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UDC 616.65-007.61-089.85-06-036-07
ASSESSMENT OF COMPLICATIONS OF TRANSURETHRAL RESECTION OF
THE PROSTATE USING THE CLAVIEN-DINDO CLASSIFICATION
Nadjimitdinov Ya.S.,
Associate Professor, PhD, Department of Urology, Tashkent Medical Academy
Akhmadaliev T.G.,
Master's student of the Department of Urology, Tashkent Medical Academy
Khusanov S.M.
Urologist
Abstract:
From 2020 to 2024, transurethral resection of the prostate was performed in 124
men with benign prostatic hyperplasia, the average age of patients was 67.8 ± 6.1 years. The
volume of adenoma before surgery was 94.25 ± 2.83 ml3. The overall complication rate was
19.4%. Additional interventions after adenoma removal were performed in 4 (3.2%) men
due to bleeding from the prostate bed (vascular coagulation) and bladder neck sclerosis
(transurethral resection).
Keywords:
Clavien-Dindo, complications, transurethral resection of the prostate
ОЦЕНКА ОСЛОЖНЕНИЙ ТРАНСУРЕТРАЛЬНОЙ РЕЗЕКЦИИ ПРОСТАТЫ С
ИСПОЛЬЗОВАНИЕМ КЛАССИФИКАЦИИ CLAVIEN-DINDO
Аннотация:
За период с 2020 по 2024 года выполнена трансуретральная резекция
простаты 124 мужчинам с доброкачественной гиперплазией простаты, средний
возраст пациентов был 67,8± 6,1 лет. Объем аденомы до операции составил 94,25±2,83
мл3. Общая частота осложнений составила 19,4%. Дополнительные вмешательства
после удаления аденомы выполнены у 4 (3,2%) мужчин в связи с кровотечением из
ложа простаты (коагуляция сосудов) и склероза шейки мочевого пузыря
(трансуретральная резекция).
Ключевые слова:
Clavien- Dindo, осложнения, трансуретральная резекция простаты.
Introduction
According to the European Association of Urology (EAU), benign prostatic hyperplasia
(BPH) is one of the most common diseases in elderly men [1]. After the age of 50, BPH is
diagnosed in 30%-40% of men, and its prevalence increases to 70%-80% in individuals over
80 years old.
Lower urinary tract symptoms (LUTS) are the main complaints in men with prostate
pathology, causing discomfort and negatively impacting quality of life. Organic infravesical
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obstruction caused by BPH leads to benign neurogenic bladder dysfunction, particularly
detrusor overactivity. If left untreated for a long time, obstruction often results in
complications such as recurrent urinary tract infections (UTIs), hematuria, bladder stone
formation, and acute or chronic urinary retention [2].
Watchful waiting (careful observation) is one of the treatment options, except in patients
with BPH complications. A decrease in urinary flow rate, the presence of residual urine,
hematuria, and upper urinary tract dysfunction are absolute indications for surgical
intervention. Transurethral resection of the prostate (TURP) remains the gold standard for
treating men with a prostate volume of 30-80 cm³ [1]. Following this procedure, patients
experience improved lower urinary tract function and a corresponding improvement in
quality of life in more than 70% of cases [3].
Despite advances in innovative technologies and the use of bipolar resectoscopes, surgical
intervention is still associated with intra- and postoperative complications. Although the
mortality and postoperative complication rates have decreased in recent years, they remain
significant, ranging from 0.1% to 11.1% [4]. Therefore, an analysis of the causes and
structure of postoperative complications is necessary to prevent their occurrence in the
future.
The Clavien-Dindo classification, proposed by Clavien P.A. and Dindo D., is the most
widely used tool for systematizing postoperative complications of TURP in surgery [5].
Mamoulakis C. et al. modified this classification to assess the severity of surgical
interventions performed for prostate pathology [6].
Objective
This study aims to assess post-TURP complications based on the Clavien-Dindo
classification, performed in a private clinic setting.
Materials and Methods
A retrospective analysis was conducted on 124 men with BPH who underwent TURP
between January 2020 and December 2024.
The mean age of the patients was 67.8±6.1 years (range: 57 to 80 years).
Preoperative assessments included:
Clinical and laboratory tests of blood and urine
Measurement of prostate-specific antigen (PSA) levels
Evaluation of LUTS severity using the International Prostate Symptom Score (IPSS)
Uroflowmetry to determine lower urinary tract dysfunction
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The surgical procedure was performed using a bipolar resectoscope (26Fr, Karl Storz,
Germany) following a standard technique.
A urethral catheter was inserted postoperatively and removed 2-3 days after surgery.
Patients were monitored for 90 days postoperatively.
To determine complications based on the Clavien-Dindo classification, we developed the
concept of “standard” postoperative course.
Criteria for a "standard" postoperative course:
Slight hematuria in urine flowing through the urethral catheter or cystostomy drainage is
allowed, but without blood clots or a decrease in serum hemoglobin levels.
Criteria for a "standard" postoperative course (continued):
Subfebrile fever or hyperthermia above 38°C, without chills, of short duration (no more than
one day) and easily controlled with antipyretics, without clinical or laboratory signs of
pyelonephritis exacerbation or sepsis.
Absence of inflammatory complications in scrotal organs.
