- Email: [email protected]
Suprapubic Prostatectomy With a Novel Catheter
Suprapubic Prostatectomy With a Novel Catheter Hooman Djaladat,* Abdorasol Mehrsai, Ali Saraji, Shahram Moosavi, Yasaman Djaladat and Gholamreza Pourmand From the Department of Urology, Mohammadi Hospital, Hormozgan University of Medical Sciences, Bandarabbas and Urology and Renal Transplant Research Center, Department of Urology, Sina Hospital, Tehran University of Medical Sciences (AM, AS, SM, YD, GP), Tehran, Iran
Purpose: We evaluated the postoperative morbidity and technical complications of a new handmade catheter used for suprapubic prostatectomy. Materials and Methods: A total of 146 patients with lower urinary tract symptoms who had indications for open prostatectomy were enrolled in the study from January 2003 to August 2004. Of the patients 96 were treated with a novel technique without a urethral catheter but with a special handmade cystostomy catheter, while the other 50 underwent the traditional procedure using cystostomy and a urethral catheter. The same surgical team operated on the 2 groups. Clot retention episodes, hemoglobin decreases, irritative symptoms, voiding status after cystostomy removal and incontinence were evaluated postoperatively. Three months later we followed the patients with symptom score, maximum flow rate and cystoscopic examination. Results: Preoperatively mean International Prostate Symptom Score was 31.6 in each group. Postoperatively none of the patients with the novel catheter complained of significant irritative urinary symptoms, clot retention and true or stress urinary incontinence. Of the cohorts 94% were satisfied with voiding but 86% of controls were satisfied. There was no report of urinary tract infection or epididymo-orchitis in the cohorts, while we found epididymo-orchitis in 4 controls (8%). Three months after the operation the mean International Prostate Symptom Score was 4.4 (range 1 to 7) and the mean maximum flow rate was 22.6 ml per second (range 14 to 25) in patients with the novel catheter, and 4.2 (range 1 to 7) and 22.5 ml per second (range 15 to 25), respectively, in those with the traditional catheter. At followup there was no bladder neck contracture but 4 patients (4.1%) showed some degree of membranous urethral stricture. We also noted 7 controls (14%) with urethral stricture. Conclusions: Transurethral prostate resection has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia. However, open adenomectomy still has a place. Urethral catheter-free suprapubic prostatectomy can be safely applied with a low postoperative risk of infection, incontinence and stricture formation. Key Words: prostate, catheterization, urethra, prostatectomy, adenoma
t is well known that in addition to urethral catheter associated discomfort, there is increased risk of ascending urethral infection, inflammation and stricture formation with urethral catheters.1,2 These complication risks are directly related to patient periurethral normal flora, aseptic catheterization and indwelling duration. Minimally invasive procedures for bladder outlet obstruction secondary to benign prostatic hyperplasia have been developed, such as visual laser ablation of the prostate, transurethral electrovaporization of the prostate, transurethral needle ablation, transurethral microwave thermotherapy, interstitial laser coagulation and transurethral incision of the prostate.3–10 They are associated with low morbidity and shortterm catheterization. However, these approaches are usually
I
Submitted for publication February 8, 2005. Study received approval from the Institutional Board Review and Medical Ethics Committee of Tehran University of Medical Sciences. * Correspondence and requests for reprints: Urology and Transplant Research Center, Sina Hospital, Hassan Abad Square, Tehran, Iran (telephone: ⫹98-21-6717447; FAX: ⫹98-21-6717447; e-mail: [email protected], [email protected]).
