the current role

7/29/2019 The Current Role

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The Current Role of Open Surgery in BPH

Andrea Tubaro *, Cosimo de Nunzio

Department of Urology, SantAndrea Hospital, 2nd School of Medicine, La Sapienza University, Rome, Italy

1. Introduction

The catastrophe theory suggests that sudden andmajor shifts occur in behaviour from small changes

in circumstances. Although the theory has not beenapplied to BPH yet, it helps explaining the suddenchange which occurred in its management whenopen prostatectomy was first proposed by Eugene

e a u - e b u u p d a t e s e r i e s 4 ( 2 0 0 6 ) 1 9 1 2 0 1

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m

Article info

Keywords:

Open prostatectomyProstatic hyperplasiaSurgeryPost-graduate training

Abstract

Objective: Open prostatectomy has been one of the distinctive features ofour specialty and the gold standard treatment of benign prostatic hyper-plasia (BPH) for over 50 years. The operation is almost abandonedin some western countries although it is still relatively commonlyperformed in others. This article reviews the evidence for openprostatectomy and discusses its current role in our daily practise andpost-graduate training programmes in urology.Materials andmethods: We have searched the Medline database for openprostatectomy, reviewed all the reported references, obtained all full textarticles we could retrieve from our and other libraries. We have read anumber of old full text articles dating before 1964 which were quoted inmore recent papers. We have read the relevant chapters of most bookson the management of BPH.Results: Open prostatectomy maintains an outstanding clinical out-

come. The procedure has the lowest failure rate amongst the differentoperations but carries also the highest morbidity rate, the largest patientburden and costs. The decreasing number of cases performed in mosturological centres will make it difficult to maintain open prostatectomyin the core curriculum of postgraduate training programmes in urology.The procedure will certainly continue to have a role in less developedcountries where BPH surgery is mostly performed by general surgeons.Conclusion: Open prostatectomy served us well for over a century but itsrole in the urologists armamentarium is declining. When the currentgeneration will retire the expertise may be lost in some countries of thewestern world.It is imperative that our skill is passed over our colleaguesoperating in less wealthy areas of the world where the procedure can still

save lives and improve patients quality of life.# 2006 European Association of Urology and European Board of Urology.

Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Urology, SantAndrea Hospital, Via di Grottarossa,1035, 00189 Rome, Italy. Tel. +39 06 3377 5760; Fax: +39 06 3377 5428.E-mail address: [email protected] (A. Tubaro).

1871-2592/$ see front matter # 2006 European Association of Urology and European Board of Urology.Published by Elsevier B.V. All rights reserved.

doi:10.1016/j.eeus.2006.07.002
mailto:[email protected]://dx.doi.org/10.1016/j.eeus.2006.07.002http://dx.doi.org/10.1016/j.eeus.2006.07.002mailto:[email protected]


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Fuller and Peter Freyer in 1895 and 1900 [1,2]. At thattime, benign prostatic obstruction was a majorcause of suffer for elderly men and death fromchronic renal failure and BPH complications was notinfrequent. The operation popularised by Freyer wasnot minor surgery, particularly when taking into

consideration the anaesthesia standards existing atthat time and mortality rate was not negligible;nevertheless the introduction of BPH surgery was areal revolution. A second, slow and equally impor-tant change was brought about in 1932 whenMaximilian Stern and Joseph McCarthy put togetherthe Stern-McCarthy instrument, the progenitor ofthe modern resectoscope, which allowed tissueresection using a wire loop under direct vision [3].The new technique slowly progressed and finallyimposed as the gold standard surgical treatment ofBPH. The prostate volume threshold between trans-

urethral surgery and open prostatectomy remainsan open issue, patients with glands of 80 to 100 mlmay be considered for open surgery in somecountries while a two stage procedure with transur-ethral resection of one prostatic lobe at a time maybe performed in other countries [4].

Before medical treatment of BPH became first linetreatment, surgery of BPH in western world, parti-cularly in US, was mainly about resection of smallprostate glands (average weight of resected tissue:21.1 gr) as patients were operated in the early stageof the disease [5]. A large amount of procedures were

performed each year but the number graduallylowered when alpha adrenoceptor antagonists and5-alpha reductase inhibitors were introduced [6].Surgery was gradually applied at an increasing laterstage of the disease. Although the average prostatevolume of surgical series performed in westerncountries may be small, the situation in othercountries may differ significantly. In the far east,for example, the majority of patients may bereferred late in the course of the disease whenacute and chronic retention develop [7].

