Currently, transurethral prostatectomy (TURP) is considered one of the best surgical treatments for benign prostatic hyperplasia. Prostate volume is an important factor in choosing a suitable modality. Although studies on the optimal cutoff for prostate size are limited, complication rates increase with prostate size. Bipolar TURP (B-TURP) is the most widely and thoroughly investigated alternative to monopolar TURP (M-TURP), especially in infirm patients. No clinically relevant differences in short-term efficacy exist between the two approaches. For larger prostate sizes (more than 80–100 g), the use of laser technologies and robotic laparoscopic-assisted prostatectomy has been increasing on a year-over-year basis. Some patients may still be candidates for open prostatectomy and we extensively described it in this chapter. Current studies confirm that new technologies are safe, with equivalent outcomes; although this makes new technologies an attractive alternative to open prostatectomy, more long-term studies are needed.
KeywordsOpen prostatectomy, Transurethral resection of prostate, Complication, Outcomes
History of Surgical Treatment for Benign Prostatic Hyperplasia (BPH)
The word urology originates from Greek ouron , meaning “urine.” In the distant past, human urine was thought to be infused with the soul, and in some times and places, some superstitious philosophies believed it had therapeutic effects [ ]. Urologic surgery also has a long history: circumcision dates back to the ancient Egyptians, and was common after that, persisting as ritual in the Jewish and Islamic religious traditions. Castration of Chinese youths for work as guards or in harems has also been alluded to [ ].
The history of urinary catheterization goes back more than 3500 years [ ], but removal of prostate adenoma dates only to the last century. In the mid-16th century, Riolan proposed that the prostate could be the reason for urinary retention [ , ]. Besides developing catheterization techniques and types, several surgical approaches were practiced to lessen patient symptoms: for example, creating a channel in the prostate transurethrally. These surgeries frequently carried a high risk of morbidity and mortality and were eventually abolished [ ].
Nearly 200 years ago, Fergusson incidentally removed a prostate during lithotomy and found that this perineal prostatectomy could alleviate patient symptoms and improve urine flow [ ]. The earliest cystoscope-like instrument was introduced in 1805, upon which the invention of other cystoscopes was founded [ ]. Along with improvements in open surgical technique, transurethral techniques were modernized. Early in the 18th century, Guthrie cut the bladder neck with a transurethral knife; after that Mercier designed numerous tools for this purpose [ ].
Four critical mutations in transurethral prostatectomies (TURPs) are believed to be: the introduction of the cystoscope by Nitze; the invention of light bulbs, used in cystoscopes, by Edison; the invention of the fenestrated tube by Young; and finally, establishment of the use of electrocautery in water-based solution by Beer [ ].
Although urology is an ancient surgical specialty, modern urology has progressed rapidly during recent decades, beginning with the uptake of minimally invasive surgery. Such instrumentation led to further progress in the form of laser technologies and high-definition video, and also the bipolar resectoscope.
Pathophysiology of BPH
The normal prostate ranges in mass between 6 and 20 g and has a steady growth rate until the 3rd decade of men’s lives, but half of men older than 50 have prostate hyperplasia [ ]. Genetic susceptibility [ ] and race [ ] influence its prevalence, and some studies support a role of metabolic syndrome, but not cigarette smoking [ , ].
Epidemiology and Socioeconomic Burden of Surgical Treatment for BPH
The prevalence of lower urinary tract symptoms (LUTS) due to BPH rises with age. Nearly 70% of men older than 70 years suffer from BPH symptoms [ ]. The economic burden of BPH is great; it is estimated in the United States at over $3 billion every year [ ]. Parallel to growing life expectancy in many countries, this burden will increase [ ].
It is reported that a third of men in their 60s and half of men above 80 years old experience symptoms of BPH [ ]. In a study in western Asia, the incidence of BPH was 2105 per 100,000 men, and the proportion of treatment increased with age until the 7th decade of life. Surgery was performed for 2.1%, half of surgeries being performed within the first 6 months after initiation of medical therapy. Transurethral resection (TUR) of the prostate was the most commonly performed surgery [ ]. Similarly, in a European cohort comprising 80,774 males, 2181 incident and 5605 prevalent LUTS/BPH cases were reported [ ].
