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Frequency of Malignancy in Clinically Benign Open Transvesical Prostatectomy- A study of 100 cases.

Byline: Azhar Ali Shah, Khush Muhammad Sohu, Immamuddin Balouch and Ghulam Hyder Rind

Abstract

Background: Enlargement of prostate can be benign and malignant. Though differentiation between the two can be made on clinical grounds and surgery but still some cases can be missed if not subjected to histopa thology.

Objectives: To find out the frequency of malignancy in patients operated for clinically benign open transvesical prostatectomy.

Study type settings and duration: It was a prospective observational study conducted in the Department of surgery (Surgical Unit -I), Ghulam Muhammad Mahar Medical College and Hospital, Sukkur from January 2011 to December 2011.

Patients and Methods: Patients presented with the history of prostatic symptoms were evaluated in surgical out-patient's department using digital rectal examination and ultrasound. The findings were recorded in a proforma and those having enlarged prostate weighing above 40gm underwent prostate specific antigen testing. Patients having no malignant findings on history, digital rectal examination and whose prostate specific antigen levels were below 10 ng/dl underwent open transvesical prostatectomy and all specimens were sent for histopathology. Those with suspicion of malignancy either on history or digital rectal examination or high prostate specific antigen were excluded from the study, also the glands below 40 gm in volume were excluded and referred for transurethral resection. All specimens were sent for hisopathology.

Results: Out of 100 cases, 41 were between 56 to 65 years of age. The mean age was 58 years. Acute urinary retention requiring catheterization was seen in 36 cases while 18 patients had symptoms suggestive of inguinal hernia but on examination had enlarged prostate. Prostate specific antigen was done in 07 patients with suspicion of malignancy but its value was below 1 0 ng/dl therefore they were included in the study. On ultrasound the gland volume ranged from 40 to 85 gm and residual post-voidal urinary volume ranged from 100 to 450ml. On histology 06 patients were found to have adenocarcinoma of prostate including 01 patient in whom mucosa of the gland was fixed but as the prostate specific antigen was below 10 ng/dl so the patient was kept in study group. Gleason score ranged from 4 to 9.

Conclusions: Direct rectal examination is not a reliable test to detect early malignant changes in prostate and all specimens should be subjected to histopathology.

Policy message: Histopathology of all operated and biopsied materials should be done to complete diagnosis.

Key words: Clinically benign prostatic hyperplasia, open prostatectomy, frequency of carcinoma in benign prostatic hyperplasia.

Introduction

Enlargement of prostate gland is common in old age. Benign prostatic hyperplasia is the common cause of its enlargement which causes bladder outflow obstruction in up to 40% men during their life time1. Carcinoma of the prostate is the 2nd commonest cause of prostatic enlargement. Differentiation between prostate cancer and benign prostatic hyperplasia is important as treatment in these conditions is different2. Cancer in most cases is diagnosed late when the tumor has extended beyond the confines of the gland making it incurable 3.

Benign prostatic hyperplasia is associated with prostate enlargement (volume more than 30 ml) and later causes decreased urinary flow, acute urinary retention and ultimately requires surgery4. Prostatectomy for benign prostatic hyperplasia confers no protection from subsequent carcinoma5.

There is scarce data on prostatic disease surgery from Pakistan3,6, therefore, the present study was done in patients over the age of 45 years presenting with symptoms suggestive of enlargement of prostate and see the frequency of carcinoma in the resected specimens.

Patient s and Methods

Male patients presenting with the history of lower urinary tract symptoms s uch as frequency of micturation, nocturia, hesitancy, urgency, dribbling and or, retention were evaluated in surgical out-patient department for prostatic enlargement. All patients underwent history and examination especially digital rectal examination and ultrasound of urinary tract with special emphasis on prostate, its volume and post-voidal residual urine. The findings were recorded in a proforma which was attached to the patient' s charts. Only patients with enlarged prostate weighing above 40gm, with no malignant findings digital rectal examination and whose prostate specific antigen levels were below 10 ng/dl were selected for the study. These patients underwent open transvesical prostatectomy and all specimens were sent for histopathology.

