Is it appropriate to perform transurethral resection of the prostate (TURP) in a patient with elevated serum creatinine (Impaired renal function)?

TURP in Patients with Elevated Serum Creatinine

TURP is appropriate and should be performed in patients with elevated serum creatinine when renal insufficiency is secondary to BPH-related bladder outlet obstruction, as this represents an absolute indication for urgent surgical decompression. 1

Absolute Indication for TURP Despite Renal Impairment

Renal insufficiency secondary to BPH is an absolute indication for surgical intervention, requiring urgent surgical decompression to prevent irreversible kidney damage. 1 The American Urological Association explicitly recommends surgical intervention when bladder outlet obstruction is causing kidney damage, making elevated creatinine from obstructive uropathy a compelling reason to proceed with TURP rather than a contraindication. 1

Expected Renal Outcomes After TURP

The reality of renal recovery after TURP in patients with obstructive renal failure is sobering:

• Only 21% (3 of 14 patients) achieved complete normalization of renal function after TURP, while 57% remained dialysis-dependent despite successful relief of obstruction. 2
• An additional 21% experienced partial improvement with moderately elevated creatinine (236-344 ng/mL) but avoided dialysis. 2
• TURP significantly improves blood urea and creatinine levels overall, though complete recovery is not guaranteed. 3
• In renal transplant recipients with elevated creatinine (mean 1.99 ± 0.83 mg/dL), TURP significantly decreased serum creatinine at 1-month follow-up without major perioperative complications. 4

Critical Pre-Operative Management

Before proceeding to TURP in patients with obstructive renal failure:

• Insert a urethral catheter immediately to decompress the bladder and upper tracts, as all patients in studies required catheterization prior to TURP. 2
• Assess whether dialysis is needed pre-operatively, as 43% (6 of 14) of patients with obstructive renal failure required dialysis before surgery. 2
• Confirm obstructive uropathy with radiological evidence (hydronephrosis on ultrasound or CT) to ensure the elevated creatinine is truly from obstruction. 2

Surgical Approach Selection

• Bipolar TURP is preferred over monopolar TURP in patients with renal impairment due to reduced risk of TUR syndrome and hyponatremia, which are particularly dangerous in patients with compromised renal function. 5, 1
• Bipolar TURP allows for longer resection times and treatment of larger prostates without the risk of hyponatremia from glycine absorption. 5, 1

Post-Operative Renal Monitoring

• Monitor for nonoliguric renal failure, which occurs asymptomatically and requires laboratory surveillance, as postoperative creatinine increases ≥20% occur in 23% of surgical patients. 6, 7
• Capsule perforation increases the risk of nonoliguric renal failure 10.6-fold, requiring heightened vigilance. 7
• Hyponatremia correlates moderately with nonoliguric renal failure (r=-0.56), necessitating close electrolyte monitoring. 7
• Most patients with nonoliguric renal failure after TURP recover with conservative management within 7 days. 7

Common Pitfalls to Avoid

• Do not delay TURP waiting for creatinine to normalize if obstruction is confirmed, as prolonged obstruction duration (though not statistically significant in one study) may worsen irreversible renal damage. 3
• Do not assume all elevated creatinine will normalize post-TURP; counsel patients that 57% may remain dialysis-dependent despite successful obstruction relief. 2
• Do not use monopolar TURP in patients with renal impairment, as TUR syndrome with hyponatremia poses catastrophic risk in patients who cannot handle fluid and electrolyte shifts. 5, 7

Additional Complications in This Population

• Urinary tract infections occur in 13.4% of post-TURP patients with renal impairment, requiring antibiotic prophylaxis consideration. 4
• Long-term urethral stricture occurs in 8.9% and bladder neck contracture in 3.3% of renal transplant recipients, necessitating extended follow-up. 4
• 86% of patients achieve spontaneous voiding after TURP, with 14% requiring clean intermittent catheterization or indwelling catheter. 2