When Should Open Prostatectomy Be Performed?

Transurethral resection of the prostate (TUR) is the method of choice in the management of benign prostatic hyperplasia (BPH). This is true for adenomas with an estimated weight of up to 60g. However, is TUR also the best procedure for adenomas larger than 60g?

Many urologists perform transvesical or retropubic open prostatectomy for prostatic adenomas weighing more than 50-60g. If the right moment is chosen for open prostatectomy in such a case, this operation is superior to TUR. The cumulative percentage of patients undergoing a second prostatectomy is substantially higher after transurethral than after open prostatectomy (12% versus 4.5%).

Investigations on this subject were conducted by Roos of al. in 1989, and the data are based on more than 50000 patients in Denmark, the United Kingdom, and Canada. A distinct difference was seen in long-term mortality, with an elevated rate for TUR patients compared to Nose receiving open prostatectomy. The follow-up periods were 3 months, 1, 5, and 8 years after the operation.

Only at the first postoperative examination after 90 days was the mortality rate for TUR patients in Denmark between aged 75-84 years slightly lower than that for open prostatectomy. In all the other age groups in all three countries the open operation was more favorable regarding long-term mortality and probability for a second prostatectomy after 1, 3, and 8 years.

Which patients should be considered for open prostatectomy? First, patients aged up to 65 years with an prostatic adenoma weighing more than 50-60g, would benefit by the lower risk of second prostatectomy. Further advantages are due to the large amount of tissue removed in short operating time, more radical tissue removal, and low rate of postoperative contracture of the bladder neck, ranging from 0.9% to 1.1%.

Disadvantages of open prostatectomy include: higher perioperative mortality, ranging from 2% to 3.1% compared to TUR (0.016-2%), higher risk of postoperative bleeding, the possibility of wound infection, and the risk of urinary infection by long-term indwelling urethral catheter.

We would like to call attention to two problems, those of urinary infection and postoperative blood loss. The incidence of postoperative urinary infection can be reduced by modifications in the open prostatectomy. From 1967 to 1976, 350 patients with prostatic adenomas were managed by the catheterless method of suprapubic transvesical prostatectomy. The aim of this technique was the avoidance of the bacterial urinary infection due to the indwelling catheter and of the bladder neck stricture.

Reference
Benign Prostatic Hyperplasia - Conservative and Operative Management - G. Hubmer, T. Colombo, and M. Rauchenwaldt