Surgical ablation of the prostate in the elderly: A comparison of efficacy and outcomes of open and endoscopic methods

AT Lawal; M Ahmed; AO Ayodeji; S Abdullahi; A Mudi; N Oyelowo; MA Tolani; HB Kolapo; L Fidelis; L Khalid; A Bello; HY Maitama

doi:10.4103/ais.ais_40_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 10 | Issue : 3 | Page : 80-85

Surgical ablation of the prostate in the elderly: A comparison of efficacy and outcomes of open and endoscopic methods

AT Lawal¹, M Ahmed¹, AO Ayodeji¹, S Abdullahi¹, A Mudi¹, N Oyelowo¹, MA Tolani¹, HB Kolapo¹, L Fidelis¹, L Khalid², A Bello¹, HY Maitama¹
¹ Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
² Division of General Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Submission	17-Sep-2020
Date of Acceptance	21-Jan-2021
Date of Web Publication	07-Aug-2021

Correspondence Address:
Dr. A T Lawal
Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ais.ais_40_20

Abstract

Background: Prostatic obstruction is a common problem of elderly men. This will often times require surgical removal of the prostate. Geriatric surgeries are froth with risks and complications, partly due to depleted functional reserves and comorbities. This study is designed to compare the efficacy and outcomes of three methods of prostatic ablation amongst elderly men.
Patients and Methods: This study was retrospective. The study population consisted of men who had surgery for relief of prostatic obstruction. Three surgeries were considered viz: Open prostatectomy/channelization, TURP, and transurethral diode laser vaporization of the prostate (DiLVP). Inclusion criteria were men aged ≥65 years, who had any of the above procedures. Exclusion criteria were synchronous urethral stricture, and prior history of prostatic, bladder or urethral surgery. Patients' demographic, pre-operative, intra-operative and post-operative details were extracted and filled into a proforma. The primary and secondary outcome measures were documented. Data analysis was done using SPSS version 20. Statistical significance was set at a P value of <0.05.
Results: Records of 70 patients were reviewed. Thirty-seven of the patients (52.9%) had open prostatectomy/channelization, 21 (30%) had TURP/channelization, while the remaining 12 (17.1%) had DiLVP. The mean ages were 69.5, 73, and 67 years for groups 1, 2, and 3, respectively. The mean duration of procedure in minutes was 87.5, 75, and 70.5 for groups 1, 2, and 3, respectively (p = 0.12). The groups did not differ in terms of need for blood transfusion (p = 0.81). The groups differed significantly in terms of time to catheter removal and hospital stay. The differences in rates of post-operative complications were statistically significant (p = 0.00). The procedures had comparable long-term rates for satisfactory voiding.
Conclusion: Elderly men have significant peri-operative risks. As such, the choice of surgical options for management of prostatic obstruction in them should be carefully considered. Endoscopic methods, especially DiLVP, are associated with fewer peri-operative complications in the elderly.

Keywords: Prostate ablation, surgery in elderly, prostate laser vaporization, prostat, TURP

How to cite this article:
Lawal A T, Ahmed M, Ayodeji A O, Abdullahi S, Mudi A, Oyelowo N, Tolani M A, Kolapo H B, Fidelis L, Khalid L, Bello A, Maitama H Y. Surgical ablation of the prostate in the elderly: A comparison of efficacy and outcomes of open and endoscopic methods. Arch Int Surg 2020;10:80-5

How to cite this URL:
Lawal A T, Ahmed M, Ayodeji A O, Abdullahi S, Mudi A, Oyelowo N, Tolani M A, Kolapo H B, Fidelis L, Khalid L, Bello A, Maitama H Y. Surgical ablation of the prostate in the elderly: A comparison of efficacy and outcomes of open and endoscopic methods. Arch Int Surg [serial online] 2020 [cited 2023 Jun 2];10:80-5. Available from: https://www.archintsurg.org/text.asp?2020/10/3/80/323465

