Scandinavian Journal of Urology

ISSN: 2168-1805 (Print) 2168-1813 (Online) Journal homepage: https://www.tandfonline.com/loi/isju20

The morbidity associated with a TURP procedure

in routine clinical practice, as graded by the
modified Clavien-Dindo system

Erik Sagen, Ruji-On Namnuan, Hans Hedelin, Olle Nelzén & Ralph Peeker

To cite this article: Erik Sagen, Ruji-On Namnuan, Hans Hedelin, Olle Nelzén & Ralph
Peeker (2019): The morbidity associated with a TURP procedure in routine clinical practice,
as graded by the modified Clavien-Dindo system, Scandinavian Journal of Urology, DOI:
10.1080/21681805.2019.1623312

To link to this article: https://doi.org/10.1080/21681805.2019.1623312

Published online: 03 Jun 2019.

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SCANDINAVIAN JOURNAL OF UROLOGY
https://doi.org/10.1080/21681805.2019.1623312

ARTICLE

The morbidity associated with a TURP procedure in routine clinical practice,

as graded by the modified Clavien-Dindo system
Erik Sagena,b , Ruji-On Namnuana, Hans Hedelinb, Olle Nelz
enc and Ralph Peekerb
a
Department of Urology, Hospital of Skaraborg, Sk€ovde, Sweden; bInstitute of Clinical Sciences at the Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden; cResearch and Development Centre, Hospital of Skaraborg, Sk€ovde, Sweden

ABSTRACT ARTICLE HISTORY

Background: Transurethral resection of the prostate (TURP) is considered the reference surgical Received 28 February 2019
method of treating benign prostatic enlargement (BPE) causing obstruction. The procedure still carries Revised 20 April 2019
a significant risk of perioperative morbidity according to previous reports. The aim of the present Accepted 20 May 2019
study was to disclose complications after TURP undertaken in routine clinical practice at a non-aca-
KEYWORDS
demic center. TURP; complications;
Methods: All patients with BPE submitted to TURP from January 2010 to December 2012 were eval- Clavien-Dindo
uated for complications occurring during hospital stay, after discharge up to the end of the third post-
operative month and finally for any late endourological re-interventions undertaken up to five years
after TURP. All complications were graded according to the Clavien-Dindo system.
Results: In total, 354 men underwent a TURP during the study period. In total, 47% had pre-operative
urinary retention. Significant co-morbidity was seen in 17% of men (ASA III–IV). Spinal anaesthesia was
applied to 312 men (88%). During hospital stay, major complications, graded as Clavien-Dindo
III,
was seen in only eight men (2.3%). Minor complications occurred in 91 men (26%). Between hospital
discharge and follow-up visit major complications were noted in 12 men (3.4%). Minor complications
occurred in 79 men (22%). The only factor that was associated with an increased risk of a major com-
plication was general anaesthesia. Late complications, requiring an endourological re-intervention,
occurred in 30 men (9.7%).
Conclusion: TUR-P in routine clinical practice was associated with a low incidence of severe complica-
tions. TUR syndrome was very rare. Within five years a small proportion of men require the transureth-
ral intervention to be redone.

Introduction The aim with the present study was to disclose the fre-
quency and severity of peri- and post-operative complica-
Transurethral resection of the prostate (TURP) is considered
tions associated with a TURP procedure.
the reference surgical method of treating benign prostatic
enlargement (BPE) causing obstruction [1,2]. The method has
excellent, well-documented results regarding post-operative Materials and methods
voiding as well as rendering a high proportion of men with
urinary retention catheter free [3]. However, TURP still carries The present study was based on a cohort previously
a significant risk of perioperative morbidity according to pre- described by the authors [12] comprising of 354 men oper-
vious reports. Short- to medium-term complications include ated on with TURP at Skaraborgs Hospital in Sweden. Data
urinary tract infections (UTI), bleeding requiring blood trans- regarding peri- and post-operative complications were col-
fusions, electrolyte imbalances and permanent incontinence lected prospectively. The local Ethical Committee at the
[4–6]. Long-term complications include urethral strictures, University of Gothenburg approved of the study (Dnr
bladder neck contractures (BNC) and re-operation due to 202-15).
residual adenomas [7–9]. The definition of pre- and perioperative variables, as well
Following a systematic review on BPE with obstruction, as the surgical procedure and perioperative care, have previ-
from the Swedish Council on Health Technology Assessment ously been described. In brief, baseline characteristics col-
in 2011, a number of areas in need of further research were lected before surgery included patient age, body mass index
identified. Contemporary data on the morbidity associated (BMI), American Society of Anaesthesiologists’ classification
with a TURP procedure from routine urological practice was (ASA), transrectal ultrasound volume of the prostate (TRUS)
asked for [10]. Such a need has also been brought forward and the use of clean intermittent self-catheterisation (CISC)
in the reporting of complications in a validated and standar- or the presence of an indwelling catheter. Invasive uro-
dised fashion [11]. dynamics, including pressure-flow studies, was not routinely