Results of the MTOPS study suggest that the use of

alpha blockers improves lower urinary tract symp-toms and flow rate but neither modifies prostategrowth, nor reduce the risk of acute retention andsurgery [8]. The high prevalence of medical treat-ment over the last two decades, might finally resultin larger prostate volumes in patients who ulti-mately progress during alpha adrenoceptor antago-nists treatment and require surgery [9]. A recentanalysis of Spanish series suggests an increase inthe prevalence of open prostatectomy and a parallelincrease in the volume of the enucleated adenomas.In the Authors series, the rate of open prostatec-tomy raised from 18.8% in 1992 to 28.6% in 2002 and

the mean adenoma weight of increased from 73 to79 grams. [9]. Whether or not a more widespread useof 5-alpha reductase inhibitors may reverse suchsituation, is unclear. Management of large prostateglands is not without consequences as Mebustand co-workers clearly identified an association

between prostate volume and the risk of complica-tion in patients undergoing TURP [10]. Morbility andcosts associated with transurethral resection oflarge prostates fostered the development of differ-ent alternative and minimally invasive treatments(TUMT, TUNA, thick loops, vaportrode, etc), unfor-tunately they worked best in small to medium sizeprostate and basically failed to provide a betteralternative for large prostate glands. Only HoLEP, theholmium enucleation of the prostate, introduced byFraundorfer and Gilling in 1998 combined the lowinvasiveness of transurethral surgery with a debulk-

ing capacity comparable to open prostatectomy [11].The technique offers outstanding clinical outcomewith short hospital stay but failed to gain wide-spread acceptance as the procedure remains chal-lenging and ablation of the enucleated tissue withthe morcellator, cumbersome [12]. Surgical treat-ment of BPH is now undergoing a new littlerevolution with the introduction of the high powerpotassium-titanyl-phosphate (KTP) laser whichoffers a bloodless endoscopic procedure that canbe performed as a day case [13]. Whether or not theGreenLight laser is going to prevail over holmium

enucleation is not the subject for this review but theforecast for 2006 is that 50% of transurethralprocedures for BPH will shift from TURP to KTPlaser in USA (data on file LaserScope, MountainView, CA, USA).

Having set the stage for surgical treatment of BPH,we will now review the evidence on open prostat-ectomy and we will try to put in the social,economic and medical perspective of the 3rdmillennium. The rate of open procedures variesamong different countries and cultures, because ofdifferent National Health Systems (NHSs), variable

economic pressure and available resources. Thequestion is not about the outcome of open prostat-ectomy but rather about the way it fits into eachnational NHS and postgraduate training pro-grammes in urology. The growing limitation offinancial resources and the inevitable trend for amore efficient use of it pose a great problem in thetraining of our postgraduates students. If openprostatectomy will not remain in the core curricu-lum of urological training, the technique is going todie when our generation will retire. Clinical outcomeis not the only determinant of success and failure ofsurgical techniques, and we have experienced how



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many of the new treatments worked miracle justfor a while. Sometimes we tend to be nostalgic withthose techniques which help identifying our speci-alty such as open prostatectomy but we can notafford to be so as failure to evolve frequently led toextinction.

To prepare this manuscript we performed athorough review of the peer-review literature. ThePubMed database was searched for open prostat-ectomy and prostate surgery as text word, 322papers were selected, 256 were obtained as full textand read as well as relevant book chapters. Originalpapers describing the various surgical techniquesand points of technique were selected. In the lack(paucity) of randomised studies, case series wereselected for data on clinical outcome. Data oncomplication rates were obtained only from manu-script in which data on early and/or postoperative

complications were reported either in a dedicatedparagraph or in tables. Eighty references were finallyused as a source of evidence for this manuscript. Webelieve we provide a balance view on the subject ofopen prostatectomy. We know that the ultimatedecision to continue performing open prostatec-tomy will remain to the individual surgeon althoughthis may not hold true for our successors.