Patients having suspicion of malignancy either on history or rectal examination were advised to test for prostate specific antigen and those with values over 10 ng/dl were excluded from the study. Also the glands weighing below 40 gm in volume were excluded from the study and these were referred for transurethral resection.

Results

A total of 100 patients were included in the study whose ages ranged between 45 to 82 years (mean 58 years) (Table) . The major presenting feature was acute urinary retention requiring catheterization in 36 cases, while symtoms suggestive of inguinal hernia were present in 18 patients but on examination they had enlarged prostate with symptoms of frequency of micturation, nocturia, hesitancy, and dribbling of urine. Prostate specific antigen was done in 07 patients who were suspected to have malignancy but it was below 10 ng/dl and therefore they were included in the study. The findings of digital rectal examination which, suggested benign nature of the gland included smooth, convex, typically elastic posterior surface of the gland, the rectal mucosa could be moved over the prostate and the median sulcus could be palpated. The ultrasound showed gland volume to range between 40 to 85 gm and the residual post-voidal urinary volume ranged from 100 to 450ml.

Table: Age distribution of the patients.

Age Range (years)###No. of patients###Percentage

45-55###32###32

56-65###41###41

66-75###19###19

>75###08###08

Total=###100###100

Histopathology of 94 specimens showed benign prostate but in 06 specimens adenocarcinoma was reported including 01 patient in which we suspected malignancy due to fixation of mucosa of the gland but as the prostate specific antigen level was below 10 ng/dl, so the patient was included in the study. Gleason score ranged from 4 to 9. The mean age of patients with carcinoma prostate was 56.8 years.

Discussion

In the present study 6% cases were found to have adenocarcinoma of the prostate on histology in an otherwise benign setting. Open transvesical prostatectomy is commonly carried out for benign prostatic hyperplasia at nearly all primary and secondary level hospitals all over the country. Cancer of prostate is common in Pakistan7,8 and in spite of taking careful history and performing digital rectal examination about 10% patients will still have prostate cancer when the specimen is subjected to histopathology following surgery for benign prostatic hyperplasia9,10. Clinically such cancers are occult and are therefore, classified as T1 tumors which are diagnosed on histo logy after being operated for benign prostate either by transuretheral resections or by open transvesical prostatectomies 5.

Adding to this risk is the chance of having cancer in the remnant prostate following surgery for benign hyperplasia and this occurs in 4% cases during the first 7 years after surgery11. Only early detected prostatic tumors are curable and even those that are detected clinically on digital rectal examination are advanced and require palliative therapy5. The classical digital rectal examination is still the mainstay for the diagnosis of prostatic disease whose accuracy for detecting cancer ranges from 20-40%12 -15. The gold standard for the diagnosis of carcinoma of prostate includes digital rectal examination, prostate specific antigen testing and transrectal sonography16. Digital rectal examination is examiner dependent with great inter -examiner variability17 .

The malignant findings on digital examination include hard to stony hard prostate lobes or nodular surface in one lobe, obliteration of median sulcus, irregular indurations and fixation of rectal mucosa over the gland5. Digital rectal examination is neither specific nor sensitive enough to detect prostate cancer and its positive predictive value ranges from 21- 53%18 .

In the present study, most of the patients who had malignancy on biopsy, were over 50 years of age and this is in accordance with other studies where the disease is seen in advancing age 5,7. We used prostate specific antigen levels above 10 ng/ml as suspicious of malignancy as reported by others 19. but despite this we had one case of carcinoma whose prostate specific antigen level was below 10 ng/ml. In the present study, the frequency of malignancy of prostate in surgically resected otherwise benign prostatic specimens was 6% which is comparable with other studies of 6%20, 6.3%21 and 8%7. Some studies have reported low frequency of 2%12 , while, others have reported figures between 13- 19%22-26 . Great variation in the frequency of carcinoma in

clinically benign prostate surgeries is probably due to difference in sample size and inclusion criteria, replacement of transurethral resection of prostate with open method and the expertise of the examiner.

Early prostate cancers can be easily missed during clinical examination and if diagnosed early they can be easily treated. As these carcinomas are curable so there is a high need of subjecting all operated specimens for histopathology.

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Publication:Pakistan Journal of Medical Research
Article Type:Clinical report
Date:Dec 31, 2012
Words:2133
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