A recent study reported that, although the rates of transurethral surgery remained steady, the use of laser prostatectomy is increasing, and replacing half of more basic TURP procedures, largely because of provider effects. However, data are lacking to support its use among elderly patients as a first choice [ ].
Factors Affecting Choice of Surgery Type
One of the most important factors for choosing open prostatectomy versus TURP is prostate size. The size of the prostate increases with age. Both the prostate and its transition zone enlarge, being quite small in young adult men but increasing dramatically in the 6th and 7th decades of men’s lives [ ].
Traditionally, suprapubic or retropubic open prostatectomy is practiced on patients with prostate volumes larger than 80–100 g, according to the American Urology Association (AUA) guidelines, although open prostatectomy is more effective than TURP in alleviating symptoms, and particularly in cases of bladder diverticuli or stones. But because of significant risk of blood loss and transfusion, and a longer hospital stay than TURP, attitudes toward the open procedure are much less favorable [ ].
Considering improvements in surgical and aesthetical technique, our previous data are in need of review; robotic laparoscopic surgery with advances in TURP instrumentation and technique makes larger prostate size less challenging. In addition to this issue, surgeon preference and expertise, and also hospital setting, play crucial roles. Unfortunately, to date we lack valuable comparative data in this field. In previous studies, for prostates larger than 80 g, more than half of TURP patients experienced at least one morbidity, and mortality was as high as 6%, while open-prostatectomy mortality rate was 3.3%; but in newer series, mortality and morbidity are near zero [ , ].
Simforoosh, from Iran, reports that open transvesical prostatectomy is an acceptable operation for prostates sized 30–70 g, with better outcomes compared to TURP [ ]. In contrast, Elshal reports that open prostatectomy causes more significant and more serious perioperative morbidity, especially with larger prostates [ ].
Altogether, it seems that the complication rate increased in very large adenomas that required long times for resection, and we can conclude that careful patient selection is crucial before surgery [ ].
Surgeon Preference and Hospital Setting
In a recent study that involved 600 urologists, 570 reported performing BPH surgery. The two practices favored by urologists included open prostatectomy and monopolar TURP. It is interesting that, stratifying by urologist age and year of residency graduation, there were no differences in practice, but higher-volume surgeons were much more likely to utilize laser technology. In full-time academic settings, robotic prostatectomy was more commonly practiced. It seems that surgeons prefer techniques with better clinical outcomes and that are safer and less invasive [ ].
Previous data showed higher mortality and morbidity among aged patients [ ], and resulted in some researchers proposing that any clinical trials comparing open prostatectomy to TURP were unethical [ ] because of the higher mortality of open prostatectomy [ , ] in comparison with TURP. This topic has been challenging up to the present, and there are contradictory data [ , ]. A recent European study (of 95, 577 cases) showed that, although there is a higher complication and mortality rate in open prostatectomy, it is associated with lower rates of intervention over the long term [ ]. However, there is no significant survival difference between TURP and open prostatectomy [ ].
Traditionally, open prostatectomy technique is the standard treatment for BPH, and it has been so for over 50 years [ ]. Two famous open techniques for prostatectomy include retropubic and suprapubic prostatectomy. In the retropubic technique, the surgeon makes a direct incision of the anterior prostatic pseudocapsule and has a direct visualization of the prostatic fossa, so the surgeon can achieve more complete adenoma removal. This technique allows precise transection of the urethra and has a better continence outcome; also during this procedure the bladder is left intact [ ]. Suprapubic prostatectomy, or transvesical prostatectomy, was originally introduced by Eugene Fuller and popularized by Peter Freyer [ ]. Suprapubic prostatectomy is preferable for patients with a large median lobe or concurrent bladder diverticulum, or with bladder calculi [ ].
Open simple prostatectomy in comparison with other methods has several established superiorities: less need for re-operation [ ], more patient satisfaction [ ], higher quality of life [ , ], and better symptom relief (objective and subjective) [ , ]; the most interesting point is that all of these benefits become more prominent at long-term follow-up. Open prostatectomy is less prone to induce electrolyte abnormalities or dysuria, and studies report that open prostatectomy may have a beneficial effect on sexual function compared to TURP [ ].