2. Surgical technique

Well before the concept of the zone anatomy wasproposed by McNeal [14], macroscopic evaluation ofthe hyperplastic gland showed a bilobar/trilobaradenoma surrounded by a peripheral gland. Asurgical plane could be developed bluntly and thehyperplastic tissue enucleated from the outerprostate. Anatomic landmarks being the bladderneck corresponding to the uppermost part of theadenoma, although this sometimes protrudes intothe bladder lumen, and the colliculus seminalis, alsoknow as the veru montanum, atthe lower most part ofthe benign tumour. Enucleation of the adenomatous

tissue between these two landmarks, guaranteesintegrity of the ureteric orifices lying above thebladder neck and the striated sphincter positionedcaudally to the colliculus. Prostatectomy is not abloodless procedure as the blood supply originatingfrom the neurovascular bundles enter the prostateat 5 and 7 oclock position, additional arteries supplythe organ from the bladder neck and from 10 and 2oclock position. The blunt interruption of theseblood vessels may results in severe bleeding whichwas once controlled by packing the new prostatecavity with gauzes and more recently by selectiveuse of the electrocautery or by inflating a catheter

balloon. An interesting discussion originated, in the1940s about the surgical approach to the hyperplas-tic tissues. The transvesical incision proposed byFreyer and supported by Hritschack and othercolleagues was fiercely opposed by Millin whoproposed to avoid entering the bladder space to

access the prostate by approaching the adenomadirectly through the peripheral prostate [1,4,15,16]. Anumber of surgical techniques consisting in variousmodifications of these two approaches have beenproposed over the years trying to minimise intra andpost-operative bleeding which sometime lead toblood transfusion [1727]. Recently laparoscopicadenomectomy was shown to be feasible withsatisfactory clinical outcome; we do not know yetwhether this is a technical exercise or a viablesurgical option [2830].

2.1. Transvesical prostatectomy

The first complete suprapubic removal of a prostaticadenoma by blind digital enucleation was per-formed by Eugene Fuller in 1884, the techniquecarried an high mortality rate (18%) and wasopposed by most surgeons [2]. The procedure wasthen adopted by Peter Freyer, an Irishman born nearClifden who studied medicine at Queens College inGalway. After taking his degree in 1874, Freyer

joined the Indian Medical Service. In 1896 hereturned to England and became part of the surgical

staff at St. Peters Hospital in London where in 1900he performed his first prostatectomy [1]. Despite a5% mortality rate, the operation was a great success.The procedure was rapidly popularised and a secondseries of one thousand patients was published in1912; the operation remained the gold standard forfifty years [31].

The surgical procedure of transvesical prostat-ectomy as it is now performed in most urologicalcentres can be referred to the original one describedby Hryntschack and published in 1951 [15]. Thepatient is placed supine, the legs slightly opened and

lowered to provide better exposure to the retropubicspace; some degree of Trendelenburg is used tobalance patient position. A catheter can be passed toempty the bladder and calibrate urethra. A shortmidline incision is made between the umbilicus andthe pubis, the rectus and pyramidalis muscles areseparated and the prevescical space is exposed.Properitoneal vasectomy, not advised routinely,may be done to prevent epididymitis. The bladderdome is freed from the peritoneum and can bebrought up to the level of the skin between two Allisforceps. A 34 cm longitudinal cystotomy is madebetween the Allis forceps, suction is used to empty

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bladder from urine. Two stay sutures are used tosuspend the bladder wall on both sides of thecystotomy. The bladder cavity is explored andureteric orifices identified. A bladder retractor(Deaver retractor or Bracci retractor) is positionedto maintain the bladder open so that the trigone

with ureteric orifices were seen throughout surgery.Electrocautery is currentlyused to incise the mucosaof the bladder neck around the urethral meatus andthen through the trigone is a tennis raquet shape.The proper plane between the adenoma and theprostate capsule is developed and the adenoma isgently dissected from the capsule with scissors. Thedissection is completed using the index finger untilonly the distal urethra attachment remains, this isfinally cut using a pair of curved scissors and theadenoma freed. Alternatively, the surgical plane canbe bluntly identified by inserting a finger into

prostatic urethra and fracturing the thin anterioradenoma under the symphysis pubis. Once theplane is identified anteriorly, it is then extendedlaterally and finally posteriorly; distal urethra canalso be divided bluntly [32]. After the adenoma isenucleated, the prostatic fossa is inspected forresidual tissue that should be removed. Interrupted,absorbable sutures are used to reconstruct thetrigone and approximate the bladder neck to theperipheral prostate to ensure haemostasis; alterna-tively, two semi-continuous sutures can be used. In1965, Malament proposed the use of an heavy (0,1)

nylon or polypropilene suture placed as purse stringaround the bladder neck, brought through the skinand tied firmly [19]. This technique closes thebladder neck and tamponades the prostatic fossa.The suture should be removed by cutting it at theskin on post-operative day 2 or 3.

