Microsoft Word - EN_5_OPEN SURGERY FOR BPH COMPARED WITH TUR-P DURI1
OPEN SURGERY FOR BPH COMPARED WITH TUR-P DURING THE LAST 5 YEARS IN THE EXPERIENCE OF SAINT JOHN CLINICAL EMERGENCY HOSPITAL BUCHAREST, DEPARTMENT OF UROLOGY
P. Geavlete, E. Constantinescu, T. Jora
Department of Urology, Saint John Emergency Clinical Hospital, Bucharest
Correspondence: Prof. Dr. P. Geavlete
Urological Depatment
042122 Bucharest, Romania
Introduction. Open surgery, once the only therapeutic option for benign prostatic
hyperplasia (BPH), is now being replaced by modern, non-invasive techniques. Our study
aims to realize the comparative analysis, in a retrospective manner, of the transurethral
resection of the prostate (TUR-P) and the open prostatectomy.
Material and methods. Between January 2002 and January 2007, in the Department of
Urology of „Saint John” Clinical Emergency Hospital were performed a number of 2210
surgical procedures for BPH, 630 (28.5%) by open surgery and 1580 (71.5%) by
endoscopy. The mean patients’ age was 70 year old. The evaluation protocol included
anamnesis, physical examination, urinalysis, seric PSA, abdominal and transrectal
2
ultrasound and urodynamic studies in selected cases. The study was performed
retrospectively, by comparative analysis of data taken from patients’ files.
Results. Although the total number of patients with BPH has constantly increased, from
2468 in 2002 to 3654 in 2006, we noticed that the total number of surgical procedures is
almost unchanged. This tendency could be explained by the increasing number of
patients treated with 5 alpha-reductase inhibitors or alpha-blockers. Nevertheless, if in
2002 TUR-P was performed in 60% of cases, in 2006 the percentage increased
significantly to 73%. The mean patients’ age in the group who underwent open surgery
was 71 years old, while in the group treated endoscopically was 69 years old. The mean
prostatic volume was 45 cm3 for the patients treated endoscopically and 80 cm3 in the
group treated by open surgery. Mean hospitalization time was 3.4 days for the group
treated by TUR-P, and 7 days for the group in which we performed open surgery. By
analyzing the number of interventions in each age group, we noticed an increase of 100%
regarding the endoscopic procedures in males aged over 80 years old, while the number
of open surgical procedures decreased by one third in the same group.
Conclusions. During the last 5 years, the number of patients treated by TUR-P constantly
increased by comparison to open surgery, due to technical and surgical experience
improvement. TUR-P offers mainly the advantages of lower intra and postoperative
complications and short hospitalization stay. This allowed the extension of endoscopic
indications, in fields which initially belonged to open surgery.
Key words: benign prostatic hyperplasia, open prostatectomy, transurethral resection of
prostate
3
Introduction
BPH with associated lower urinary tract syndrome remains one of the most
important cause that determined many elderly people to come for urological evaluation.
During the last 100 years, a lot of treatments, both medical and surgical, have
been recommended. Currently, even medical therapy is more and more used, surgical
treatment still represents an important option. Between the various surgical options, the
two most important were represented by open prostatectomy and TUR-P.
Open prostatectomy was first proposed by Eugene Fuller and Peter Freyer in 1895
and 1900 [1], [2]. Surgical operation proposed by Freyer was not at all minor at that
time, particularly considering morbidity and mortality rate, but even in these conditions,
the introduction of BPH surgery was a revolution for the therapy of BPH. During the
time, open prostatectomy was performed especially retropubic or transvesically [3,4].
The second important change was brought in 1932 when Maximilian Stern and Joseph
McCarthy introduced the Stern-McCarthy instrument, the ancestor of the modern
resectoscope [5]. This endoscopic technique slowly progressed and imposed and is
recognised in our days as the surgical gold standard treatment of BPH.
The prostate volume threshold between transurethral surgery and open
prostatectomy remains an open issue, patients with glands of 80 to 100 cc being
considered for open surgery in some countries [6], [7], while a two steps procedure with
TUR of one prostatic lobe at a time is preferred in other countries. At the beginning of the
endoscopic era, TUR-P was mainly addressed to small prostate glands (average resected
4
tissue about 20-30 g) as patients were operated in the early stage of the disease [5].
Initially, a lot of procedures were performed each year but the number gradually
decreased when alpha adrenoreceptor antagonists and 5-alpha reductase inhibitors were
introduced [8]. Starting with the continuous increasement of medical therapy, surgery
was gradually applied at a later stage of the disease, many patients being referred late,
when the complications, represented especially by acute or chronic retention, occured [7].