0022-5347/06/1756-2083/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
reserved for men with moderate symptom severity and a small to medium prostate.11 Traditionally patients with acute urinary retention, persistent or recurrent UTIs, severe hemorrhage from the prostate, bladder calculi, high I-PSS unresponsive to medical therapy and renal insufficiency as a result of chronic bladder outlet obstruction are treated with TURP or open prostatectomy. Open prostatectomy offers the advantages of a lower re-treatment rate and more complete removal of the prostate adenoma under direct vision, while it avoids the risk of additional hyponatremia (TURP syndrome).12 It can be performed by the retropubic or suprapubic approach. The standard suprapubic approach consists of enucleating the hyperplastic adenoma through an extraperitoneal incision of the anterior bladder wall. Finally, a urethral catheter and cystostomy are fixed. There is a certain risk of postoperative morbidity associated with this surgical technique, including hemorrhage, clot retention, incontinence, urethral or bladder neck stricture and UTI. Some are related to urethral catheters, such as severe bladder irritation, ascending UTI or epididymo-orchitis and urethral stricture formation. In this study suprapubic prostatectomy was done without urethral catheterization but with a suprapubic handmade cys-
2083
Vol. 175, 2083-2086, June 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(06)00344-2
2084
SUPRAPUBIC PROSTATECTOMY WITH NOVEL CATHETER
tostomy, which led to decreased postoperative urethral catheter related complications. PATIENTS AND METHODS The study was a multicenter trial, mainly done at Sina Hospital, Tehran University of Medical Sciences from January 2003 to August 2004. The Institutional Board Review and Medical Ethics Committee of Tehran University of Medical Sciences approved the study. It comprised 146 patients. They presented to our outpatient urology clinic with significant symptoms of bladder outlet obstruction secondary to benign prostatic hyperplasia. They had indications to undergo open prostatectomy, eg in a patient with a 20 gm prostate adenoma was opened because of severely limited hip joint flexion, which prevented TURP (table 1). The prospective, randomized, controlled trial allocated patients in a way that for every 2 patients operated on with the novel technique 1 was treated with the traditional procedure (96 and 50, respectively). Mean age was 69.9 ⫾ 7.5 years in the 2 groups. All patients with suspicious digital rectal examination or increased prostate specific antigen underwent transrectal ultrasonographic needle biopsy of the prostate to exclude prostate carcinoma. Perioperative antibiotics were prescribed in all patients. Preoperatively routine biochemical laboratory tests, ultrasound and panendoscopic examination, if indicated, were performed to rule out urethral stricture or bladder malignancy. Prostate adenoma weight was measured after enucleation using a digital electronic scale. We recorded bladder irritative symptoms using the I-PSS table (assumed to be significant if the score was more than average in any patient), postoperative hemoglobin decrease, first 24-hour drain collection, balloon volume, time to complete balloon emptying, episodes of clot retention as we tapered irrigation 1 day after operation while there was no gross hematuria, voiding status after cystostomy removal, incontinence according to the International Continence Society outline 1 week postoperatively and urogenital infections. Three months later I-PSS, uroflowmetric study and panendoscopic examinations to rule out bladder neck or urethral stricture formation were done in all patients. All patients were completely informed and provided consent regarding the new or traditional technique. The independent sample t, chi-square and Fisher’s exact tests were used to compare parameters between the 2 groups. How to Prepare a 24Fr 3-Way Foley Catheter to be Applied in This Technique 1) The distal catheter eyes are blocked by tying distal to the catheter balloon using 1-zero silk. 2) Two 10 ⫻ 5 mm outlet openings are made starting 10 mm proximal to the balloon.
TABLE 1. Indications for open prostatectomy in patients entered in our study No. Pts Large adenoma Large adenoma ⫹ synchronous hernia repair Large bladder diverticula ⫹ recurrent UTI Multiple bladder stones Hip prosthesis or severe osteoarthritis Large median lobe making TURP technically difficult Total
66 29 14 16 11 10 146