Different techniques for draining the bladderhave been described. A 2022 Fr three way urethralcatheter can be placed transurethrally so that the tipof the catheter and the balloon remained in thebladder. In addition, a No. 20 to 24 Fr Malecotsuprapubic tube is placed into the dome of the

bladder and secured with a 4-0 chromic purse-stringstitch. The suprapubic tube exits the bladderthrough a separate stab incision at the lateral aspectof the dome, avoiding the peritoneal cavity. Alter-natively a 2022 Fr 3 way catheter is positioned withthe balloon inside the prostatic fossa, which isinflated from 30 to 40 ml according to prostate size.

Hryntschak also proposed to use deep transversestitches at the bladder neck so placed to incorporatethe urethral catheter when tied [15]. These stitcheswere used to completely tamponade the prostaticfossa by occluding the bladder neck completely.When the catheter is removed tension on the

stitches is relieved allowing the bladder neck toassume its normal contour.

After the removal of the retractor and theaspiration of any residual clots, the bladder is closedby a 2/0 plain purse string stitch inserted deeply intothe detrusor muscle so as to produce adequate

inversion of the edges of the incision and to ensure awatertight closure. A suction drain is placed in theextravescical space and the abdominal wound isclosed. Bladder irrigation with saline is required for23 days postoperatively to prevent clot formationand bladder tamponade. The catheter is removedafter 45 days once urine has cleared.

The transvesical approach allows an ideal view ofthe bladder neck and ureteric orifices, it may beadvantageous in case of concomitant bladder con-ditions such as bladder diverticula and large stones,in the presence of large middle lobes protruding into

the bladder, when severe obesity makes access tothe retropubic space difficult.

2.2. Retropubic prostatectomy

The technique of retropubic prostatectomy wasdevised by Terrence Millin, an Irishman. Followingan outstanding undergraduate curriculum in Ire-land, he then moved to England where he becameMember of the Royal College of Surgeons. An avidproponent of the transurethral diathermy loopdeveloped by McCarthy in New York, on December

1, 1946 he published a landmark paper in TheLancet, entitled Retropubic Prostatectomy: A NewExtravesical Technique [16]. The new procedurewas immediately considered an outstandingadvancement in surgery and Millins operationcontributed greatly to reducing mortality of openprostatectomy. Millins prostatectomy was rapidlyexported in USA where it was first presented at theAUA meeting in Buffalo in 1947 and two years later itwas first performed live in USA by Millin.

The patient is placed supine on the operatingtable with a slight Trendelenburg position in order to

encourage venous drainage from prostatic bed,thereby reducing haemorrhage. A 1015 transverselower abdominal incision, 3 cm above the symphy-sis pubis is performed. The rectus and pyramidalismuscles are widely separated and the retropubic fatis gently separated to expose the bladder and theprostate. The three blades of a Millin retractor areintroduced to better expose the anterior surface ofthe prostate and the bladder wall. Swabs can beplaced in the paraprostatic gutters to dry theoperating field from blood and make access to theperipheral prostate easier. Two stay sutures arethen placed deep through the prostatic capsule, just



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below the bladder neck, delimitating an areathrough which a transverse incision is made acrossthe anterior prostatic capsule exposing the ade-noma. To improve haemostasis, ligation of thedorsal venous complex and of the prostatic arteries,as they enter the prostatovesical junction, may be

required [18]. After the adenoma is exposed, a pair ofscissors is used to create a surgical plane betweenthe adenoma and the capsule, blind dissection withthe pulp of the index finger may also be used tocomplete the enucleation. The prostate apex isidentified, urethra is carefully divided undervisual control; proximal urethra is then alsodivided at the bladder neck. After the adenoma iscompletely freed from any attachment, it isremoved and the prostatic capsule is packed withgauze swabs to control bleeding by direct pressure.All bleedings vessels are either coagulated under

visual control or sutured, two absorbable suturesare normally placed at 5 and 7-oclock positionthrough the bladder neck and prostatic capsule toensure haemostasis. After the ureteric orifices areidentified, trigonisation is performed by resecting awedge of the posterior vesical neck and thenapproximating the edges. A three-ways catheter isfinally inserted into the bladder and the ballooninflated. The prostatic capsule can now be closedachieving a watertight closure. The two initial staysutures are tighten together. Drainage of the Retziusspace is assured before closing the abdomen.

