SIU 2018: BPH Panel: Enucleation Techniques: Is There a Role for Open?

Seoul, South-Korea (UroToday.com)  Oussama Elhage, MD gave a talk on the utilization of the simple open prostatectomy for the treatment of prostatic adenoma in benign prostatic hyperplasia (BPH).  Current data show that prostates are getting larger. According to the European Association of Urology (EAU) guidelines, simple open prostatectomy should be considered for patients with large prostates (>80 cc). The American Urologic Association (AUA) guidelines have a very similar recommendation, recommending simple open prostatectomy for large prostates.

The surgery entails getting into the plane of the prostate adenoma and using the surgeon's finger to separate the prostatic adenoma from the rest of the prostate, and then to completely remove it en-block.

In 2015 a study comparing simple open prostatectomy to bipolar vaporization, resection, and enucleation in large prostates over the size of 80 cc was published. Overall 320 patients were included, randomized to 4 arms: Transurethral resection (TUR) in saline, Transurethral vaporization in saline, bipolar plasma enucleation of the prostate, and simple open prostatectomy. The results demonstrated that the shortest operative time was with open prostatectomy and bipolar enucleation, hemoglobin drop was the highest in open prostatectomy, the largest amount of resected issue was with open prostatectomy, and the longest time with a catheter was also with open prostatectomy. 1

Another randomized smaller study compared open trans-vesical prostatectomy to TURP for prostates greater than 80 cc. Overall 69 patients were enrolled, with a mean prostate volume of 131 cc-138 cc.2 The results of this trial demonstrated that simple open prostatectomy had a higher blood transfusion rate, longer catheter time and longer hospital stay. However, the maximal urinary flow was much higher with open prostatectomy (+175.5% vs. +88%), patients dissatisfaction was lower with open prostatectomy (9% vs. 16%), and failure rate was much better as well (0% vs. 4.6%).

A systematic review analyzed and compared open prostatectomy to Holmium laser enucleation (HOLEP).3 This was a systematic review of 3 randomized trials, including 263 patients with prostate volumes ranging between 115-125 cc. The operative time was shorter with open prostatectomy (90 min vs. 135 min), the catheter time was longer with open prostatectomy (9 vs. two days), but the reoperation rate was similar (6% vs. 5%). When prospectively analyzing the learning curve of HOLEP, it seems this technique has a very steep learning curve, exceeding 20 cases. The operating time and difficulty of the procedure seem the most important problems for the beginner. 4

Dr. Elhage showed the contemporary status of open prostatectomy, using data from a large population-based database, including more than 35000 patients between 2002-2012. A total of 6% had BPH, with a mean age of 72, and a mean hospital stay of 4 days. The results demonstrated that the mortality rate was 0.4%, with 17% of the patients requiring cystolithotomy as well, due to a large bladder stone. A total of 5% of the patients also had a bladder diverticulum.

A major advantage of the open prostatectomy compared to all other newer minimally invasive approaches, incorporating new technology, is the low cost of the open procedure. For example, in Iran, open prostatectomy costs only 270 USD.

Dr. Elhage summarized his talk, stating that the disadvantages of the open prostatectomy include its high blood transfusion rate, higher risk of complication, longer hospital stay, longer catheter time, and unsatisfactory Cosmesis. However, the major advantages which need to be remembered are The excellent improvement of symptoms, great patient satisfaction, low reoperation rate, significantly low cost, ability to concomitantly remove bladder stones, one of the only choices if a urethral stricture exists, and if your center does not have a laser.

 
Presented by: Oussama Elhage, MD London, United Kingdom 

References:
1. Geavlete B, et al. J. Endourol 2015
2. Ou R et al. Urology 2010
3. Jones P et al. Arab J. of Urology 2016
4. Robert G et al. BJU Int. 2016
 
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea 
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