The distance between openings should not exceed 10 mm. Care must be taken not to traumatize the balloon lumen. 3) A 5 mm inlet opening is created by resecting over the inlet lumen in the area between the new outlet openings proximal to the balloon. Surgical Technique All operations were done through a lower midline or Pfannenstiel incision with the patient under spinal anesthesia. After incising the lower median abdominal wall fascia and muscles the anterior bladder wall is opened and the prostate adenoma is enucleated. After approximating the bladder neck mucosa with the prostate capsule using 3-zero chromic sutures the balloon of the previously prepared 24Fr Foley catheter is inserted in the prostatic lodge by a transvesical approach and fixed to the bladder mucosa by 2-zero plain suture next to its entry into the bladder dome. This is done to prevent catheter dislodgment or its bending in the bladder. The catheter balloon inside the prostatic lodge is filled to a volume suitable to apply pressure inside the prostate lodge to control bleeding. The catheter tip distal to the balloon should be inserted inside the posterior urethra. Catheter outlet eyes made proximal to the balloon are applied in a way that faces toward the anterior abdominal wall. The bladder wall is closed in 3 layers and a tube drain is left in the space of Retzius. The abdominal wall layers are repaired subsequently. Irrigation is started in the operating room and the wound is dressed. Starting 1 hour postoperatively and then within the next 24 to 36 hours the balloon fluid is emptied gradually. Diluted contrast medium (30% Urografin®) is used for balloon filling and within 24 hours postoperatively the balloon site is evaluated by pelvic x-ray. The suprapubic cystostomy catheter is removed in 5 to 7 days (see figure). RESULTS A total of 96 patients underwent open prostatectomy with the novel catheter compared to 50 in whom the traditional catheter was used. Preoperatively mean I-PSS was 31.6 (range 21 to 35) in patients with the novel catheter and 31.6 (range 24 to 35) in the control group. Of patients with the novel catheter 21 (21.8%) and 9 (18%) with the traditional technique had an indwelling catheter before surgery due to urinary retention. In these patients at least 1 trial without a catheter had failed and, hence, they were considered to have severe bladder outlet obstruction. Mean Qmax was 4.1 (range 0 to 11) and 4.2 ml per second (range 0 to 14) in patients with the novel and traditional techniques, respectively. Postoperatively mean prostate adenoma weight was 63.3 gm (range 20 to 110) in those with the novel catheter and 64.3 gm (range 55 to 85) in the control group. Mean balloon volume was 29.5 cc (range 10 to 50). Average first 24-hour drain leakage was 155 ml in the cohort vs 168 ml in controls. There was no report of clot retention or significant irritative symptoms in patients with the novel catheter, while 22 (44%) and 19 (38%) in the control group had significant irritative symptoms and at least 1 episode of clot retention, respectively (p ⬍0.001). In the cohort 95 patients voided comfortably after cystostomy removal and 1 failed to void. He performed intermittent self-catheterization because cystourethroscopy did not show any obstructive lesion. Early incontinence (1 week postoperatively) was recorded in 3
SUPRAPUBIC PROSTATECTOMY WITH NOVEL CATHETER
2085
epididymo-orchitis in patients with the novel catheter but this was identified in 4 (8%) in the traditional group (p ⬍0.05). The same prophylactic antibiotic protocol had been used in the 2 groups. We performed a panendoscopic examination in all patients. Complete epithelialization occurred in the prostatic fossa in almost all patients. At 6 months of followup 4 patients (4.1%) with the novel catheter had a membranous urethral stricture compared to 7 (14%) with the traditional procedure, including 4 with a penile urethral stricture and 3 with bladder neck contracture. Table 2 shows the postoperative improvement in I-PSS and Qmax. DISCUSSION
Sinahoo catheter inside prostatic lodge. 1, balloon. 2, outlet eyes. 3, inlet eye. 4, posterior urethra. 5, prostatic surgical capsule. 6, catheter fixation site in bladder wall.
patients (4%) with a novel catheter but in 31 controls (62%) (p ⬍0.001). It improved in more than 95% of cases at 3 months of followup in each group. We started emptying the balloon 1 hour postoperatively, which was completed within 24 to 36 hours. During balloon deflation 2 patients had intravesical balloon dislodgment and extravesical leakage of irrigant fluid through the draining tube, which was assessed by pelvic x-ray. They were treated with transurethral catheterization. The postoperative decrease in hemoglobin was 0.8 gm/dl in the cohort vs 1.9 gm/dl in controls. None of the cases but 2 controls needed blood transfusion. There was no record of
