Simple Perineal Prostatectomy: Lessons Learned from a Modern Series

0022-5347/03/1701-0115/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 170, 115–118, July 2003 Printed in U.S.A.

DOI: 10.1097/01.ju.0000071681.03755.b3

SIMPLE PERINEAL PROSTATECTOMY: LESSONS LEARNED FROM A MODERN SERIES JONATHAN E. BERNIE

AND

JOSEPH D. SCHMIDT

From the Division of Urology, Department of Surgery, University of California San Diego Medical Center and Veterans Affairs Medical Center, San Diego, California

ABSTRACT

Purpose: Experience with simple perineal prostatectomy has not been well described in the recent literature. We describe our operative technique and compare objective demographic, preoperative, intraoperative and postoperative parameters in patients undergoing open prostatectomy for benign prostatic hyperplasia via 3 routes, namely perineal, retropubic, and suprapubic. Materials and Methods: We retrospectively reviewed all cases of open prostatectomy at Veterans Affairs Medical Center, San Diego between August 2001 and September 2002. A total of 22 patients were identified. Objective parameters were recorded and compared, including patient age, history of urinary retention, ultrasound volume, prostate specific antigen, patient and specimen weight, operative time, estimated blood loss, transfusion requirement, days of hospitalization and postoperative analgesic requirement. Results: In the 22 patients who underwent open prostatectomy the operative approach was perineal in 6, retropubic in 8 and suprapubic in 8. Operative time and hospital stay were significantly less in the perineal prostatectomy group. Conclusions: Simple perineal prostatectomy is a viable alternative for most patients considered candidates for open prostatectomy and it is our preferred approach for obese patients. With perineal prostatectomy patients may expect shorter hospitalization and less analgesic requirement but likely require a longer period of catheter drainage. KEY WORDS: prostate, prostatectomy, prostatic hyperplasia

Simple perineal prostatectomy has not been well described or reported in the recent literature. With the advent of less invasive treatment options for benign prostatic hyperplasia (medical management, thermotherapy, laser ablation, needle ablation, microwave therapy and transurethral resection of the prostate) open procedures for benign enlargement have become less common. In addition, the perineal surgical approach is not familiar to many urologists because at most training centers the focus is largely on retropubic and transvesical prostatectomy. Perineal lithotomy has been well described and it was standard treatment for bladder stones many years ago. The first report of the removal of prostatic tissue via a perineal approach was that of Covillard in the 17th century but it was not until the middle of the 19th century when this approach became more common.1– 8 Goodfellow popularized this method and performed this routinely and successfully in the late 1800s.4, 5 Young modified the technique several years later and described the current standard surgical approach.7 Our use of the perineal approach was initiated last year when we assumed care of several morbidly obese patients with significant lower urinary symptoms in whom medical therapy had failed. Management was complicated by the fact that they had significant prostatic enlargement (gland volume greater than 150 cc on ultrasound). Simple perineal prostatectomy was our preferred approach due to presumed improved postoperative recovery and technical ease. We hypothesized that with simple perineal prostatectomy patients would have improved recovery time and postoperative analgesic requirements compared with those treated with prostatectomy via the retropubic or transvesical approach. We describe our recent experience with simple periAccepted for publication February 21, 2003.

neal prostatectomy and compare several objective parameters to those of retropubic and transvesical prostatectomy. MATERIALS AND METHODS

