BPH affects ≈ 70% of men aged > 70 years and is a significant cause of morbidity for those with BPH of > 60 g [1,2]. It has traditionally been treated by suprapubic trans- or extravesical prostatectomy [3,4]. Despite improvements in perioperative care, the complication rate remains significant. Severe bleeding occurred in 11.6% of patients analysed in a recent multicentre retrospective study , with a transfusion rate of 8.2%; sepsis in 8.6% and a median hospitalization of 7 days after surgery were also reported. The progress in laparoscopic techniques now permits an extension of its use to complex oncology (radical prostatectomy) and reconstructive surgery . The laparoscopic retropubic approach seems to be an excellent alternative to open surgery for treating obstructive prostatic hyperplasia of > 60–70 g and not reasonably treatable by TURP . Patients with enlarged prostates (>60 g) scheduled for open prostatectomy were offered the option of a laparoscopic approach; we report the first five cases, with a description of the surgical procedure.
Prostate volume was determined before surgery by a DRE and TRUS; cystoscopy was not used systematically. The patient is placed in the dorsal lithotomy position with slightly raised legs, allowing a DRE. Insufflation is produced in the pre-peritoneal space by a Veress needle introduced 2 cm above the pubis, after passing the posterior fascia. The first 12-mm trocar is then placed with a modified open technique just below the umbilicus for the laparoscope. Dissection with the laparoscope has to be careful so as not to open the peritoneum. Three 5-mm ports are placed under visual control in the pre-peritoneal space (Fig. 1). The Retzius space is dissected and pre-prostatic fat removed (Fig. 2).
The prostatic capsule is opened 3–4 cm transversally according to prostate size. Haemostatic sutures are placed at the 5 and 7 o’clock positions. Coagulation is obtained by bipolar diathermy. For the first three patients the right index finger was introduced through a 2-cm suprapubic incision into the capsule, permitting enucleation of the adenoma as with the open technique (Fig. 3). After closing the incision, CO2 was again insufflated to control the section of the adenoma at the apex, which is always visible with the laparoscope. For the last two patients, enucleation was entirely under laparoscopic control without using the finger. The specimen was then placed in the lateral prostatic fossa to await removal. A 22 F irrigation catheter is then introduced (Fig. 4) and a running suture of 2–0 polyglactin used to close the prostatic capsule (Fig. 5). A suction drain is placed in the Retzius space by a lateral trocar. The bladder is irrigated as before with a saline solution. At the end of the procedure, the specimen is placed in a laparoscopic bag and extracted through the enlarged umbilical incision.
In the five patients the adenoma was > 120 g in three and 60–120 g in the other two. The median (range) operative duration was 95 (125–55) min (55 for the last two interventions). After surgery no opioids were necessary; the urethral catheter was removed on the third day in all patients, with a return home the day after, with normal continence. No prostatic adenocarcinoma was encountered at the pathological examination. There was no blood transfusion or infection reported.
COMPARISON WITH OTHER METHODS
Many approaches for BPH of > 60 g have been described, and experience has narrowed these down to the suprapubic transvesical operation (Freyer) or retropubic prostatectomy (Millin) [2,3]. Our main goal was to show the feasibility of the laparoscopic technique and the short training period for teams already familiar with laparoscopy. This technique is similar to that of Millin at the anatomical level.
ADVANTAGES AND DISADVANTAGES
Despite prolonged and worldwide practice, suprapubic transvesical or prevesical approaches still present significant morbidity rates (6–10%) and blood loss, both during and after surgery [3,7]. The operation is often lengthy, with a relatively high incidence of postoperative wound infection and secondary haemorrhage . Retropubic prostatectomy remains a useful procedure, with minor bleeding in the prostatic fossa and relative freedom from infection in the bladder . Moreover, the postoperative course for the patient and nursing staff is remarkably easy [6,9].
Open surgery may involve blood loss and transfusions (4–12%), morbidity, and a prolonged hospital stay and recovery time [4,6]. A high incidence of wound infection after surgery is also reported when prolonged urinary drainage is necessary. The laparoscopic approach to BPH appears to be a simple and reproducible technique, which is learned easily. The fastest operation was in the last patient and the slowest in the first. We consider that this intervention can be done in 1 h once training is completed. The inflammatory or noninflammatory feature of the prostatic fossa is certainly a major influence on the dissection time, and more so if the enucleation is not assisted with a finger. A clear improvement in experience between the first and fifth case, showing lower blood loss, catheter times and complication rates, is difficult to confirm in this limited series, but the duration was reasonable in these five patients, especially considering that the adenomas were bulky.
One advantage of this technique is the direct visual monitoring allowed by laparoscopy, which enabled selective coagulation and an excellent joining of the capsule [10,11]. This advantage with laparoscopic vision thus permits better control both of the apex and of haemostasis, which becomes more selective. The blood loss was undoubtedly lower than those published elsewhere, because of the pressure created by the CO2 insufflation . Furthermore, the incision is smaller, although it must be large enough to extract the operative specimen. Pain is apparently reduced, because no retractor is needed and the incision is smaller. The hospital stay is shorter (4 days) with less risk of parietal defects. Moreover, medical and surgical complication rates were similar in the two approaches .
DIFFICULTIES AND COMPLICATIONS
Laparoscopic adenectomy is a demanding technique which requires substantial training, needing perhaps more than five cases to reach a plateau for operative duration and complication rates . The difficulty is that the access must be extraperitoneal during procedure. Opening the peritoneum during dissection entails creating a pneumoperitoneum, which disturbs the dissection. There must be then more Trendelenburg tilt and the incision in the peritoneum must be enlarged. Mastering surgical suturing is imperative, as the suture space is particularly limited in this access. The dissection is easy, even when starting to experiment with laparoscopy. The presence of a median lobe requires a large incision of the bladder neck but the surgery remains feasible.
In conclusion, laparoscopic adenectomy is simple and reproducible, with a hospital stay and blood loss apparently less than with the retropubic approach. The laparoscopic approach to a large adenoma is undoubtedly an alternative which must be confirmed by studies on more patients, and represents a new step in training for laparoscopic radical prostatectomy.