Introduction

Obstruction of the lower urinary tract caused by an enlarged prostate is a common problem seen in men with advancing age,^[1] this is especially so in the elderly. The obstruction could be from a benign or malignant enlargement of the prostate. Less invasive methods of prostate ablation are believed to give better surgical outcomes and transurethral resection of the prostate (TURP) has being the gold standard surgical treatment for benign or malignant prostatic obstruction (PO).^[2],[3] Much bigger glands have traditionally being managed by open prostatectomy/channelization.^[2] However, with the advent of Lasers in urologic practice, a new method of surgical management of PO was added to the armamentarium.^[4],[5] Holmium Laser (HoL) is the commonest laser used for prostatic surgery, but other types of lasers like the diode laser have come into play.^[6],[7] However, the immediate morbidities associated with the open prostatectomy/channelization, like increased blood transfusion rates, increased time to catheter removal, and longer duration of hospital stay have persistently given the impetus for continued consideration of the transurethral procedures.^[6]

With our ageing population, more elderly men are presenting for surgical relief of prostatic obstruction. Generally speaking, geriatric surgeries are froth with increased risks and complications.^[8] Urological surgeries in the elderly have been studied^[8] and various articles have compared at least two of these three procedures viz; TURP, Transurethral vapor resection of the prostate (TUVRP), HoLEP, and Open prostatectomy.^{[7],[9],[10],[11],[12],[13],[14],[15]} However, to the best of our knowledge none have compared open prostatectomy/channelization with TURP and transurethral diode laser vaporization of the prostate, even so in the elderly. The purpose of this study was to assess the outcomes and comparative efficacy of open prostatectomy/channelization, TURP, and transurethral diode laser vaporization of the prostate amongst the elderly.

Patients and Methods

This was a retrospective study carried out in a single tertiary hospital in Nigeria. The study population included all men aged 65 years and above that have had any of the above three surgeries for relief of prostatic obstruction. Traditionally, the patients were counselled and a decision on the type of procedure was made based on the prostate size, presence or absence of associated bladder pathologies like bladder stone, and bladder diverticulum, patients' ability or otherwise to be placed in Lloyd-Davies position, and patients' preference. At surgery time, all the patients were fit for any of the three chosen procedures. The operation register and patients records were reviewed to select patients who had open prostatectomy/channelization, TURP/channelization, and diode laser electrovaporization of the prostate over a five-year period (June 2013 to June 2018). The surgeries were classified as follows: group one = Open prostatectomy/channelization (OP/C), group two = TURP/channelization (TURP/C), group three = Diode laser vaporization of the prostate (DiLVP). Inclusion criteria were all patients who have had any of the above three procedures for relief of prostatic obstruction due to BPH or prostate cancer, age ≥65 years. Exclusion criteria were synchronous urethral stricture, and prior history of prostatic, bladder, or urethral surgery.

Patients' age and other demographics were extracted and documented. Details of pre-operative urogenital symptoms and comorbidities were noted. DRE findings were noted as either benign or suspicious of prostate cancer. The details of basic investigations like hematocrit, PSA, abdominopelvic ultrasound, and prostate biopsy where indicated, were documented. The pre-operative working diagnoses were noted. Intraoperative details of surgeries and perioperative management were extracted. Post-operative subjective outcomes and complications were also noted. Diagnoses of complications were made using clinical methods and relevant investigations such as urine microscopy, culture and sensitivity, retrograde urethrogram, and micturating cystourethrogram as may be required.

The primary outcome measures were intra-operative and peri-operative morbidity, and post-operative complications such as urethral stricture, bladder neck stenosis and need for re-operation. The secondary outcome measure of interest was subjective improvement in voiding function.

Data analysis was done using SPSS version 20. Basic descriptive statistics were computed. Fisher's exact test was used to compare categorical variables. One way analysis of variance with Dunnet T3 correction was used to compare quantitative data between the groups. Statistical significance was set at a P value of <0.05.

Results

The records of seventy (70) patients were analyzed. Thirty-seven of the patients (52.9%) had open prostatectomy/channelization (OP/C), 21 (30%) had TURP/channelization (TURP/C), while the remaining 12 (17.1%) had transurethral diode laser vaporization of the prostate (DiLVP).

The demographics and preoperative variables for the three groups are shown in [Table 1].