We retrospectively reviewed all cases of open prostatectomy at Veterans Affairs Medical Center, San Diego between August 2001 and September 2002. A total of 22 patients were identified. Three approaches were used, including simple perineal prostatectomy in 6 cases, simple retropubic prostatectomy in 8 and transvesical subtotal prostatectomy in 8. The surgical procedure was selected after lengthy discussion with the patient regarding different approaches, perceived advantages and disadvantages, and expected postoperative course according to postoperative guidelines. Objective parameters were recorded and compared, namely patient age, history of urinary retention, ultrasound volume, prostate specific antigen (PSA), patient and specimen weight, operative time, estimated blood loss, transfusion requirement, days of hospitalization and postoperative analgesic requirement. Patients were given acetaminophen with codeine No. 3 tablets (2 tablets every 4 hours) for postoperative analgesia with 2 mg morphine sulfate intravenously (IV) every 2 hours as needed for breakthrough pain. The amounts dispensed were available in the hospital chart and patients were interviewed at the first postoperative appointment to determine the number of pain pills ingested after hospital discharge. Total analgesic equivalents were then determined for each patient and compared among groups.9 Preoperative evaluation. Patients who presented to the urology outpatient clinic with significant lower urinary symptoms unresponsive or poorly responsive to medical therapy were considered for surgical therapy. Those with signif-

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icant enlargement (greater than 80 gm) of the prostate on digital rectal examination were considered potential candidates for open prostatectomy. Further evaluation included history and physical examination, PSA, urinalysis, urine culture, urodynamic testing and transrectal ultrasound to obtain an objective measure of prostate volume. Prostate biopsy was performed prior to open prostatectomy when indicated. Open prostatectomy was considered when ultrasound confirmed a significantly (greater than 80 cc) enlarged prostate gland. Surgical technique. The surgical technique for simple perineal prostatectomy has been described in detail. Briefly, we describe our technique. Patients are brought to the operating room, placed supine and administered general anesthesia and intravenous antibiotics. They are then placed in the exaggerated lithotomy position, shaved, prepared and draped in the usual fashion. An O’Connor rectal shield is placed to exclude the anus and secured with silk sutures. The bladder is emptied. A curved Lowsley tractor is placed into the bladder and the wings are opened. A single ampule of indigo carmine is given IV to facilitate visualization of the ureteral orifices. An inverted U-shaped incision is made in the perineum and dissection through the various tissue planes is done with electrocautery with care taken to avoid rectal injury (fig. 1). Hand held narrow Deaver and Gouley retractors assist with visualization. The anterior layer of Denonvilliers’ fascia is then exposed and a transverse capsulotomy performed with electrocautery (figs. 2 and 3). Adenoma enucleation is performed sharply and with blunt finger dissection. The Lowsley tractor is removed and a tenaculum is used to expose and bring the adenoma into the operative field (fig. 4). Attachments are transected sharply. The specimen is then removed and weighed. After the completion of enucleation the bladder neck is grasped at the 6 o’clock position and 2 hemostatic 2-zero polyglactin sutures are placed at the 5 and 7 o’clock positions. The bladder is digitally and visually examined for stones or another pathological condition and the ureteral orifices are examined to confirm efflux of blue dye. A 24Fr 3-way catheter is then placed via the urethra into the bladder with 50 cc sterile water in the balloon. The capsulotomy is closed with running 2-zero polyglactin A 1⁄2-inch Penrose drain is placed, brought out the left side of the wound and secured to the skin. Colles fascia is closed with interrupted 2-zero polyglactin, as is the deep dermal layer. The skin is closed with interrupted 3-zero chromic. The catheter is irrigated and taped to the patient leg on mild traction. A belladonna and opium suppository is placed via the rectum prior to extubation. Slow continuous bladder irrigation with normal saline is initiated.

FIG. 2. Prostate capsule is exposed

Postoperative catheter drainage guidelines. Patients who underwent simple retropubic prostatectomy were maintained on catheter drainage for at least 3 days and the catheter was removed when the urine was clear/pink. For transvesical prostatectomy urethral and suprapubic catheters were placed. Continuous bladder irrigation was maintained until the urine cleared, at which time the urethral Foley catheter was removed. The cystostomy tube was left to straight drainage for 5 to 7 days. A voiding trial was initiated at this time. If patient residual urine volume was low on several occasions, the catheter was removed. For perineal prostatectomy urethral catheters were placed and left to straight drainage until an outpatient cystogram was performed on postoperative day 10. If the cystogram confirmed absent capsular urinary extravasation, the catheter was removed. RESULTS

