Background: Transurethral resection of prostate (TURP) is the gold standard in the surgical treatment of symptomatic benign prostatic hyperplasia (BPH). Blood loss is one of the most common complications of TURP. Objective: To evaluate the effect of preoperative dutasteride on bleeding related to TURP in patients with BPH. Materials and Methods: This prospective interventional study was done in the department of urology, Dhaka Medical College Hospital, Dhaka, Bangladesh during the period of July 2016 to June 2017. A total of 70 cases of BPH planned for TURP were included in this study according to the statistical calculation. Patients were randomly allocated to control group A (TURP without dutasteride) and dutasteride group B (TURP with dutasteride). Each group consisted of 35 patients. Group B patients were treated with dutasteride 0.5 mg/day for 4 weeks before TURP. The main outcome of blood loss was evaluated in terms of reduction in serum hemoglobin (Hb) and hematocrit (Hct) levels, which were measured before and 24 hours after surgery. Data were analyzed and compared by statistical tests. Results: Comparison of outcome between groups shows that there was a significant difference in term of pre-post operative change of hemoglobin and hematocrit levels in the control group A compared to the dutasteride group B (Hb = 2.96 ± 0.80 gm/dl vs. 1.81 ± 0.71 gm/dl, respectively, p = 0.001; Hct = 11.20% ± 2.12% vs. 6.07% ± 2.02%, respectively, p = 0.02). A significant lower mean blood loss was observed in the dutasteride group compared to the control group. Conclusion: Preoperative dutasteride therapy reduces blood loss related to TURP in patients with BPH. This therapy can be practiced to reduce surgical bleeding associated with TURP.
Benign prostatic hyperplasia (BPH) is the most common urological problem. Patients with BPH who do not respond to medical treatment often undergo transurethral resection of the prostate (TURP), the gold standard for surgical treatment [
This prospective interventional study was carried out in the department of urology, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh during the period of July 2016 to June 2017. This study was approved by the Ethical Review Committee, Dhaka Medical College, Dhaka, Bangladesh. Written informed consent was taken from every case. Each study subject was evaluated by history, physical examination and investigations. History was taken regarding lower urinary tract syndrome (LUTS), urinary tract infection, bronchial asthma, diabetes mellitus, hypertension, ischemic heart disease, any hematological disorders and any prostatic or urethral surgery. Physical examination included general examination, examination of the renal region and other parts of genitourinary system. All patients were investigated properly by-Urine for R/M/E and C/S to identify urinary tract infection (UTI), if any infection detected that was treated according to antimicrobial sensitivity; Serum prostate-specific antigen (S. PSA) to exclude carcinoma of prostate; S. Creatinine to exclude renal insufficiency due to obstructive uropathy; S. Electrolyte to identify any electrolyte imbalance; Complete blood count (CBC) was done to see Hemoglobin (Hb) levels, Hematocrit (Hct) levels, Platelet counts, etc; Blood for Bleeding time (BT), Clotting Time (CT), Prothrombin time (PT) and Activated partial thromboplastin time (APTT) were done to see any coagulation disorder; Ultrasonogram of KUB with post void residue (PVR) was done to evaluate the size, volume and echo-texture of prostate and any hydronephrotic change or hydroureter or any other pathology in the KUB region; Uroflowmetry to see urinary flow rate.
A total of 70 cases of symptomatic BPH planned for TURP were selected. Patients with BPH who did not respond to medical therapy with an alpha-blocker, urinary refractory retention, chronic retention of urine and recurrent UTI were selected. Patients were excluded if they had chronic renal failure, any bleeding disorder, previous prostatic or urethral surgery, recurrent gross hematuria, bladder stones and evidence of prostate cancer. Patients who received any 5ARI (Finasteride or dutasteride) or aspirin or antiplatelet drugs before the study and had a previous hypersensitivity to dutasteride were also excluded. If serum prostate-specific antigen (S. PSA) levels were found high (>4 ng/ml), transrectal ultrasound guided prostate biopsies were carried out before TURP.
Total seventy (70) patients were allocated. Among them, the control group A (TURP without dutasteride) consisted of 35 patients did not receive preoperative dutasteride and the dutasteride group B (TURP with dutasteride) consisted of 35 patients were treated with dutasteride 0.5 mg/day for 4 weeks before TURP. All the odd-numbered cases were allocated for group A; the even-numbered cases were allocated for group B. Patients who had a perforation of the prostatic capsule during surgery were excluded from the study and the same allocation was replaced by the successive cases. There were no reported adverse events that considered to be drug-related.
