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Keywords:

  • benign prostatic hyperplasia;
  • open simple prostatectomy;
  • early vascular control

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

OBJECTIVE

To determine the feasibility of open simple prostatectomy with early vascular control in the treatment of benign prostate hyperplasia (BPH), and thus reduce blood loss.

PATIENTS AND METHODS

Thirty-seven patients were reviewed from 1991 to 2002; 34 had a Millin's and three a Freyer's prostatectomy performed by one surgeon, with early vascular control.

RESULTS

The mean operative duration was 1.3 h and the mean blood loss 841 mL, with a mean decrease in haemoglobin level of 22 g/L. Six (16%) of the patients received a blood transfusion. The mean weight of the prostate removed was 97.8 g; the duration of catheterization and the hospital stay after surgery were 6.21 and 11.7 days, respectively. There was one (3%) death and one case of pulmonary embolism. Three patients (8%) developed stress incontinence. Two failed to void after surgery and one developed acute retention 3 years later. Five patients developed recurrent obstructive symptoms.

CONCLUSION

Open simple prostatectomy with early vascular control reduces the amount of blood loss, rendering it a safe option for treating BPH.


Abbreviations
AAA

abdominal aortic aneurysm.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Prostatic enlargement is a major problem in older men and with increased age the mortality and morbidity of any surgical procedure increases. When TURP was established as the standard of treatment for BPH the use of open surgery decreased significantly and subsequently some surgeons have become reluctant to use it because of the perception that it is associated with greater blood loss than TURP [1]. Others have reported a more complicated postoperative course and a longer hospital stay associated with open simple prostatectomy than after TURP [2]. With a modification of open simple prostatectomy to include early vascular control [3,4] it is possible to reduce blood loss and thus make the procedure a safer alternative for treating BPH.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Retrospectively, patients undergoing open simple prostatectomy by one surgeon between 1991 and 2002 were reviewed. The age, type and duration of the procedure, haemoglobin levels before and after surgery, blood loss and the number of blood units transfused were obtained from the medical records. The duration of catheterization and hospital stay, complications and subsequent procedures used were also recorded. In the same period the number of TURPs by the same surgeon was also recorded.

The operative technique used was a modification of that described previously [3,4]. After draping, a 24 F three-way Foley catheter was inserted and left exposed in the operative field. The balloon was filled with 50 mL of water, to be used later to retract the bladder cranially via the middle blade of the Balfour retractor. A midline subumbilical incision was made and either Millin's or Freyer's open prostatectomy used, according to the indications and intraoperative findings. Before capsulotomy or vesicotomy the vesses were controlled by ligating the dorsal venous plexus, bilaterally clamping the internal iliac arteries, and ligating the inferior vesical vessels. After this the capsule was incised transversely for Millin's prostatectomy, or the bladder was opened longitudinally for Freyer's prostatectomy.

The right and left adenoma were removed separately with the apical dissection being under direct vision for the Millin method. The bladder neck was not reconstructed. The capsule was closed with interrupted figure-of-eight absorbable sutures. The previously inserted 24 F Foley catheter remained in situ and was connected on the table to continuous bladder irrigation with normal saline.

For Freyer's prostatectomy the bladder was closed with a running absorbable suture and an additional catheter placed suprapubically. A retropubic suction drain was inserted in both cases. The fascia was closed using Nylon and the skin by staples. Antibiotics were only used if there was infected urine or if the patient had an indwelling catheter for managing urinary retention before surgery.

Urine output and vital signs were monitored 4-hourly for the first 24 h and 8-hourly thereafter. A full blood count and serum level of urea and electrolytes were measured after 1 and 2 days, and as dictated by clinical need thereafter.

For Millin's prostatectomy the urethral Foley catheter remained in place until the urine was clear and then removed; for the Freyer's prostatectomy the urethral catheter was removed when the urine was clear and the suprapubic catheter removed at ≈ 10 days, after a trial of voiding by clamping the suprapubic catheter.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Thirty-seven consecutive patient (mean age 73.2 years, range 60–84; six > 80 years) had an open simple prostatectomy with early vascular control, 34 using the Millin and three the Freyer method; in the same period, 1156 TURPs were undertaken by the same surgeon, so that open prostatectomy accounted for 3% of the surgical procedures for BPH.

The mean (range) operative duration was 1.3 (0.75–2.7) h, the blood loss 841.4  (380–2000) mL, with a mean decrease in haemoglobin level of 22 g/L. The mean (range) haemoglobin levels before and after surgery were 131.4 (94–162) and 112 (88–133) g/L. Six (16%) of the 37 patients received a blood transfusion; four had a low haemoglobin level before surgery (<120 g/L) and one with renal impairment had to receive blood with haemodialysis (Table 1). The corresponding haematocrit of the transfused patients is also shown; all but one patient had a decrease in haematocrit after surgery.

