We compared the peri-operative, continence and oncological outcomes of RARP between matched men with and without previous history of TURP. The non-TURP group had more complete nerve sparing than the TURP group. The two groups did not statistically differ in the peri-operative, two-year continence and oncological outcomes. TURP-induced peri-prostatic adhesions and distorted planes contribute to the difficulty associated with the posterior dissection, bladder neck dissection and nerve-sparing in RARP.(8) The loss of elasticity of the bladder neck and friable urethral stump post-TURP can make the urethra-vesical anastomosis challenging.(9) Studies on open, laparoscopic and radical radical prostatectomy after TURP report a higher risk of PSM, blood loss and bladder neck stricture.(10),(11),(12),(13) Surgical robotic platforms with magnified three-dimensional vision and wristed instruments have been shown to aid the surgeon in challenging dissections. Few studies have compared the outcomes of RARP in men with a prior history of TURP.
In the late 2000s, Martin et al. compared RARP versus Open Retropubic Radical Prostatectomy in men who had previous TURP history.(14) 24 men with prior TURP and/or brachytherapy were compared to 510 men without TURP without matching. The groups did not differ in blood loss, hospital stay, operative time, peri-operative, oncological and continence outcomes.(14) Another study by Gupta et al. compared 26 men with TURP history versus 132 unmatched men without prior TURP.(15) This study found more blood loss and poorer continence rates at six and twelve months follow-up (p = 0.07). This study included a predominantly High D’amico risk group (68.35%), which is characteristic of the distribution found in unscreened populations.(15)
An unmatched comparison by Su et al. involving 2693 men reported a significantly more blood loss, console time, hospital stay and poorer continence at 12 months in post-TURP men.(16) Some of the early studies even recorded a higher incidence of rectal injury (18.75% vs. 0%, P < 0.001) and major complications (18.8% vs. 1.1%, P < 0.001).(17) A recent comparative study from the US found no remarkable difference in perioperative, oncological and functional outcomes in post-TURP men on three-year follow-up.(18) Our study demonstrated no significant difference in blood loss, console time, hospital stay, postoperative BCR and continence rates in the TURP group, even at two years of follow-up.
Tugcu et al. compared RARP outcomes in 25 men with prior TURP/Open simple prostatectomy versus 36 matched men who did not. They found longer console time (195 vs 160 min, p = 0.016), more blood loss (p = 0.001) and frequent need for bladder neck reconstructions (p = 0.001) in the post-TURP men. A significant proportion of post-TURP men developed more bladder neck/anastomotic strictures in this study. However, the study found no significant difference in the 12-month continence and potency rates between the groups.(19)
Zugor et al. conducted a propensity score-based matched-pair analysis of RARP outcomes in eighty men with and without previous TURP. This study found longer console times (189 min versus 149 min, p = 0.069) and more frequent bladder neck reconstructions (58.7% versus 2.5%, p = 0.073) in the TURP group, albeit statistically insignificant. Duration of hospital stay, PSM, continence (87.5% versus 91.25%) and potency rates (70.3%/86.5%) were unremarkable among the groups in the study.(20) Another matched-pair analysis from India revealed higher but statistically insignificant rates of PSM (30.5% versus 25%, p = 0.54) in post-TURP men. However, this study did not find any significant difference between the one-year oncological and continence outcomes. On multivariate analysis, previous TURP was not associated with any higher risk of PSM, BCR, or incontinence. However, this study involved an unscreened population with predominantly D’amico high-risk prostate cancers.(21)
Liu et al. recently published their systematic review/meta-analysis on this topic. Eight comparative studies involving 4186 patients were analysed. The TURP group had longer console times (p = 0.002), higher blood loss (p = 0.006), and bladder neck reconstruction rates (p = 0.03). The TURP group had high PSM (p = 0.007) with comparable hospital stay, nerve sparing, complication rates, continence recovery, potency and BCR rates on follow-up.(22)
Limitations of the study:
Our study is a matched study comparing the long-term outcomes of RARP in men with a history of TURP from a high-volume referral centre in the UK. However, it is not without limitations. This is a single-centre, retrospective study conducted among men presenting with predominantly D’amico low and intermediate-risk prostate cancer (> 50% of sample size). Therefore, the results may not be extrapolated to men with high-risk prostate cancer. Despite propensity score-matching, the sample size was small to perform sub-group analysis. Bladder neck reconstruction, duration of catheterisation, potency rates and urethral stricture/bladder neck stenosis rates were not compared due to incomplete data.