Prostatic Hypertrophy in Indonesia

THE JorRNAL OF UROLOGY

Vol. 88 No. 2 August 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S.A.

PROSTATIC HYPERTROPHY IN INDONESIA R.E.TAN From the Surgical Department, Stella Maris Hospital, Macassar, Indonesia

A survey of the literature indicates that there is no agreement among surgeons in regard to the treatment of prostatic adenoma. Theoretically every prostate may demand its own method of approach but in practice any operation thoroughly mastered ,viii serve the surgeon well in almost all instances. ) .. ctually each patient with prostatic disease demands his own preoperative investigation, the proper selection, and the highest standard of postoperative care. Often these demands cannot be maintainrcl in the central general hospitals in Indonesia's provincial capitals, even less in minor hospitals of the remote islands, being clepri vecl as they arc of proper laboratorv means. Most ~f the prostatectomies in Indonesia are clone by general surgeons ,vho use the classical suprapubic prostatectomy of Freyer. The exact results obtained by these surgeons are generally not known. However, unofficially most Indonesian surgeons will agree that the mortality rate is high and may reach more than 10 per cent. During the last year in some clinics (in Sourabaya and Macassar) three methods have been used in an endeavor to reduce mortality rate and morbidity: 1) retropubic, 2) suprapubic and 3) perinea! prostatectomy. The choice of operation is determined by 1) the general condition of the patient, 2) the skill and armamentaria in the hospitals and 3) the size and type of prostatic enlargement. The second factor is very important in Indonesia. Rarely does a surgeon know all three methods perfectly; he usually is familiar with one method only and applies it to every case of prostatic hypertrophy and carcinoma. Most of the facts here stated are already known in more developed countries, equipped as they are with all up-to-date instruments. Therefore, it is interesting that, notwithstanding many unfavorable factors and circumstances, our results in prostatectomy are not so disappointing, although they cannot compete with the figures reported by Turner and Belt for morbidity in simple and total perinea! prostatcctomy and those of

Accepted for publication November 17, 1961.

298

Cooper for retropubic and suprapubic prostatectomy. THE MATERIAL

The material for this report was collected by the author at Sourabaya and Macassar from 1956 to September 1961. At Sourabaya in a 2 year period (from the first of 1956 to the end of 1957) a total of 79 patients underwent a prostatic operation: retropubic prostatcctomy, 44 cases; suprapubic prostatectomy, 6 cases; simple perinea! prostatectomy, 23 cases; radical perinea! prostatcctomy, 6 cases. Often the indication for the method of operation is not basrd upon the size and type of the prostate, but merely the skill of the surgeon, even if the procedure is done by the senior surgeon. At :vracassar, from 1954 to September 1961, 44 sufferers underwent prostatcctomy. Here also the indication of the method of prostatectomy merely depends upon the skill of the operator. In the first 6 years almost all prostatectomies were done by Freyer's classical method. Perinea! and rctropubic prostatectomy has been done only during the past 2 years. The author prefers thr perinea! route. Of these 44 operations, suprapubic prostatectomy was done in 13 cases; retropubic prostatcctomy, 2 cases; simple perinea! prostatectomy, 20 cases and radical perinea! prostatectomy, 9 cases. The postoperative complications of each n1ethod are to be found in the hospital records. Hmvever, many of these records often do not contain any information in regard to complicaTABLE

1. Preoperative status of 123 patients undergoing prostatectorny [

Patient's Condition

Complications

1-------I I

Total Number T u b erculosis

D.1abetes

I':iear t diseases

I Hb. Level in gm. %

------1--- - - ---

Poor. Moderate. Good.

28 84 11

15

20

i

1 7

.

7-15 2

9-14 11-15

299

PROSTATIC HYPERTROPHY

tions and in many instances it is not known whether the patient is living.

socially and economically, and their homes are remotely situated in East Java and Celebes. Diseases which often complicate prostatic adenoma or carcinoma are tuberculosis of lungs, diabetes, pleuritis and anemia. We have to ascertain that the genmal condition is no contraindication for prostatectomy if the hospitalization period lasts long enough to make the patient fit again. Here it may be prolonged from 7 to 107 days. However, the poor general condition of patients, with tuberculosis and the like, causes more serious morbidity after operation. The postoperative care may last as long as 48 days. The complications are mostly retarded wound healing, urinary fistula and wound dehiscence.

GENERAL CONDITION OF PATIENT

As a rule, the patient's condition is not good (table 1). Most of those who are admitted to the urological wards belong to the poorer classes, 2. Renal condition of 123 patients preoperative hospitalization; number of deaths

TABLE

Renal Function ~

s"

..CJ

z"

Bad. 2 Poor. 23 Moderate. 86 Good. .... 12

MaxiRange of mum OperaPreoptive Hos- erative pitaliza- Hospitaltion With ization No Other With Diseases Other

"'

~

8

"' ·s"' t5 -~"

~

" s

..CJ

0

z" ~ --- -- -87 107 18

"'s

1;l,

0

Diseases

---51-64 12-71 9-30 7-28

Causes

00

iJ

-

--

6 6

6

--

-

-

-

-

5

-

-

..CJ

i:i"'

~

-

THE RENAL CONDITION

The renal condition and the preoperative hospitalization are summarized in table 2.

