Year : 2006 | Volume
: 22 | Issue : 1 | Page : 68--70
Prostate stents as ultima ratio in unfit patients
J Reichle1, S Turk1, F Chinegwundoh1, Noor NP Buchholz2,
1 Dept. of Urology, Newham University Hospital, London, United Kingdom
2 Barts and The London NHS Trust, London, United Kingdom
Noor NP Buchholz
Director Endourology and Stone Services, Barts and The London NHS Trust, London EC1A 7BE
Prostate stents have widely been abandoned. Indeed, to date there are many minimally invasive treatment options which can benefit even patients who are medically unfit to undergo transurethral resection of the prostate (TURP). We present three cases that illustrate that, in spite of all those new options, prostate stents, in particular the thermo-expandable ones that can easily be removed if necessary, have some value as a last resort in selected cases.
|How to cite this article:|
Reichle J, Turk S, Chinegwundoh F, Buchholz NN. Prostate stents as ultima ratio in unfit patients.Indian J Urol 2006;22:68-70
|How to cite this URL:|
Reichle J, Turk S, Chinegwundoh F, Buchholz NN. Prostate stents as ultima ratio in unfit patients. Indian J Urol [serial online] 2006 [cited 2021 Jul 25 ];22:68-70
Available from: https://www.indianjurol.com/text.asp?2006/22/1/68/24662
Medically unfit patients with chronic urinary retention pose a problem in urological practice. Prostate stents have been advocated in such patients, but have not widely been used because of associated risks of dislocation and urinary infection. In spite of our endourology service being able to offer minimally invasive therapies for high risk patients, such as Transurethral Needle Ablation of Prostate (TUNA) and Transurethral Ethanol Ablation of Prostate (TEAP), there remains a small group in which prostate stents are the ultima ratio ( lat: last argument, last option ). The only other alternative for those patients would be a life on the catheter, with a significant drop in quality of life and other adherent clinical problems. Therefore, we believe that prostate stents are useful in selected patients, even in the presence of established minimally invasive treatment options and we illustrate this with three typical cases.
An 87 year old man suffered from chronic urinary retention with an indwelling catheter since two years. He was deemed medically unfit for prostate surgery because of chronic anaemia, reduced systolic function and chronic atrial fibrillation, for which a pacemaker was implanted 4 months ago. Medical therapy of bladder outflow obstruction with alpha-blockers and alpha-reductase inhibitors had failed. In the past, he had undergone a rectum amputation. Therefore, transrectal ultrasound which is needed for both, TUNA and TEAP, could not be perfomed. It was decided to proceed with a prostate stent under local anaesthesia. By means of flexible cystoscopy, a prostate stent (Memokath 028®, Engineers and Doctors, Kvistgaard/ Denmark) was implanted into the moderately enlarged but obstructive prostate. Post-operatively, the patient could not micturate spontaneously and a ward nurse inserted an indwelling urethral catheter, despite explicit previous warnings from the surgeons not to do so. The stent was thus dislodged into the bladder. The patient was then transferred to our tertiary referral centre, where the old stent was removed from the bladder and a new slightly longer one was inserted, both by means of flexible cystoscopy under local anaesthetic. The patient enjoys a life without catheter now and has not suffered any stent-related complications over a follow-up period of 7 months.
A 77 year old man with a known adenocarcinoma of the prostate developed urinary retention in spite of ongoing hormonal therapy. A 6-months trial on alpha-blockers combined with alpha-reductase inhibitors on top of hormonal therapy did not bring any relief. A combination of chronic obstructive pulmonary disease (COPD), hypertension and congestive heart failure with atrial fibrillation rendered him medically unfit for palliative prostate surgery. To date, the effects of TUNA, TEAP and other minimally invasive therapy options on prostate cancer are not known, or have not been sufficiently explored. However, most treatments would require an intact prostatic capsule which may be jeopardized by the cancer. Therefore, it was decided to treat the patient with a prostate stent, as described above. As in the first case, the patient had initial post-operative urinary retention and again, a ward nurse inserted an indwelling urethral catheter dislodging the stent in the process. A week later, the dislodged stent was removed transurethrally by flexible cystoscopy and replaced by a new stent, as described above. As a precaution, a suprapubic catheter was inserted in the same session. A pelvic X-ray confirmed the correct position of the new stent. An initial trial without catheter (by clamping the suprapubic catheter) failed and the patient was discharged and scheduled for another trial 4 weeks later. Unfortunately, after 3 weeks, he developed a severe stroke and died a few days later.