Our study aimed to realize the comparative analysis, in a retrospective manner, of
the transurethral resection of the prostate (TUR-P) and the open prostatectomy.
Material and methods
Between January 2002 and January 2007, in the Department of Urology of Saint
John Clinical Emergency Hospital were diagnosed with BPH 10370 patients, 2210 being
treated by surgical procedures, 630 (28.5%) by open surgery and 1580 (71.5%) by
transurethral resection.
Medical treatment
Open prostatectomy
5
The evaluation protocol in all cases included anamnesis, physical examination
with digital rectal examination, urine culture, serum PSA, abdominal and transrectal
ultrasound. Urodynamic studies were performed in selected cases [9]. The study was
performed retrospectively, by comparative analysis of data taken from patients folders.
The considered elements were represented by the age of the patients, the associated
pathology, the complications rate and the histopathological results.
Figure 2. Doppler ultrasound revealing vascularization of the prostate
Results
Although the total number of patients with BPH has constantly increased, from
2468 in 2002 to 3654 in 2006, we noticed that the total number of surgical procedures
was almost unchanged
treated surgically
Open prostatectomy
TUR-P 250 320 314 369 307
Table 1. Number of patients treated by open prostatectomy and TUR-P since 2002
This tendency could be explained by the increasing number of patients treated by
5-alpha reductase inhibitors or alpha-blockers. Nevertheless, if in 2002 TUR-P was
performed in 60% of the cases, in 2006 the percentage increased significantly to 73%,
proving the TUR-P has gradually increased as the main surgical treatment option.
By analyzing the number of interventions in each age matched group, we noticed
an increase of 100% regarding the endoscopic procedures in males aged over 80 years
old, while the number of open surgical procedures decreased by one third in the same
group. This could be explained by the lower incidence rate of complications determined
by TUR-P, which imposed it as the preferred option to treat elderly patients.
The associated pathology for the two groups, including patients treated by open
prostatectomy and TUR-P, was represented comparatively in tables 2 and 3:
Year 2002 2003 2004 2005 2006 Open
prostatectomy 151 135 141 106 117
Acute urinary retention
78 37 39 39 33
Lithiasys 20 10 21 13 14 Hematuria 7 6 6 2 2
Bladder tumor
Diverticulum 2 0 0 0 0
7
Table 2. Associated pathology in patients treated by open prostatectomy
Year 2002 2003 2004 2005 2006 TUR-P 250 320 314 369 307
Acute urinary
38 50 50 54 51
Lithiasys 16 17 20 26 33 Hematuria 5 0 1 7 4
Bladder tumor
Diverticulum 0 0 1 1 2
Table 3. Associated pathology in patients treated by TUR-P
In our experience, the incidence of associated pathology is mainly the same in
both groups, showing that both open surgery and TUR-P can resolve with the same
efficacy BPH and the encountered associated pathology. (Figure 3)
8
Figure 3. BPH associated with lithiasis
The mean patients’ age in the group that underwent open surgery was 71 years
old, while in the group treated endoscopically was 69 years old as it can be seen in tables
4 and 5. It can be clearly seen that, in our experience, the surgical treatment was
generally addressed to patients over 60 years old, about 50% of them being between 71 to
80 years old.
Mean age Less than 50
51-60 61-70 71-80 Over 80
2002 71.2 0 3 61 74 13 2003 71.5 0 5 46 69 15 2004 71.25 1 5 49 72 14 2005 72.53 0 4 30 37 15 2006 72.27 0 4 34 63 16
Table 4. Patients age in open prostatectomy group
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Mean age Less than 50
51-60 61-70 71-80 Over 80
2002 69.78 0 9 119 104 17 2003 68.98 2 29 135 124 30 2004 69.39 1 24 134 127 28 2005 69.54 0 40 137 260 31 2006 70.49 3 20 103 149 32
Table 5. Patients age in TUR-P group
The histopathological examination reveals mainly BPH but also PIN- low grade
and high grade and prostate cancer were found. Patients with PIN-HG were followed by
PSA monitoring and transrectal ultrasound prostate biopsy when PSA velocity was over
0.75 ng/ml/year and in patients with prostate cancer bilateral orchiectomy or total
androgen blockade were performed.