Bladder irrigation is maintained until urine clearand catheter is usually removed 3 days later.Individual variations of the described techniqueare obviously possible.

The retropubic approach offers an ideal view ofthe prostate gland and prostate cavity after enuclea-tion of the adenoma, allows direct visualization ofthe adenoma and prostatic urethra, and causelimited trauma to the urinary bladder.

2.3. Laparoscopic extraperitoneal Millin prostatectomy

The possibility to perform a Millins prostatectomyin laparoscopy was proven by Porpiglia and co-workers in 2005, the operation is challenging a itsrole in our armamentarium is yet to be defined. Itmay remain a technical exercise or it may be anadditional step in the trend toward convertingmost urological procedures into laparoscopicsurgery [29].

The patient lies on the table in lithotomicposition. An incision is performed right below theumbilicus and an extraperitoneal space is developedlike in the radical prostatectomy. A Hasson trocar isthan inserted under the umbilicus and other 4

trocars (3 of 5 mm and 1 of 12 mm) are inserted in afan shape. The anterior wall of, the prostate and thepelvic fascia are exposed; the superficial dorsal veincomplex is coagulated. A transversal incision isperformed on the anterior wall of the prostatecapsule and the adenoma is bluntly dissected with

the tip of scissors or Maryland dissection forcepsfrom the anterior prostate capsule. The dissection isthen completed and finally the adenoma is freedfrom the bladder neck. The sacral lip of the bladderneck is sectioned. When the adenoma is very large,each lobe can be freed and removed separately.Haemostasis is achieved using bipolar or monopolarforceps to secure small vessels while transcapsulararteries are sutured. Trigonisation is performedclosing the midline incision through the sacral lipof the bladder neck and posterior surgical capsulewith 3 stitches. A catheter is introduced, and the

balloon inflated into the bladder. The prostaticcapsule is closed with running or interrupted suture.Paravescical drainage is left in the pelvic area andthe adenoma removed with an Endo-catch. Thecatheter is maintained for 3 to 5 days.

A laparoscopic transvescical approach hasbeen proposed by Sotelo and co-workers andpermitted the concomitant management of anycoexistent intravesical pathology, such as bladdercalculi [30].

3. Clinical outcome of open prostatectomy

Open surgical removal of prostatic adenomaremained the gold standard treatment of BPH formany decades. The conversion from open totransurethral surgery occurred gradually; openprostatectomy is still relatively common in somecountries while has been almost abandoned inothers. Results of many old papers on openprostatectomy should be interpreted with cautionas many standards involving anaesthesiology, trans-fusion medicine, surgery and outcome research,

changed in the last decades. Randomised studies ofopen prostatectomy versus TURP are scanty and nonew trials are foreseen for ethical reason. Never-theless, several studies indicate that open prostat-ectomy provides outstanding relief of bladder outletobstruction and lower urinary tract symptoms[3338]. In a landmark study, Meyhoff and co-workers demonstrated in a comparative randomisedstudy that open prostatectomy is well accepted bypatients with only 9% of patients were dissatisfiedby treatment compared to 15% of the TURP group(Table 1) [3941]. Tubaro and co-workers evaluatedthe 1 year clinical and urodynamic outcome of



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patients treated with sovrapubic prostatectomy [36].Open prostatectomy induces a significant reductionof symptom score and improvement of quality of lifeindex after 1 year of treatment. Of the patients, 84%

described themselves as delighted with the resultsobtained and none had a quality of life scoregreater than 3 with a mean value of 0.2. In theirseries 60% of patients become asymptomatic aftertreatment and 96.9% had a flow rate greater than15 ml/sec. A significant improvement of voidingvolume, post void residual volume and bladder wallthickness was also observed (Table 2). Varkarakisand co-workers have recently confirmed these data[37]. They retrospectively evaluated 151 patients

who underwent open transvesical prostatectomy forBPH (prostate larger than 70 grams) during a five-year period. The improvement at 8 to 12 months, asdocumented by an increase in Qmax, decrease in

PVR urine volume, and decrease in lower urinarytract symptoms and quality of life improvement,was statistically significant after the procedure anddid not change significantly even after longer follow-up (41.8 months).