Urethral catheter complications, such as patient discomfort, infection and stricture formation, are well known. Ibrahim et al reported that post-prostatectomy bacteriuria is probably caused by postoperative ascending infection along the urethral catheter, although there was not enough evidence to attribute bacteriuria to preexisting septic foci in the adenoma.13 Intraoperative contamination and infection from distant foci were also unlikely causes. In 1992 Wurnschimmel and Lipsky reported that in a prospective followup of 178 patients who underwent TURP during 12 to 20 months urethral stricture developed in 14%.1 Of the 11 factors studied the only one that was a statistically significant risk was an indwelling catheter for more than 3 days. They concluded that urethral ischemia might increase the risk of urethral stricture. According to our study only 4 patients (4%) with the novel catheter had a urethral stricture compared to 7 controls (14%). Although this was not statistically significant (p ⫽ 0.1), it may emphasize the role of urethral catheters in the pathogenesis of urethral stricture. In regard to prostatic lodge bleeding, the good control of bleeder sites can minimize bleeding from the prostatic capsule. Insertion of the novel catheter balloon inside the prostatic lodge and applying pressure over the capsule wall (tampon-like effect) can effectively control bleeding. This leads to a decreased number of clot retention episodes and less of a decrease in hemoglobin. Applying the catheter balloon away from the trigone minimized bladder irritation symptoms and decreased postop-
TABLE 2. Preoperative and postoperative results in 96 patients undergoing suprapubic prostatectomy with novel catheter vs 50 with traditional technique Variables No. pts Mean I-PSS ⫾ SD (range): Preop Postop Mean ml/sec Qmax ⫾ SD (range): Preop Postop Mean gm prostate wt ⫾ SD (range) Mean cc balloon vol ⫾ SD (range) Mean 24-hr drain collection 1 ⫾ SD (ml) No. complications (%): Significant immediate or late postop bladder irritative symptoms Clot retention Bladder neck or urethral stricture Postop epididymo-orchitis Mean hemoglobin decrease (mg/dl) No. catheter dislodgment (%) No. early postop incontinence (%)
Novel Catheter 96
Traditional Technique
p Value
50
31.6 ⫾ 3.5 (21–35) 4.4 ⫾ 2.2 (1–7)
31.6 ⫾ 3.3 (24–35) 4.2 ⫾ 2.1 (1–7)
4.1 ⫾ 2.8 (0–11) 22.6 ⫾ 2.6 (14–25) 63.3 ⫾ 15.6 (20–110) 29.5 ⫾ 9 (10–50) 155 ⫾ 63.5
4.2 ⫾ 2.4 (0–14) 22.5 ⫾ 2.7 (15–25) 64.3 ⫾ 16.3 (55–85) 168.8 ⫾ 67.4
0.2 (independent samples t test)
—
22 (44)
⬍0.001 (chi-square test)
— 4 (4.1) — 0.8 2 (2.2) 3 (4)
19 (38) 7 (14) 4 (8) 1.9 — 31 (62)
⬍0.001 (chi-square test) 0.1 (chi-square test) ⬍0.012 (Fisher’s exact test) ⬍0.001 (independent samples t test) ⬍0.001 (chi-square test)
2086
SUPRAPUBIC PROSTATECTOMY WITH NOVEL CATHETER
erative morbidity and patient discomfort. It was also associated with less early incontinence (4% vs 62%). Possible hypotheses are no trigone irritation, no interference with external urethral sphincter function and less patient discomfort, which are due to urethral catheter exclusion. Fujita et al reported that epididymo-orchitis was significantly associated with postoperative catheterization and postoperative UTI.2 There was no report of UTI or epididymo-orchitis in our study, maybe due to urethral catheter exclusion. In this study we tried to avoid a urethral catheter without compromising the surgical outcome. Patient comfort due to not having a urethral catheter allows them to ambulate and achieve better tolerance in the early postoperative period. Also, we should consider the economic benefit of omitting 1 of 2 catheters with this novel technique. A pitfall of this new technique is catheter dislodgment. It occurred in 2 patients, leading to urinary extravasation that was managed successfully by a transurethral catheter. It is our recommendation to start catheter balloon emptying (at least 20% of balloon volume) as early as 1 hour postoperatively. It seems to be enough for bleeding control and it prevents bladder neck ischemia and subsequent contracture. However, this is a prospective pilot study. We suppose that this new catheter requires further study and it should be applied in a larger population to be evaluated more comprehensively. CONCLUSIONS Catheter-free suprapubic prostatectomy is safe and effective. Patient comfort, good outcome and low morbidity, especially infection and stricture formation, are advantages associated with this technique. Also, it may be a help to discharge patients home sooner.
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9. 10.
11.
ACKNOWLEDGMENTS Doctor Tajik assisted with the manuscript. 12.
Abbreviations and Acronyms I-PSS Qmax TURP UTI
⫽ ⫽ ⫽ ⫽
International Prostatic Symptom Score maximum urinary flow rate transurethral prostate resection urinary tract infection
13.