CONTACT Erik Sagen [email protected] Department of Urology, Hospital of Skaraborg, 541 85 Sk€
ovde, Sweden
ß 2019 Acta Chirurgica Scandinavica Society
2 E. SAGEN ET AL.

used. Perioperative variables included anaesthesia type, dur- grades I and II were pre-defined as mild-to-moderate compli-
ation of surgery, surgeons experience, weight of resected cations and Clavien-Dindo grades
III as major
tissue, blood loss, irrigation fluid balance, post-operative complications.
catheter drainage time and duration of hospital stay. Treatment of a suspected and/or a confirmed urinary tract
Hospital stay was calculated in days, starting from anaesthe- infection with either intravenous or oral antibiotics, during
sia start up until the time of discharge from hospital. hospital stay or treated with oral antibiotics by the primary
care physician after discharge and until follow-up was
defined as a Clavien-Dindo grade II complication.
Surgical procedure and perioperative care During a period of five years after surgery, supplementary
The TURP procedure was performed using a Ch 26 monopo- endourological interventions, e.g. redo-TURP, incision of BNC,
lar resectoscope set at 180W cutting and 80W coagulation internal urethrotomy, were registered. These data were col-
mode (dry cut). Treatment with anti-aggregants and anti- lected retrospectively.
coagulants was discontinued three and five days, respect-
ively, before surgery. A preoperative INR of <1.4 was
Statistical analysis
accepted. A pre-operative urine culture was available for all
patients. Patients with a pre-operative negative urine culture Median values with quartiles were presented as descriptive
were given a single prophylactic dose of an antibiotic, while statistics for continuous variables, as most of them were of
patients with an indwelling catheter and/or a positive urine ordinal data type. For categorical variables, frequencies and
culture were treated against bacteriuria for ten days, starting percentages were presented. To explore the association
the day before surgery. Thirteen surgeons, of whom six were between pre-operative variables and complications we used
residents-in-training, performed the operations. Post-opera- a logistic regression model. All variables with a p-value < 0.2
tively a Ch 22 three-way catheter was inserted and bladder in a univariate analysis were included in the multivariate
irrigation was commenced with normal saline solution. A trial model. A p-value < 0.05 was considered statistically signifi-
without a catheter (TWOC) was as a rule initiated on the first cant. All data were analysed using SPSS version 22.0 (Inc,
post-operative day and the patient was encouraged to void. Chicago, IL).
If this trial failed up to a maximum of three attempts during
the following days, the patient was sent home with an
indwelling catheter and returned to the ward for a new
Results
attempt two weeks later. In total, 354 men underwent a TURP procedure. Patient
demographics are presented in Table 2. In total, 47% of men
were operated on due to urinary retention; 135 men used
The categorisation of complications
CISC and 30 men had an indwelling catheter prior to the
The complications were assessed into three subcategories; operation. Significant co-morbidity was seen in 17% of men
(1) hospital stay, (2) the time between discharge from hos- (ASA III–IV).
pital and the follow-up visit after three months and (3) late Perioperative variables are presented in Table 3. Spinal
endourological re-interventions within five years. anaesthesia was applied to 312 (88%) patients and the
remainder had general anaesthesia. The total cohort mean
resection speed was 0.37 g/min, mean blood loss per resec-
Defining and grading of complications tion time was 2.81 mL/min and mean blood loss per
Complications were defined and graded according to the
modified Clavien-Dindo system (Table 1) [13]. Clavien-Dindo Table 2. Patient demographics (n ¼ 354).
Median IQR
Table 1. The Clavien-Dindo grading system for the classification of surgical Age 70 63–76
complications. BMI 26 24–29
TRUS (cc) 50 37–66
Grade Definition PSA 3.2 1.7–5.8
I Any deviation from the normal post-operative course without IPSS (0–35) 20 15–25
the need for pharmacological treatment or surgical, Bother score (0–6) 4 3–5
endoscopic and radiological interventions. Acceptable Qmax (mL/s) 7.4 5.2–9.8
therapeutic regimens are: drugs such as antiemetics, PVR (mL) 185 75–450
antipyretics, analgesics, diuretics and electrolytes and
physiotherapy. This grade also includes wound infections n %
opened at the bedside. Indwelling catheter 135 38
II Requiring pharmacological treatment with drugs other than CISC 30 9
those allowed for grade I complications. Blood transfusions ASA grade
and total parenteral nutrition are also included. I 105 30
IIIa Requiring surgical, endoscopic or radiological intervention not II 189 53
under general anaesthesia III 59 16.7
IIIb Requiring surgical, endoscopic or radiological intervention under IV 1 0.3
general anaesthesia
BMI, body mass index; TRUS, transurethral ultrasound scan; PSA, prostate spe-
IVa Single organ dysfunction (including dialysis)
cific antigen; IPSS, international prostate symptom score; Qmax, maximal urine
IVb Multiorgan dysfunction
flow; PVR, post-void residual urine; CISC, clean intermittent self-catheterisation;
V Death
ASA, American Society of Anaesthesiologists.
 SCANDINAVIAN JOURNAL OF UROLOGY 3

