An increase in serum prostate-specific antigen (PSA) levels in patients with urinary retention has been frequently reported.1–3 In clinical settings, it is sometimes difficult to determine the cause of PSA elevation. Routine PSA testing before transurethral resection of prostate (TURP) in these patients remains controversial. Some urologists advocate preoperative PSA testing, while others find it unnecessary and even misleading.4 In cases with PSA elevation, pre-TURP transrectal ultrasound (TRUS)-guided biopsy carries certain risks, because the biopsy may worsen the urinary retention and may result in complications. Factors influencing the decision of whether or not to perform the biopsy include the patient's age, willingness, health condition, past PSA data, past biopsy results, and the urologist's preferences. The aim of this study was to determine whether concomitant TRUS-guided biopsy and TURP was viable in patients with urinary retention and elevated serum PSA (≥ 4 ng/mL).
We retrospectively reviewed patients referred to the urology department for urinary retention from March 2007 to May 2015. Patients older than 80 years and those with serum PSA<4 ng/mL or PSA≥100 ng/mL were excluded from this study. These patients were excluded because the value of prostatic biopsy in this age group was questionable, and serum PSA≥100 ng/mL was regarded as an important indicator of metastatic disease. Patients with trauma- or drug-related bladder outlet obstruction, previous bladder or prostate malignancies, acute neurologic conditions, and urosepsis were also excluded. All patients signed an informed consent document before the operation. A total of 34 patients underwent concomitant TRUS-guided prostate biopsy and TURP. Prostate volume was measured by transrectal ultrasound (BK Medical Hawk 2102 EXL; BK Medical, Herlev, Denmark). All patients received bowel preparation with cleansing phosphate enema (Evac enema, 118 mL) the night before surgery and perioperatively were intravenously administered a prophylactic broad-spectrum antibiotic. Under spinal or general anesthesia, the patient was placed in the lithotomy position. A 12-core needle biopsy using an 18-gauge needle biopsy gun (Bard Peripheral Vascular Inc., Tempe, AZ, USA) was performed under transrectal ultrasound guidance. Routine fiberocystoscopy was performed to rule out any unexpected prostatic and bladder lesions. Bipolar TURP (PlasmaKinetic Tissue Management System; Gyrus Medical Ltd., Cardiff, UK) was carried out using the standard procedures. Oral quinolone was given for 5 days. The pathologist examined the resected prostate chips and biopsy specimens separately.
The patients’ demographic data, preoperative PSA levels, prostate volume, PSA density, length of hospitalization, length of catheterization, recatheterization rate, postoperative complications, and TURP and biopsy pathological results were recorded. Results were compared to those of a separate cohort of 40 patients with prostate enlargement-related urinary retention who underwent TURP alone during the study period. In these 40 patients, PSA testing was not collected before TURP. The results were compared using an independent t test and Fisher's exact test. A p value<0.05 was considered to be statistically significant.
The mean age of the patients was 71.6 years. The mean PSA levels were 16.9 ng/mL. The mean prostate volume was 60.8 cm3. Comparison between patients with cancer and benign prostatic hyperplasia (BPH) showed no statistically significant differences in patients’ age, serum PSA levels, prostate volume, and prostate-specific antigen density (PSAD; Table 1).
Overall, prostate cancer was detected in eight cases (23.5%; Table 2); it was detected by both TRUS-guided biopsy and TURP in five cases, by TURP alone in two cases, and by biopsy alone in one case. In the case diagnosed by biopsy alone, the PSA levels were 6.66 ng/mL, adenocarcinoma was found in all 12 cores, and the Gleason score was 5+5. The Gleason score was 3+3 and 3+4 in the two cases detected by TURP alone.
No statistically significant differences in patient age, postoperative fever, recatheterization for urine retention, urge incontinence, urinary tract infection, bladder neck contracture, length of hospitalization, and length of catheterization were found. The cancer detection rate was significantly higher (8/34 vs. 2/40; p=0.023) in the group of concomitant TRUS-guided biopsy and TURP (Table 3).