TURP was done under a standard protocol of the operative procedure with spinal anesthesia in the dorsal lithotomy position. After urethrocystoscopy to see the anatomical landmark and morphology of enlarged prostate, urethral dilatation was done by Otis urethrotome up to 28 Fr. TURP was performed with a continuous flow 26 Fr. Resectoscope with 1.5% glycine irrigation fluid. Resection was started at 11 O’clock (right lobe) or 1 O’clock (left lobe) then gradually downwards up to the level of 6 O’ clock position. After the completion of one lobe, another lateral lobe was resected in a similar fashion. If the median lobe ease enlarged, it was resected first to increase the flow of irrigation fluid. The depth of resection was extended as far as the prostatic capsule. After complete resection systemic hemostasis was undertaken, starting at bladder neck particularly from mucosal margin at 5 and 7 O’clock position. Then each lateral lobe was checked from 1 to 5 (clockwise, Left lobe) and 7 - 11 O’clock (counterclockwise, Right lobe). All chips of prostatic tissue were evacuated with Ellik’s evacuator. Prostate volume was measured and sends for histopathological examination. The procedure was performed by the urologists. The surgeon was blind to each patient’s profiles regarding preoperative dutasteride therapy to prevent a possible bias. Postoperative care carried out via an indwelling 20 Fr. Tri-channel foley’s catheter with a 30 ml urethral catheter balloon and continuous 0.9% normal saline bladder irrigation was done until the hematuria disappeared. During the postoperative period, both groups were compared with respect to clot retention, continuous bladder irrigation, and post-operative hospital stay. The patients had been discharged if they could void with clear urine. The outcome variables between groups were blood loss, indicated by the reduction in hemoglobin (Hb) and hematocrit (Hct) levels, which were estimated by measuring Hb and Hct values before surgery and 24 hours after surgery.
Data were processed and analyzed with the help of SPSS (Statistical package for social sciences) Version 22.0, Microsoft Excel version 15.31 and the internet. Statistical analysis was done with the “t” test, chi-square (χ2) test and Fisher’s exact test and the p-value of 0.05 considered as statistically significant.
The present study intended to evaluate the effect of preoperative dutasteride therapy on bleeding related to TURP in patients with BPH. A total of 70 cases of BPH were allocated to group A (TURP without dutasteride) and group B (TURP with dutasteride). The main outcome variable between groups was blood loss in terms of reduction of pre-operative and post-operative hemoglobin (Hb) and hematocrit (Hct) levels. Results of both groups were compiled and compared.
The majority (around 54.28%) of the patients in both the groups were in the age range 61 - 70 years. Out of 35 cases in each group, 51% in Group-A and 57% in Group-B were between 61 - 70 years of age. About 20% in Group-A and 17% in Group-B were between ≥50 - 60 years. Only 28% in Group A and 25% in Group B were found more than the age of 70 years. The groups were not statistically different in terms of age (p = 0.7609) (
About 63% of the prostatic volume in both the groups were in range 61 - 80 gm. 31% in Group-A and 37% in Group-B had a prostatic volume between 61 - 70 gm. No significant difference was observed between groups in terms of prostatic volume (62.96 ± 10.03 gm vs. 61.99 ± 10.15, p = 0.69) (
S. PSA level in total study patients (Mean ± SD) was 3.19 ± 1.43 ng/ml in Group-A and 3.20 ± 1.96 ng/ml in Group-B. No significant difference was observed between the groups in terms of S. PSA level (p = 0.78) (
About 45.72% in Group-A and 42.87% in Group-B had resected prostatic volume between 31 - 40 gm. No significant difference was observed between groups in terms of resected prostatic volume (33.36 ± 9.01 gm vs. 32.05 ± 10.14 gm, p = 0.78) (
Age | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
≥50 - 60 | 07 (20.00) | 06 (17.14) | |
61 - 70 | 18 (51.42) | 20 (57.14) | |
>70 | 10 (28.58) | 09 (25.72) | |
Total | 35 (100.0) | 35 (100.0) | |
Mean ± SD | 65.22 ± 5.61 | 65.62 ± 5.34 | 0.7609 |
Values in the parentheses denote the corresponding percentage. Data were analyzed using Student’s t-Test and level of significance was <0.05.
Prostatic Volume (gm) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
41 - 50 | 04 (11.42) | 09 (08.58) | |
51 - 60 | 09 (25.72) | 10 (28.58) | |
61 - 70 | 11 (31.42) | 13 (37.14) | |
71 - 80 | 11 (31.42) | 09 (25.71) | |
Total | 35 (100.0) | 35 (100.0) | |
Mean ± SD | 62.96 ± 10.03 | 61.99 ± 10.15 | 0.6902 |
Values in the parentheses denote the corresponding percentage. Data were analyzed using Student’s t-Test and the level of significance was <0.05.
