Selection of the urine derivation method in patients with acute urinary retention before surgical treatment of benign prostatic hyperplasia

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Introduction

High-frequency acute urinary retention (AUR) requires urgent hospitalization of a patient in a urological hospital. In a 5-year-follow-up past study, every tenth man of age 60–70 years had at least 1 episode of AUR, while the AUR occurrence rate was 30% in men during another 10-year-follow-up study [2, 5, 7]. Generally, AUR in men is caused by benign prostatic hyperplasia (BPH), which occurs in 50%–70% of the patients [3–5]. It is the fear of urinary retention, and not the symptoms of urination disorder, that often propels a patient to visit a urologist. It is already known that, on an average, AUR occurs in 10% of men aged >70 years [1, 6]. The epidemiological data indicate that, with an increase in the volume of prostate of >40 cm³ and that of the prostate-specific antigen (PSA) level in blood at >1.4 mg/mL, the risk of AUR increases by 4 times [3, 5]. The probability of AUR in the male gender is 8-times greater in those aged >70 years than in those of age 40 years [3].

In most cases of emergency hospitalization, the doctors do not have all the necessary information to perform a one-stage prostatectomy or transurethral resection (TUR) of the prostate. The lack of data on the PSA level is of particular importance, as it does not eliminate the chances of prostate cancer. In such situations, as well as in the absence of a tendency to restore spontaneous urination after catheter removal, an open or trocar cystostomy is generally practiced.

The present study aimed to optimize the choices of approaches to preoperative drainage of the bladder.

Materials and methods

The study was conducted using the case-control methodology.

A retrospective analysis of the results of treatment of patients admitted to the urology department of the State Clinical Hospital No. 8 during 2015–2018 was performed. The patients enrolled in the study met the criteria of the presence of AUR caused by BPH, which was confirmed by the results of ultrasound examination and the drainage of the bladder as an approach of preparation for surgery in order to eliminate the chances of BPH. Depending on the approach used to perform drainage, all patients were distributed into 3 groups: group 1 (catheterization of the bladder with a urethral catheter), group 2 (epicystostomy), and group 3 (trocar epicystostomy).

As per the literature, the number of patients with bladder catheterization was 164, with epicystostomy was 59 people, and with trocar epicystostomy was 57 people. A total of 280 people were included in the study.

The estimates of the effect of the treatment method on the disease outcome were determined via one-way analysis of variance (ANOVA). We assumed X as a certain general population that can be influenced by some qualitative factor F, which has p levels F₁, F₂, …, F_p. One-way ANOVA was used to determine whether the factor F has a significant effect on the value of X. For this, the factor variance s²_fact (2), generated by the effect of the factor, and the residual variance s²_res, due to random causes, were compared. If the difference between these variances was significant, then the factor F was considered to have a significant effect on the population X. In this case, in order to identify which of the factor levels had the greatest influence on the population X, a pairwise comparison of the means corresponding to different values of F_i, i = 1, n, was performed. We considered the number of tests at different levels to be different, with q₁ tests performed at the F₁ level, q₂ tests performed at the F₂ level, …, and q_p tests performed at the F_p level. To simplify the calculations, instead of individual cases x_ij, i was the number of the test, j was the number of the factor level, y_ij = x_ij – C was used, where C is the average of all observations x_ij. To determine whether the variances s²_fact and s²_res differed significantly, the null hypothesis H₀: s²_fact = s²_res was tested using Fisher’s test at a significance level of α = 0.95.

 

The outcome of treatment of a BPH patient was assigned a certain discrete numerical value of the natural series in accordance with the degree of manifestation, wherein 1 indicated surgical treatment performed for BPH without complications, 2 implied surgical treatment for BPH that had immediate and long-term complications, and 3 indicated surgical treatment performed for BPH, which was fatal.

Research outcomes

The comparative characteristics of the methods of urinary bladder drainage for AUR are presented in Table. The vast majority of bladder catheterizations were performed without using anesthesia (n = 158, 96.3%) and the catheterizations under intravenous anesthesia were performed in 6 patients (3.7%). In the epicystostomy group, catheterizations under intravenous anesthesia were performed in 27 patients (45.8%) and catheterizations under spinal anesthesia in 32 patients (54.2%). In the trocar epicystostomy group, 57 (100%) surgeries were performed under local anesthesia.