Wurnschimmel, E. and Lipsky, H.: Urethral stricture after TURP and transvesical prostatectomy. Urology A, 31: 374, 1992 Fujita, K., Kimura, T., Saito, K., Kitagawa, M., Furuhata, T., Uyama, K. et al: Epididymitis after transurethral prostatectomy. Clin Ther, 10: 56, 1988 Cowles, R. S., 3rd, Kabalin, J. N., Childs, S., Lepor, H., Dixon, C., Stein, B. et al: A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of the benign prostatic hyperplasia. Urology, 46: 155, 1995 Kaplan, S. A., Santarosa, R. P. and Te, A. E.: Transurethral electrovaporization of the prostate: 1-year experience. Urology, 48: 876, 1996 Schulman, C. C., Zlotta, A. R., Rasor, J. S., Hourriez, L., Noel, J. C. and Edwards, S. D.: Transurethral needle ablation [TUNA]: safety, feasibility, and tolerance of a new office procedure for treatment of benign prostatic hyperplasia. Eur Urol, 24: 415, 1993 Campo, B., Bergamaschi, F., Corrada, P. and Ordesi, G.: Transurethral needle ablation (TUNA) of the prostate: a clinical and urodynamic evaluation. Urology, 49: 847, 1997 Ogden, C. W., Reddy, P., Johnson, H., Ramsay, J. W. and Carter, S. S.: Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction. Lancet, 341: 14, 1993 Javle, P., Blair, M., Palmer, M., Jenkins, S. A. and Parsons, K. F.: The role of an advanced thermotherapy device in prostatic voiding dysfunction. Br J Urol, 78: 391, 1996 Muschter, R. and Hofstetter, A.: Technique and results of interstitial laser coagulation. World J Urol, 13: 109, 1995 Cornford, P. A., Biyani, C. S., Brough, S. J. and Powell, C. S.: Daycase transurethral incision of the prostate using the holmium:YAG laser: initial experience. Br J Urol, 79: 383, 1997 Han, M., Alfert, H. J. and Partin, A. W.: Retropubic and suprapubic open prostatectomy. In: Campbell’s Urology, 8th ed. Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. and A. J. Wein. Philadelphia: W. B. Saunders Co., vol. 2, sect VI, chapt. 41, pp. 1423–1434, 2002 Mebust, W. K., Holtgrewe, H. L., Cockett, A. T. and Peters, P. C.: Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol, 141: 243, 1989 Ibrahim, A. I., Bilal, N. E., Shetty, S. D., Patil, K. P. and Gommaa, H.: The source of organisms in the post-prostatectomy bacteriuria of patients with pre-operative sterile urine. Br J Urol, 72: 770, 1993
Purpose: We evaluated the postoperative morbidity and technical complications of a new handmade catheter used for suprapubic prostatectomy. Materials and Methods: A total of 146 patients with lower urinary tract symptoms who had indications for open prostatectomy were enrolled in the study from January 2003 to August 2004. Of the patients 96 were treated with a novel technique without a urethral catheter but with a special handmade cystostomy catheter, while the other 50 underwent the traditional procedure using cystostomy and a urethral catheter. The same surgical team operated on the 2 groups. Clot retention episodes, hemoglobin decreases, irritative symptoms, voiding status after cystostomy removal and incontinence were evaluated postoperatively. Three months later we followed the patients with symptom score, maximum flow rate and cystoscopic examination. Results: Preoperatively mean International Prostate Symptom Score was 31.6 in each group. Postoperatively none of the patients with the novel catheter complained of significant irritative urinary symptoms, clot retention and true or stress urinary incontinence. Of the cohorts 94% were satisfied with voiding but 86% of controls were satisfied. There was no report of urinary tract infection or epididymo-orchitis in the cohorts, while we found epididymo-orchitis in 4 controls (8%). Three months after the operation the mean International Prostate Symptom Score was 4.4 (range 1 to 7) and the mean maximum flow rate was 22.6 ml per second (range 14 to 25) in patients with the novel catheter, and 4.2 (range 1 to 7) and 22.5 ml per second (range 15 to 25), respectively, in those with the traditional catheter. At followup there was no bladder neck contracture but 4 patients (4.1%) showed some degree of membranous urethral stricture. We also noted 7 controls (14%) with urethral stricture. Conclusions: Transurethral prostate resection has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia. However, open adenomectomy still has a place. Urethral catheter-free suprapubic prostatectomy can be safely applied with a low postoperative risk of infection, incontinence and stricture formation. Key Words: prostate, catheterization, urethra, prostatectomy, adenoma
t is well known that in addition to urethral catheter associated discomfort, there is increased risk of ascending urethral infection, inflammation and stricture formation with urethral catheters.1,2 These complication risks are directly related to patient periurethral normal flora, aseptic catheterization and indwelling duration. Minimally invasive procedures for bladder outlet obstruction secondary to benign prostatic hyperplasia have been developed, such as visual laser ablation of the prostate, transurethral electrovaporization of the prostate, transurethral needle ablation, transurethral microwave thermotherapy, interstitial laser coagulation and transurethral incision of the prostate.3–10 They are associated with low morbidity and shortterm catheterization. However, these approaches are usually
I
Submitted for publication February 8, 2005. Study received approval from the Institutional Board Review and Medical Ethics Committee of Tehran University of Medical Sciences. * Correspondence and requests for reprints: Urology and Transplant Research Center, Sina Hospital, Hassan Abad Square, Tehran, Iran (telephone: ⫹98-21-6717447; FAX: ⫹98-21-6717447; e-mail: [email protected], [email protected]).