Table 1.  Details of the six patients who had a blood transfusion
VariablePatient
123456
  • *

    With haemodialysis.

Units transfused  4  4  2  4  2*  2
Haemoglobin, g/L
Before100 94120 114111139
After 110106103102 88 98
Haematocrit
Before  0.325  0.281  0.351  0.338  0.340  0.397
After  0.298  0.321  0.308  0.301  0.264  0.291

Incidental carcinoma was found in six patients (17%), mostly as a small focus of adenocarcinoma. The mean PSA level was 14.61 (3.2–50) ng/mL. From the histology report the mean prostate weight was 97.8 (34–275) g; 24 patients (70%) had a prostate of ≥ 70 g and four of < 50 g (one with a fixed right hip, one with a bladder stone, one with a prominent median lobe and the last had ill-defined landmarks); 11 men had a prostate of 50–99 g (one with a bladder stone), 17 of 100–149 g (one bladder stone) and four of > 150 g.

Patients who had a Millin's prostatectomy had their catheter removed at 6.2 (4–11) days after surgery; for those who had a Freyer prostatectomy it was 10 days after, with suprapubic catheterization for 16.3 days. The mean hospital stay was 11.7 (6–38) days after surgery. The increased hospital stay was related to concomitant medical conditions and placement problems rather than surgical recovery.

There was one death (3%) in a patient with severe aortic valve stenosis who developed a myocardial infarction and died on the first day after surgery. A second patient developed a pulmonary embolus but subsequently recovered (Table 2). Overall, 34 patients (92%) were continent with no reports of leakage or need for pads or appliances. Three patients (8%) had stress incontinence with two of these using pads (5%) and the third with stress incontinence used no pads or appliances. Four patients failed the first trial without catheter and two needed transurethral resection of apical tissue. Five patients developed recurrent obstructive symptoms, three caused by urethral strictures (at 10, 4 and 12 months, respectively) and two by bladder neck stenosis (2 and 4 months, respectively). One patient needed resection 3 years later for re-growth of the prostate. There were no complications caused by the temporary clamping of the internal iliac arteries.

Table 2.  Complications and the subsequent procedures
ComplicationProcedure
3 Stress incontinence1 Cystoscopy
4 Failed trial without catheter2 TURP
1 Acute retention1 TURP
5 Obstructive symptoms3 strictures, 1 urethrotomy + 2 urethral dilatations
2 Bladder neck stenosis2 bladder neck incision
1 Pulmonary embolism
Wound infection & dehiscence + failed trial without catheterRepair

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Freyer performed his first prostatectomy in 1900 and claimed the operation as an original breakthrough [5]. This claim was not strictly valid as 7 years previously Mansell Moullin at The London Hospital reported all the cases of prostatectomy then known [6]. The operation had first been used (by mistake) as early as 1884 [7], again by McGill in Leeds [8], and by Goodfellow [9] and Fuller in the USA [10].

By 1912, Sir Peter Freyer, who reported his results with 1000 patients, had popularized the procedure [11]. Terrence Millin reported his experience of retropubic prostatectomy with 20 patients in 1945 [12]. In a letter, Millin reported in 1969: ‘My personal experiences with TUR commenced in 1930 and by 1949 I had carried out some 2000 TURs. By 1940 my percentage was 80%[percentage of TURs] approximately but with the introduction of safer open prostatectomy the percentage declined to less than 10%[percentage of TURs] in the years before I retired’[13].

With the emergence of TURP and the development of excellent optical instruments, TURP became established as the standard treatment for BPH. A generation of surgeons emerged very familiar with TURP and considered it as the first choice for the surgical treatment of BPH, even when open surgery might be indicated because the prostate was large. Such surgeons accepted the risks of prolonged TUR and some adopted a two-stage TURP to avoid open surgery, with its stigma of blood loss.

Open prostatectomy should be considered when the prostate is > 75 g; it is also the procedure of choice for men who have a concomitant bladder condition, e.g. symptomatic bladder diverticulum or a large, hard bladder calculus. It can be considered in patients with unilateral or bilateral inguinal hernias, as these can be repaired preperitoneally at the same time through the same incision [14]. Another indication for open prostatectomy is ankylosis of the hips, that prevents proper placement of the patient in the dorsal lithotomy position for TURP [3].

With larger glands the operative duration is longer than for TURP, with an increased chance of TUR syndrome, and thus open surgery is a better option. In an analysis by Roos et al.[15] comparing the outcomes of TURP and open surgery, the former was associated with a higher incidence of a second prostatectomy and open surgery with lower long-term mortality. In a study by Meyhoff and Nordling [16] surgery for obstruction or recurrence was required in 7% of cases after open surgery and 17–25% after TURP.

