Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Surgery increased quality of life in benign prostatic hyperplasia

ACP J Club. 1995 July-Aug;123:1. doi:10.7326/ACPJC-1995-123-1-001


Source Citation

Wasson JH, Reda DJ, Bruskewitz RC, et al. for the Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med. 1995 Jan 12;332:75-9.


Abstract

Objective

To compare immediate transurethral prostatic resection (TURP) with watchful waiting in men with moderate benign prostatic hyperplasia (BPH).

Design

Randomized controlled trial with mean follow-up of 2.8 years.

Setting

9 U.S. Veterans Affairs medical centers.

Patients

556 consecutive men (mean age 66 y) who were referred to urology clinics with moderate BPH. Exclusion criteria were age < 55 years, previous prostatic surgery or radiation treatment, inability to walk, active urinary tract infection, prostatic or bladder cancer, postvoiding residual urine volume > 350 mL, elevated serum creatinine levels, and other serious illness. Follow-up was 95%.

Intervention

280 men were assigned to TURP within 2 weeks (249 had surgery); 276 men were assigned to watchful waiting. Patients were seen after 6 to 8 weeks and semi-annually for 3 years.

Main outcome measures

Treatment failure (mortality, repeated or intractable urinary retention, residual urinary volume > 350 mL, new bladder calculi, incontinence, high symptom scores, or increased serum creatinine levels). Secondary outcomes assessed the effect of urinary difficulties on activities of daily living, sexual function, social activities, and general well-being.

Main results

Compared with the watchful-waiting group, patients in the surgery group had fewer treatment failures; fewer occurences of urine retention, high residual urine volume, and high symptom scores; more diagnoses of prostatic cancer (Table); and more quality-of-life scores that improved. 24% of the watchful-waiting group ultimately had surgery. The groups did not differ for mortality, general well-being, social activities, and sexual performance.

Conclusion

Transurethral resection of the prostate compared with watchful waiting resulted in fewer treatment failures and reduced rates of urinary symptoms and provided a better quality of life on the basis of perceived urinary difficulties.

Source of funding: Department of Veterans Affairs Medical Research Council.

For article reprint: Dr. J.H. Wasson, Department of Veterans Affairs Medical and Regional Office Center, White River Junction, VT 05009, USA. FAX 802-296-5150.


Table. Immediate transurethral prostatic resection (TURP) vs watchful waiting for benign prostatic hyperplasia*

Outcomes at mean 2.8 y TURP Watchful waiting RRR (95% CI) NNT (CI)
Treatment failure 8% 17% 52% (23 to 70) 11 (7 to 30)
Occurrence of urine retention 0.4% 2.9% 88% (25 to 98) 39 (19 to 177)
High residual urine volume 1.1% 5.8% 82% (42 to 94) 21 (12 to 53)
High symptom score† 0.36% 4.3% 92% (51 to 99) 26 (15 to 57)
RRI (CI) NNH (CI)
Prostate adenocarcinoma 8.6% 2.9% 196% (38 to 537) 18 (11 to 53)

*Abbreviations defined in Glossary; RRR, RRI, NNT, NNH, and CI calculated from data in article.
†Defined as ≥ 21 on 2 consecutive measures or ≥ 24 on 1 measure (maximum symptom score is 27).


Commentary

TURP is currently the most common major surgical procedure in older men, but we know little about its efficacy and sequelae, particularly among patients with moderate symptoms. In these cases, use of surgical treatment largely depends on subjective factors, including patient preferences, urologist and primary care physician preferences, and socioeconomic factors. This randomized trial focuses on the large subgroup of patients who have moderate symptoms and for whom TURP is usually optional. The authors are to be congratulated on a meticulous study with careful follow-up and analysis. It makes a major contribution to the field.

With regard to clinical applications, 2 points should be mentioned. A minor but interesting point is the 10% detection rate of prostate cancer in the TURP group compared with 3% in the watchful-waiting group. Was this a benefit or a disadvantage of TURP?

The interpretation of this trial is even more important, particularly in light of the addition of finasteride (1) and terazosin (2) to the therapeutic armamentarium since the initiation of the trial. Although the quality of life in the surgery group improved, > 80% of those in the watchful-waiting group did not have treatment failure, and although 24% of the watchful-waiting group ultimately required surgery, > 75% did not. Clearly, little is gained by immediate surgery, particularly with the availability of pharmacotherapy to alleviate symptoms.

Alfred I. Neugut, MD, PhD
Columbia-Presbyterian Medical CenterNew York, New York, USA


References

1. Gormley GJ, Stoner E, Bruskewitz RC, et al. The effect of finasteride in men with benign prostatic hyperplasia. The Finasteride Study Group. N Engl J Med. 1992;327:1185-91.

2. Brawer UK, Adams G, Epstein H. Terazosin in the treatment of benign prostatic hyperplasia. Terazosin Benign Prostatic Hyperplasia Study Group. Arch Fam Med. 1993;2:929-35.


Author's Response

If TURP does not cause impotence or incontinence, what does a patient gain from medications? Compared with watchful waiting, how much will medications help a man not particularly bothered by his urinary problems? Long-term outcome information about BPH medications is lacking (1). We need to remind our patients of this.

John H. Wasson, MD

1. McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign prostatic hyperplasia: diagnosis and treatment. AHCPR Publication No. 94-0582. February 1994.


Author's update

Five-year follow-up (1) confirms these results.

1. Flanigan RC, Reda DJ, Wasson JH, et al. 5-year outcome of surgical resection and watchful waiting for men with moderately symptomatic benign prostatic hyperplasia: a Department of Veterans Affairs Cooperative Study. J Urol. 1998;160:12-7.