Urinary retention is the main indication for surgery in approximately one fourth of male patients who undergo TURP.5 It has been reported that urinary retention increases the serum PSA levels by up to six-fold over the normal limits.1–3 There is no consensus regarding the standard approach to this condition. Some doctors advocate TURP alone, while others routinely perform preoperative TRUS-guided biopsy. Chen et al6 reported simultaneous TURP and TRUS-guided biopsy to release acute urinary retention and documented a definite diagnosis. We excluded patients older than 80 years because the value of prostatic biopsy in this age group was questionable, and serum PSA≥100 ng/mL was excluded because it was regarded as an important indicator of metastatic disease.7,8
The rate of incidental cancer detected by TURP was 22% before PSA testing, and decreased to 9.8% in the past two decades.9 In our study, prostate cancer was found in eight of 34 patients (23.5%). Most of the cancers (7/8) were found in the TURP chips. However, the one case missed in the TURP chips and detected by concomitant TRUS-guided biopsy was a high-risk cancer (Gleason 5+5) with PSA of 6.66 ng/mL. This result stresses the importance of preoperative explanation to the patient. There were no Gleason scores higher than 8 in the TURP chips. This observation also concurs with earlier report which indicated that prostate cancers originating in the transitional zone are usually less invasive than those originating in the peripheral zone.10 In the cohort of 40 patients who underwent TURP alone without testing PSA levels before the operation, the cancer detection rate was 5%. The significantly higher (p=0.023) cancer detection rate can be explained by the following factors: patients in the group of concomitant TRUS-guided biopsy and TURP had elevated PSA levels, however, the PSA level was not checked in the other 40 patients, resulting in an unknown ratio of elevated- to normal-PSA levels. The higher cancer detection rate can also be attributed to TRUS-guided biopsy, which was obtained from the peripheral zone tissue.
The patients we enrolled into the study underwent prostate ultrasound after Foley catheterization for acute urinary retention. The measurement of prostate volume was influenced by the catheter and inflammation. In addition, urinary retention increases the serum PSA level with a wide range from two- to six-fold.1,2 Comparison between patients with cancer and BPH showed no statistically significant differences in PSAD. Hence, we consider that PSAD is not a reliable cancer predictor for patients with acute urinary retention.
Present-day complications of TURP are relatively minor owing to improved technologies such as surgical devices and imaging systems. Concomitant TRUS-guided biopsy and TURP is safe, as shown in our study. The incidence of urinary tract infection (UTI) after TRUS-guided biopsy ranges between 2% and 6%, and bacteremia was reported in ˜30–50% of these patients.11 Nam et al12 reported that the rate of readmission within 30 days was 4.1% in patients who underwent TRUS-guided biopsy, with infection as the main cause. UTI occurred in 1.7–14.0% of patients after TURP.13 Due to urinary retention and urethral catheterization, we used an extended course of oral antibiotics to prevent postoperative UTI. In our study, postoperative fever occurred in five patients (14.3%), whereas two patients (5.7%) were readmitted due to UTI confirmed by urine culture and bacteremia confirmed by blood culture. In contemporary studies, the rate of urinary retention post-TURP has been reported to be from 3% to 9.9% and the rate of temporary urge incontinence was 30–40%.13,14 By comparison, 5.9% of our patients suffered from transient urinary retention, while 20.6% patients complained of temporary urge incontinence. Two recatheterized patients voided successfully, and the incidence of de novo urge incontinence declined to 2.9% after 6 months. Major late complications of TURP include urethral stricture (range, 2.2–9.8%) and bladder neck contracture (range, 0.3–9.2%).13 Only one patient in our study had bladder neck contracture at 14 months and remained symptom-free after undergoing bladder neck incision. Comparison with a cohort of patients who underwent TURP alone, revealed no statistically significant differences in patient age, postoperative fever, UTI, bladder neck contracture, recatheterization rate, urge incontinence, length of hospitalization, and length of catheterization (Table 3). This result attests to the safety of concomitant TRUS-guided biopsy and TURP in urinary retention patients.
A potential disadvantage of concomitant TURP and TRUS-guided biopsy concerns patients with prostate cancer who are suitable candidates for radical prostatectomy. Previous studies showed that patients with a history of TURP had poorer outcomes after laparoscopic radical prostatectomy, and previous TURP also presented a challenge to surgeons during robot-assisted radical prostatectomy.15,16 However, other studies reported that although the procedure is technically more demanding, when performed by expert surgeons, the overall urinary function outcomes and frequency of positive surgical margins appear to be similar.17–21
Urodynamic studies were not performed in our patients prior to surgery. Previous studies showed that even if preoperative urodynamic exams in urinary retention patients suggested an unfavorable outcome, especially in those younger than 80 years, most could void by themselves without catheterization at 3 months post-TURP.22,23 Two of our patients with temporary urinary retention requiring recatheterization voided successfully 1 month post-TURP.
Limitations of our study include small sample size, varying source of patients’ referrals, and the retrospective nature of the study. There were potential study biases in that many patients were referred from other clinics and the interval between PSA examination and acute urinary retention episode varies. Further prospective multi-center studies with a larger sample size are required to provide future guidelines for this controversial clinical issue.
In conclusion, this study revealed the safety and value of concomitant TRUS-guided biopsy and TURP in urinary retention patients with elevated serum PSA. Concomitant TRUS-guided biopsy is a viable option during TURP for patients with urinary retention and elevated serum PSA.
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