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Complications After Surgery for Benign Prostatic Enlargement: a Population-­ Based Cohort Study in Ontario, Canada

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Complications After Surgery for Benign Prostatic Enlargement: a Population-­ Based Cohort Study in Ontario, Canada Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-032170 on 30 December 2019. Downloaded from Complications after surgery for benign prostatic enlargement: a population- based cohort study in Ontario, Canada Rano Matta ,1,2 Erind Dvorani,3 Christopher Wallis,1,2 Amanda Hird,1,2 Joseph LaBossiere,4 Girish Kulkarni,1,5 Ronald Kodama,1,6 Lesley Carr,1,6 Sidney B Radomski,1,5 Refik Saskin,2,3 Sender Herschorn,1,6 Robert K Nam1,2,3,6 To cite: Matta R, Dvorani E, ABSTRACT Strengths and limitations of this study Wallis C, et al. Complications Objectives To examine the complication rates after after surgery for benign benign prostatic enlargement (BPE) surgery and the effects ► A major strength of this study includes population- prostatic enlargement: a of age, comorbidity and preoperative medical therapy. population- based cohort study level data with the ability to follow patients after Design A retrospective, population- based cohort study in Ontario, Canada. BMJ Open their index procedure irrespective of where compli- using linked administrative data. 2019;9:e032170. doi:10.1136/ cations are managed within the province. Setting Ontario, Canada. bmjopen-2019-032170 ► There is potential for misclassification using admin- Participants 52 162 men≥66 years undergoing first BPE istrative data to identify outcomes. ► Prepublication history and surgery between 1 January 2003 to 31 December 2014. ► Although we adjust for geography and income, the additional material for this Intervention Medical therapy preoperatively and surgery paper are available online. To regional variations within Ontario might limit the for BPE. view these files, please visit generalisability of our results to other jurisdictions. Primary and secondary outcome measures The the journal online (http:// dx. doi. ► We do not have data on prostate size, urinary symp- primary outcome was overall 30- day postoperative org/ 10. 1136/ bmjopen- 2019- toms, extent of resection during the index procedure complication rates. Secondary outcomes included BPE- 032170). and the specific technology used for resection be- specific event rates (bleeding, infection, obstruction, yond electrical, laser or open surgery. Received 11 June 2019 trauma) and non- BPE specific event rates (cardiovascular, ► We were unable to evaluate postoperative functional Revised 09 November 2019 pulmonary, thromboembolic and renal). Multivariable outcomes besides urinary obstruction. Accepted 04 December 2019 analysis examined the association between preoperative medical therapy and postoperative complication rates. Results The 30- day overall complication rate after http://bmjopen.bmj.com/ BPE surgery was 2828 events/10 000 procedures and progression of their disease as the severity © Author(s) (or their increased annually over the study period. Receipt of of LUTS,4 the size of the prostate5 and the employer(s)) 2019. Re- use preoperative -blocker monotherapy (relative rate (RR) α cumulative incidence of urinary retention6 permitted under CC BY- NC. No 1.05; 95% CI 1.00 to 1.09; p=0.033) and antithrombotic commercial re- use. See rights medications (RR 1.27; 95% CI 1.22 to 1.31; p<0.0001) increase with time and age. When medical and permissions. Published by was associated with increased complication rates. or conservative therapy for patients eventu- BMJ. ally becomes ineffective, surgery is offered. 1 Among the ≥80- year- old group, the rate of complications Surgery, Division of Urology, increased by 39% from 2003 to 2014 (RR 1.39; 95% CI The recommended surgical treatments for University of Toronto, Toronto, 1.21 to 1.61; p<0.0001). The mean duration of medical patients with urinary symptoms secondary to on September 29, 2021 by guest. Protected copyright. Ontario, Canada 2Institute of Health Policy and conservative management increased by a mean of 2.1 BPE are either endoscopic resection, vapouri- Management and Evaluation, years between 2007 and 2014 (p<0.0001 for trend). sation or enucleation or simple prostatec- University of Toronto, Toronto, Conclusions Thirty-day complication rates after BPE tomy.7 By this point, patients are often older Ontario, Canada surgery have increased annually between 2003 and 2014. 