resection weight was 7.7 mL/g. A median of 46% (25%) during the follow-up period. Five men and one man
(IQR ¼ 38–53) of the preoperative TRUS volume was resected. suffered from two and three complications, respectively.
Table 4 shows complications occurring during hospital Again, the vast majority of complications were mild-to-mod-
stay and categorized according to the Clavien-Dindo system. erate in nature. Major complications were noted in 12
In all, 100 complications occurred in 89 men (25%) during men (3.4%).
the hospital stay. Eleven men suffered from two complica- One episode of fulminant TUR syndrome, requiring treat-
tions during the hospital stay. The vast majority of complica- ment in the ICU, was noted and one mild case of TUR syn-
tions were of mild nature comprising Clavien-Dindo grades I drome was managed by the administration of electrolytes on
and II. Failure to void following TWOC was seen in 57 men the urology ward. One patient required bilateral percutan-
(16%), of whom 41 men had been operated on due to urin- eous nephrostomies post-operatively due to hydronephrosis
ary retention and 16 men due to LUTS alone. These men and a raised creatinine level. One patient died during the fol-
were sent home with an indwelling catheter and a further low-up period. This was unrelated to the TURP procedure.
TWOC was performed two weeks later on the urology ward. In univariate analysis, the risk of suffering a major compli-
Major complications, graded as Clavien-Dindo
III were seen cation, defined as a Clavien-Dindo grade
III, was signifi-
in eight men (2.3%). cantly higher in men receiving general anaesthesia for TUR-P
Table 5 shows complications occurring after discharge (p-value ¼ 0.045) and there was a tendency for association
from hospital and up to the planned follow-up visit three (p-value < 0.2) with respect to ASA grade, greater surgical
months later. In total, 97 complications occurred in 90 men experience and irrigation fluid balance (Table 6). The four
variables were included in a multivariate model and the only
Table 3. Perioperative variables (n ¼ 354). variable that remained statistically significant was general
Median IQR anaesthesia (p-value ¼ 0.008 and OR ¼ 5.3 with
Operation time (min) 63 48–83 95% CI ¼ 1.5–18.3).
Resection weight (g) 23 14–35 The cohort was followed for five years and 310 men
Blood loss (mL) 177 67–440
Irrigation fluid balance (mL) –215 552–100 remained for final analyses. Forty-four men had died during
Catheter time (h) 19 15–39 this period. Late complications, requiring an endourological
Hospital stay (days) 2 1–3 re-intervention, occurred in 30 men (9.7%). These included
Catheter-free at discharge (%) 84
BNC, urethral strictures and residual adenomas in nine