0022-5347/06/1756-2083/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
reserved for men with moderate symptom severity and a small to medium prostate.11 Traditionally patients with acute urinary retention, persistent or recurrent UTIs, severe hemorrhage from the prostate, bladder calculi, high I-PSS unresponsive to medical therapy and renal insufficiency as a result of chronic bladder outlet obstruction are treated with TURP or open prostatectomy. Open prostatectomy offers the advantages of a lower re-treatment rate and more complete removal of the prostate adenoma under direct vision, while it avoids the risk of additional hyponatremia (TURP syndrome).12 It can be performed by the retropubic or suprapubic approach. The standard suprapubic approach consists of enucleating the hyperplastic adenoma through an extraperitoneal incision of the anterior bladder wall. Finally, a urethral catheter and cystostomy are fixed. There is a certain risk of postoperative morbidity associated with this surgical technique, including hemorrhage, clot retention, incontinence, urethral or bladder neck stricture and UTI. Some are related to urethral catheters, such as severe bladder irritation, ascending UTI or epididymo-orchitis and urethral stricture formation. In this study suprapubic prostatectomy was done without urethral catheterization but with a suprapubic handmade cys-
2083
Vol. 175, 2083-2086, June 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(06)00344-2
2084
SUPRAPUBIC PROSTATECTOMY WITH NOVEL CATHETER
tostomy, which led to decreased postoperative urethral catheter related complications. PATIENTS AND METHODS The study was a multicenter trial, mainly done at Sina Hospital, Tehran University of Medical Sciences from January 2003 to August 2004. The Institutional Board Review and Medical Ethics Committee of Tehran University of Medical Sciences approved the study. It comprised 146 patients. They presented to our outpatient urology clinic with significant symptoms of bladder outlet obstruction secondary to benign prostatic hyperplasia. They had indications to undergo open prostatectomy, eg in a patient with a 20 gm prostate adenoma was opened because of severely limited hip joint flexion, which prevented TURP (table 1). The prospective, randomized, controlled trial allocated patients in a way that for every 2 patients operated on with the novel technique 1 was treated with the traditional procedure (96 and 50, respectively). Mean age was 69.9 ⫾ 7.5 years in the 2 groups. All patients with suspicious digital rectal examination or increased prostate specific antigen underwent transrectal ultrasonographic needle biopsy of the prostate to exclude prostate carcinoma. Perioperative antibiotics were prescribed in all patients. Preoperatively routine biochemical laboratory tests, ultrasound and panendoscopic examination, if indicated, were performed to rule out urethral stricture or bladder malignancy. Prostate adenoma weight was measured after enucleation using a digital electronic scale. We recorded bladder irritative symptoms using the I-PSS table (assumed to be significant if the score was more than average in any patient), postoperative hemoglobin decrease, first 24-hour drain collection, balloon volume, time to complete balloon emptying, episodes of clot retention as we tapered irrigation 1 day after operation while there was no gross hematuria, voiding status after cystostomy removal, incontinence according to the International Continence Society outline 1 week postoperatively and urogenital infections. Three months later I-PSS, uroflowmetric study and panendoscopic examinations to rule out bladder neck or urethral stricture formation were done in all patients. All patients were completely informed and provided consent regarding the new or traditional technique. The independent sample t, chi-square and Fisher’s exact tests were used to compare parameters between the 2 groups. How to Prepare a 24Fr 3-Way Foley Catheter to be Applied in This Technique 1) The distal catheter eyes are blocked by tying distal to the catheter balloon using 1-zero silk. 2) Two 10 ⫻ 5 mm outlet openings are made starting 10 mm proximal to the balloon.