Table 1: Comparison of demographics & pre-operative parameters amongst the 3 groups

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The mean duration of procedure in minutes was 87.5, 75, and 70.5 for groups one, two, and three respectively. This difference was not statistically significant (p = 0.12). None of the patients in the TURP/C and DiLVP groups had blood transfusion, while 7 (18.9%)) of the OP/C group had blood transfusion. This was statistically not significant (p = 0.81). The mean time to catheter removal in days was 5.4, 4.1, and 2.8 for groups 1, 2, and 3, respectively. Overall, this difference was statistically significant (p = 0.00). However, subgroup analysis using the Dunnet T3 test revealed that no difference existed in this regards between the TURP/C vs DiLVP groups (p = 0.25). The difference between the other subgroups i.e., TURP/C vs OP/C and DiLVP vs OP/C were however sustained. The average hospital stay in days were 5.6, 4.1, and 2.8 for groups 1, 2 and 3 respectively. This was statistically significant (p = 0.00). However, post hoc analysis using the Dunnet T3 test showed no significant difference in this regards between the OP/C vs TURP/C groups (p = 0.07). Perioperative variables between the three groups are shown in [Table 2].

Table 2: Comparison of perioperative parameters amongst the 3 groups

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Post-operative complications were noted for the three groups. The rate of occurrence of post-operative LUTS are 1 (2.7%), zero, and 3 (25.0%) for groups 1, 2, and 3, respectively. This was statistically significant (p = 0.03). The incidence of post-operative AUR was 1 (2.7%), 2 (9.5%), and 1 (8.3%) for groups 1, 2, and 3, respectively. This difference was also found to be statistically significant (p = 0.00).

The incidence of post-operative UTI was 2 (5.4%), 5 (23.8%), and 1 (8.3%) for the OP/C, TURP/C and DiLVP groups, respectively. This difference is not related to the time to catheter removal and was found to be statistically significant (p = 0.00). UTI was diagnosed based on suggestive post-operative LUTS and confirmed on urine microscopy, culture, and sensitivity. The difference in incidence rates of retrograde ejaculation, erectile dysfunction, urethral stricture, bladder neck stenosis, and reoperation were all statistically significant (p = 0.00).

Details of early (within the fourth post-operative week) and late (beyond the 4^th post-operative week) complications observed in the three groups are shown in [Table 3].

Table 3: Comparison of early and late complications between the three study groups

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The average follow up period in months was 15, 17, and 16 respectively for groups one, two, and three, respectively. This was not significantly different (p = 0.13).

When voiding function was subjectively assessed by the fourth post-operative week, and 30 (81.1%), 11 (52.4%), and 11 (91.7%) of the OP/C, TURP/C and DiLVP respectively were satisfied with their voiding function. This was statistically significant (p = 0.03). However, by the first completed year the voiding satisfaction rates were 34 (91.9%), 18 (85.7%), and 12 (100%) for the OP/C, TURP/C, and DiLVP, respectively. This was not significant (p = 0.07).

There was no relationship between the incidence of perioperative complications and presence of comorbidities.

Discussion

Surgical ablation of the prostate remains a major treatment option for bladder outlet obstruction due to prostatic enlargement. Three methods of surgical ablation of the prostate viz; open prostatectomy/channelization, TURP/channelization, transurethral diode laser vaporization of the prostate (DiLVP) were compared in this study. It is generally believed that methods ensuring complete removal of the obstructing gland give better long-term functional outcome in terms of resolution of LUTS.^[9],[16] This gives an edge to open prostatectomy over the two transurethral procedures under focus here. However, the immediate problems associated with the open prostatectomy/channelization like increased blood transfusion rates, increased time to catheter removal and longer duration of hospital stay have persistently given the impetus for continued patronage of the transurethral procedures.^[6] This group of elderly men are said to be complication-risk prone, mainly due to presence of co-morbidities and poor physiologic reserves.

Age wise there was no difference between the TURP/C and the DiLVP groups, as compared to the open prostatectomy/channelization group. This may be due to the disparity in the sizes of the two transurethral groups as compared to the open surgery group. The transurethral surgery groups have a significantly higher proportion of urban dwellers and people with higher educational status when compared to the open prostatectomy/channelization group. These two parameters are inter-related. More educated people are likely to reside in the urban areas, and are more likely to afford the more expensive transurethral procedures due to better financial status and increased access to health insurance schemes. The OP/C and the TURP/C groups had a higher comorbidity profile as compared to the DiLVP groups. This is not surprising though, as these same groups had a significantly higher mean age when compared to the DiLVP group. This is in contrast to the report by Alexandre Larouche et al.^[10] in 2014, wherein the LASER group had a higher comorbidity profile.^[10] The mean age of this group in their study was also significantly higher. Despite the lower mean PCV in the open surgery group, no significant difference existed between all three groups as far as this parameter is concerned.