1

-

-

THE CHOICE OF THE APPROACH TABLE

In choosing the method for each special case, we consider 1) the general condition of the patient, 2) the size and shape of the prostate, 3) the evidence of carcinoma and 4) to a lesser degree, the specialized skill of the surgeon. General condition of patient. I have already mentioned that the first factor is of no importance in cases of prostatectomy. Of the three methods at our disposal, we observed that patients withstand perineal prostatectomy satisfactorily, probably due to the fact that this method provides complete ligation of all bleeding points. Size and shape of prostate. The perineal approach is used for prostatic enlargement of medium size (20-50 gm.) and early cases of prostatic carcinoma. Retropubic prostatectomy

3. Deaths 00

iJ

Causes

"'

NumMethod of Prostatectomy ber of Cases

~

"'""'

0

00

"t0 " ·s"' ..CJB" § 5 J i:i"' z ~ -- -- -- -~

..CJ

Retropubic prostatectomy. Suprapubic prostatectomy. Simple perineal prostatectomy. Radical perineal prostatectomy ....

46

10

2

19

1

1

1

1

7

1

43 15

TABLE

4. Postoperative complications Bleeding

Method

Retropubic prostatectomy-46 cases .... Suprapubic prostatectomy-19 cases. Perineal prostatectomy simple-43 cases .. . . .. . ..... radical-15 cases ....

Epididymitis

Immediate

Remote --- - Late

3

2

-

-

2

-

-

1

1 1

-

-

Osteitis Pubis

Wound Dehiscence

Incontinence

Fistula Total

Partial

--- - -

3

5

13

1

-

1

2

4

-

-

-

-

-

-

4 1

17 1

2 -

8 3

1

300

R. E. TA:-i"

is used for moderate to large prostatic adenoma (more than 20 gm.) or if perinea! prostatectomy has failed, i.e. after perforation of the rectum. Suprapubic prostatectomy is used for prostatic aclenoma of medium or large size vesical deviations necessitating attention at the same time, i.e. diverticula and tumors. Suprapubic prostatecton1y is also used to remove medium to large prostatic adenoma when the patient has undergone a previous bladder operation. We are obliged to do retropubic or perinea! prostatectomy for adenomas which are smaller than 20 gm. Much bleeding and a longer postoperative hospitalization were experienced in these cases. The postoperative hospitalization may often last as much as 48 clays. .Evidence of carcinoma. Patients with early prostatic carcinoma are treated by radical perinea! prostatectomy, which was performed in only 3 patients out of a total number of 79 prostatectomies done at Sourabaya. At Macassar 9 radical perinea! prostatectomies have been done. Patients in whom perinea! biopsy revealed an adenoma, but after operation were found to have carcinoma were treated only by orchiectomy, because most of them refused a second (radical) operation which could have cured them of carcinoma. Of such cases, nine are reported at Sourabaya and 14 at :;\facassar. Treatment of advanced prostatic carcinoma involves greater difficulties. As transurethral resection cannot be performed in these cases one is often obliged to perform an enucleation to relieve the obstruction. Out of 4 patients treated in this manner three died within a short time. THE PROSTATECTOMY

Perinea! prostatectomy is done according to the method of Belt-Ebert-Surber, retropubic prostatectomy according to the method of Terence Millin, suprapubic prostatectomy according to the method of Hryntschak. In all cases, as mentioned earlier, the blood loss may vary from 300 to 2000 cc (in extremely difficult cases). It is of importance that rarely one is able to restitute completely the blood loss. Only in exceptional cases are patients given 1000 cc blood. Often not more than 500 cc is given and sometimes no blood at all. The operative time may last from 30 to 150 minutes. As shown in table 3, the number of deaths clue

to bleeding is not great if one considers that we often have to operate without blood at all. We prefer perinea! prostatectomy as this method gives the greatest chance to stop bleeding. Moreover we especially prefer this method for patients in poor physical condition and for those cases in which no blood is available. COMPLICATIONS

Complications which may often appear after prostatectomy are epiclidymitis, hemorrhage, osteitis pubis, impotence, wound clehiscence, urinary fistula and incontinence of urine. The figures of each complication are listed in table 4. 1Vound dehiscence often occurs in patients who suffer from underfeeding . FOLLOWUP REPORTS

Generally speaking, the followup report of most cases is not satisfactory. 1Ve consider ourselves fortunate if some tidings of the patient still reach us after 1 year. Most of the patients disappear without giving any word about their physical condition. SUMMARY

.A brief report has been made of the results of prostatectomy in J\facassar and Sourabaya. Although our figures cannot compete with those that arc reported abroad, we should be satisfied with the results achieved, taking into account that little or no blood is available for the patient. Of the four methods, only retropubic, suprapubic and perinea! prostatectomy arc clone. REFERENCES BELT, E., EBERT, C. E. AND SURBER, A. C.: A new anatomic approach in perinea! prostatectomy. J. U rol., 41: 482-497, 1939. CooPER, H. G.: Retropubic prostatectomy. J. Urol., 77: 297-304, 1957. HRYNTSCHAK, T.: Sur la prostatectomie suspubienne transvesica.le avec fermeture immediate de la vessie selon la technique de Hryntschak. J. d'urol., 55: 337-341, 1949. MILLIN, T.: Retropubic prostatectomy. In: Urology, edited by M. Campbell. Philadelphia: W. B. Saunders, Co., 1954, vol. 3, pp. 20462068.

MILLIN, T.: Retropubic Urinary Surgery. Edinburg: E. and S. Livingstone, 1947. TURNER, R. D. AND BELT, E.: A study of 229 consecutive cases of total perinea] prostatectomy for cancer of the prostate. J. Urol., 77: 62-77, 1957.

TORNER, R. D. AND BELT, E.: The results of 1694 consecutive simple perinea] prostatectomies. J. Urol., 77: 853-863, 1957.