One of the main disadvantages of open prostat-ectomy is the high rate of morbidity which isgenerally higher than reported for transurethralsurgery Table 1. Data reported in Table 3 show alarge variability which may reflect improvement in


Table 1 Outcome parameters of a randomized trial of transurethral versus transvesical prostatectomy [3941]

N. LUTS Qmax Morbidity Patients dissatisfaction Failure Rate

TURP 43 90% +88% 53% 16% 4.6%

Open 32 87.5% +175.5% 68% 9% 0

Table 2 The effect of open prostatectomy on bladder wall thickness and other outcome parameters [38]

IPSS QL Voiding Volume (ml) Qmax (ml/sec) PVR (ml) Bladder Wall Thickness (mm)

Baseline 19.4 4.4 4.9 0.9 290 9 9.1 5.3 128 113 5.2 0.7

1 year 1.5 2.7 0.2 0.4 427 82 29.1 8.9 8 18 2.9 0.9

Difference 18.5 5.1 4.7 1.1 211 107 +19.8 124 115 2.3 1

p 0.0001 0.0001 0.001 0.0001 0.0001 0.0001

Table 3 Overall complication rate in patients undergoing open prostatectomy

Author Year N. pts Complication rate (%)

Any method Retropubic Transvesical

Blue and Campbell [63] 1958 1,000 3.5 3.5

Stearns [64] 1961 500 11.4 11.4

Lenko [65] 1965 233 17.2 17.2

Beck [66] 1970 1,346 40.8 40.8

Nicoll [67] 1974 525 18.3 18.3

Bollmann and Zigg [68] 1976 262 57.3 57.3

Lund and Dingsor [69] 1976 67 46.5 46.5

Lenko [70] 1977 227 21.8

Davillas [71] 1978 1,000 12.5 12.5

Nicolescu [72] 1983 360 28.5 28.5

Lesiewicz [73] 1985 250 43.6 43.6

Jasinki [20] 1985 385 21.5 21.5Murshidi [74] 1989 60 28.6 28.6

Liu [75] 1991 63 14.3 14.3

Lewis [76] 1992 73 36

Meier [49] 1995 240 19.6 19.6

Mearini [77] 1998 1,051 13.6 13.6

Condie [78] 1999 200 14 14

Tubaro [38] 2001 32 31.2 31.25

Serretta [42] 2002 1,804 36.9 36.9

Adam [45] 2004 201 23

Varakarakis [37] 2004 232 17 17

Total 9879

Median 21.8 14.8 26.2

Mean 25.7 24.2 26.2


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anaesthesiology techniques and patients care overthe years but also reflects variability in howmorbidity was measured. Nowadays, better patientsselection, better anaesthesia techniques, change intransfusion policies, and improvement of surgicalstandards may be responsible for the observeddecrease in complication rates. The overall rate ofmorbidity and mortality associated with openprostatectomy is considered to be lower thanreported in the early seventies. Intraoperative andperi-operative haemorrhage still is associated with

open prostatectomy and transfusion rate is still amajor concern. In the series evaluated by Tubaroand co-workers an autologous blood unit wastransfuse in the 68% of patients evaluated. Otherreports showed a 11.2% of severe bleeding whonecessitate of blood transfusion in 73% of patients[42]. Considering an overall 23% transfusion rateafter this procedure (AUA guidelines), it may still beprudent to have 1 to 2 units of autologous bloodavailable at the time of open prostatectomy. Woundcomplication or urinary fistula can also be ofconcern in the immediate postoperative period in

the 0.44% of patients [42,37]; this most likely resultsfrom an incomplete closure of the prostatic capsulain retropubic prostatectomy or the cystotomy insuprapubic prostatectomy [42,37]. This complicationwill usually resolve spontaneously and is managedwith continued catheter drainage.

Hospital stay is usually longer with open proce-dures with a mean hospitalisation ranging from 6 to10 days in the modern series and it is due to amedian of 5 day of catheterisation time [36,37,42].Urinary tract infection is a rare complication (68%)thanks to the modern antibiotic prophylactics and is

comparable to that observed after TURP [4]. Urinaryincontinence is a rare event after open prostatec-tomy and should be minimised by a preciseenucleation of the prostatic adenoma with a mini-mal risk of injury to the external sphincter. Lateurologic complications are not common and includebladder neck contractures (BNC) and urethralstrictures with an incidence comparable to TURP(220%). Erectile dysfunction occurs in 3% to 5% ofpatients undergoing an open prostatectomy; it ismore common in older men than in younger men.Retrograde ejaculation in another common compli-cations after open procedures and is observed in 80%

to 90% of patients. Deep vein thrombosis, pulmon-ary embolus, myocardial infarction, and a cerebralvascular event are observed in less than 1% of openprostatectomy with an overall mortality rate whichapproach zero [4,5]. Failure rate is also extremelylow and is estimated between 0 to 8% [4]. Outcomesof open prostatectomy versus TURP as evaluated bythe American Urological Association guidelines aresummarised in Table 4.