Table 4. Complications occurring during hospital stay graded according to Clavien-Dindo grade (n ¼ 354).
Grade n (%) Complication type
I 63 (18) Urinary retention/failure to void (n ¼ 57)
Mild TUR syndrome (n ¼ 1)
Miscellaneous including vasavagal reactions, syncope, falls (n ¼ 5)
II 36 (10) Urinary tract infection requiring peroral antibiotics (n ¼ 12)
UTI requiring intravenous antibiotics (n ¼ 16)
Anaemia requiring blood transfusion (n ¼ 9)
IIIa 4 (1.1) Bladder tamponade requiring evacuation of blood clot (n ¼ 3)
Raised creatinine/hydronephrosis requiring percutaneous drainage (n ¼ 1)
IIIb 3 (0.8) Bladder tamponade requiring evacuation of blood clot (n ¼ 3)
IVa 2 (0.6) Hypovolaemic shock (n ¼ 1)
TUR syndrome (n ¼ 1)
IVb 0
V 0
TUR syndrome, transurethral resection syndrome caused by absorption of irrigating fluids leading to dilutional hyponatraemia
of varying severity.
UTI: urinary tract infection.

Table 5. Complications occurring between hospital discharge and follow-up graded according to Clavien-Dindo
grade (n ¼ 354).
Grade n (%) Complication type
I 40 (11) Haematuria requiring drainage and irrigation (n ¼ 9)
Urinary retention (n ¼ 28)
Meatal stricture requiring clean intermittent dilatation (n ¼ 3)
II 45 (13) UTI requiring peroral antibiotics (n ¼ 39)
UTI requiring intravenous antibiotics (n ¼ 3)
Deep venous thrombosis (n ¼ 2)
Blood transfusion (n ¼ 1)
IIIa 5 (1.4) Bladder tamponade requiring evacuation of blood clot (n ¼ 3)
Meatal stricture requiring surgery (n ¼ 2)
IIIb 4 (1.1) Bladder tamponade requiring evacuation of blood clot (n ¼ 4)
IVa 2 (0.6) Urosepsis (n ¼ 1)
Myocardial infarction (n ¼ 1)
IVb 0
V 1 (0.3) Death following hepatitis and surgery for a femoral fracture (n ¼ 1)
UTI: urinary tract infection.
4 E. SAGEN ET AL.

Table 6. Univariate analysis of factors that influence the incidence of major complications (Clavien-Dindo
III).
Severe complications during hospital stay and/or during
follow-up
Variable tested No Yes p-value
Median (IQR) Median (IQR)
Age 70 (63–76) 70 (65–75) 0.662
BMI 26.4 (24.4–28.7) 25.7 (22.7–27.4) 0.234
TRUS 50 (37–66) 52.5 (35–64) 0.688
PSA 3.2 (1.7–5.9) 3.5 (1.1–4.3) 0.546
OR time 63 (48–83) 64 (54–82) 0.953
Resection weight 23 (14–35) 23 (10–39) 0.699
Irrigation fluid balance 224 (553; 69) þ107 (452; 522) 0.102
Blood loss 170 (69–433) 246 (66–549) 0.642
ASA grade 2 (1–3) 2 (2–3) 0.122
n (%) n (%)
Catheter use 0.848
No 178 (94) 11 (6)
Indwelling catheter 128 (95) 7 (5)
CISC 29 (97) 1 (3)
Surgeon experience 0.154
Specialist 162 (96) 6 (4)
Resident 173 (93) 13 (7)
Anaesthesia type 0.045
Spinal 298 (95) 14 (5)
General 37 (88) 5 (12)