FIG. 1. Perineal skin incision

Table 1 lists patient demographics and preoperative characteristics for the 3 open prostatectomy procedure groups. Preoperatively patients were similar in age, urodynamic parameters, history of urinary retention, PSA, body weight and prostate volume. Table 2 lists intraoperative parameters and outcomes for the 3 types of open prostatectomy. The serial Student t test with the Bonferroni correction was used for statistical analysis. Among the 3 groups differences in the weight of the enucleated adenoma were not statistically significant. Operative time was significantly less for the perineal approach (75 minutes) than for the suprapubic (98 minutes, p ⬍0.02) or retropubic (109 minutes, p ⬍0.04) approach. Although differences in estimated blood loss were not statistically signifi-

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FIG. 3. Transverse capsulotomy

FIG. 4. Adenoma enucleation

cant (perineal versus suprapubic), none of the 6 patients treated with perineal prostatectomy received transfusion, whereas 3 in the suprapubic and retropubic groups received blood transfusions. The total analgesic requirement was less in the perineal prostatectomy group (4 codeine equivalents) than in the suprapubic or retropubic prostatectomy group (19 and 12 codeine equivalents, respectively) but it did not achieve statistical significance. For the perineal prostatectomy cohort hospitalization (2 days) was significantly shorter than for the suprapubic (6 days, p ⬍0.001) and retropubic (5 days, p ⬍0.05) prostatectomy groups. Complications developed in 4 patients. A patient treated with perineal prostatectomy had wound dehiscence requiring dressing changes. The wound closed after two weeks. He also experienced 2 episodes of clot retention, later discovered to be due to aspirin and ibuprofen, which had been resumed on postoperative day 3 when the patient was at home. Another patient who underwent perineal prostatectomy had bladder neck contracture, which was incised transurethrally 4 months postoperatively. A patient treated with suprapubic prostatectomy was in persistent urinary retention, necessitating maintenance of a suprapubic tube for 4 weeks postoperatively. In addition, a patient who underwent a retropubic operation required clean intermittent catheterization for 4 weeks postoperatively due to urinary retention. Two patients had minimal extravasation on cystography on day 10 after perineal prostatectomy. Catheter drainage was continued an additional 5 days, at which time repeat cystogram was normal and the catheter was removed in each patient. In another patient treated with perineal prostatectomy a small, low grade superficial bladder tumor was detected and excised at operation during digital examination of the bladder.

TABLE 1. Demographic and preoperative clinical parameters in 3 prostatectomy procedure groups Parameter

Perineal Suprapubic Retropubic

Demographics: No. pts 6 8 8 Av age 72 73 71 Preop: Bladder capacity (cc) 272 302 371 102 113 80 Detrusor pressure at max flow (cm H2O) Max flow (cc/sec) 8 6 8 Post-void residual vol (cc) 120 195 189 Av ultrasound vol (cc) 124 139 118 Av PSA (ng/ml) 7 15 16 Av pt wt (lbs) 214 181 192 No. urinary retention history 3 4 6 For all parameters, values in the perineal prostatectomy group were not significantly different from those in the suprapubic or retropubic prostatectomy group (p ⬎0.05). DISCUSSION

With the advent of medical therapy and minimally invasive treatment options for benign prostatic hypertrophy open prostatectomy has become less common. When necessary, several approaches are available (suprapubic, retropubic and perineal). Although it is feasible in many patients, perineal prostatectomy may be a preferred option for obese patients because recovery time and analgesic requirements appear to be decreased compared with a retropubic or transvesical operation. The major disadvantage of the perineal operation is a longer period of catheter drainage compared with the retropubic or transvesical operation. The reason for this duration of catheterization is that perineal capsulotomy seems to heal more slowly, likely due to the dependent position of the capsulotomy and continued contact with urine.

