Year : 2000 | Volume
: 16 | Issue : 2 | Page : 122--125
A clinical review of fifty consecutive cases of retropubic prostatectomy for benign prostatic hyperplasia
Vatsala D Trivedi, Mukund G Andankar, Sujata Salve-Satwekar
Lokmanya Tilak Municipal General Hospital, Mumbai, India
Vatsala D Trivedi
Department of Urology, Lokmanya Tilak Municipal Medical College, Sion, Mumbai - 400 022
Objective: To present a clinical review of 50 consecutive retropubic prostatectomies done for large size glands at our institution from Jan. 1992 to Dec. 1998 and to clarify , the role of retropubic prostatectomy by modified Millin«SQ»s technique.
Material and Methods: 10% of the patients who needed intervention for benign prostatic hyperplasia were subjected to open retropubic prostatectomy by modified Millin«SQ»s technique. The decision to subject the patient to open surgery was based on prostatic size detected by abdominal ultrasonography, digital rectal examination and cystoscopy.
Results: The weight of the adenoma removed varied from 68 to 205 gms. Most of the patients voided with a good stream with little discomfort. One patient developed membranous urethral stricture postoperatively. Two patients had incontinence of urine which improved subsequently over a duration of 6 to 8 weeks.
Conclusion: We feel open retropubic prostatectomy by modified Millin«SQ»s technique has minimal morbidity and is a good alternative for large size glands in benign prostatic hyperplasia.
|How to cite this article:|
Trivedi VD, Andankar MG, Salve-Satwekar S. A clinical review of fifty consecutive cases of retropubic prostatectomy for benign prostatic hyperplasia.Indian J Urol 2000;16:122-125
|How to cite this URL:|
Trivedi VD, Andankar MG, Salve-Satwekar S. A clinical review of fifty consecutive cases of retropubic prostatectomy for benign prostatic hyperplasia. Indian J Urol [serial online] 2000 [cited 2020 Jan 25 ];16:122-125
Available from: http://www.indianjurol.com/text.asp?2000/16/2/122/22210
Surgical treatment of benign prostatic hyperplasia was introduced over a century ago with the first description of a planned open enucleation of the prostate by Bellfield  and later by Frayer in 1900.  The retropubic approach was however first described and popularised by Millin in 1945 ., Today, the majority of patients who require an operation for BPH undergo TURP. However approximately 5% to 10% of them undergo some type of open prostatectomy. 
We present a clinical review of 50 cases of retropubic prostatectomy for BPH carried out at our institution from Jan. 1992 to Dec. 1998.
Material and Methods
Total 10% of our patients of benign prostatic hyperplasia requiring intervention underwent retropubic prostatectomy. The decision to subject the patient to open surgery was based mainly on prostatic size, detected on abdominal ultrasonography, digital rectal examination and cystoscopy.
The patients with associated bladder pathology warranting open surgery and with larger glands were subjected to open prostatectomy. Two patients had associated ankylosis of hip preventing proper placement of the patient in the dorsal lithotomy position, hence were subjected to open surgery.
The gland size is finally determined on cystoscopy, performed just prior to surgery. The patients with gland size more than 60 to 70 gms and for whom the urologist felt that the resection time may extend beyond 90 minutes were subjected to open retropubic prostatectomy. The preoperative preparation of patient included routine laboratory investigations and serum PSA. Special emphasis was placed on evaluation of cardiac and neurological status.
We used Terence Millin's original technique with little alteration, somewhat as described by Walsh et al in 1990.  The extraperitoneal exposure of prostate is carried out by Pfannensteil incision. The dorsal vein complex and lateral pedicles at the prostatovesicular junction are ligated by no. 1 zero chromic catgut on 5/8 circle needle. This method effectively controls venous and arterial bleeding.
The wedge resection of bladder neck is carried out if bladder neck is found to have a relatively small opening along with advancement of bladder mucosa into the prostatic fossa. The watertight closure of transverse capsulotomy is accomplished with no. 1 chromic catgut. We routinely perform bilateral vasectomies. A per urethral Foley's 20F catheter is kept with 50 ml. balloon to ensure that balloon does not slip into the prostatic fossa. We do not keep a suprapubic catheter and ensure diuresis with intravenous fluids and diuretics. The catheter is removed on 3rd or 4th postoperative day in an ambulatory patient with clear urine.
The average age of the patients who underwent open retropubic prostatectomy was 64 years, the youngest being 58 years old and the oldest 84 years old. The average weight of prostatic adenoma was 78 gm., the smallest being 68 gm. and the largest 205 gm.
2 patients had associated small bladder calculi which could be removed through the same capsulotomy incision. The histopathology showed benign prostatic hyperplasia in 48 patients and prostatic intraepithelial neoplasia in 2 patients. The prostate specific antigen was in normal range in all these patients.
We did not encounter reactionary haemorrhage warranting intervention. However, 2 patients returned with secondary haemorrhage on tenth postoperative day, and were treated successfully by conservative management. Only 3 patients required intraoperative blood transfusion. 94% of the patients voided with a good stream with little discomfort. 4% of men had incontinence of urine which improved subsequently over a period of 6 to 8 weeks. I patient developed short stricture of urethra two months following surgery at prostatomembranous junction. He was treated with visual internal urethrotomy. One patient had a suprapubic fistula which healed after 6 weeks of conservative management. The average duration of surgery was 1 hour. The mean hospital stay was 6 days.
We encountered superficial wound infection in 10 patients, the incidence being on higher side. This was seen particularly in patients with a per urethral catheter for a prolonged duration preoperatively. The maximum duration of catheterisation observed was 6 months in one of our patients. One patient died postoperatively, due to myocardial infarction on fifth postoperative day.
With the advent of medical therapy, the number of interventions for benign prostatic hypertrophy have significantly reduced. A recent survey of U.S. Medicare data base revealed that the absolute number of prostatectomies decreased over 30% despite increase in number of males enrolled in the Medicare programme.  However, TURP remains the gold standard of treatment of BPH and has stood the test of time.
The risks associated with TURP like haemorrhage and TUR syndrome increases with increase in resection time, size of gland and age. Mebust et al  in his study reported increased incidence of TUR syndrome and haemorrhage if the gland is more than 45 gms and resection time is more than 90 mins. Hence, open surgery does play an important role especially in large size glands. There are few conditions in which TURP cannot be performed due to technical reasons e.g. ankylosis of hips preventing dorsal lithotomy position. Associated bladder pathologies like calculi, diverticulum also warrant open surgery. 
One of the essential problems of prostatic surgery no matter which type has always been the question of operative haemostasis. Recognising the marked vascularity of the prostate and the excessive bleeding that might occur during surgery, many authors have modified the original technique described by Millin's. Dettmar  described continuous sutures of the edges of bladder neck to achieve complete separation of the bladder cavity from prostatic bed thereby preventing blood entering the bladder leading to clot retention. The value of ligation of dorsal vein complex and lateral pedicles have made it possible to perform the enucleation of adenoma in an almost bloodless field avoiding the need for blood transfusion, as described by Walsh et al.  The retropubic approach also allows excellent anatomic exposure and visualisation of interior of the prostatic cavity for residual adenoma and bleeding points.
We followed a similar technique and have not encountered haemorrhage of severe nature in any case and only 3 of 50 patients required intraoperative blood transfusion. All 3 had a low haemoglobin per cent preoperatively. A slight red colour of urine was common on the first and second day after the operation. 2 of our patients had secondary haemorrhage on the 10th postoperative day managed by antibiotics, intravenous fluids and bladder washes [Table 1]. In a few cases we encountered the problem of blockage of catheter by small clots. It was however possible to remove the clots from the catheter by energetic suction. We ensure the diuresis for 24 hours by administration of intravenous fluids and diuretics which avoid accumulation of blood and clot formation.
Bilateral vasectomies reduce the risk of epididymitis as described by Joseph Osterling et al.  We routinely carry out this procedure and have not encountered epididymitis even in a single patient. We do not keep a suprapubic catheter, reducing the morbidity further.
With the retropubic approach accurate and sharp division of the urethra is possible decreasing the risk of incontinence. Only 2 of our patients had this complication with the incidence of 4%. However both the patients improved over 6 to 8 weeks on conservative management.
The mean duration of hospital stay was 6 days which also includes the preoperative stay of I or 2 days for stabilisation of compromised cardiorespiratory status. TURP, considered the gold standard in management of BPH, also has significant associated complications. The mortality rate noted at 30 days varies from 0.2% to 2.5% as described by different authors. ,, The immediate morbidity rate following TURP is reported as 18%. , The most important complication in the immediate postoperative period were failure to void (6.5%), bleeding requiring transfusion (3.9%) and clot retention (3.3%). The incidence of TUR syndrome was described to be 2%, perforation of the prostatic capsule with extravasation 2% and epididymitis 0.18%. , The incidence of these complications increased significantly in patients with age more than 80, acute urinary retention and a resection time exceeding 90 minutes. 
Although it is not our objective to compare TURP with open surgery, it is clearly seen that open retropubic prostatectomy is safe, less time-consuming and associated with minimal morbidity. Hence we feel that it is a good alternative for large size glands of benign prostatic hyperplasia.
|1||Bellfield WT. Operations on the enlarged prostate with a tabulated summary of cases. Am J Med Sci 1890: 100: 439.|
|2||FreyerP. A new method of performing prostatectomy. Lancet 1900: 1: 774.|
|3||Millin T. Retropubic prostatectomy. A new extravesical technique. Report on 20 cases. Lancet 1945: 2: 693.|
|4||Millin T. Retropubic prostatectomy. J Urol 1948: 59: 267-274.|
|5||Walsh PC. Osterling JE. Improved hemostasis during simple retropubic prostatectomy. J Urol 1990: 143: 1203-1204.|
|6||Holtgrewe HL. Economic issues and the management of benign prostatic hyperplasia. Urology 1995: 46 (suppl 3A): 23-25.|
|7||Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC and writing committee. Transurethral prostatectomy: immediate and postoperative complications. A co-operative study of thirteen participating institutions evaluating 3,885 patients. J Urol 1989: 141: 243-247.|
|8||Osterling JE. Retropubic and suprapubic prostatectomy. In: Campbell's Urology. 7th ed. Philadelphia, Saunders, 1998; 2: 1529-1541.|
|9||Dettmar H. Modification of technique for retropubic prostatectomy: Report of 100 cases. J Urol 1959; 81: 558-561.|
|10||Holtgrewe HL, Valk WL. Factors influencing the mortality and morbidity of transurethral prostatectomy: A study of 2015 cases. J Urol 1962; 87: 450-459.|
|11||Melchior J, Valk WL, Foret JD, Mebust WK. Transurethral resection of the prostate via perineal urethrostomy: complete analysis of 7 years of experience. J Urol 1974; 111: 640-643.|
|12||Blue GD, Campbell JM. A clinical review of one thousand consecutive cases of retropubic prostatectomy. J Urol 1958; 80: 257-259.|