(2.9%), five (1.6%) and 16 men (5.2%), respectively. The haemoglobin levels post-operatively and, hence, there might
median re-intervention time period was seven months have been an under-estimation regarding the need for a
(IQR ¼ 5–14) after the first TURP. blood transfusion. However, it should be emphasised that
transfusions carry a risk of adverse reactions [18] and its rou-
tine use should be avoided unless appropriate indications
Discussion
are met. Conversely, the incidence of post-operative infec-
The majority of complications, sub-categorised between tions was high, this presumably due to the limited adherence
those occurring during hospital stay on the one hand and to relevant guidelines regarding pre-operative prophylaxis in
those occurring between discharge from the hospital and our department during the study period. Another possible
the follow-up visit at the outpatient clinic three months after explanation for the high incidence of UTI treatment after dis-
surgery on the other hand, were of minor-to-moderate charge from hospital might be that a man seeking help in a
Clavien-Dindo grade. The incidence of more serious compli- primary care setting with symptoms of urgency/frequency/
cations was very low. Fully developed TUR syndrome and dysuria could have been mistakenly judged to have a UTI
death during the postoperative period occurred once. The when in fact they suffered from well-known and very com-
third sub-category, late endourological reinterventions, com- mon post-operative irritative symptoms.
prised 30 out of 310 patients (9.7%), a percentage quite in We have reported failure to void following TURP as a
keeping with what has previously been reported [6,14]. Clavien-Dindo grade I complication. However, we are also of
Perioperative bleeding was low compared to other the firm opinion that a failure to void following catheter
reported series [7,8,15]. The prostate is a highly vascularised removal after TURP should not be regarded as a complica-
organ and some degree of bleeding is expected during any tion per se, but rather recognised as an undesired post-
surgical approach to BPE. Haemorrhage is the main cause of operative course. In a man with an indwelling catheter, or
surgical vision loss, which can lead to prolonged operation using CISC, it is not uncommon with failure to void immedi-
time, capsular perforation, fluid absorption and excessive use ately after a TURP. The return to the use of an indwelling
of irrigation fluids, all of which are risk factors for the TUR catheter may be prompted by several reasons, such as a
syndrome and sepsis [16]. Previous studies have shown that post-operative oedema of the resection cavity or a detrusor
the risk of bleeding increases with increased prostate size, under-activity that went unrecognised during the pre-opera-
longer operative time, increasing amount of tissue resected, tive workup. Catheter dependence at follow-up could be
general anaesthesia, the previous use of an indwelling cath- seen as occurring secondary to detrusor under-activity
eter and the use of antiplatelet or anticoagulation therapy [19,20]; invasive urodynamics with pressure flow studies was
[5,6,17]. Our technique using dry cut with high energy set- not routinely applied in the present series, and, hence, it is
tings for cutting (180 W) and coagulation (80 W) might be impossible to establish whether the men in the present ser-
one explanation for the low bleeding volume in our ies had detrusor under-activity.
study cohort. One man required bilateral percutaneous nephrostomies
There was a low incidence of blood transfusion in this post-operatively due to a rising creatinine level and hydro-
present series, mirroring the low blood loss during surgery. nephrosis confirmed by an ultrasound scan. This was most
In our department we do not routinely measure likely due to a high grade locally advanced prostate cancer,
 SCANDINAVIAN JOURNAL OF UROLOGY 5

