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Transvesical Prostatectomy in elderly patients: an experience at Saidu Teaching hospital Swat
Liaqat Ali et.al
Original Article
Transvesical Prostatectomy in elderly
patients: an Experience at Saidu
Teaching Hospital Swat
Objective: To determine the efficacy, safety and post-operative complications of
transvesical prostatectomy (TVP) at Saidu teaching hospital, Swat.
Study Design: Descriptive study.
Place and Duration: Department of General and Urological Surgery, Saidu teaching hospital,
Swat from March 2004 to December 2005.
Materials and Methods: A total of 146 patients were included by non probability
convenient sampling. The data were collected on a structured proforma which included age,
presentation, comorbids, type of anesthesia, rate of blood transfusion, early complication,
histology, follow up, late complications and improvement in symptoms and quality of life.
The data were analyzed through SPSS.
Results: The mean age of the patients was 67.8 years (Range 45-100years). 88 (60.2%)
patients presented with acute urinary retention, 39 patients (26.7%) presented with severe
International prostate symptoms score (IPSS) and the remaining 19 patients (13%)
presented with the of complication of obstructive uropathy. Comorbids were present in 41
patients (28%). Transvesical prostatectomy was performed under general anesthesia in 121
patients (82.8%) and spinal anesthesia in 25 patients (17.1%). Blood transfusion was
required in 23 patients (15.7%). 42 (28.7%) patients had some kind of early postoperative
complications, such as febrile UTI (n= 13), clot retention (n=11), suprapubic urinary fistula
formation (n= 4), wound infection (n=10) and miscellaneous complications (n=5). There was
no mortality in our study. Regarding histology benign prostatic hyperplasia was found in
124 patients (84.9%) and adenocarcinoma prostate in 12 patients (8.2%). We regularly
followed up our 84 patients (57.5%) with mean follow up period of 14± 3.5 months and
recorded 7 (8.3%) late postoperative complications among them. 5 patients developed
urethral stricture and 2 patients remained incontinent for 3 months. Significant
improvement in symptoms and quality of life was recorded in 61 (72.6%) patients.
Conclusion: Transvesical prostatectomy is an effective and safe surgical method in the
management of symptomatic grossly enlarge prostate in the remote areas, where either the
expertise or the endoscopic equipments for transurethral resection of prostate are not
available.
Key Words: Transvesical prostatectomy. Transurethral resection of prostate. Enlarged
prostate.
Introduction
Prostate is a male sex organ located beneath
the bladder neck and rests upon urogenital diaphragm
with the approximate weight of 20 gm. Prostate is
involved in a variety of diseases like benign prostatic
hyperplasia (BPH), adenocarcinoma prostate, and
prostatitis etc. 1 BPH is the most common benign
tumour in men and its incidence is age-related. The
estimated prevalence is 25 % in men aged 40 to 79
years). 2 There are a number of modalities for the
Ann. Pak. Inst. Med. Sci. 2008;4(3): 148-151
Liaqat Ali
Nasir Orakzai
Manzoor Ali
Centre of Kidney Diseases,
Hayat Abad Medical Complex,
Peshawar.
Address for Correspondence:
Dr Liaqat Ali,
Senior Registrar,
Centre of Kidney Diseases,
Hayat Abad Medical Complex,
Peshawar.
treatment of urinary bladder outlet due to BPH, however
the aim of treatment is to improve the quality of life. 3
Prostatectomy is one of the most commonly
performed operations across the world. Open
prostatectomy was the only option for the surgical
management of BPH until 6th and 7th decade of the 20th
century, however the frequency of open prostatectomy
has gradually decreased with the widespread use of
endoscocpic equipments.4 Transurethral resection of the
prostate (TURP) is now considered as
the gold
standard for treatment of BPH because it is less
148
Transvesical Prostatectomy in elderly patients: an experience at Saidu Teaching hospital Swat
invasive, cost effective and is associated with reduced
hospital stay and decrease morbidity. 5,6
The ratio of open prostatectomy to endoscopic
resection varies in different parts of world depending
upon a variety of factors. Open surgery may be
performed in form of transvesical prostatectomy and
retropubic prostatectomy. Currently the indications for
transvesical prostatectomy are large adenoma
especially when it is associated with large bladder stone
and diverticulum.7
Another indication for open
prostatectomy is the unavailability of endoscopic
equipments especially in the rural areas of developing
world. 8
Historically
McGill and Belfield described
suprapubic transvesical partial enucleation of the
prostate in the late 1800s, however it was until Fuller
and Frayer, when complete enucleation of the gland
gained widespread acceptance.9
The present study was carried out to evaluate
our experience of transvesical prostatectomy and
determine its efficacy, safety and post-operative
complications in our patients.
