Rashid Ahmad ( Department of Surgery, Ayub Medical College, Abbottabad. )
Gul Mohammad ( Department of Surgery, Ayub Medical College, Abbottabad. )
The result of 200 transvesical prostatectomies performed over a period of 3 years at the District Headquarter Hospital in Abbottabad are reviewed. The indications of operation were prostatism (28%), acute retention (64%) and chronic retention (8%). The mean stay in the Hospital was 14 days and mortality 2% (JPMA 37:192 , 1987).
There was a time when open prostatectomy was considered a dangerous operation at District Headquarter Hospital level. This paper presents a retrospective study of 200 consecutive transvesical prostatectomies at an upgraded District Headquarter Hospital in Abbottabad between 1983 and 1985. These operations constituted 3.5% of all operations performed at this Hospital during the 3 year period.
PATIENTS MATERIAL AND METHODS
The indications for surgery were:
(i) Prostatism hesitancy, urgency, reduced stream, day time frequency and nocturia in 28% cases;
(ii) acute urinary retention in 64% cases;
(iii) chronic retention in 8%. Profuse haematuria was not a presenting feature.
(b) Evaluation of Patient:
Preliminary assessment included careful histoiy, general, carclio-pulmonary examination as well as rectal examination, urine analysis, haemoglobin and complete blood count, blood urea, blood sugar and chest and abdominal X-rays (KUB). Serum acid phosphatase, urine culture and intravenous pyeiogram were done when necessary. Four patients were diabetic. In 56 patients (28%) blood urea was greater than 40 mg/dl and, in six, greater than 100 mg/dl. The haemoglobin ranged between 9.8 and 14.0 g/dl. Age ranged between 50 and 80 years, and eighty percent of these patients were in their sixties.
(c) Surgical Procedure:
Either a transvesicalprostatectomy (n1 74) or wedge excision of the bladder neck (n=26) was performed under general anaesthesia. A No. 24 Foley catheter was inserted per urethra and the bladder was closed around an intravesical tube. Continuous irrigation with normal saline was done routinely. On average 30 litres were needed. On the 3rd day suprapubic tube was removed. Four patients who bled unduly at operations had their pros. tatic cavities packed with gauze. Postoperatively co-trimaxazole injection B.D. (100 patients) or ampiclox 500 mg 8 hourly (100 patients) were used for 7 days. Eighty percent patients were transfused two pints of blood, 5% needed more than 2 pints of blood and 11% needed one pint of blood. In 4% blood was not needed. Sixty five per cent patients were discharged on 8th post-operative day. The remaining 35% were discharged between 14th day to 21st day.
(d) Associated conditions:
Twenty-two (11%) patients had associated intravesical stones, 14 patients (7%) had carcinoma of the prostate confirmed histologically; two (1%) had transitional cell bladder carcinoma and were subjected to radiotherapy.
(e) Complications: (Table-I)
Fifty four patients (27%) developed suprapubic leakage due to which their hospitalisation was prolonged. These were treated conservatively by an indwelling urethral catheter. Thirty eight patients (19%) developed wound infection due to E.Coli (12%) and proteus (7%). Severe post-operative haemorrhage was seen hi 5 (2.5%) patients who had to be re-explored and their prostatic cavities packed with gauze. Mild secondary haemorrhage occurred on 5th to 7th days in some cases which was treated with bladder wash and change of antibiotic. Acute epididymoorchitis was present in only 6 (3%) patients who settled with antibiotics. Occasionally patients developed this complication more than a month after operation. Postoperative urinary incontinence was also seen which invariably disappeared within a few days. No patient was permanently incontinent. Stricture of the urethra developed in 7% of the patients. Osteitis pubis developed in 2 (1%) patients within 1-12 weeks of the operation, necessitating removal of sequstrum in one patient.
Four patients died within 30 days of operation from cardio-respiratory disease.
The advantage of transvesical prostatectomy is that secondary or incidental changes, e.g., bladder stones, diverticulae and cancers may be dealt with synchronously. Cystoscopy which is routine in retropubic prostatectomy is usually not required1.
Transurethral prostatectomy is not yet developed in our hospital; even in special centres the open operation is often preferred for exceptio. nally large gland and when there are associated large bladder stones or diverticulae. Transvesical prostatectomy in our experience is safe and easy. The safety of the operation is the result of a better understanding of the disease, improved laboratory facffities, safer anaesthesia, more efficient postoperative care, antibiotics and blood transfusion. The low mortality in the present series compares favourably with other published series2-4. The morbidity was high and may be attributed to prolonged and improper catheterisation before operation and lack of control of infection.
1. Whitle, M.K. Prostatectomy. Ann. R. Coil. Surg. EngL, 1973; 52:304.
2. Morris, G.E., Tatle, JJ.and Leach, R.D. The changing trend in prostatectomy in a District General Hospital. Ann. R. Coil. Surg. EngL, 1985; 67:361.
3. Rains, A. J.H. and Ritchi, H.D. Bailey and Love short practice of Surgery. 18th ed. London, Lewis, 1981,p. 1273.
4. William, C.R. The value of frusemide in 110 consecutive prostectomies. Br. J. Surg, 1972; 59:190.