No drainage dysfunction that leads to bladder emptying disorders or an increase in serum
creatinine due to upper urinary tract dysfunction.
Statistical Analysis
Simple descriptive statistics were performed using IBM SPSS Statistics for Windows,
version 20.0.
Results
Mean prostate/adenoma volume before surgery, measured by transrectal sonography:
94.25±2.83 cm³
Mean weight of removed tissue during TURP: 84.25±4.22 g
Mean duration of the surgical procedure: 74.53±6.80 min
Mean hospital stay: 4.38±1.19 days
A total of 24 patients (19.4%) experienced complications after TURP, deviating from the
standard postoperative course (see table).
Five patients (I degree) required increased urethral catheter tension due to hematuria,
without blood clots or drainage dysfunction.
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In two of these patients, catheter replacement and blood transfusion were additionally
performed (II degree).
Five patients (4.0%) developed urinary tract infections (UTIs) (I degree), confirmed by
clinical and laboratory data.
Two patients (1.6%) developed acute orchiepididymitis (I degree).
Enhanced antibacterial therapy successfully managed the infectious-inflammatory
complications of TURP.
Two patients (2.4%) experienced urinary incontinence, treated with a comprehensive
approach including anticholinergics, nonsteroidal anti-inflammatory drugs (NSAIDs), and
physiotherapy (II degree).
Two patients (4.4%) developed postoperative bleeding from the adenoma bed, leading to
blood clot formation in the bladder and tamponade (IIIb degree).
These patients underwent coagulation of bleeding vessels, blood transfusion, and
subsequently had no further bleeding episodes.
Table.
Complications of TURP from the perspective of the modified classification Clavien-
Dindo (n=124).
Degree
Complication
Therapy
Number
of
patients (%)
I
Intense blood staining of urine
through catheter
Acute pyelonephritis
Acute orchiepididymitis
Infusion
therapy,
increasing
catheter
tension
Correction
of
antibacterial therapy
5 (4,0)
5 (4,0)
2 (1,6)
II
Bleeding from the bed of the
removed prostate, impaired
drainage function due to blood
clots
Urinary incontinence
Blood
transfusion,
bedside
catheter
replacement
Cholinolytics,
physiotherapy
2 (4,4%)
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3 (2,4)
IIIb
Bleeding from the bed of the
removed
prostate,
bladder
tamponade
Postoperative sclerosis of the
neck of the bladder
Cystoscopy, coagulation
of bleeding vessels of the
bed of the removed
adenoma
TUR of sclerosis
2 (1,6)
2 (1,6)
IVb
TUR syndrome
Treatment in the intensive
care
unit
(diuretics,
infusion therapy)
3(2,4)
Total
24 (19,4)
Syndrome after Transurethral Resection of the Prostate (TURP)
The syndrome after TURP was observed in three patients (2.4%), who were transferred to
the intensive care unit for appropriate treatment. After therapy, the patients were moved
back to the ward, the urethral catheter was removed, and the rehabilitation period proceeded
without complications. After 4 months, two patients developed bladder neck sclerosis, as
shown by urethrogram, and they underwent TURP of the narrowed section, with subsequent
good results.
Discussion
In our study, the incidence of postoperative complications was 24.74%, which is consistent
with the results of other authors who used the Clavien-Dindo classification of complications
(9.1%-34.4%) [7].
Agrawal M. et al. identified 9.1% complications after TURP, a lower rate than in our study
[8]. This difference is attributed to the fact that patients with urinary incontinence were
treated by a general practitioner. Bladder neck stricture typically develops after three to four
months following TURP, whereas the authors observed patients for only two months.
According to Mamoulakis C. et al. [6], the overall complication rate was 15.7%, though
more patients had urethral catheters before the operation (70.1%) compared to our study
(19.7%). Additionally, the average prostate size before surgery in our study was larger than
in the study by these authors (94.25±2.83 cm³ vs 80.88±12.02 cm³, p<0.004). These factors
are thought to negatively affect the complication rates.
The overall complication rate reported by Agrawal M. et al. was 34.4%, which is higher than
the rate in our study [7]. However, it is notable that these authors considered transitory
postoperative hematuria as a complication. We believe that hematuria that does not require
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medical treatment occurs in all patients after TURP and should not be classified as a
complication unless it necessitates blood transfusion or interventions for clot evacuation
and/or vascular coagulation. Additionally, urethral catheter dysfunction due to blood clots
should not be regarded as a complication, as this is usually resolved by flushing the catheter.
Stress urinary incontinence was observed in three patients (2.4%). One patient regained
bladder control after 6 months, while the other two showed significant improvement, though
some degree of stress incontinence persisted.
Bladder neck sclerosis developed in two patients (4.4%), who underwent TURP of the
sclerosis tissue. After this procedure, their urination became satisfactory. Some authors
report the incidence of bladder neck sclerosis or posterior urethral stricture as 2.2%-9.8%
[4,5]. In our study, the incidence of bladder neck sclerosis was lower due to the use of a
resectoscope with continuous irrigation flow, which avoids the need for frequent instrument
removal to decompress the bladder, as well as the larger prostate/adenoma volume.
Conclusion
TURP is an effective treatment method for patients with prostatic adenoma, associated with
minimal life-threatening complications that can be easily managed.
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