8 9 3 and more frail, which may increase the rate Institute for Clinical Evaluative Preoperative medical therapy with alpha blockers or of perioperative complications.10 Sciences, Toronto, Ontario, antithrombotics was independently associated with higher Studies evaluating surgical therapy for BPE Canada rates of complications. Over this time, the duration of 4 Division of Urology, University conservative therapy also increased. have reported rates of postoperative morbidity of Alberta, Edmonton, Alberta, greater than 10%.10–12 However, there are Canada 5 few clinical studies evaluating the effects of Division of Urology, University INTRODUCTION medical therapy on perioperative outcomes, Health Network, Toronto, Ontario, Canada Medical therapy as first- line treatment for and these have been highly controlled with 8 9 13 6Division of Urology, Sunnybrook patients with lower urinary tract symptoms small sample sizes. To our knowledge, Health Sciences Centre, Toronto, (LUTS) from benign prostatic enlargement there are no large, population-based studies Ontario, Canada (BPE) has enabled men to delay or avoid examining the effect of medical management 1 2 Correspondence to surgery. Watchful waiting (conservative on surgical complications. Thus, we evaluated Dr Rano Matta; management) is also a reasonable manage- the trends in 30- day complications and re- op- rano. matta@ mail. utoronto. ca ment option.3 Some men with BPE will develop eration following BPE surgery, and the factors Matta R, et al. BMJ Open 2019;9:e032170. doi:10.1136/bmjopen-2019-032170 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-032170 on 30 December 2019. Downloaded from Table 1 Baseline characteristics of men undergoing benign legal status under Ontario’s health information privacy prostatic enlargement (BPE) surgery from 2003 to 2014 in law allows it to collect and analyse healthcare and demo- Ontario, Canada graphic data, without consent, for health system evalu- ation and improvement. Each of the data sources used Total cohort has been validated previously (online supplementary data Variable n=52 162 sources). All analyses were performed between June 2018 Mean age (years; SD) 75.76 ±6.41 and January 2019 and were consistent with Strengthening Intervention type (N, %) the Reporting of Observational Studies in Epidemiology TURP 45 463 87.2% reporting guidelines. Laser 5925 11.4% Study subjects Open 774 1.5% All individuals≥66 years old who had BPE surgery from 1 Preoperative urinary obstruction* (N, %) 25 779 49.4% January 2003 to 31 December 2014 were eligible (supple- 5ARI medication (only) in year prior to 2378 4.6% mentary eTable 1 for cohort selection). We included only surgery (N, %) the first procedure (index procedure) for each patient, which included transurethral resection of the prostate -blocker medication (only) in year prior 20 600 39.5% α (TURP) using electrocautery, transurethral laser surgery to surgery (N, %) (including enucleation or vapourisation using any laser 5ARI and α-blocker in year prior to 14 450 27.7% modality) or simple prostatectomy. These were captured surgery (N, %) using intervention codes during their hospitalisation (see No BPE medications prior to surgery (N, 14 734 28.2% supplementary eTable 2). Individuals were followed from %) the date of index procedure to 30 days post procedure. Antithrombotic in year prior to surgery 12 837 24.6% To determine the duration of time between initiating (N, %) BPE medication and surgical therapy, we restricted the Charlson Comorbidity Index (N, %) cohort to men≥80 years old to ensure a 15-year look- back 0 40 694 78.0% period to age 65, since the cost of prescription medica- 1 3961 7.6% tion in Ontario is covered for all patients starting at this age and therefore dispensing records are available. 2+ 7507 14.4% Income quintile (N, %) Exposure Missing 167 0.3% The primary independent variable was receiving a prescription for medical therapy for BPE. We captured 1 9553 18.3% this using prescription claims for 5α-reductase inhibitors 2 10 728 20.6% (5ARI) and α-blockers indicated for BPE, in the year http://bmjopen.bmj.com/ 3 10 263 19.7% prior to surgery (see supplementary eTable 3 for list of 4 10 689 20.5% medications). 5 10 762 20.6% Covariates Rural residence (N, %) 7264 13.9% We collected information on important covariates that *Preoperative urinary obstruction events include: urinary retention, may confound the association between medication use bladder neck obstruction or obstructive uropathy. and postoperative outcomes including age at surgery, ARI, α-reductase inhibitor; TURP, Transurethral resection of the year of surgery, Charlson Comorbidity Index- based hospi- on September 29, 2021 by guest. Protected copyright. prostate. talisations in the 5 years preceding the index procedure, prescription claims for antithrombotics (see supplemen- tary eTable 3 for list of medications), geographical region associated with these outcomes, in a population- based of residence (Local Health Integration Network) and sample of patients≥66 years old in Ontario, Canada. income quintile. We also identified patients who had a urinary obstruc- tion event (urinary catheterisation, bladder neck obstruc- METHODS tion or obstructive uropathy) in the 2 years prior to their Data sources and setting index surgery (see
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