S. PSA (ng/ml) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
Mean ± SD | 3.19 ± 1.43 | 3.20 ± 1.96 | 0.7833 |
Values are presented as Mean ± SD. Data were analyzed using Student’s t-Test and the level of significance was <0.05.
Resected Prostatic Tissue (gm) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
≥10 - 20 | 04 (11.42) | 04 (11.42) | |
21 - 30 | 06 (17.14) | 08 (22.86) | |
31 - 40 | 16 (45.72) | 15 (42.87) | |
41 - ≥50 | 09 (25.72) | 08 (22.86) | |
Total | 35 (100.0) | 35 (100.0) | |
Mean ± SD | 33.36 ± 9.01 | 32.05 ± 10.14 | 0.782 |
Values in the parentheses denote the corresponding percentage. Data were analyzed using Student’s t-Test and the level of significance was <0.05.
Over 45% of the patients of Group-A required 61 - 90 minutes for the operation to be completed, while 60% of Group-B patients required 61 - 90 minutes for operation. The mean time required for operation was lower in the group B (74.62 ± 16.01 minutes) than that in the group A (83.49 ± 18.33 minutes) and the difference approaching the level of significance (p = 0.0349) (
In group A and group B, pre-operative Hb was 14.01 ± 1.21 gm/dL and 13.95 ± 1.23 gm/dL, respectively. On the other hand, preoperative Hct was 43.50% ± 3.11% and 43.04% ± 3.24%, respectively. No significant difference was observed (p-value 0.821 & 0.549) between the groups in terms of pre-operative hemoglobin (Hb) and hematocrit (Hct) levels (
Postoperative Hb was 11.05 ± 1.38 and 12.13 ± 1.30 gm/dl respectively in group A and group B. On the other hand postoperative Hct was 32.29% ± 2.12% and 36.97% ± 2.02% respectively between the groups. There was a significant difference (p-value 0.012 and 0.001) between the groups in terms of postoperative hemoglobin and hematocrit levels (
Mean difference of pre-postoperative change of Hb was 2.96 ± 0.80 and 1.81 ± 0.71 gm/dl as well as Hct was 11.20% ± 2.12% and 6.07% ± 2.02% respectively in between group A and group B. Significant difference was observed (p-value 0.001 and 0.02) in term of pre-post operative change of hemoglobin and hematocrit levels in the dutasteride group compared to the control group (
Operation Time (min) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
<60 | 06 (17.14) | 07 (20.00) | |
61 - 90 | 16 (45.72) | 21 (60.00) | |
>90 | 13 (37.14) | 07 (20.00) | |
Total | 35 (100.0) | 35 (100.0) | |
Mean ± SD | 83.49 ± 18.33 | 74.62 ± 16.01 | 0.0349 |
Values are represented as Mean ± SD. Data were analyzed using Student’s t-Test and the level of significance was <0.05.
Pre-Operative Hb & Hct | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
Pre-operative Hb | 14.01 ± 1.21 | 13.95 ± 1.23 | 0.821 |
Pre-operative Hct | 43.50 ± 3.11 | 43.04 ± 3.24 | 0.549 |
Values were represented as Mean ± SD. Data were analyzed using Student’s t-Test. The level of significance was <0.05.
Post-Oprative Hb & Hct | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
Post-operative Hb | 11.05 ± 1.38 | 12.13 ± 1.30 | 0.012 |
Post-operative Hct | 32.29 ± 2.12 | 36.97 ± 2.02 | 0.001 |
Values were represented as Mean ± SD. Data were analyzed using Student’s t-Test. The level of significance was < 0.05.
Pre-Post Operative Change of Hb & Hct | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
Pre-postoperative change Hb | 2.96 ± 0.80 | 1.81 ± 0.71 | 0.001 |
Pre-postoperative change Hct | 11.20 ± 2.12 | 6.07 ± 2.02 | 0.02 |
Values were represented as Mean ± SD. Data were analyzed using Student’s t-Test. The level of significance was <0.05.