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SIMPLE PERINEAL PROSTATECTOMY TABLE 2. Intraoperative and postoperative parameters in 3 prostatectomy procedure groups Parameter

Intraop: Av adenoma wt (gm) Range adenoma wt (gm) Operative time (mins) Estimated blood loss (cc) No. transfused Postop: Av codeine tablets (equivalents) Av No. codeine tabs Av IV morphine (mg) Av hospital days

Perineal

Suprapubic

82 60–142 75 367 0

96 69–140 98 531 3

4 3.5 1 2

19 17 7 6

Our subjective impression is that removal of a large median lobe or bladder stone is not more difficult with the perineal operation. Increased blood loss in the retropubic group can be explained by significant bleeding in 2 patients, of whom 1 had a 325 gm (1,800 cc) adenoma removed and the other had chronic renal insufficiency (2,100 cc). When these patients were excluded from analysis, the differences in blood loss among the groups were not statistically significant. Several limitations of this analysis exist. It was a small series, which could make data analysis difficult to interpret. Also, our review was retrospective. A larger, prospective randomized trial of the various techniques of open prostatectomy would objectively test our hypotheses. Despite the limitations simple perineal prostatectomy is a reasonable alternative for the appropriate patient. CONCLUSIONS

Simple perineal prostatectomy is our preferred method for open prostatectomy in obese patients. Compared with the transvesical and retropubic operations patients clinically recovered more rapidly, had fewer analgesic requirements and left the hospital sooner. Patients should be counseled that, although postoperative convalescence appears to be improved, a longer period of catheter drainage should be expected. The perineal approach is a viable alternative for most patients considered candidates for open prostatectomy. REFERENCES

1. Freyer, P. J.: One thousand case of total enucleation of the prostate for radical cure of the enlargement of that organ. Br Med J, 2: 868, 1912 2. Belt, E., Ebert, C. E. and Surber, A. C., Jr.: A new anatomic approach in perineal prostatectomy. J Urol, 41: 482, 1939 3. Freyer, P. J.: A new method of performing prostatectomy. Lancet, 1: 774, 1900

Perineal Vs Suprapubic p Value

Retropubic

⬎0.05 — ⬍0.02 ⬎0.05 ⬎0.05

106 50–325 109 1,163 3

⬎0.05 ⬎0.05 ⬎0.05 ⬍0.001

12 11 4 5

Perineal Vs Retropubic p Value ⬎0.05 ⬍0.04 ⬍0.01 ⬎0.05 ⬎0.05 ⬎0.05 ⬍0.05

4. Gibson, T. E.: George E. Goodfellow (1855–1910). Invest Urol, 7: 107, 1969 5. Goodfellow, G.: Median perineal prostatectomy. J Am M Ass, 43: 194, 1904 6. Stutzman, R. E.: Open prostatectomy. In: Glenn’s Urologic Surgery, 5th ed. Edited by S. D. Graham, Jr. Philadelphia: Lippincott-Raven Publishers, pp. 255–268, 1998 7. Young, H. H.: The early diagnosis and radical cure of carcinoma of the prostate. Bull Johns Hopkins Univ, 16: 315, 1905 8. Young, H. H.: Benign hypertrophy of the prostate. In: Young’s Practice of Urology, Philadelphia: W. B. Saunders Co., vol. 1, pp. 417–500, 1926 9. Reisine, T. and Pasternak, G.: Opioid analgesics and antagonists. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed. Edited by J. G. Hardman. New York: McGraw Hill, p. 521, 1996 EDITORIAL COMMENT The authors document in another surgical disease the usefulness of the perineal approach to the prostate. This surgical technique has been little used in the last 2 decades, having first fallen victim to retropubic and retropubic prostatectomy, and later to pharmaceutical and minimally invasive strategies for the relief of obstructive symptomatology. Their selection criteria focused on the obese patient with a prostate of greater than 80 cc. However, I would expand the indication to include the patient who has had extensive lower abdominal surgery or who may have mesh in the lower abdomen, just as we do for patients needing radical prostatectomy. I was interested to find that blood loss was similar to that seen with radical retropubic prostatectomy and suspect that it is due to decreased venous bleeding since the perineum is elevated above the heart, reducing venous pressure at the level of the prostate. David Paulson Division of Urology Duke University Medical Center Durham, North Carolina