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Is open prostatectomy really obsolete?
ISOPENPROSTATECTOMYREALLYOBSOLETE? C. SERVADIO,
M.D.
From the Institute of Urology, Beilinson Medical Center, Petah Tiqva, and Tel Aviv University Sackler School of Medicine, Israel ABSTRACT-A total of 1,066 prostatectomies treated by us from 1985 to 1989 were reviewed. The necessary comprehensive data were available on 710 cases. Open (Millin’s retropubic) prostatectomy (RPP) was the procedure of choice for large glands and transurethral resection (TURP) for smaller glands: 408 had had RFP and 262 TURP; 14.5 percent of the TURP group eventually needed a second procedure during a one to six-year follow-up compared with only 2.6 percent of the RPP group. Forty other patients who had been operated on elsewhere were referred to usfor a second, repeat procedure; 30 also previously had had a TURl? Total hospitalization, operating time, and complications were better in the long run in the RPP group compared with the TURP group. It is believed that open prostatectomy still has a respectable place in urology and therefore, should be considered and also taught to residents for use in dealing with large glands.
The evolution of prostatectomy, the gradual development of the open procedure since the beginning of this century, and later the introduction of the transurethral approach, have all been described repeatedly and elegantly. 1-4 With the constant improvement in endoscopic instruments and the simultaneous use of sophisticated videocameras, transurethral resection of the prostate (TURP) has gradually become the procedure most widely advocated and used in several countries, thus rendering the open procedure obsolete or even virtually unknown to many urologists today. Have we perhaps gone too far? Have we perhaps discarded a good procedure which still has a place in routine urology, and, in particular, in a very common clinical situation? For several reasons our policy has been to adopt the transurethral approach5 for the smaller gland only and to perform the open procedure by the retropubic (Millin) method (RPP)6 for the larger glands. We have recently reviewed our clinical material to re-examine and re-evaluate this policy. Material and Methods A total of 1,066 patients who have had prostatectomy in our service from 1985 to 1989 have
UROLOGY
/ NOVEMBER
1992
/ VOLUME
40, NUMBER 5
been studied retrospectively: 38 percent had TURP5 and 62 percent RPP after Millin’s technique.e All patients had the same routine preoperative assessment, and once the indication for surgery was confirmed, based on conventional obstructive and irritative symptoms, they were referred for either RPP or TURP The choice was based almost invariably on the estimated prostatic volume only. The volume of the gland was estimated by digital rectal examination and also by transrectal echography. Either general or spinal anesthesia was used in both groups, and the type of anesthesia given had nothing to do with the type of surgery chosen. Average operating time for the open procedure usually exceeded the transurethral approach by no more than ten to fifteen minutes. Bleeding was similar in both groups. TURP patients were usually discharged from hospital three to four days after surgery while the RPP patients usually remained in hospital two to three days longer. Surgery was performed by all members of the staff, the residents being assisted by the more senior members. Perioperative antibiotics were used routinely in patients with active urinary tract infection or an indwelling catheter; a full course of
419
TABLEII. TABLEI.
Rehospitalization
without repeat surgery
Complication Acute urinary tract infection Acute retention Gross hematuria Urethral and bladder neck stricture Wound infection Orchiepididymitis Fistula TOTALS
Post-RPP Post-TURP (406) (262) 7 4 3 4 2 2 1 1 1 1 16(3.8%)
1
Rehospitalization for reoperation
1st Operation
2nd Operation
Done at Beilinson Medical Center RPP (408)
TURP (262)
Done elsewhere Open prostatectomy
(10)
. .
1
TURP (30)
. .
12 (4.6%)
Re-RPP 0 11 i Re-TURP Re-RPP 7 i Re-TURP 31 TOTAL3 Re-RPP 1Re-TURP : Re-RPP 8 1Re-TURP 22 TOTAL3
appropriate antibiotics was given to render urine sterile. All cases were usually followed for three to six months unless some problem arose. A retrospective study was done, with a follow-up of one to six years (mean 3.8 years).