Blood loss was evaluated in terms of reduction of preoperative and postoperative Hb (gm/dl) and Hct% level. There was a significant mean change of hemoglobin (Hb) and hematocrit (Hct) levels in the dutasteride group compared to the control group (p = 0.02 vs. p = 0.001) (
About 60% of Group-B cases required > 30 L irrigating fluid in TURP in comparison to 65.72% of Group A. On the other hand ≤ 30 L irrigating fluid required in TURP, 34% in Group A and 40% in Group B. The difference was statistically significant (p = 0.0074) (
Continuous bladder irrigation for more than 2 days was required in 48.58% in Group-B and 74.29% cases in Group A. On the other hand, less than 2 days was required in 51.42% in Group-B and 25.72% in Group A. The difference was statistically significant (p < 0.007) (
Comparison between the groups shows that 8.57% in Group-A and 5.71% in Group-B developed clot retention. This difference was statistically not significant (p = 0.479) (
Comparison of hospital stay between groups demonstrated that 94.28% of the subjects of Group-B had stayed at the hospital for ≤ 3 days following the TURP. In Group-A 82.86% had to stay at the hospital for ≤ 3 days. The mean hospital stay was shorter in dutasteride group B (2.69 ± 0.58 day) than control group A (3.20 ± 0.79 day). This result was statistically significant (p-value = 0.003) (
For decades, transurethral resection of the prostate (TURP) has been the gold-standard therapy for symptomatic benign prostatic hyperplasia (BPH).
Irrigating Fluid (L) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
≤30 | 12 (34.20) | 14 (40.00) | |
>30 | 23 (65.72) | 21 (60.00) | |
Total | 35 (100) | 35 (100) | |
Mean ± SD | 34.14 ± 7.07 | 29.83 ± 5.60 | 0.0074 |
Values are represented as Mean ± SD. Data were analyzed using Student’s t-Test and the level of significance was <0.05.
Duration of Continuous Bladder Irrigation (Day) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
≤2 | 09 (25.72) | 18 (51.42) | |
>2 | 26 (74.29) | 17 (48.58) | |
Total | 35 (100.0) | 35 (100.0) | |
Mean ± SD | 2.92 ± 0.52 | 2.48 ± 0.62 | 0.007 |
Values were represented as Mean ± SD. Data were analyzed using Student’s t-Test. The level of significance was <0.05.
Clot Retention | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group A (TURP without dutasteride) (n = 35) | ||
Yes | 3 (08.57) | 2 (05.71) | 0.479 |
No | 32 (91.43) | 33 (94.29) | |
Total | 35 (100.0) | 35 (100.0) |
Values in the parentheses denote the corresponding percentage. Data were analyzed using Fisher’s exact test. The level of significance was <0.05.
Post-Operative Hospital Stay (Days) | Group | p-value | |
---|---|---|---|
Group A (TURP without dutasteride) (n = 35) | Group B (TURP with dutasteride) (n = 35) | ||
≤3 | 29 (82.86%) | 33 (94.28%) | |
>3 | 06 (17.14%) | 02 (05.72%) | |
Total | 35 (100.0) | 35 (100.0) | |
Mean ± SD | 3.20 ± 0.79 | 2.69 ± 0.58 | 0.003 |
Values are represented as Mean ± SD. Data was analyzed using Student’s t-Test and the level of significance was <0.05.
Perioperative blood loos is one of the most common complications of TURP. If it persists, it may necessitate blood transfusion and can lead to clot retention in the postoperative period. The efficacy of dutasteride in the treatment of gross hematuria associated with BEP is well established [
A total of 70 Patients with BPH who were to undergo TURP, enrolled in this study by purposive sampling followed by inclusion and exclusion criteria. Patients allocated into two groups; the control group consisted of 35 patients did not receive preoperative dutasteride and the interventional (dutasteride) group consisted of 35 patients were treated with dutasteride 0.5 mg/day for 4 weeks before TURP. Blood loss was evaluated in terms of reduction in serum hemoglobin (Hb) and hematocrit (Hct) levels, which were measured before surgery and 24 hours after surgery.
Martov et al. found a significant reduction in blood loss in patients by using dutasteride for at least one month before TURP compared to the control group [
Hahn et al. found that 2 to 4 weeks pretreatment with dutasteride did not significantly reduce blood loss in TURP [
Preoperative dutasteride therapy reduces blood loss related to TURP in patients with BPH. This therapy can be practiced to reduce surgical bleeding associated with TURP.
It was a single center study with relatively small sample size. All complications of TURP were not included in the study. Moreover surgeon’s heterogeneity was the mentionable limitation of this study.
The authors declare no conflicts of interest regarding the publication of this paper.
Rahman, M.Md., Johura, F.-T., Rasul, A.Md., Bhuiyan, A.K.M.M., Ali, M.I., Hossain, S.Md., Islam, K.Md., Rahman, A.K.M.S. and Al Shatil Ashrafee, F. (2019) Effect of Preoperative Dutasteride on Bleeding Related to Transurethral Resection of Prostate in Patients with Benign Prostatic Hyperplasia. Journal of Biosciences and Medicines, 7, 157-169. https://doi.org/10.4236/jbm.2019.75017