanese endourology and ESWL society member Nippon Hinyokika Gakkai Zasshi. 2003 May;94(4):495-502.

[18] Nawrocki JD, Bell TJ, Lawrence WT, and Ward JP: A randomized controlled trial of transurethral microwave thermotherapy. British Journal of Urology, 1997;79:389-393.