Printer Friendly

Transurethral resection versus transvesical approach for benign prostatic hyperplasia.

INTRODUCTION: Benign Prostatic hyperplasia (BPH) is the commonest cause of urinary problems in elderly males affecting the quality of life (1). About 10% of patients will need surgical intervention at some stage. Dihydrotestosterone, the active form of testosterone (Through action of 5-alpha reductase) is responsible for prostatic hyperplasia and 5-alpha reductase inhibitors provide base for medical treatment. Modalities of treatment include watchful wait, medical treatment like alpha blockers and fenesterides for small prostate with mild symptoms and surgical treatment like TUIP, TURP2, and open prostatectomy for symptomatic prostates of

Moderate to large size, laser ablation, thermotherapy, use of uretheral stents and ballooning for poor risk patients. (3,4) Transuretheral resection of prostate (TURP) has replaced open transvesical prostatectomy. (5,6) in developed countries, a procedure still common in developing countries where lack of facilities and late presentation with huge prostate is the reason for employing it. (7)

The prostate volume threshold between transurethral surgery and open prostatectomy remains an open issue, patients with glands of 80 to 100 ml may be considered for open surgery in some countries while a two stage procedure with transurethral resection of one prostatic lobe at a time may be performed in other countries (8). Other main reason for employing open prostatectomy is associated complications like vesical calculus or diverticulae. Open prostatectomy is still enjoying a respectable place in urology because long term results and patients compliance rate are acceptable. (9,10) Open prostatectomy (Milan's and transvesical) is one stage procedure intended to remove prostatic adenoma. (11) It appears more horrible from the scene of blood but it is safe and easy to perform. No special or sophisticated equipment is required. The possibility to perform a Millin's prostatectomy in laparoscopy was proven by Porpiglia and coworkers in 2005, the operation is challenging its role in our armamentarium is yet to be defined. It may remain a technical exercise or it may be an additional step in the trend toward converting most urological procedures into laparoscopic surgery. (12)

A laparoscopic transvesical approach has been proposed by Sotelo and co-workers and permitted the concomitant management of any coexistent intravesical pathology, such as bladder calculi. (13) Hospital stay is usually longer with open procedures with a mean hospitalisation ranging from 6 to 10 days in the modern series and it is due to a median of 5 day of catheterisation time. (14,15,16) Urinary tract infection is a rare complications(6-8%) thanks to the modern antibiotic prophylactics and is comparable to that observed after TURP. (8) Some of the new transurethral techniques, such as holmium, enucleation and photoselective vaporization of the prostate with KTP laser, already proved efficacious in dealing with large prostates. (17,18) The implementation of these two technique will probably make open prostatectomy redundant in specialized center's although they have not become yet the gold standard for the treatment of large prostate glands. Holmium enucleation suffers a long learning curve and significant capital investment which may limits its availability outside large institutions. (19) Photo selective vaporisation is still a very young technique with a very short logbook. Although 5-years data have been recently published, these data need to be confirmed in extramural studies. (20) this study was carried out to analyze and compare the results of transvesical and transurethral prostatectomy as these are procedures carried out in our set up.

AIMS AND OBJECTIVES: To compare the following in transvesical and TURP.

1. Immediate complication;

2. Hospital stay;

3. Days of immobilization;

4. Duration of indwelling catheter;

5. Mortality and Morbidity.

MATERIALS AND METHODS: In the present study we had analyzed 50 cases of benign enlargement of prostate with signs and symptoms of urinary obstruction, admitted and treated from August 2012 to August 2014 in Basaveshwar Teaching & General Hospital, Gulbarga attached to M. R. Medical College, Gulbarga. Selected 25 cases for TURP and 25 cases of transvesical Prostatectomy with suprapubic drainage catheter procedure.

During this period of study no case was treated with retropubic prostatectomy and no case was treated with Freyer's prostatectomy with primary closure of bladder. Pre-operative assessment was done in all cases. Pre-operative catheterization was done in 24 cases. The analyzed data of the study is compared and discussed with reference to the other series in literature. Patients having associated complications and post-op morbidities were compared. Informed consent was taken from the patients and the study had been approved by the ethical committee.