2002 2003 2004 2005 2006 BPH 122 101 117 88 98
PIN-low grade
PIN- HG 7 10 10 7 5 Prostate cancer
7 8 3 3 5
Table 6. Histopathological specimen results in open prostatectomy group
2002 2003 2004 2005 2006 BPH 219 277 272 320 262
PIN-low grade
PIN- HG 9 7 9 12 10 Prostate cancer
7 8 10 9 11
Table 7. Histopathological specimen results in TUR-P group
10
The mean prostatic volume was 45 cm3 for the patients treated endoscopically and
80 cm3 in the group treated by open surgery. Mean hospitalization time was 3.4 days for
the group treated by TUR-P, and 7 days for the group in which we performed open
surgery.
Open prosta- tectomy
Table 8.Comparative complications in patients treated by TUR-P and open prostatectomy
( BNC- bladder neck contracture, UTI- urinary tract infection)
The complications rate was higher in the open prostatectomy group, as it is
represented in table 8. The transfusion of the autologous blood was almost double in
patients treated by open prostatectomy comparing with TUR-P. Also, with higher rates,
cardiovascular or thromboembolic complications and urinary tract infections have been
found especially after prostatectomy. Secondary procedures and bladder neck contracture
were especially found in patients treated by TUR-P.
Discussions
Open prostatectomy (transvesical or retropubic) was the gold standard surgical
treatment of BPH for many decades. The transition from open to transurethral surgery
occurred gradually, TUR-P being currently the main surgical option used to treat patients
11
with BPH [10], [11]. Results of many studies on open prostatectomy should be
interpreted with caution as long as many parameters involving anaesthesia, transfusion,
surgery and outcome have changed in the last period [3],[4],[12],[13], [14], [15].
Several studies indicated that open prostatectomy provides outstanding relief of
bladder outlet obstruction and lower urinary tract symptoms [16], [17], [18],[19], [20]. In
a reference and well documented study study, Meyhoff demonstrated that open
prostatectomy is well accepted by patients with only 9% of them being unsatisfied
compared to 15% of the TURP group [21], [22], [23].
Another study, published by Tubaro, evaluated the 1 year clinical and urodynamic
outcome in patients treated by open suprapubic prostatectomy [20], [24] and proved that
it induced a significant reduction of IPSS score and improved the index of quality of life
(QL), 84% of patients describing themselves as delighted with the results obtained and
none having a QL score greater than 3. In their study, 60% of patients became
asymptomatic after treatment and 96.9% had a flow rate greater than 15 ml/sec. A
significant improvement of voiding volume, post voiding residual volume and bladder
wall thickness was also observed [25], [26], [27].
Varkarakis confirmed these data, retrospectively evaluating 151 patients who
underwent open transvesical prostatectomy for BPH (prostate larger than 70 grams)
during a five-year period [19]. The improvement at one year follow-up, documented by Q
max increase, post voiding residual urine and lower urinary tract symptoms decrease and
quality of life amelioration, was statistically significant and has not changed at 4 years
after surgery.
12
One of the main disadvantages of open prostatectomy is the high rate of
morbidity, which is generally higher than reported for TUR-P. Actually, better patients
selection and progresses of anesthetic and surgical techniques determined a significant
decrease in complication rates, which are considered to be lower than reported in early
seventies.[20], [25],[27].
hemorrhage associated with open prostatectomy and transfusion rate remains a major
concern. In the study published by Tubaro, blood transfusion was needed in about 28% of
patients evaluated. Other reports showed a lesser incidence (about 11%) of severe
bleeding which necessitated blood transfusions [24], [25]. Considering an overall 23%
transfusion rate after this procedure (AUA guidelines), it is recommended to prepare
about 2 units of autologous blood at the time of open prostatectomy. Our results were
similar with these, and we consider that risk of bleeding is not at all negligible and should
be taken into consideration before choosing between TUR-P and transvesical
prostatectomy, even if open surgery is performed by an experienced surgeon.
Wound complications could also be an important reason of concerns in the
postoperative period in less than 4% of patients [18], [19], [24]; being determined by an
incomplete closure of the prostatic capsule in retropubic prostatectomy or the cystostomy
tube in suprapubic prostatectomy [20]. This complication will usually resolve
spontaneously by maintaining the urethro-vesical catheter drainage.
Hospital stay is usually longer with open procedures with a mean hospitalization
ranging from 6 to 10 days in the modern series and it is due to a median of 5 day of
catheterization time [22], [23], [24].