patients in the TURP group severe incontinence developed, against 1 of 408 patients in the RPP group. There was only one postoperative death in this series of 1,066 cases; 1 patient in the TURP group died of acute myocardial infarction
Results
Comment
Of 1,066 patients operated on, data for a retrospective study were available in 710 cases. TURP was done in 262 and 408 had an open procedure, almost invariably the Millin retropubic procedure. The other 40 cases had had their original prostatectomy elsewhere and were seen by us because of complications; 10 hadhadanopenprocedureand30alsohadhad a TURP originally. Operating time was slightly longer for the open procedure and hospital stay two to three days longer on average. Otherwise there were no significant discrepancies between the two techniques and groups, except the total number of cases for each. The average age was seventyone years. During the follow-up period, 16 patients (3.8%) from the RPP group and 12 patients (4.6%) from the TURP group required readmission because of infection, retention, secondary bleeding, or a variety of other acute complications which required immediate medical attention (Table I). Thirty-eight TURP patients (14.5 % ) compared with only 11 RPP patients (2.6 % ) needed a repeat hospitalization and had to undergo a repeat surgery, the majority requiring a repeat TURP or transurethral incisions for bladder neck stenosis (Table II). Of the 40 patients initially operated elsewhere (30 had had a TURP) and in need of a second procedure, 28 had TURP and 12 RPP performed by us. In 2 of 262
There is general agreement that TURP is an excellent procedure. ’ It requires skill and expertise, and, when performed well and on patients properly selected, it gives satisfactory long-term results. Modern endoscopic equipment and light videocameras have rendered such a procedure today easier to teach and easier to master. Hospital stay and patient discomfort are reduced. Yet, the open procedure is still an excellent procedure, and when dealing with a large gland, the enucleation is rapid and the total operating time in relation to the prostatic volume to be removed is even shorter than in the transurethral procedure. Postoperative problems do occur but are infrequent. It seems that what appears to be a simpler and more rapid procedure in the short term may eventually bring less gratifying results in the long term, with a significantly higher need for reoperation at a later date. This has also been observed by others.*~g We have recently completed a study using transrectal echography during the actual prostatectomy in a group of 25 cases.‘O There was a definite impression that the open enucleation gives a better adherence to surgical anatomy demarcation lines compared with the TUR. This fact, among other points, ensures a reduced danger of damaging the distal urethral segment which in turn may lead to incontinence. One may, of course, argue that the results have a lot to do with the surgeon’s skill.
420
UROLOGY / NOVEMBER1992 / VOLUME40, NUMBER5
But this presumably procedures.
applies
equally
Institute of Urology Beilinson Medical Center Petah Tiqva 49100, Israel
to both
Conclusion References
Much attention has been given in recent years to develop and encourage the use of “keyhole” surgery instead of conventional, old-fashioned open surgery. Transurethral prostatectomy has, until recent times, placed the urologist in a leading position among the various surgical disciplines. Indeed TURP has rightly gained world-wide popularity and has, therefore, gradually been imitated by many other surgical specialities. Open prostatectomy is being performed less frequently in many countries. Many urologists today do not even know how to perform an open prostatectomy. Is this a change for the better? In recent years the justification for this change is being questioned for different reasons. Based on our experience and that of others, it appears than open retropubic prostatectomy may still be regarded as an excellent procedure, reserved for large glands. It requires only minimal increase in hospital stay; there is practically no more operating time needed and no additional complications, and it certainly gives a better long-term result.
UROLOGY
i
NOVEMBER
1992
i
VOLUME
40, NUMBER
1. Chisholm CD: Prostatectomy: past and present, in Hinman F Jr: Benign Prostatic Hypertrophy, New York, Springer Verlag, 1983, p 35. 2. Blandy JP: The history and current problems of prostatic obstruction in benign prostatic hypertrophy, in Blandy JP, and Lytton B (Eds): The Prostate, London, Butterworth & Co, 1986, p 12. 3. Walsh A: Indications for prostatic surgery and selection of operation, in Fitzpatrick JM, and Krane RJ (Eds): The Prostate, Edinburgh, Churchill Livingstone, 1989, p 137. 4. Walsh TN, and Kelly DC: Historical view of prostatectomy, in Fitzpatrick JM, and Krane RJ (Eds): The Prostate, Edinburgh, Churchill Livingstone, 1989, p 143. 5. Nesbit MR: Transurethral prostatic resection, in: Campbell’s Urology, Philadelphia, Saunders Co., vol. III, 1963, p 2611. 6. Millin T: Retropuhic Urinary Surgery, Edinburgh, Livingstone, 1947. 7. Mebust WK: Transurethral prostatectomy, in Lepor H, and Walsh PC (Eds): Urologic Clinics of North America, Philadelphia, Saunders Co., vol 17, no 3, 1990, pp 575-585. 8. Roos NP, and Ramsey EW: A population-based study of prostatectomy: outcomes associated with differing surgical approaches, J Urol 137: 1184 (1987). 9. Roos NP, et al: Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia, N Engl J Med 320: 1120 (1989). 10. Servadio C, and Cytron S: Intraoperative transrectal ultrasonography during prostatectomy. Presented at the 22nd S.I.U. Congress, Seville, Spain, 1991.