RESULTS:

The overall average duration of preoperative hospital stay was 7.06 days. The overall average duration of postoperative hospital stay was 12.58 days. In transvesical procedure the average postoperative hospital stay was 16.08 days. In TURP the average postoperative hospital stay was 6.24 days.

Mortality Rate: During the period of this study, there was no mortality. Incidence of mortality was 0%.

DISCUSSION: The prostate undergoes significant growth during fetal development and puberty. After puberty, the prostate size remains more or less constant till it undergoes benign enlargement or may commence to atrophy and decrease in size. Guess (21) (1990) suggested that there is a progressive increase in the diagnosis of benign prostatic hyperplasia in men with increase in age i.e. 26% in men 41-50 years old and 9% in men 71-80 years old. G1yn (22) (19 8 5) reported an incidence of 78% for benign prostatic hyperplasia in men by the age of 80 years.

In this study, all the maximum incidence of cases operated by two procedures falls under the age group of' 50 to 90 years with a mean age of 69.6 years. Poor urinary flow and hesitancy were the commoner obstructive symptoms while increased frequency and nocturia were complained by many among the commoner irritative symptoms in a study by Pinnock ET a1 (23) (1997).

In the present study frequency of micturation and loss of projection, acute retention of urine were the commonest symptoms complained by the patients in both the series, in addition to the above symptoms 76% had dysuria and 2% had hematuria. 21.3% of patients were admitted with urinary retention. Duration of the complaints varied from 2 days of more than one year.

In post-op period catheter was removed on average 2.60 days in transvesical prostatectomy group while in TURP it was removed on average 7.88 days. In the transvesical prostatectomy, postoperative hospital stay was 16.08 days, while no patients stayed more than 30 days. In TURP average duration of post-operative stay was 6.24 days. In transvesical prostatectomy, days of immobilization was 6.48 days, while in TURP it was only 3.12 days on average. 4% of patients undergoing prostatectomy developed wound infection (Nanninga and O'Connor, 1986).24 it was reported that the reason for a high wound infection rate was a high incidence (20-50%) of acute urinary retention in patients undergoing prostatic surgery requiring pre-operative Foley's catheterization. Other complications like urinary incontinence and urethral stricture and erectile dysfunction are in the range of 2-3%. Melchier (25) in 1974 reported a 1.3% mortality rate for prostatectomy. In this study, postoperative hemorrhage occurred in one patient and this required re-exploration on the same day. Postoperative wound infection in 4 (16%), post-operative complications like urethral stricture (2%) and UTI in 2% patients were noted.

According to McConnell (1994), efficacy of open, prostatectomy is greater than for any other treatment options available for the obstructing prostate gland. Abrams in 1979 using symptomatic and urodynamic criteria showed that 88% patients improved following prostatectomy. In the present series, Morbidity in terms of wound infection vesico-cutaneous fistula, U.T.I., epididymo-orchitis were present in transvesical prostatectomy and none in TURP. Patients also had urgency, incontinence and dysuria. Usually incontinence, dysuria improved within 6 weeks on following up the patients. The overall improvement after surgery on follow up was found to be 82.8%. The rest of the patients were lost to follow up after a period of 2 months and thus the symptomatology could not be studied in these patients.

CONCLUSION: The present study shows that TURP has definite advantage over the transvesical suprapubic drainage procedure, because of shorter period of hospitalization, postoperative complications are less frequent, shorter duration and less severe. It has got lowest mortality and morbidity rates.

DOI:10.14260/jemds/2015/112

REFERENCES:

(1.) Tammela T. Benign prostatic hyperplasia. Practical treatment guidelines: Drugs-Aging, 1997 May; 10 (5): 349-66.

(2.) McConnell J. D., Barry M. J., Bruskewitz R. C. Benign prostatic hyperplasia: diagnosis and treatment. Agency for Health Care Policy and Research: Clin. Pract. Guidel. Quick. Ref. Guide Clin., 1994 Feb.; (8): 1-17.