4. Cost analysis

Analysis of direct and indirect costs suggests thatopen prostatectomy is the most expensive surgicalprocedureforBPH.Anoldanalysisfroma1994AHCPRdocument, based on Medicare data for the years198889, shows an average 12,788 US$ for openprostatectomy (costs for primary treatment and 1year follow-up) versus an average of 8,606 US$ forTURP, the costs for second year of treatment afterprimary treatment were 69 and 360 US$, respectively[5]. The higher costs of treatment are obviously

related to the longer hospital stay while the lowerexpenses after primary treatment are instead relatedto the lowest re-treatmentrate of open surgery.Is theadditional cost worth while? Notwithstanding thepaucity of randomised trials, the answer is probablynot as the outcome of holmium enucleation alreadyproved comparable to open surgery at a much lowercost [43]. From a surgeon perspective, money iscertainly nota premiumcategory fordecision makingbut costs certainly include intangible ones such astreatment burden and in this respect any treatmentallowing early patient discharge, reduced time away

from work and social activities, and particularly thepossibility to mange patients as a day case, may wellplay a fundamental role in decision making, parti-cularly in Europe.

5. Postgraduate training

Open prostatectomy, either performed through aretropubic or a transvescical approach, is not aneasy procedure and a long learning curve isexpected. The decreasing number of proceduresperformed in western countries may jeopardise


Table 4 Outcomes of surgical therapies: estimates of occurrence of adverse events (adapted from AUA guidelines)

BNC Incontinence UTI Transfusion rate Cardiovascular/Thromboembolic Secondary procedure

TURP 7% (58) 3% (25) 6% (59) 8% (511) 2% (08) 5% (46)

Open 8% (217) 6% (120) 8% (317) 27% (2332) 1% (08) 1% (08)

Data are expressed as percentage values and range [4].


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adequate postgraduate training for our future resi-dents. In thelast years in USA and Europe we assistedto a significant reduction in the number of surgicalprocedures performed for BPH due to the success ofmedical therapy and various alternative treatments.The decreasing number of endoscopic procedures

may even make difficult to guarantee our residentsenough cases to secure proper training in transure-thral resection of the prostate. When the option isavailable, surgeons often prefer a surgical techniquethey are most familiar with, and many urologistmight prefer TURP or minimally invasive treatmenteven in large glands because they will not becomfortable with open prostatectomy. Academicmedicine should make sure residents in urologyreceive adequate training for proper management oflarge prostate glands and one of the new endoscopictechniques (holmium or KTP laser) will probably be

the new standard. Laparoscopic prostatectomy is adifficult operation and the chance of being adoptedwidely are nil. A recent analysis of the PharMetricsPatient-CentricDatabase (from July1999to June2002)showed that open prostatectomy accounted for 0.1%of BPH surgery in USA [44]. The case, at least in thatcountry, is closed, after a good hundred years post-graduate training in open prostatectomy is over. Thefate of the operation in Europe is yet to be decided,although some plea for maintaining open prostat-ectomy in our resident curriculum [45] this willdepend upon the availability of enough cases for our

residents.

6. Current indications

Open prostatectomy is one of the oldest surgicalprocedures in urology. It has been used for morethan 50 years as the standard treatment until TURPbecame the new gold one. Open prostatectomy iscertainly a valuable option in less developed areas ofthe world where there is no access to transurethralsurgery and BPH is frequently managed by general

surgeons [4648]. Improved surgical techniquesachieving optimal control of bleeding from thebladder neck can achieve morbidity rates whichcompare favourably with TURP series [49]. In Europe,open surgery is still performedin the two digit range:12% in Sweden, 14% in France, 32% in Italy and 40%in Israel showing how this is still considered avaluable option, while it remains in the one digitrange in UK, Australia and USA [37,50,44]. Openprostatectomy has been reserved for the manage-ment of large prostate glands. Steg reported anaverage weight of enucleated tissue of 61 grams inopen prostatectomy series versus 25 grams in TURP