In this study, there was no difference between the three groups in terms of the duration of the procedure. Despite this, it is worthy of note that the duration was shortest for the DiLVP group. This is likely due to better hemostasis, and the attendant better vision associated with DiLVP^[6],[11] as compared to the other two procedures. Other authors also reported a shorter operating time for laser prostatectomy (HoLEP) compared to TURP.^[12] Yang K et al. reported a much lower lasing time.^[17] Other workers^[18] reported a significantly shorter operating time for DiLVP as compared to plasmakinetic enucleation and resection of the prostate.

Time to catheter removal was significantly lower for the TURP and DiLVP group as compared to the open surgery group. This is similar to findings earlier reported, in line with post-operative standards of care.^{[6],[14],[18]}

The duration of hospital stay was also significantly lower in the DiLVP group as compared to the TURP/C and OP/C groups. Mehmet et al.^[15] reported a similarly lower time to catheter removal in favor of DiLVP. This is easily allowed for by the better hemostasis, less post-operative hemorrhage and shorter time to clear irrigation seen in this group. Thus, fostering time to catheter removal and subsequent discharge.^[6] Though time to catheter removal of the TURP/C was shorter than for the open surgery, in the initial part of our learning curve we were a bit reluctant to discharge TURP/C patients after removal of urethral catheter. Thus, prolonging the duration of hospital stay. The gains made in the TURP/C patients encouraged the authors to discharge the DiLVP patients shortly after catheter removal.

Overall, four patients had post-operative LUTS. One in the OP/C group and three in the DiLVP group. These were mainly irritative—urgency and urge incontinence. This is similar to reports from earlier studies.^[6] While generally, this may be due to tissue necrosis and subsequent sloughing associated with the use of interstitial LASERs.^{[6],[19],[20],[21],[22]} This may not be absolutely so in DiLVP because of the immediate TUR-like effect. However, associated tissue edema may be contributory.^[6] Furthermore, secondary vesical changes following lower urinary tract obstruction (LUTO) may play a role.^[6] In contrast, some other workers found no difference in post-operative incidence of urge incontinence between the TURP and OP/C groups.^[9] These patients were managed conservatively and all had complete resolution of these symptoms within 2 weeks. Four patients in all, had AUR after catheter removal. One each for the OP/C and DiLVP and two for the TURP/C group. All were managed with recatheterization and removal after 7-10 days. The patients who had AUR post- TURP/C and –OP/C proceeded to develop bladder neck stenosis (BNS) which was managed with transurethral bladder neck incision and resection of residual prostate in the TURP/C groups. The one patient with AUR in the DiLVP group did not have BNS at 1.5 years post-operative. The AUR in this patient may be due to significant inflammatory edema associated with the use of this LASER.^[6] Retrograde ejaculation occurred in more of the open surgery group (20/37), while ED and urethral stricture occurred only in the TURP/C group, affecting 1 and 2 patients respectively. The occurrence of urethral stricture in these patients may be due to use of 26Fr sheath with the associated back and forth movement.

Only four patients in all, had re-operation. Three in the TURP/C group and one in the open surgery group. Of those in the TURP/C group, one had BNS while the other two had anterior urethral strictures. They were managed with transurethral incision of the bladder neck and urethroplasty respectively. This is similar to the report by Nasser et al.^[9] who showed that eight out of 51 patients undergoing TURP had re-operation as compared to a similarly sized open prostatectomy group, in which none of the patients were re-operated.

Conclusion

Elderly men present with significant depletion in physiologic reserves and increased propensity to develop peri-operative morbidities, complications and even death. As such, the choice of surgical options for the management of prostatic obstruction in the elderly should be carefully considered. The endoscopic methods for prostatic ablation, especially DiLVP, provide safe, fast, and efficient options for the ablation of obstructing prostate glands in elderly men.

Limitations

This study has several limitations:

This was a retrospective study, thus objective outcome measures like Qmax that weren't in routine use as at the time the patients were managed, could not be used despite their utility. A prospective study design, with availability of uroflowmeter will address this.
The patient population in all the groups were heterogeneous in terms of diagnoses. Even though most of the patients had BPH, the existence of advanced adenocarcinoma of the prostate amongst the groups may impact negatively on the outcomes. This shortcoming can easily be addressed by a prospective study design with groups that are more homogeneous.
The follow up period of 15-17 months though short, but this was what was available, due to the retrospective nature of the study. This limitation can be made good with a prospective study design.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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