5
421
M.D.
From the Institute of Urology, Beilinson Medical Center, Petah Tiqva, and Tel Aviv University Sackler School of Medicine, Israel ABSTRACT-A total of 1,066 prostatectomies treated by us from 1985 to 1989 were reviewed. The necessary comprehensive data were available on 710 cases. Open (Millin’s retropubic) prostatectomy (RPP) was the procedure of choice for large glands and transurethral resection (TURP) for smaller glands: 408 had had RFP and 262 TURP; 14.5 percent of the TURP group eventually needed a second procedure during a one to six-year follow-up compared with only 2.6 percent of the RPP group. Forty other patients who had been operated on elsewhere were referred to usfor a second, repeat procedure; 30 also previously had had a TURl? Total hospitalization, operating time, and complications were better in the long run in the RPP group compared with the TURP group. It is believed that open prostatectomy still has a respectable place in urology and therefore, should be considered and also taught to residents for use in dealing with large glands.
The evolution of prostatectomy, the gradual development of the open procedure since the beginning of this century, and later the introduction of the transurethral approach, have all been described repeatedly and elegantly. 1-4 With the constant improvement in endoscopic instruments and the simultaneous use of sophisticated videocameras, transurethral resection of the prostate (TURP) has gradually become the procedure most widely advocated and used in several countries, thus rendering the open procedure obsolete or even virtually unknown to many urologists today. Have we perhaps gone too far? Have we perhaps discarded a good procedure which still has a place in routine urology, and, in particular, in a very common clinical situation? For several reasons our policy has been to adopt the transurethral approach5 for the smaller gland only and to perform the open procedure by the retropubic (Millin) method (RPP)6 for the larger glands. We have recently reviewed our clinical material to re-examine and re-evaluate this policy. Material and Methods A total of 1,066 patients who have had prostatectomy in our service from 1985 to 1989 have
UROLOGY
/ NOVEMBER
1992
/ VOLUME
40, NUMBER 5
been studied retrospectively: 38 percent had TURP5 and 62 percent RPP after Millin’s technique.e All patients had the same routine preoperative assessment, and once the indication for surgery was confirmed, based on conventional obstructive and irritative symptoms, they were referred for either RPP or TURP The choice was based almost invariably on the estimated prostatic volume only. The volume of the gland was estimated by digital rectal examination and also by transrectal echography. Either general or spinal anesthesia was used in both groups, and the type of anesthesia given had nothing to do with the type of surgery chosen. Average operating time for the open procedure usually exceeded the transurethral approach by no more than ten to fifteen minutes. Bleeding was similar in both groups. TURP patients were usually discharged from hospital three to four days after surgery while the RPP patients usually remained in hospital two to three days longer. Surgery was performed by all members of the staff, the residents being assisted by the more senior members. Perioperative antibiotics were used routinely in patients with active urinary tract infection or an indwelling catheter; a full course of
419
TABLEII. TABLEI.
Rehospitalization
without repeat surgery
Complication Acute urinary tract infection Acute retention Gross hematuria Urethral and bladder neck stricture Wound infection Orchiepididymitis Fistula TOTALS
Post-RPP Post-TURP (406) (262) 7 4 3 4 2 2 1 1 1 1 16(3.8%)
1
Rehospitalization for reoperation
1st Operation
2nd Operation
Done at Beilinson Medical Center RPP (408)
TURP (262)
Done elsewhere Open prostatectomy
(10)
. .
1
TURP (30)
. .
12 (4.6%)
Re-RPP 0 11 i Re-TURP Re-RPP 7 i Re-TURP 31 TOTAL3 Re-RPP 1Re-TURP : Re-RPP 8 1Re-TURP 22 TOTAL3
appropriate antibiotics was given to render urine sterile. All cases were usually followed for three to six months unless some problem arose. A retrospective study was done, with a follow-up of one to six years (mean 3.8 years).