TABLE 1. Indications for open prostatectomy in patients entered in our study No. Pts Large adenoma Large adenoma ⫹ synchronous hernia repair Large bladder diverticula ⫹ recurrent UTI Multiple bladder stones Hip prosthesis or severe osteoarthritis Large median lobe making TURP technically difficult Total
66 29 14 16 11 10 146
The distance between openings should not exceed 10 mm. Care must be taken not to traumatize the balloon lumen. 3) A 5 mm inlet opening is created by resecting over the inlet lumen in the area between the new outlet openings proximal to the balloon. Surgical Technique All operations were done through a lower midline or Pfannenstiel incision with the patient under spinal anesthesia. After incising the lower median abdominal wall fascia and muscles the anterior bladder wall is opened and the prostate adenoma is enucleated. After approximating the bladder neck mucosa with the prostate capsule using 3-zero chromic sutures the balloon of the previously prepared 24Fr Foley catheter is inserted in the prostatic lodge by a transvesical approach and fixed to the bladder mucosa by 2-zero plain suture next to its entry into the bladder dome. This is done to prevent catheter dislodgment or its bending in the bladder. The catheter balloon inside the prostatic lodge is filled to a volume suitable to apply pressure inside the prostate lodge to control bleeding. The catheter tip distal to the balloon should be inserted inside the posterior urethra. Catheter outlet eyes made proximal to the balloon are applied in a way that faces toward the anterior abdominal wall. The bladder wall is closed in 3 layers and a tube drain is left in the space of Retzius. The abdominal wall layers are repaired subsequently. Irrigation is started in the operating room and the wound is dressed. Starting 1 hour postoperatively and then within the next 24 to 36 hours the balloon fluid is emptied gradually. Diluted contrast medium (30% Urografin®) is used for balloon filling and within 24 hours postoperatively the balloon site is evaluated by pelvic x-ray. The suprapubic cystostomy catheter is removed in 5 to 7 days (see figure). RESULTS A total of 96 patients underwent open prostatectomy with the novel catheter compared to 50 in whom the traditional catheter was used. Preoperatively mean I-PSS was 31.6 (range 21 to 35) in patients with the novel catheter and 31.6 (range 24 to 35) in the control group. Of patients with the novel catheter 21 (21.8%) and 9 (18%) with the traditional technique had an indwelling catheter before surgery due to urinary retention. In these patients at least 1 trial without a catheter had failed and, hence, they were considered to have severe bladder outlet obstruction. Mean Qmax was 4.1 (range 0 to 11) and 4.2 ml per second (range 0 to 14) in patients with the novel and traditional techniques, respectively. Postoperatively mean prostate adenoma weight was 63.3 gm (range 20 to 110) in those with the novel catheter and 64.3 gm (range 55 to 85) in the control group. Mean balloon volume was 29.5 cc (range 10 to 50). Average first 24-hour drain leakage was 155 ml in the cohort vs 168 ml in controls. There was no report of clot retention or significant irritative symptoms in patients with the novel catheter, while 22 (44%) and 19 (38%) in the control group had significant irritative symptoms and at least 1 episode of clot retention, respectively (p ⬍0.001). In the cohort 95 patients voided comfortably after cystostomy removal and 1 failed to void. He performed intermittent self-catheterization because cystourethroscopy did not show any obstructive lesion. Early incontinence (1 week postoperatively) was recorded in 3
SUPRAPUBIC PROSTATECTOMY WITH NOVEL CATHETER
2085
epididymo-orchitis in patients with the novel catheter but this was identified in 4 (8%) in the traditional group (p ⬍0.05). The same prophylactic antibiotic protocol had been used in the 2 groups. We performed a panendoscopic examination in all patients. Complete epithelialization occurred in the prostatic fossa in almost all patients. At 6 months of followup 4 patients (4.1%) with the novel catheter had a membranous urethral stricture compared to 7 (14%) with the traditional procedure, including 4 with a penile urethral stricture and 3 with bladder neck contracture. Table 2 shows the postoperative improvement in I-PSS and Qmax. DISCUSSION
Sinahoo catheter inside prostatic lodge. 1, balloon. 2, outlet eyes. 3, inlet eye. 4, posterior urethra. 5, prostatic surgical capsule. 6, catheter fixation site in bladder wall.