A 66 year old man developed a recurrent urinary retention with hydronephrosis. Combination therapy with alpha-blockers and alpha-reductase inhibitors had failed. Apart from two cerebral infarctions some time ago and an accident long time ago which had caused injury to the cerebellum, he was deemed reasonably fit to undergo TURP. The above conditions had however led to significant muscle contractions and it was found during pre-admission assessment, that he could not spread his legs enough to position him into anything resembling a lithotomy position. Therefore, the patient underwent flexible cystoscopy in the supine position and insertion of a Memokath® prostate stent, as described above. Post-operatively, the patient was able to pass urine freely and he went home the same day. During 9 months of follow-up, there have been no stent-related complications.
TURP remains the gold-standard for the treatment of bladder outflow obstruction (BOO) caused by the prostate. Compared to alternative treatments, it has the best long time results, with about 80% of patients experiencing a reduction of voiding symptoms and an improvement of urinary flow. However, TURP may not be indicated in high risk patients with severe co-morbidities, mostly coronary or pulmonary diseases, which are widespread in elderly men.
For this group of patients, it is useful to have a repertory of alternative therapies at hand, the so-called minimally invasive therapies. TEAP, TUNA, laser ablation of prostate, transurethral microwave thermotherapy (TUMT) and prostatic stents, all are considered to be more or less minimally invasive. At our institution, we offer high-risk patients either TUNA- if they are deemed fit enough for general anaesthesia but recommended to avoid blood loss, prolonged theatre time and the risk of TURP-syndrome, or TEAP for the same reasons and if they are deemed unfit for general or spinal anaesthesia. Both treatments have been used in our hands on a considerable number of patients with good success. Both treatments lead to a significant reduction in bladder outflow obstruction and an improvement in quality of life, with a favourable risk profile and no serious complications.,
Prostate stents are another possibility to assure a connection between the bladder and the urethra at the distal end of the prostate gland. They have been used successfully in medically unfit patients. The insertion is technically not very difficult. A flexible cystocopy is performed and there is no need for spinal or general anaesthesia. However, prostatic stents are associated with significant complications, mainly stent encrustation, urinary tract infections and stent dislocation. This is why stents are not used in our institution as a first line treatment for BOO in unfit patients. The vast majority of medically unfit patients can be relieved of their indwelling catheters by means of other minimally invasive treatment options which treat the prostate as an organ, rather than by bypassing it. If successful, these treatments provide lasting relief hopefully for the remaining lifetime of the patient.
On the other hand, prostate stents do work fine, if they work. But if they fail due to the above mentioned complications, they will at the least need some form of re-treatment and at the most, can endanger the life of the patient. If a stent has to be used, the Memokath® may minimize some of the problems since it is thermo-labile and expands along the lines of the prostate, has no tissue reaction with over or in-growth of mucosa or prostate tissue and can easily and atraumatically be removed after having been softened with cold water and uncoiled. Memokath® prostate stents have been used successfully in unfit patients, albeit there is only one study to date, which is reported with 15 patients. As mentioned above, we do treat the majority of such patients with alternative treatment options other than stents. However, if patients are unfit to undergo TURP and have additional problems which disqualify them from those treatments, then even in a well equipped endourology unit, stents may be used as a last resort. The reasons may be technical problems with US-guidance required for TUNA and TEAP (i.e. no rectum, inability to spread legs etc.), or contraindications (i.e. prostate cancer where the effect of TUNA and TEAP has not been evidenced to date).
p0 atients with urethral strictures, renal or bladder calculi, active urinary tract infections, or bladder neck stenosis should not have prostate stents. Likewise, patients with impending interventions such as ureterorenoscopy or lithotrypsie of renal stones should be ruled out, or critically discussed. It is also not recommended to use prostate stents if the median lobe is clearly enlarged, or the prostatic urethra is shorter than 2 cm 3sub .
Nevertheless, the above cases illustrate that in spite of their associated complications, prostate stents may be the only solution left for a selected sub-group of patients who are medically unfit to undergo TURP and have additional problems, making the application of minimally invasive treatment options such as TUNA, TEAP, TUMT etc. inadvisable, or even impossible. Therefore, even if minimally invasive options are readily available, it may be useful to have a few prostate stents on the shelf as ultima ratio .
Another point is that the first two cases demonstrate it is not enough to insert the stents, but one must make sure that they stay in situ. Effective information and instruction of nurses, junior doctors and other carers is crucial to avoid indwelling urethral catheter insertions and dislodgement of the stent. This is more important in countries like ours where the procedure is rarely used and therefore carers are not familiar with it.
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