that was subsequently recognised. Nevertheless, an acciden- reported by Mamoulakis et al. [13], represents a straightfor-
tal coagulation over both ureteral orifices during surgery is, ward and easily applicable tool that may help urologists to
of course, another possible explanation. classify the complications of TURP in a more objective and
One death occurred during the follow-up period. This detailed way. It may serve as a standardized platform of
occurred after discharge from the hospital and was judged communication among clinicians allowing for adequate com-
to be unrelated to the TURP procedure. The patient was parisons between studies.
readmitted to the hospital two weeks after TURP due to However, certain shortcomings limit its use in urology. In
chronic active hepatitis. During the subsequent hospital stay general, the Clavien-Dindo classification applies only to post-
he suffered from a fall, resulting in a femoral fracture neces- operative and not intra-operative complications. It is not
sitating surgery. Postoperative circulatory failure was the based on the severity and morbidity but on the magnitude
cause of his death. of the management of a complication. It does not differenti-
Two episodes of TUR syndrome were registered in this ate between early and late post-operative complications [30].
patient cohort. TUR syndrome is a serious and potentially Despite these limitations, we believe that it is an improve-
life-threatening complication of TURP, as one of the require- ment of the presently adopted varying outcome reporting
ments of monopolar resection is the use of hypotonic fluid. after surgical procedures in urology.
Early perforation of the capsule and venous sinuses results in A potential limitation, albeit also a strength, in our study
the absorption of hypotonic solution and a dilutional hypo- was that the operations were carried out by a heterogenous
natraemia. Previous reports have shown incidences of TUR
group of surgeons, including residents-in-training. Our results
syndrome between 0.8 and 1.4% [5,21]. Our results indicate
should be generalizable and reflect the realities of daily prac-
that modern TURP techniques can be performed with a very
tice at most urological departments worldwide.
low risk of TUR syndrome (0.6%).
The use of antibiotics, perioperative care and the access
Morbidity and mortality have declined during the deca-
to a refined instrument armamentarium have decreased the
des, even though we are operating larger prostates than was
mortality and the morbidity of the modern TURP. Although
the case in the past and even though men currently getting
technological advances have made for a safer procedure,
TURP are older and have more comorbidities than men from
intra-operative and post-operative events remain a concern
earlier TURP studies [7]. Regarding mortality, earlier studies
and have been a primary reason for the emergence of com-
from the 1960s and 1970s report rates of 1.3% and 2.5%,
petitors, for example transurethral microwave thermotherapy
respectively [22,23]. Mebust et al. [4] found a mortality rate
of 0.2% in 1989 and Reich et al. [5] a mortality rate of 0.1% [31], UroLift [32] and aqua-ablation [33]. However, it should
in 2008. be noted that even so-called minimally invasive techniques
The only significant factor that could predict a major com- are not performed without risk.
plication was the type of anaesthesia used. General anaes-
thesia was associated with a higher complication rate. It has
previously been shown that surgical stress and anaesthesia
Conclusion
cause immunosuppression that may predispose patients to
post-operative infections [24]. Spinal anaesthesia may be less TURP is nowadays associated with low peri- and post-opera-
immunosuppressive than general anaesthesia [25]. In a study tive morbidity. It is a safe procedure that should still be
by Reeves and Myles [26], spinal anaesthesia was shown to regarded as the gold standard method and offered to men
be associated with less adverse events during and after suffering from BPE-related problems. The Clavien-Dindo clas-
a TURP. sification is a simple, standardised and straightforward
Long-term complications have previously been reported approach to grade and report post-operative complications
to occur at a 2.2–9.8% rate of urethral strictures, a 0.3–9.2% related to the TURP procedure.
rate of BNC, and an overall retreatment rate of 3–14.5% [6].
In the present series, the corresponding incidence rates were
somewhat similar. In a large cohort study by Tasci et al. [27],
urethral strictures and BNC occurred in 3.2% and 1.1% of Acknowledgements
men, respectively, figures in keeping with our findings. Special acknowledgements to our statistician, Salmir Nasic, and our
The Clavien-Dindo system for classifying surgical compli- urology research nurses, Karin Jonsson and Kristel K€alleskog.
cations focuses mainly on the therapeutic consequences of a
complication, emphasizing the level of intervention required
to deal with it [28]. The system is usually used to report
complications occurring up to 90 days after surgery. The Disclosure statement
principal strength of this system is that it is standardised and No potential conflict of interest was reported by the authors.
has been well validated. Urologists have previously been
criticised for not using standardised methods of outcome
reporting [29]. Up to date there has been little use of the Funding
system in common urological procedures such as BPE-related This study was supported by a grant from The Research and
interventions. The modified Clavien-Dindo system, as Developement Centre at Skaraborgs Hospital.
6 E. SAGEN ET AL.

ORCID technique: a single-centre randomized trial of 202 patients. BJU

Int. 2010;105:1560–1564.
Erik Sagen http://orcid.org/0000-0001-8089-067X [16] Kavanagh LE, Jack GS, Lawrentschuk N. Prevention and manage-
Olle Nelz
en http://orcid.org/0000-0002-2631-2761 ment of TURP-related hemorrhage. Nat Rev Urol. 2011;8:504–514.
[17] Uchida T, Ohori M, Soh S, et al. Factors influencing morbidity in
patients undergoing transurethral resection of the prostate.
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