In the present study three patients (8%) developed a urethral stricture after open prostatectomy and required further surgery. Interruption of the internal iliac artery circulation can lead to pelvic ischaemia, which can manifest in different ways, either serious (colorectal ischaemia, gluteal necrosis and neurological deficit from distal spinal cord ischaemia or lumbosacral plexus ischaemia) or disabling complications like buttock claudication and sexual dysfunction. These complications can occur with abdominal aortic aneurysm (AAA) repair, when use of the internal iliac artery is necessary to facilitate endoluminal repair. The incidence and severity of the symptoms depends on many factors: (i) unilateral or bilateral occlusion; (ii) stenosis of the origin of the remaining internal iliac artery; and (iii) the status of the collateral circulation around the internal iliac artery [17]. Usually major complications are not common and other comorbid factors contribute to the complications such as shock and distal embolization [18]. While most symptoms are transient and resolve with time, they can be problematic [19,20]. AAA repair can cause and contribute to these complications as it can compromise spinal cord circulation and the disease can involve the origin of the inferior mesenteric artery. In cases of abnormal placentation, balloon occlusion of the internal iliac arteries is used before surgery, after Caesarean delivery and before hysterectomy; this is a safe procedure and reduces the amount of blood loss [21]. Walsh applied bulldog clamps on the internal iliac arteries in radical retropubic prostatectomy after pelvic lymph node dissection in an attempt to reduce blood loss in the remainder of the procedure [22]. Temporary occlusion of the internal iliac arteries during radical retropubic prostatectomy was shown to reduce the need for blood transfusion [23].

In the present study the temporary occlusion of the internal iliac arteries caused no neurological deficit, colorectal ischaemia or gluteal ischaemia, and it seems that a brief occlusion of the internal iliac arteries does not cause pelvic ischaemia, but the above complications could occur if the procedure were prolonged and the internal iliac arteries clamped for a long time.

In conclusion, there is still a place for open simple prostatectomy; it can be completed in a reasonable time with minimal blood loss if vascular control is applied, and with an acceptable incidence of complications. We advocate using open simple prostatectomy for men with a large prostate and concomitant bladder pathology, e.g. stones or bladder diverticula.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  • 1
    Serretta V, Morgia G, Fondacaro L et al. Open prostatectomy for benign prostate enlargement in southern Europe in the late 1990s. a contemporary series of 1800 interventions. Urology 2002; 60: 623
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    Fujita K, Kimura T, Saito K et al. Comparison of transurethral and open subcapsular prostatectomy: relation to weight of prostate. Clin Ther 1988; 10 (Special issue): 711
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    Oesterling J. Retropubic and suprapubic prostatectomy. In WalshPC, RetikAB, VaughanED, WeinAJ eds, Campbell's Urology, Vol. 2, 7th edn. Philadelphia: WB Saunders, 1998: 1529–40
  • 4
    Walsh PC, Oesterling JE. Improved haemostasis during simple retropubic prostatectomy. J Urol 1990; 143: 12034
  • 5
    Freyer PJ. Total extirpation of the prostate for radical cure of enlargement of that organ. Br Med J 1901; 2: 125
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    Mansell-Moullin CW. Enlargement of the Prostate: its Treatment and Cure. London: Lewis, 1894
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    Freyer PJ. One thousand cases of total enucleation of the prostate for radical cure of enlargement of that organ. Br Med J 1912; 2: 868
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    Millin T. Retropubic prostatectomy: new extravesical technique. Report on 20 cases. Lancet 1945; 11: 693
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    Millin T. Letter to LPB 10 November 1969
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    Schlegel PN, Walsh PC. The use of the preperitoneal approach for the simultaneous repair of inguinal hernia during surgery on the bladder and prostate. World J Surg 1989; 12: 5559
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    Roos NP, Wennenberg JE, Malenka DJ et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med 1989; 320: 11204
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    Meyhoff HH, Nordling J. Long term results of transurethral and transvesical prostatectomy. Scand J Urol Nephrol 1986; 20: 2733
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    Yano OJ, Morrissey N, Eisen L et al. Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms. J Vasc Surg 2001; 34: 20411
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    Mehta M, Vieth FJ, Ohki T et al. Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure. J Vasc Surg 2001; 33 (Suppl. 2): S2732
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    Lee WA, O'Dorisio J, Wolf YG et al. Outcome after unilateral hypogastric artery occlusion during endovascular aneurysm repair. J Vasc Surg 2001; 33: 9216
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    Kidney DD, Mguyen AM, Ahdoot D et al. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. Am J Roentgenol 2001; 176: 15214
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    Walsh PC. Anatomic radical retropubic prostatectomy. In WalshPC, RetikAB, VaughanED, WeinAJ eds. Campbell's Urology. Vol. 3, 7th edn. Philadelphia: WB Saunders, 1998: 2565–88
  • 23
    Peter CA, Walsh PC. Blood transfusion and anaesthetic practices in radical retropubic prostatectomy. J Urol 1985 July; 134: 813