Materials and Methods
This descriptive study was undertaken at the
Department of general and urological surgery, Saidu
teaching hospital, Swat from
March
2004
to
December 2005.
A total of 146 patients were included by non
probability convenient sampling. All the patients with
definite indication for prostatectomy and were fit for
anesthesia were included while those with pre-existing
urethral stricture or who had prostatectomy in the past
were excluded.
Informed consent was taken from all the
patients. History, physical examination and relevant
investigations were carried out in all the patients.
Patients were then subjected to transvesical
prostatectomy.
Suprapubic pfannenstiel incision was made in
all patients. A longitudinal incision was used to enter the
bladder. A circumferential incision was made around the
urethral orifice at the bladder neck, followed by digital
enucleation of the adenoma. After removal of the
adenoma, the places of visible bleeding at the bladder
neck were controlled with electrocautry. A 20-22 Fr
three-way irrigating Foley catheter was passed through
the urethra, the balloon was inflated to 30-50 ml and the
balloon was left in the bladder. The bladder was closed
in two layers with a running absorbable suture (Vicryl 1).
Extravesical drain was used for drainage. Abdominal
wall was closed in layers with absorbable suture and
skin was closed with prolene. Continuous saline
irrigation was performed until the clearance of clot and
gross bleeding. Intravenous broad spectrum antibiotics
Ann. Pak. Inst. Med. Sci. 2008;4(3): 148-151
Liaqat Ali et.al
were used for the initial 48 hours followed by oral
antibiotics. Patients were discharged at the fourth day
postoperatively. Urethral catheter was removed on 7th
day in most of the cases. All the surgical specimens
were subjected to histopathological evaluation.
Patients were regularly followed up initially on
monthly basis for 3 months and then 3 months for the
next 12 months.
The data were collected on a structured
proforma which included age of the patient,
presentation, comorbids, type of anesthesia, rate of
blood transfusion, early complication, histology, follow
up, late complications and improvement in symptoms
and quality of life. The data were analyzed through
SPSS.
Results
A total of 146 patients were included in the
study. The mean age of the patients was 67.8 years
( range 45 to 100 years).
88 (60.2%) patients presented with acute
urinary retention, 39 patients (26.7%) presented with
severe International prostate symptoms score IPSS and
remaining 19 patients (13%) presented with various
complications of enlarge prostate including obstructive
uropathy with azotemia ( n=9 ), bladder stone due to
enlarge prostate ( n= 7 ) and chronic retention with
overflow incontinence ( n= 3 ).
Table I : Early postoperative complications
of Transvesical prostatectomy. ( n=42 )
Type of Complication
Number of
patients (%)
Febrile UTI
13(8.9)
Clot retention
11( 7.5 )
Vesicocutaneous fistula
04( 2.7 )
Wound Infection
10( 6.8 )
Respiratory tract Infection
01(0.68 )
Failure to void after Catheter
03( 2.05)
removal
41 patients (28%) had associated comorbids.
These included hypertension ( n=16 ), diabetes ( n=10 )
, both hypertension and diabetes ( n=9 ) and others (
n=6).
The median prostatic weight on ultrasound scan
was 58.5 gm ( range 48-165gm)
121 patients were operated under general
anesthesia while 25 patients were operated under spinal
anesthesia. Blood transfusion was required in 23
patients (15.%).