13
Urinary tract infection is a rare complication (6–8%) thanks to the modern
antibiotic prophylactics and is comparable to that observed after TURP. In order to
minimize the incidence of urinary infection, we consider that urine culture before surgery
is mandatory and prophylactic therapy with a broad-spectrum antibiotic is absolutely
needed.
Urinary incontinence is a rare event after open prostatectomy and should be
minimized by a precise and complete enucleation of the adenoma with a minimal risk of
injury of the external sphincter. After TUR-P, the incidence can be higher due both to the
injuries of the internal sphincter and/or the incomplete resection of the peri-apical tissue.
Late urologic complications are not common and include bladder neck
contractures (BNC) and urethral strictures with an incidence comparable to TURP (2–
20%). Erectile dysfunction occurs in 3% to 5% of patients undergoing an open
prostatectomy; it is more common in older men than in younger men. Retrograde
ejaculation is another common complication after open procedures and is observed in
80% to 90% of patients.
Deep vein thrombosis, pulmonary embolus, myocardial infarction, and a cerebral
vascular event are observed in less than 1% of open prostatectomy with an overall
mortality rate which is approximately zero.
Outcomes of open prostatectomy versus TURP were evaluated by the American
Urological Association guidelines and are represented in Table 9.
14
Table 9. Outcomes of surgical therapies: estimates of occurrence of adverse events
(adapted from AUA guidelines) (BNC – bladder neck contracture, UTI – urinary tract
infection)
Complications also could occur after open prostatectomy by developing
pathological processes in the prostatic fossa, all of these being treated endoscopically
[28].
Another important element is represented by the cost. Analysis of costs suggested
that open prostatectomy is the most expensive surgical procedure for BPH. An analysis
from 1994 AHCPR document, based on Medicare data for the years 1988–89, showed an
average 12,788 US$ for open prostatectomy (costs for primary treatment and 1 year
follow-up) versus an average of 8,606 US$ for TURP [29].
The higher costs of treatment are related to the longer hospital stay while the
lower expenses after primary treatment are instead determined by the lowest re-treatment
rate of open surgery. Even the cost is not the main parameter in the decision of the
urologist, any treatment allowing early patient discharge, rapid social reinsertion and
particularly the possibility to manage patients as a day case must be considered [19].
BNC Incontinence UTI Transfusion
6% (5–9)
8% (5–11)
Open 8%
8% (3–17)
27% (23–32)
15
As published by Geavlete, the intra and postoperative rate of complications
determined by TUR-P is not at all negligible, even lower comparing with transvesical
prostatectomy [30], [31].
As a modern tendency, the high prevalence of medical treatment over the last two
decades could finally determine larger prostate volumes in patients who ultimately
progress during alpha adrenoceptor antagonists’ treatment and require surgery and it is
not known yet if whether or not a widespread use of 5-alpha reductase inhibitors could
reverse this situation [32], [33].
Morbidity and costs associated with transurethral resection of large prostates
influenced the development of different alternatives of minimally invasive treatments
(TUMT, TUNA, etc), but they are useful in small to medium size BPH and failed to
provide a superior alternative for large prostate glands.
Holmium enucleation of the prostate, HoLEP introduced by Fraundorfer and
Gilling in 1998 seems to represent the best option, offering the low invasiveness of
transurethral surgery with a debulking capacity comparable to open prostatectomy [34].
Another option could be represented by the introduction of the high power potassium-
titanyl-phosphate (KTP) laser which offers a bloodless endoscopic procedure that can be
performed as a day case. As a perspective in the next future, it is expected that 50% of
transurethral procedures for BPH will shift from TURP to KTP laser in USA [35], [36].
Conclusions
16
In our department, during the last 5 years, the number of patients treated by TUR-
P constantly increased by comparison to open surgery, due to technical and surgical
experience improvement. We consider that even open transvesical prostatectomy offers
the highest probability of symptomatic improvement and the lowest failure rate, it also
has the highest rate of surgical complications and the highest costs but it must be
performed in large adenoma, over 70 grams. Although open prostatectomy is one of the
oldest procedures introduced in urology, the improvement of surgical techniques
determined a superior control of bleeding from the bladder neck and in skilled hands can
achieve morbidity rates comparable with TUR-P.
TUR-P represents the minimally invasive therapy for BPH, representing the
solution of choice, and offering the advantages, not negligible at all, of lower intra and
postoperative complications and short hospitalization stay.
These reasons allowed the extension of endoscopic indications, in fields which
initially belonged to open surgery.
Even modern technology determined important changes in the approach and
treatment of BPH, open prostatectomy and TUR-P still represent the main options.
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