 

Comparative characteristics of bladder drainage methods in case of acute urinary retention

Сравнительная характеристика методов дренирования мочевого пузыря по поводу острой задержки мочеиспускания

Characteristics of the indicator	Group 1	Group 2	Group 3
Anesthesia
Not used	158 (96.3%)	0	0
Local	0	0	57 (100%)
Intravenous anesthesia	6 (3.7%)	27 (45.8%)	0
Spinal anesthesia	0	32 (54.2%)	0
Technical difficulties during the procedure
Yes	57 (34.8%)	8 (13.6%)	7 (12.3%)
No	107 (63.2%)	51 (86.4%)	50 (87.7%)
Successful procedure
Yes	121 (73.8%)	59 (100%)	2 (4%)
No	43 (26.2%)	0	55 (96%)
Need for repeated drainage
Yes	45 (27.4%)	0	0
No	119 (72.6%)	59 (100%)	57 (100%)
Infectious and inflammatory diseases of the lower urinary tract
Urethritis	143 (87.2%)	2 (3.4%)	0
Prostatitis	56 (34.1%)	7 (11.9%)	4 (7%)
Infectious and inflammatory diseases of the scrotum organs	24 (14.6%)	2 (3.4%)	1 (1.8%)

 

Interventions were successfully performed in 121 (73.8%) patients in the catheterization group, in 59 (100%) patients in the epicystostomy group, and in 55 (96%) patients in the trocar epicystostomy group. Subjective difficulties in performing the manipulation were noted in 57 (34.8%) cases while draining the bladder with a urethral catheter, in 8 (13.6%) cases when performing an epicystostomy, and in 7 (12.3%) cases when performing a trocar epicystostomy. The need for repeated drainage arose in 45 (27.4%) patients in the bladder catheterization group.

After the manipulation during hospitalization, 143 (87.2%) patients from the group 1 had urethritis, 56 (34.1%) patients had prostatitis, and 24 (14.6%) patients had infectious and inflammatory diseases of the scrotal organs. In group 2, these indicators were 2 (3.4%) for urethritis, 7 (11.9%) for prostatitis, and 2 (3.4%) for infectious and inflammatory diseases of the scrotal organs, respectively. In group 3, the smallest numbers of cases of prostatitis (n = 4, 7%) and infectious and inflammatory diseases of the organ scrotum (n = 1, 1.8%) were recorded.

TUR was performed in all patients with BPH (n = 280).

At the same time, patients with BPH and AUR (n = 164) underwent catheterization as a preoperative intervention for urine derivation, with subsequent TUR. In this group, cases of an infectious and inflammatory process were recorded in 143 (87.2%) patients. For 59 patients, an open epicystostomy was selected as the preoperative urine derivation method. In this group, cases of an infectious and inflammatory process were recorded in 9 (15.2%) patients. Trocar cystostomy was applied in 57 patients as a preoperative urine derivation method. In this group, cases of an infectious and inflammatory process after PG TUR were recorded in 4 (7.0%) patients.

ANOVA results revealed that the outcomes of treatment of patients with BPH and AUR differed significantly. However, the hypothesis that M (X₁) = M (X₂) = ... = M (X_n) was rejected, since when testing it, F_obs = 4.4 exceeded F_cr = 4.2, at a value level of 0.05. This equation indicated that it was quite acceptable to compare the treatment results among the groups, and lower the value of M, better were the long-term results.

The most optimal method of urine derivation before TUR in patients with BPH was a combination of TUR of the prostate gland with trocar cystostomy (mean M = 1.07). When TUR was combined with open epicystostomy, the average M was 1.15. Disappointing data were obtained after performing TUR in BPH when using a urethral catheter before the surgery as a method of urine derivation.

Conclusion

Based on the data obtained as a result of the analysis, it can be concluded that drainage of the urinary bladder in case of AUR by using a trocar epicystostomy bears subjective difficulties no more often than by other methods discussed herein, with a consistently high percentage of successful procedures that eliminated the need for repeated drainage. Trocar epicystostomy was accompanied by the least number of infectious and inflammatory diseases of the lower urinary tract that could be performed exclusively under local anesthesia; therefore, it can be recommended as a method of choice for preoperative drainage of the bladder.

The authors declare no conflict of interests.

About the authors

Denis O. Gusev

Samara City Clinical Hospital No. 8

Author for correspondence.
Email: k.mary96@mail.ru

Urologist

Russian Federation, Samara

Allahverdi Dilan ogly Adilov

Orenburg State Clinical Hospital No. 1

Email: k.mary96@mail.ru

Andrologist

Russian Federation, Orenburg

Sergey M. Pikalov

Samara Regional Clinical Hospital named after V.D. Seredavin

Email: Serpik66@mail.ru

Urologist, Head of the Urology Department

Russian Federation, Samara

Alexander A. Zimichev

Samara State Medical University

Email: zimichew@mail.ru

Doctor of Medical Sciences, Associate Professor, Department of Urology

Russian Federation, Samara

References

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