Out of 146 patients, 42 (28.7%) patients had
149
Transvesical Prostatectomy in elderly patients: an experience at Saidu Teaching hospital Swat
some kind of early postoperative complication. (Table I)
Regarding
histology
benign
prostatic
hyperplasia was found in 124 patients (84.9%) and
adenocarcinoma prostate in 12 patients (8.2%). We
could not record the results of 10 histological
specimens. We regularly followed up our 84 patients
(57.5%) with mean follow up period of 14± 3.5 months
while 62 patients (42.4%) were lost with in first 30 days
of follow up. We recorded 7 (8.3%) late postoperative
complications in our 84 followed up patients. These
included
urethral stricture ( n=5 ) and stress
incontinence for 3 months. ( n=2 )
The stress
incontinence
resolved spontaneously without any
intervention. There was no recurrence of disease in our
patients.
The improvement in the symptoms and quality
of life (QOL) was dramatic in majority of our patients
especially those who had presented with acute urinary
retention. The detail of improvement in symptoms and
QOL among the regularly followed 84 patients is shown
in Figure I.
n=84
Static 10 (11.9%)
Significant
improvement 69
(82.1%)
Deroriated 5
( 5.9%)
Figure I: Improvement in symptoms and
Quality of life. ( n=84 )
Discussion
There are a number of modalities for the
surgical management of symptomatically enlarge
prostate, however TURP is still considered as the gold
standard because of its being less invasive, effective,
safer and attended by less complications.
Transvesical prostatectomy is still commonly
performed procedure for the surgical management of
prostate especially in the rural areas across the globe
where either the expertise or endoscocpic equipments
are not available. It is reasonably safe and effective in
hands of trained and qualified surgeons. 10
The weakness of our study is that we lost
significant number of our patients 62 (42%) in follow up.
The probable reason for such high percentage is that
patients might have landed in private clinics of some
consultants or even the general practitioners GPs in the
remote areas of Swat.
Ann. Pak. Inst. Med. Sci. 2008;4(3): 148-151
Liaqat Ali et.al
Our data showed that majority of our patients 88
(60%) presented with urinary retention, Although this
observation is quite contrary to the studies of developed
countries where the frequency of urinary retention due
to enlarge prostate ranges from 8%-10%, however
probably due to lack of health education and delivery
system, the frequency of urinary retention in developing
world is as high as our figures. 8,10
Urinary retention is a frequent presentation
among our patients. This may be attributed to lack of
health education as our aging males presume the
change in voiding habits as an aging process. They
usually seek medical advice in emergency when they
are unable to void. Further research is desired to study
the sociocultural factors that lead to delay in seeking
medical advice in patients with enlarge prostate in our
population.
Blood transfusion was required in 23 patients
(15.%) in our series. The rate of blood transfusion varies
between 1% to 35% in various other studies. Condie
reported 1%, while Stutzmen and Mc Connel have
reported 15 % and 35 % transfusion rates respectively
8,9
.
Present study showed that 42 patients (28%)
developed some kind of early post operative
complications that is in conformity with published
literature. 11-13
The mortality rates for both transurethral and
open prostatectomies have decreased significantly in
the past three decades. In most series the early
mortality rate for TURP was 0.02% to 2.5% and 0.3%
to5.8% for open prostatectomy.10,14
In our series there was no mortality. This
reflects the fact that TVP is a safe procedure in
experienced hands and especially when proper
selection of the patient, vigilant preoperative and
postoperative care is ensured.
Two of our patients (2.3%) developed mild
stress urinary incontinence, that resolved spontaneously
with in 3 months. There was no patient of total
incontinence in the present study. In other published
studies the rate of stress incontinence varied from 0.5%
to 7.5% and the rate of true incontinence is 0.1% to
0.8%. 15-17
In present study, there was significant
improvement in symptoms and QOL in majority (82.1%)
of our patients especially those with history of urinary
retention. This is in conformity with other published
studies. 9,10
Conclusion
Transvesical prostatectomy is an effective and
safe surgical method in the management of
symptomatic grossly enlarged prostate in the remote
areas, where either the expertise or the endoscopic
equipments for transurethral resection of prostate are
not available.
150
Transvesical Prostatectomy in elderly patients: an experience at Saidu Teaching hospital Swat
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