series [51]. The Vth International Consultation onBPH considered that open prostatectomy remainsindicated in patients with prostate larger than80100 grams and in patients with coexisting dis-orders which may benefit from their repair at thesame time of prostatectomy: such as hernia, large

bladder stone and diverticula [5258].Although open prostatectomy was first developedas a transvesical procedure which was then perfec-tioned by Hritschack, following to the introduction ofthe retropubic approach by Terence Millin a largenumber of surgeon embraced the new technique.Surgeons preference mostly depends on training,when one of the two techniques is mastered, it isdifficult to adopt the other approach. The discussionontheprosandconsof eithertechniquehas now beenongoing for decades, retropubic prostatectomy isconsidered to have a lower rate of complications

compared to the transvesical approach (23.8 versus42.2%, respectively) [5]. Data summarised in Table 3confirm the large variability of complication ratereportedinthepeer-reviewliterature(from3.5to57.3,mean 21.8, median 25.7) depending on which com-plications were considered and how they weremeasured. Our analysis confirms the higher rate ofadverseeventsinsovrapubicprostatectomy(Table3).Although the use of a transvesical approach might bemore reasonable when a bladder comorbidity exists(e.g., large bladder stone or diverticula) and theretropubic approach may be preferred in all other

circumstances,wedoubtthatmanysurgeonswillfeelconfident to switch operation easily and training willcontinueto be based upon the experience (retropubicor transvesical) of the individual centre/surgeon.

Someof the newtransurethral techniques,suchasholmium enucleation and photoselective vaporisa-tion of the prostate with KTP laser, already provedefficaciousin dealing with large prostates [59,60].Theimplementation of these two technique will probablymake open prostatectomy redundant in specialisedcentres although they have not become yet the goldstandard for the treatment of large prostate glands.

Holmium enucleation suffers a long learning curveand significant capital investment which may limitsits availability outside large institutions [61]. Photo-selective vaporisation is still a very young techniquewithaveryshortlogbook.Although5-yearsdatahavebeen recently published, these data need to beconfirmed in extramural studies [62].

7. Conclusion

Surgeons easily become sentimental with proce-dures which served well for so many decades. It is



9/11

impossible to calculate how many patients benefitfrom open prostatectomy since the procedure wasintroduced more than 100 years ago but theprocedure was long considered one of the distinctivefeatures of our specialty. In a world dominated byfinancial issues, all national health systems have

been forced to reconsider allocation of resources,the inevitable trend toward reducing the number ofinpatient beds, increasing day case surgery andlowering treatment costs already favoured alter-native surgical techniques such as transurethralresection and holmium enucleation. Planning ofpostgraduate training programmes in urology mustbalance the time and costs of training a resident for acertain surgical procedure with the future needs thenew generation of urologists will have to fulfil. In atime when many countries consider now to plandifferential training schemes for consultant urolo-

gists and consultant urological surgeons, teachingopen prostatectomy is almost certainly redundant.This is not cause for sadness, many urologicaloperations passed and new interventions wereintroduced. Failure to adapt is a major risk particu-larly in a lively area such as medicine and surgery.Open prostatectomy remains a nice operation in thewestern world and it is bound to disappear; it willremain a useful technique in many developingcountries where it may still serve patients well.We need to ensure the surgical expertise developedin our institutions over the decades will not be lost

but rather transferred to our colleague surgeonsworking in less wealthy areas of the world. We willalways remain in great debt with Eugene Fuller,Peter Fryer, Terrence Millin and all those surgeonswho pioneered benign prostate surgery making areal contribution to medicine and to our specialty.

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CME questions

Please visit www.eu-acme.org/europeanurology

to answer these CME questions on-line. The CMEcredits will then be attributed automatically.

1. What is the mean complications rate of openprostatectomy reported in the peer review litera-ture?A. >15B. >20C. >25D. >30%

2. The 5-year projected failure rate of open prosta-

tectomy isA. 2%B. 4%C. 6%D. 8%

3. In 1995, the percentage of open prostatectomyprocedure in USA in all surgical procedures forBPH was

A. 20%D. >30%

5. Terence Millin wasA. IrishB. English

C. AmericanD. French

6. The incidence of erectile dysfunction followingopen prostatectomy isA. 03%B. 35%C. 510%D. 101%
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