(3.) Sandhu J. S., NgC, Vanderbrink B. A., Egan C., Kaplan S. A., Te A. E. High power potassium titanyl-Phosphate Photo selective LASER vapourization of prostate for treatment of benign prostatic hyperplasia in men with large prostate. Urology, 2004 Dec.; 64 (6): 1155-9.

(4.) AUA guideline on management of benign prostatic hyperplasia. Chapter 1: Diagnosis and treatment recommendations. J Urol 2003; 170: 530-47.

(5.) Mearini E., Marzi M., Mearini L., Zucchi A., Porena M. Open prostatectomy in benign prostatic hyperplasia: 10-year experience in Italy: Eur. Urol., 1998 Dec.; 34 (6): 480-5.

(6.) Ali M. N. The outcome of transuretheral resection of prostate. J. Coll. Physician Surg. Pak. Dec., 2001; 11 (12): 743-6.

(7.) Ahmad M. Retropubic prostatectomy for benign prostatic hyperplasia. An analysis of 140 cases. J. Coll. Physicians Surg. Pak., June, 2001; 11 (6): 389.

(8.) Khan M., Khan S., Nawaz H., Pervez A., Ahmad S., Din S.U. Transvesical prostatectomy still a good option. J. Coll. Physicians Surg. Pak., April, 2002; 12 (4): 212-5.

(9.) Lewis D.C., Burgess N. A., Hudd C., Matthews P.N. Open or transurethral surgery for the large prostate gland: Br. J. Urol., 1992 Jun.; 69 (6): 598-602.

(10.) Aurangzeb M. Open prostatectomy: is it a safe procedure? J. Postgraduate Med. Institute, June, 2004; 18 (2): 242-9.

(11.) Richter S., Lang R., Zur F., Nissenkorn I. Infected urine as a risk factor for post-prostatectomy wound infection: Infect. Control Hosp. Epidemiol., 1991 Mar., 12 (3): 147-9.

(12.) Porpiglia F, Terrone C, Renard J, Grande S, Musso F, CossuM, et al. Transcapsular adenomectomy (Millin): a comparative study, extraperitoneal laparoscopy versus open surgery. Eur Urol 2006; 49:120-6.

(13.) Sotelo R, Spaliviero M, Garcia-Segui A, Hasan W, Novoa J, Desai MM, et al. Laparoscopic retropubic simple prostatectomy. J Urol 2005; 173:757-60.

(14.) Tubaro A. Open prostatectomy. In: Chapple C, McConnell JD, Tubaro A, editors. Current Therapy of BPH. London: Martin Dunitz Ltd; 2000. pp. 75-92.

(15.) Varkarakis I, Kyriakakis Z, Delis A, Protogerou V, Deliveliotis C. Long-term results of open transvesical prostatectomy from a contemporary series of patients. Urology 2004; 64:306-10.

(16.) Serretta V, Morgia G, Fondacaro L, Curto G, Lo bianco A, Pirritano D, et al. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology 2002; 60:623-7.

(17.) Naspro R, Suardi N, Salonia A, Scattoni V, Guazzoni G, Colombo R, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol 2006; 50:563-8.

(18.) Te AE, Malloy TR, Stein BS, Ulchaker JC, Nseyo UO, Hai MA. Impact of prostate-specific antigen level and prostate volume as predictors of efficacy in photoselective vaporization prostatectomy: analysis and results of an ongoing prospective multicentre study at 3 years. BJU Int 2006; 97:1229-33.

(19.) Seki N, Mochida O, Kinukawa N, Sagiyama K, Naito S. Holmium laser enucleation for prostatic adenoma: analysis of learning curve over the course of 70 consecutive cases. J Urol 2003; 170:1847-50.

(20.) Malek RS, Kuntzman RS, Barrett DM. Photoselective potassium-titanyl-phosphate laser vaporization of the benign obstructive prostate: observations on long-term outcomes. J Urol 2005; 174:1344-8.

(21.) Guess HA, Arrighi HM et al, "The cumulative prevalence of prostatism matches the autopsy prevalence of BPH", Prostate 1990.