Regardless of its excellent clinical outcome in long-term follow up [ ] and rapid improvement of most subjective and objective parameters, and notwithstanding that its excellent urodynamic outcome can be considered the standard for comparison of all other treatments [ ], unfortunately open prostatectomy carries a considerable mortality and morbidity [ ]. There are reports, on the other hand, that show morbidity and mortality during utilization of simple open prostatectomy is very low [ ]. Traditionally, perioperative bleeding has been found to be the most common complication; blood transfusion has a risk of transfusion reactions and infectious disease transmission [ ] and there is considerable economic burden [ ], although it seems with evolving surgical methods, this is far less of a concern [ , ].
In open prostatectomy, the surgeon may have to incise the bladder neck or the prostate capsule, which can cause damage to erectile nerves and vessels [ ]; thus, erectile dysfunction occurs, but only in < 5% of cases [ ]. Although it is reported that retrograde ejaculation happens in most patients after surgery [ ], this problem seems to be less prevalent in minimally invasive prostatectomy [ ].
Urinary extravasation can be seen as afunctional drainage; in the transvesical technique it is usually result in incomplete bladder repair and in the retropubic technique is the result of incomplete prostate pseudocapsule repair; both are treated by managing bladder drainage by cystotomy or urethral catheter, and both eventually resolve in less than 10 days in most cases [ ].
Less than 6.5% of patients re-experience LUTS due to bladder neck contracture. Bladder neck contracture is a medium-term adverse effect, happening months after prostatectomy [ , ]. Regardless of several published studies describing guidelines and algorithms for urethral strictures, further evidence-based studies are needed [ ]; but traditionally, the initial treatment is gentle dilatation with a urethral Nelaton catheter or cystoscope [ ]. Although historically, the rate of deep vein thrombosis is low in open prostatectomy [ ], it is still the most common nonurologic complication, and although rare, it is potentially lethal [ ].
One large study with 35,171 patients reported that the overall complication rate was 28%, with bleeding at the top of the list. In total, 0.4% of patients experienced in-hospital mortality. They conclude that older age, black ethnicity, and other comorbidities are risk factors for complications [ ].
When compared with TURP, simple prostatectomy offers the advantages of a lower re-treatment rate and more complete removal of the prostatic adenoma under direct visualization. It also avoids the risk of dilutional hyponatremia (the TUR syndrome) that occurs in approximately 2% of patients undergoing a traditional monopolar TURP [ , , , ].
Robot-Assisted Laparoscopic Approaches
Minimally invasive simple prostatectomy has been introduced as an effective and safe treatment option for men with bothersome LUTS secondary to enlarged prostates. It provides comparable functional outcomes to open prostatectomy, with less blood loss and shorter length of hospital stay, despite the longer operative time required. To decrease mortality and morbidity of open prostatectomy, several techniques and instruments have been established. Robot-assisted laparoscopic prostatectomy is safe and reproducible when performed by experienced robotic surgeons, and this approach is worth considering in cases of high-volume prostate adenomas [ ]. However, there is some concern about hemostasis during this procedure [ ]. In contrast, a systematic review of published data on robot-assisted simple prostatectomy outcomes showed that in eight published studies, reporting a total of 109 cases from 2008 to 2012, transfusion prevalence was 0% and mean resected prostate weight was 94 g. This transfusion rate in robotic procedures was lower than that reported in simple open prostatectomy [ ].
In very recent research regarding a single-center experience, an author reported that results favor robot-assisted simple prostatectomy over other techniques with respect to overall lower morbidity, shorter hospital stay, and decreased indwelling catheter time, with similar symptom relief (subjective and objective) and even comparable operative times to holmium laser; but it is obvious that it requires significant training, and the high cost of new equipment hampers the widespread adoption of this technology [ ].
TUR of the Prostate
TURP is the present gold standard for BPH surgery [ , ]. It is still considered so by the American Urological Association [ ], Canadian Urological Association [ ], and the European Urological Association (which considers it as the treatment of choice for 30- to 80-g prostates) [ ]. Its safety in larger prostates is controversial, but it has even been reported that standard M-TURP, with some alteration in resection technique, will allow surgeons to resect a prostate size between 80 and 120 g [ ]. Adoption of such techniques as alternatives to open prostatectomy is currently hampered by the lack of high-quality randomized clinical trials (RCTs) comparing them to standard TURP.
