We studied postoperative mortality and mortality risk factors among Finnish men who underwent surgery for BPH in Finland. TURP was by far the most common operation type for BPH in Finland from 2004 to 2014. The overall mortality rate of the study population was 1.10% during the 90 days postoperative period, and the most common underlying causes of death were malignancy and cardiac disease. Laser vaporization had a lower mortality (0.59%) when compared to TURP (1.16%). Aging, CCI score, atrial fibrillation, and study period were identified as independent risk factors for higher postoperative mortality. The excess 90 days postoperative mortality rate was nevertheless low (<0.5%) in all age groups.
The results show that there is mortality related to elective endourologic procedures for BPH. Even though the excess mortality was low in our findings, it was significantly associated with older age. The 90 days postoperative mortality after TURP was 1.16% in our study, which is considerably higher than in a nationwide BPH treatment-related mortality recently reported by Eredics et al (0.5 %). This difference might be explained by the fact that Eredics et al. included only in-hospital mortality . In our study, the mortality rate was based on the Causes of Death Registry, covering all deaths that occurred during the study period, irrespective of place of death. Another difference between the studies was the inclusion of patients with established prostate cancer (PCa). Including patients with prostate cancer in our study is justified, since the majority of these patients experience bladder outlet obstruction mostly because of concomitant BPH. Also, Crow et al. reported that there seems to be no excess postoperative mortality or complications after TURP in PCa patients . More importantly, in our study, prostate cancer diagnosis was not found to be an independent risk factor for higher postoperative mortality.
This study is similar to Gilfrich and coworkers’ 2016 large study of 95,577 cases from a nationwide German health insurance database. The research design differed in that Gilfrich et al. studied 30 days postoperative mortality, whereas our study focused on 90 days postoperative mortality. Nevertheless, the postoperative mortalities were surprisingly similar after laser vaporization (0.58 %) and open prostatectomy (0.51 %), even when disregarding the time frame difference .
Bhojani et al. compared TURP and laser operations using data from the American College of Surgeons National Surgical Quality Improvement Program database (2006–2011). They found that laser vaporization of the prostate was associated with decreased blood transfusions, length of stay, and reintervention rates, but there was no significant difference in perioperative mortality between laser (0.3%) or TURP (0.4%). Advanced age and non-Caucasian race increased the risk of morbidity and mortality, whereas normal preoperative albumin and higher hematocrit levels were recognized as predictors of lower overall complications . Patel et al. also used the National Surgical Quality Improvement Program database (2006–2011) to quantify complication rates, perioperative outcomes, and predictors for urological procedures. They found that TURP had the highest morbidity rate of prostatic endoscopic procedures (0.62 %). They also analyzed morbidity rates of photoselective vaporization of the prostate (GreenLight laser) (0.46 %), radical retropubic prostatectomy (0.35 %), and laparoscopic radical prostatectomy (0.11 %). Patel et al. studied the morbidity of urologic surgical procedures regardless of the indication for surgery. Therefore, it is safe to conclude that patients with PCa were included in this patient cohort. The difference in the 30 days postoperative mortality after TURP between the studies by Patel et al. and Bhojani et al. is 0.22%. This difference could hypothetically be explained by the different participant exclusion/inclusion criteria—Bhojani et al. did not report the possible exclusion of PCa patients .
The hypothesis that laser operations for bladder outlet obstruction are lower-risk procedures and, therefore, are more frequently performed in elderly men than TURP or open prostatectomy is only partly supported by our results. Although there is a statistically significant association between age and operation type, the differences are small, and laser procedures are not more commonly performed in elderly men. More importantly, men who underwent laser procedures had significantly lower 90 days postoperative mortality compared to men who underwent TURP. However, no consensus prevails concerning the issue. Bhojani et al. found no difference in overall complications or perioperative mortality between TURP and laser operations , whereas Gilfrich et al. concluded that laser operations demonstrated favorable results for transfusions and bleeding, but increased long-term reinterventions when compared to TURP . Even though postoperative mortality after a laser procedure was significantly lower than that after TURP in both the uni- and multivariable analyses in the current study, there might be unidentified variables and/or factors influencing these results.
There is an ongoing dialogue about whether oral anticoagulation should be ceased for TURP. Patients taking these medications have a higher rate of perioperative bleeding. However, if prescribed for secondary prevention, withholding OAC is associated with an increased rate of cardiovascular and cerebrovascular complications [12, 13]. Although we acknowledge that OAC is used in a variety of medical conditions and not solely for atrial fibrillation, in our study, atrial fibrillation was used as a surrogate for oral anticoagulation. Due to the retrospective nature of this study and the lack of detailed clinical information, it was not possible to identify patients who ceased OAC preoperatively. However atrial fibrillation was found to be an independent risk factor for increased mortality (2.60%). In the future, further studies on on-going OAC and the choice of operation type for LUTS are needed.
To study the real-world mortality data of patients with BPH who had undergone surgery, patients with PCa were included in the study cohort. PCa and BPH are not mutually exclusive, and even though the likelihood of detecting incidental PCa by surgery has decreased in the era of prostate-specific antigen (PSA) testing, 5.2–6.4% of newly identified PCas are still detected after surgery for BPH [14,15,16]. The inclusion of PCa patients may elevate the total mortality of the study population and mortality related to TURP, since postoperative 90 days mortality following palliative TURP is estimated to be 3.4% . At the same time, patients who had been diagnosed with urinary system tumors were excluded from this study to examine actual KED procedures. This exclusion is justified, since when a physician is treating or diagnosing a urinary system neoplasm, they might plan to take a sample of the prostate, which may lead to entering a KED procedure code into the surgical report, even though the actual KED procedure was not performed.
This study was based on nationwide data from the Finnish Institute for Health and Welfare. The resulting data set of 39,320 patients over a 10 years period is a major strength of this study. In addition, the registry covers every hospital in Finland, and the data are truly nationwide. A general limitation of this study is the lack of detailed clinical information, and the data are limited to diagnosis and operation coding. Due to this deficiency, we were unable to identify and grade postoperative complications that may have caused death. Moreover, since the NCSP does not separate monopolar and bipolar TURP or specific types of laser operations, we were unable to classify operation types more accurately; therefore, certain differences within the operation groups may have remained unnoticed.
In conclusion, surgical treatment for LUTS seems to be safe for all age groups since the excess mortality after procedures was found to be less than 0.5%. In this nationwide cohort study, the results indicated a lower postoperative mortality after laser operations than after TURP. Aging, CCI score, and atrial fibrillation were identified as independent risk factors for higher postoperative mortality. Therefore, considering the risks and benefits of operating on a case-by-case basis is strongly recommended.