(22.) Glyn R, Campion EW, bonchord GR et al, "The development of BPH among volunteers in the normative aging study", SM) Epid. 121; 781, 1985.

(23.) Pinnock VB and Marshall VR, the Med. Journal of Australia 1997; 167: 62-65.

(24.) Nanninga, O'Connor V et al, "Surgery of enlarged prostate gland". Urol., 1986; 632-39.

(25.) Melchier, Valk W, Foret et al, "Analysis of 7 years of 2223 consecutive cases of prostatectomy", 3. Urol. 1974.

S. S. Karbhari [1], Veeresh Hosamani [2], Nagnath Hulsoore [3], R. B. Dhaded [4]

AUTHORS:

[1.] S. S. Karbhari

[2.] Veeresh Hosamani

[3.] Nagnath Hulsoore

[4.] R. B. Dhaded

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Surgery, MRMC, Gulbarga.

[2.] Post Graduate, Department of Surgery MRMC, Gulbarga.

[3.] Post Graduate, Department of Surgery MRMC, Gulbarga.

[4.] Professor & HOD, Department of Surgery MRMC, Gulbarga.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. S. S. Karbhari, Associate Professor, Department of Surgery, M. R. Medical College, Gulbarga.

E-mail: sharankarbhari@gmail.com.

Date of Submission: 25/12/2014.

Date of Peer Review: 26/12/2014.

Date of Acceptance: 06/01/2015.

Date of Publishing: 13/01/2015.
Table 1: Age wise distribution

                Transvesical            TURP
Age group
(years)       No.    Percentage     No.    Percentage

50-60         11         44          5         20
61-70         06         24          6         24
71-80         06         24          9         36
81-90         02         08          3         12
91-100        --         --          2         08

Table 2: Symptom-wise distribution

                                          Transvesical
Symptoms
& Signs                                No.     Percentage

Frequency                              25        100.00
Dysuria                                23        92.00
Loss of projection                     15        60.00
Acute retention                        16        64.00
Straining retards stream                7        28.00
Dribbling                               5        20.00
Urgency                                 2         8.00
Retention with overflow                --          --
Previous history of retention          12        48.00
Chronic retention                       5        20.00
Haematuria                              1         4.00

                                           TURP
Symptoms
& Signs                                No.     Percentage

Frequency                              25        100.00
Dysuria                                15        60.00
Loss of projection                     20        80.00
Acute retention                        19        76.00
Straining retards stream                9        36.00
Dribbling                               6        24.00
Urgency                                 1         4.00
Retention with overflow                 1         4.00
Previous history of retention          12        48.00
Chronic retention                      --          --
Haematuria                              1         4.00

Table 3: Immediate Postoperative Complications

Nature of Complication     Transvesical      TURP

Hiccoughs                       1             2
Disorientation                  2             1
Bleeding                        1             1
Clot Retention                  --            3
Hypertension                    1             1
Hypotension                     --            --
Chest pain                      1             --

Table 4: Delayed Postoperative Complications

Nature of Complication      Transvesical     TURP

Leakage of SPC                   4            --
UTI                              1            --
Wound Infection                  4            --
Stricture                        1            --
Epididymo-orchitis               1            --
Pneumonic Consolidation          --           --

Table 5:Days of Post-op Indwelling Catheter

                          Transvesical          TURP
Days of Post-op
indwelling Catheter     No.   Percentage     No.   Percentage

0-3                     --           --      22           88
4-6                     18           72      03           12
6-9                     07           28      --           --

Table 6: Days of Post-op Immobilization

                      Transvesical           TURP
Days of
Immobilization     No.    Percentage    No.   Percentage

0-3                --         --        18        72
4-6                15         70        07        28
6-9                10         30        --        --
COPYRIGHT 2015 Akshantala Enterprises Private Limited
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2015 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:ORIGINAL ARTICLE
Author:Karbhari, S.S.; Hosamani, Veeresh; Hulsoore, Nagnath; Dhaded, R.B.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jan 15, 2015
Words:2417
Previous Article:A rare case report of acalculous cholecystitis in a dengue attacked pregnant woman.
Next Article:Case report of an unusually large renal calculus.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters