Hypothesis / aims of study
Benign Prostatic Enlargement (BPE) is due to histologic prostatic hyperplasia that causes benign prostatic obstruction (BPO) leading to a vast array of lower urinary tract symptoms (LUTS). Its incidence is age related: at the age of 55, approximately 1 out of 4 men report bothersome LUTS, and by 75 years of age, roughly half of men complain about of troublesome LUTS. First line therapy is behavioural modification plus the possibility of adjuvant pharmacotherapy. Surgery is recommended in specific cases, ultimately to avoid kidney injury, and when LUTS persist despite conservative treatment. According to international guidelines, open prostatectomy (OP) and endoscopic enucleation should be offered to treat moderate to¬ severe LUTS in men whose prostatic size is greater than 80mL. OP can be performed either by retropubic (ORP) or suprapubic (OSP) technique. OP is arguably the most effective surgery, although more invasive when compared to endoscopic enucleation, which is not available worldwide yet. Like every surgery, OP has advantages and disadvantages. However, there is no robust data comparing the outcomes of ORP compared to those of OSP. We hypothesise ORP would have better results concerning the perioperative period due to the preservation of the bladder wall integrity. The main endpoint is to compare ORP to OSP in the preoperative, perioperative and postoperative periods.
Study design, materials and methods
We report a retrospective study including patients who underwent OP at a tertiary centre, between 2011 and 2015. Data was collected in patients’ records with a minimum follow¬ up time of 3 years. Variables under analysis were, in the preoperative: age, body mass index (BMI), Charlson Comorbidity Index (CCI), prostate specific antigen (PSA), anticoagulation/antiplatelet therapy, 5 alpha reductase inhibitors, bladder stones/diverticula, prostatic volume, maximum flow rate (Qmax), International Prostatic Symptoms Score (IPSS), haemoglobin; in the perioperative: surgery duration, intraoperative haemorrhage; in the postoperative: haemoglobin, blood transfusion, duration of stay, haematuria, days with catheter, Clavien-Dindo classification, Qmax, PSA, IPSS, prostatic volume.
Statistical analysis was performed in STATA v.13™ using the appropriate test for quantitative and qualitative measures and uni- and multivariate logistic regressions with a significance level of 0.05.
In the period of interest, 424 OP were included – 170 (40.0%) ORP and 254 (60.0%) OSP. The patients’ mean age was 70.4±8.0 years, BMI of 26.6±3.6kg/m2, and median CCI of 1.0. The mean haemoglobin level was 14.3±1.5g/dL, the mean Qmax was 9.2±3.5mL/s, and the mean prostatic volume was 113.7±33.6mL. Both groups were comparable regarding all preoperative variables. Regarding the perioperative period, the duration of surgery was longer in OSP (98.7 vs. 78.4 min, p=0.001), but there were no differences in intraoperative haemorrhage (507 vs. 453mL, p=0.27). In the postoperative period, ORP led to fewer days of haematuria (4.1 vs 5.8, p =0.001), of catheter use (5.6 vs. 7.1, p =0.001), and of hospital stay (5.9 vs. 7.9, p=0.001). In terms of incidence of early complications, no significant differences were detected (p=0,63). There were no significant differences in the postoperative Qmax (21.9 vs 22.4mL/s, p=0.12) Later complications (namely storage LUTS and bladder neck contracture) were more frequent in OSP (18.6% vs. 8.2%, p=0.009). We could not find other statistically significant differences using logistic regression models. In a subgroup analysis, patients who had an indwelling catheter preoperatively had more infections and/or wound dehiscence in the OSP group (21.2% vs 0.0%, p=0.003).
Interpretation of results
Although this is a retrospective study, the groups under analysis are comparable, regarding the predetermined variables. Missing data did not permit a more comprehensive evaluation and comparison of the outcomes of both techniques. Contrarily to some literature, significant differences in intraoperative haemorrhage between techniques were not found. However ORP was associated with earlier cessation of postoperative haematuria, and consequently catheter removal, concurring to a shorter hospital stay. It seems to be a good option for patients with indwelling catheters.
ORP has a statistically significant advantage over OSP in terms of shorter procedural time, earlier cessation of postoperative haematuria, earlier catheter removal, and overall shorter hospital stay, at our Institution. Furthermore, it has shown lower incidence of long term complications. Our data suggest ORP may be preferable over OSP. Further studies comparing open surgery to minimally invasive approaches are undergoing.