patients (4%) with a novel catheter but in 31 controls (62%) (p ⬍0.001). It improved in more than 95% of cases at 3 months of followup in each group. We started emptying the balloon 1 hour postoperatively, which was completed within 24 to 36 hours. During balloon deflation 2 patients had intravesical balloon dislodgment and extravesical leakage of irrigant fluid through the draining tube, which was assessed by pelvic x-ray. They were treated with transurethral catheterization. The postoperative decrease in hemoglobin was 0.8 gm/dl in the cohort vs 1.9 gm/dl in controls. None of the cases but 2 controls needed blood transfusion. There was no record of
Urethral catheter complications, such as patient discomfort, infection and stricture formation, are well known. Ibrahim et al reported that post-prostatectomy bacteriuria is probably caused by postoperative ascending infection along the urethral catheter, although there was not enough evidence to attribute bacteriuria to preexisting septic foci in the adenoma.13 Intraoperative contamination and infection from distant foci were also unlikely causes. In 1992 Wurnschimmel and Lipsky reported that in a prospective followup of 178 patients who underwent TURP during 12 to 20 months urethral stricture developed in 14%.1 Of the 11 factors studied the only one that was a statistically significant risk was an indwelling catheter for more than 3 days. They concluded that urethral ischemia might increase the risk of urethral stricture. According to our study only 4 patients (4%) with the novel catheter had a urethral stricture compared to 7 controls (14%). Although this was not statistically significant (p ⫽ 0.1), it may emphasize the role of urethral catheters in the pathogenesis of urethral stricture. In regard to prostatic lodge bleeding, the good control of bleeder sites can minimize bleeding from the prostatic capsule. Insertion of the novel catheter balloon inside the prostatic lodge and applying pressure over the capsule wall (tampon-like effect) can effectively control bleeding. This leads to a decreased number of clot retention episodes and less of a decrease in hemoglobin. Applying the catheter balloon away from the trigone minimized bladder irritation symptoms and decreased postop-
TABLE 2. Preoperative and postoperative results in 96 patients undergoing suprapubic prostatectomy with novel catheter vs 50 with traditional technique Variables No. pts Mean I-PSS ⫾ SD (range): Preop Postop Mean ml/sec Qmax ⫾ SD (range): Preop Postop Mean gm prostate wt ⫾ SD (range) Mean cc balloon vol ⫾ SD (range) Mean 24-hr drain collection 1 ⫾ SD (ml) No. complications (%): Significant immediate or late postop bladder irritative symptoms Clot retention Bladder neck or urethral stricture Postop epididymo-orchitis Mean hemoglobin decrease (mg/dl) No. catheter dislodgment (%) No. early postop incontinence (%)
Novel Catheter 96
Traditional Technique
p Value
50
31.6 ⫾ 3.5 (21–35) 4.4 ⫾ 2.2 (1–7)
31.6 ⫾ 3.3 (24–35) 4.2 ⫾ 2.1 (1–7)
4.1 ⫾ 2.8 (0–11) 22.6 ⫾ 2.6 (14–25) 63.3 ⫾ 15.6 (20–110) 29.5 ⫾ 9 (10–50) 155 ⫾ 63.5
4.2 ⫾ 2.4 (0–14) 22.5 ⫾ 2.7 (15–25) 64.3 ⫾ 16.3 (55–85) 168.8 ⫾ 67.4
0.2 (independent samples t test)
—
22 (44)
⬍0.001 (chi-square test)
— 4 (4.1) — 0.8 2 (2.2) 3 (4)
19 (38) 7 (14) 4 (8) 1.9 — 31 (62)
⬍0.001 (chi-square test) 0.1 (chi-square test) ⬍0.012 (Fisher’s exact test) ⬍0.001 (independent samples t test) ⬍0.001 (chi-square test)
2086
SUPRAPUBIC PROSTATECTOMY WITH NOVEL CATHETER
erative morbidity and patient discomfort. It was also associated with less early incontinence (4% vs 62%). Possible hypotheses are no trigone irritation, no interference with external urethral sphincter function and less patient discomfort, which are due to urethral catheter exclusion. Fujita et al reported that epididymo-orchitis was significantly associated with postoperative catheterization and postoperative UTI.2 There was no report of UTI or epididymo-orchitis in our study, maybe due to urethral catheter exclusion. In this study we tried to avoid a urethral catheter without compromising the surgical outcome. Patient comfort due to not having a urethral catheter allows them to ambulate and achieve better tolerance in the early postoperative period. Also, we should consider the economic benefit of omitting 1 of 2 catheters with this novel technique. A pitfall of this new technique is catheter dislodgment. It occurred in 2 patients, leading to urinary extravasation that was managed successfully by a transurethral catheter. It is our recommendation to start catheter balloon emptying (at least 20% of balloon volume) as early as 1 hour postoperatively. It seems to be enough for bleeding control and it prevents bladder neck ischemia and subsequent contracture. However, this is a prospective pilot study. We suppose that this new catheter requires further study and it should be applied in a larger population to be evaluated more comprehensively. CONCLUSIONS Catheter-free suprapubic prostatectomy is safe and effective. Patient comfort, good outcome and low morbidity, especially infection and stricture formation, are advantages associated with this technique. Also, it may be a help to discharge patients home sooner.
REFERENCES 1.
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ACKNOWLEDGMENTS Doctor Tajik assisted with the manuscript. 12.
Abbreviations and Acronyms I-PSS Qmax TURP UTI
⫽ ⫽ ⫽ ⫽
International Prostatic Symptom Score maximum urinary flow rate transurethral prostate resection urinary tract infection
13.
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