Transurethral resection of the prostate for patients with grade III urinary symptoms following transperineal implantation of the prostate

PURPOSE/OBJECTIVE: Patients (Pts) undergoing a I-125 or Pd-103 transperineal implant of the prostate (TPIP) experience urethritis of a varying degree. Most pts with mild to moderate symptoms can be treated with alpha blocking agents. Few pts will experience urethritis that does not respond to medical management, or persists beyond three half life's of the isotope. These pts will have significant quality of life complaints related to their symptoms. The purpose of this study is to present our results of Transurethral resection of the prostate (TURP) for patients with grade III urethritis. MATERIALS AND METHODS: Between November 1992 and January 1996, 378 patients underwent TPIP for clinically localized cancer. Treatment consisted of either a Pd-103 or I-125 implant either alone or in combination with external beam radiation and/or hormones. All the implants used a peripheral loading and urethral sparing technique. All pts were followed after the implant and assessed by DRE, PSA, and symptoms. The grading of urinary symptoms was as follows: Grade I-successful relief with pyridium or an equivalent medication, Grade II-pts requiring various doses of alpha blockers, Grade III-pts with persistent symptoms despite medical management. RESULTS: Of the 378 pts undergoing implant, 358 had sufficient follow-up to be included in this review. Forty two pts (12%) received hormone downsizing prior to implantation. Two hundred and two (56%) underwent a Pd-103 implant and 156 (44%) a I-125 implant; 15 underwent EBRT plus I-125 and 27 with EBRT and Pd-103. One hundred and fifty five (43%) pts experienced grade I urethritis during the first three half life's of the implant, while 116 (32%) experienced grade II urethritis. Twenty eight pts (8%) experienced grade III urethritis that persisted beyond three half life's of the implant. All grade III pts were offered TURP and 26 elected to undergo this procedure. Of the twenty six pts undergoing TURP, 100% experienced relief of their symptoms. One patient subsequently experienced mild stress incontinence. Eleven of the 26 (42%) were sexually active prior to implant. Eight of the 11 (73%) remain sexually active post implant, and all eight are sexually active following TURP. Pts undergoing a Pd-103 implant had a slightly higher incidence of TURP (19 pts-0% vs. 7 pts-4% for I-125), although this was not significant. We were unable to predict patients that required a TURP based on preimplant prostate size, stage, gleason score, use of hormones or PSA. (All p values > 0.5). Twenty five of the 26 pts have a PSA that has nadir'd below 1.5 ng/ml or have a PSA that continues to fall with a median follow-up of 57 weeks (28-196 weeks). Twenty four of the TURP pathologies were negative for tumor. CONCLUSIONS: Most pts that undergo TPIP will experience urethritis that can be treated successfully with medications. Those pts with symptoms beyond the third half life of the isotope and/or those that do not respond to medical management can be successfully palliated with TURP. This procedure is well tolerated by the patients with all pts reporting relief. TURP should be considered safe and effective in for this patient population