patients in the TURP group severe incontinence developed, against 1 of 408 patients in the RPP group. There was only one postoperative death in this series of 1,066 cases; 1 patient in the TURP group died of acute myocardial infarction
Results
Comment
Of 1,066 patients operated on, data for a retrospective study were available in 710 cases. TURP was done in 262 and 408 had an open procedure, almost invariably the Millin retropubic procedure. The other 40 cases had had their original prostatectomy elsewhere and were seen by us because of complications; 10 hadhadanopenprocedureand30alsohadhad a TURP originally. Operating time was slightly longer for the open procedure and hospital stay two to three days longer on average. Otherwise there were no significant discrepancies between the two techniques and groups, except the total number of cases for each. The average age was seventyone years. During the follow-up period, 16 patients (3.8%) from the RPP group and 12 patients (4.6%) from the TURP group required readmission because of infection, retention, secondary bleeding, or a variety of other acute complications which required immediate medical attention (Table I). Thirty-eight TURP patients (14.5 % ) compared with only 11 RPP patients (2.6 % ) needed a repeat hospitalization and had to undergo a repeat surgery, the majority requiring a repeat TURP or transurethral incisions for bladder neck stenosis (Table II). Of the 40 patients initially operated elsewhere (30 had had a TURP) and in need of a second procedure, 28 had TURP and 12 RPP performed by us. In 2 of 262
There is general agreement that TURP is an excellent procedure. ’ It requires skill and expertise, and, when performed well and on patients properly selected, it gives satisfactory long-term results. Modern endoscopic equipment and light videocameras have rendered such a procedure today easier to teach and easier to master. Hospital stay and patient discomfort are reduced. Yet, the open procedure is still an excellent procedure, and when dealing with a large gland, the enucleation is rapid and the total operating time in relation to the prostatic volume to be removed is even shorter than in the transurethral procedure. Postoperative problems do occur but are infrequent. It seems that what appears to be a simpler and more rapid procedure in the short term may eventually bring less gratifying results in the long term, with a significantly higher need for reoperation at a later date. This has also been observed by others.*~g We have recently completed a study using transrectal echography during the actual prostatectomy in a group of 25 cases.‘O There was a definite impression that the open enucleation gives a better adherence to surgical anatomy demarcation lines compared with the TUR. This fact, among other points, ensures a reduced danger of damaging the distal urethral segment which in turn may lead to incontinence. One may, of course, argue that the results have a lot to do with the surgeon’s skill.
420
UROLOGY / NOVEMBER1992 / VOLUME40, NUMBER5
But this presumably procedures.
applies
equally
Institute of Urology Beilinson Medical Center Petah Tiqva 49100, Israel
to both
Conclusion References
Much attention has been given in recent years to develop and encourage the use of “keyhole” surgery instead of conventional, old-fashioned open surgery. Transurethral prostatectomy has, until recent times, placed the urologist in a leading position among the various surgical disciplines. Indeed TURP has rightly gained world-wide popularity and has, therefore, gradually been imitated by many other surgical specialities. Open prostatectomy is being performed less frequently in many countries. Many urologists today do not even know how to perform an open prostatectomy. Is this a change for the better? In recent years the justification for this change is being questioned for different reasons. Based on our experience and that of others, it appears than open retropubic prostatectomy may still be regarded as an excellent procedure, reserved for large glands. It requires only minimal increase in hospital stay; there is practically no more operating time needed and no additional complications, and it certainly gives a better long-term result.
UROLOGY
i
NOVEMBER
1992
i
VOLUME
40, NUMBER
1. Chisholm CD: Prostatectomy: past and present, in Hinman F Jr: Benign Prostatic Hypertrophy, New York, Springer Verlag, 1983, p 35. 2. Blandy JP: The history and current problems of prostatic obstruction in benign prostatic hypertrophy, in Blandy JP, and Lytton B (Eds): The Prostate, London, Butterworth & Co, 1986, p 12. 3. Walsh A: Indications for prostatic surgery and selection of operation, in Fitzpatrick JM, and Krane RJ (Eds): The Prostate, Edinburgh, Churchill Livingstone, 1989, p 137. 4. Walsh TN, and Kelly DC: Historical view of prostatectomy, in Fitzpatrick JM, and Krane RJ (Eds): The Prostate, Edinburgh, Churchill Livingstone, 1989, p 143. 5. Nesbit MR: Transurethral prostatic resection, in: Campbell’s Urology, Philadelphia, Saunders Co., vol. III, 1963, p 2611. 6. Millin T: Retropuhic Urinary Surgery, Edinburgh, Livingstone, 1947. 7. Mebust WK: Transurethral prostatectomy, in Lepor H, and Walsh PC (Eds): Urologic Clinics of North America, Philadelphia, Saunders Co., vol 17, no 3, 1990, pp 575-585. 8. Roos NP, and Ramsey EW: A population-based study of prostatectomy: outcomes associated with differing surgical approaches, J Urol 137: 1184 (1987). 9. Roos NP, et al: Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia, N Engl J Med 320: 1120 (1989). 10. Servadio C, and Cytron S: Intraoperative transrectal ultrasonography during prostatectomy. Presented at the 22nd S.I.U. Congress, Seville, Spain, 1991.
5
421