What is the role of Transurethral Resection of the Prostate (TURP) in the management of prostate cancer?

Role of TURP in Prostate Cancer

TURP has no role in the primary treatment of prostate adenocarcinoma, but serves as a palliative procedure to relieve bladder outlet obstruction in patients with locally advanced or metastatic disease who have failed medical management. 1, 2

Primary Treatment Context

• TURP is NOT indicated for curative treatment of prostate adenocarcinoma. 1
• For localized prostate cancer, definitive treatment options include radical prostatectomy, external beam radiation therapy, or brachytherapy—not TURP. 1
• Previous TURP is actually a relative contraindication to brachytherapy due to increased risk of urinary complications and incontinence (8.7% requiring post-implantation TURP). 1
• Patients who have undergone TURP can still receive brachytherapy if a minimal channel TURP was performed, leaving at least 1 cm rim of prostate tissue around the defect, with at least 3 months interval for healing. 1

Palliative Role in Advanced Disease

TURP serves as palliative therapy for bladder outlet obstruction in patients with locally advanced or metastatic prostate cancer. 3, 2

Specific Indications for Palliative TURP:

• Bladder outlet obstruction (69% of cases) causing urinary retention or severe lower urinary tract symptoms in patients with advanced prostate cancer. 2
• Gross hematuria (22% of cases) from locally advanced disease. 2
• Patients who have received androgen deprivation therapy and/or radiotherapy but continue to have obstructive symptoms. 3, 4

Patient Selection Considerations:

• Urodynamic studies should be considered before palliative TURP to confirm bladder outlet obstruction, as only 29% of symptomatic patients with prostate cancer actually have urodynamic BOO. 4
• Other urodynamic findings include detrusor overactivity (29%), underactive/acontractile detrusor (15%), or normal studies (10%), which would not benefit from TURP. 4
• Patients with castration-resistant prostate cancer, Charlson comorbidity index ≥5, and advanced age have poorer survival outcomes. 2

Expected Outcomes

Functional Results:

• 95% of patients with urodynamic-proven BOO void spontaneously at 12 months post-TURP, with improved flow rates. 4
• Mean PSA reduction of 46% occurs after palliative TURP. 3
• 27% of patients require repeat TURP procedures, and 28% eventually need an indwelling catheter. 2

Safety Profile:

• Mortality rate is low at 2-3.1%. 3, 2
• TURP syndrome occurs in only 1.5% of cases. 3
• Clavien grade 0-2 complications occur in 93% of patients, with only 5% experiencing grade 3 complications. 2
• Two-fold higher hemoglobin drop occurs in palliative TURP compared to TURP for benign disease. 5

Important Caveat:

• TURP is ineffective for relieving ureteral obstruction—nephrostomy tubes or ureteral stents in place before pTURP remain indefinitely in all cases. 2

Incidental Cancer Detection

• Prostate cancer is incidentally detected in 4-15% of TURP specimens performed for presumed benign prostatic hyperplasia. 6
• When cancer is found incidentally (T1a/T1b disease), management depends on tumor grade, stage, patient age, and life expectancy. 6
• Active treatment (surgery or radiotherapy) is indicated in T1a patients with life expectancy >10 years and in the majority of T1b patients. 6

Urothelial Carcinoma Exception

The only curative role for TURP in prostate malignancy is for urothelial (transitional cell) carcinoma of the prostate involving the prostatic urethra or ductal acini without stromal invasion. 1

• TURP combined with intravesical BCG is the primary treatment for urothelial carcinoma limited to the prostatic urethra without acinar or stromal invasion. 1
• Postsurgical intraprostatic BCG is recommended after TURP for this indication. 1
• If stromal invasion is present, cystoprostatectomy with or without urethrectomy is required instead. 1