M-TURP is now the standard TURP technique for treating BPH, primarily because of its well-documented long-term efficacy [ ]. Monopolar resection, which remains a popular choice for BPH, has been regarded as safe based on long-term patient follow-up, but it can cause acute complications such as electrolyte imbalances, bleeding, and urethral strictures. Although significant technical improvements over past decades have decreased the occurrence of adverse events associated with the procedure, concerns remain regarding complications such as the TUR syndrome, bleeding, and urethral strictures [ , ]. A prospective, large-scale, multicenter, observational study has revealed that although TURP mortality has decreased as low as 0.1%, morbidity remains high (11.1%) [ ].
Not only did morbidity and mortality decline, but also, in a study combining a total of 3470 patients from 67 studies, RCTs of M-TURP during recent decades contain larger prostates, in comparison with large cohort studies of past eras [ ].
In the B-TURP system, an electrical circuit is completed locally during ablation; energy is restricted to a pathway between a resection loop and resectoscope tip or sheath. A systematic review showed that B-TURP has a decreased risk of TUR syndrome and clot retention in comparison with M-TURP. The bipolar system is the preferred choice in diabetic patients, or those who have cardiac pacemakers or infirm health [ ]. On the other hand, surgeons also favor B-TURP in larger prostates. B-TURP definitely reduces the incidence of bleeding intraoperatively [ ].
A metaanalysis of 24 studies that compared M-TURP and B-TURP reported that no statistically significant differences were found in International Prostate Symptom Score (IPSS) or health-related quality-of-life scores. Maximum urinary flow rates were higher in M-TURP at 3, 6, and 12 months, but the difference was not important clinically. B-TURP had fewer adverse outcomes than TUR, especially clot retention and blood transfusion, although this study had some major methodological limitations like short follow-up, and considering that, this review should be interpreted with caution [ ]. But overall, we can conclude that B-TURP, at least in the short term, has a comparable result.
In studies, risk of dysuria reported was 0 in B-TURP and 0.8% in M-TURP [ , , ]. In a study by Simforoosh, dysuria was more prominent after TURP than open prostatectomy [ ].
B-TURP (in 0.2%) and M-TURP (in 2.2%) can cause urgency [ , , ], while it is also reported that the best symptom relief after open prostatectomy is for the symptom of urgency [ ].
Open prostatectomy causes significant reduction of LUTS after the procedure [ ]. Considering available data, it is concluded that the IPSS decrease in open prostatectomy is similar to that in TURP [ ]. Previous data concluded that there was no significant difference in terms of IPSS between M-TURP and B-TURP in the short term [ ] or the long term [ , ].
Quality of Life
Short-term improvement of quality of life is greater with open prostatectomy in many studies [ , , , ], although there are a few studies showing similar outcomes between open and transurethral procedures in quality of life improvement [ ].
Peak Flow Rate Improvement
Q max improvement is similar in monopolar and B-TURP [ , ] and in both, is lower than in open prostatectomy [ ], although there are some studies showing similar outcomes comparing open and transurethral procedure peak flow rate improvement [ ].
Residual Urinary Volume Reduction
Although residual volume is lower in B-TURP than M-TURP [ ], the difference is clinically nonsignificant [ ] and the result is similar to that resulting after open prostatectomy [ , ].
Hematuria rate as well as the mean hemoglobin drop and incidence of clot retention are greater in open prostatectomy, but this is not clinically significant in a limited number of studies [ , ]. Obviously, intraoperative bleeding is lower in the B-TURP group than in the M-TURP group [ , , , ].
Resected Prostate Weight
Although open prostatectomy has better outcomes in larger prostates, TURP is limited to prostates of less than 80 to 100 g; it seems reasonable that there is lower resected prostate weight in TURP than in open prostatectomy, especially in B-TURP [ , , ], but there are scant data comparing similar resected tissue weights [ ].
Open prostatectomy is an open procedure with a greater risk of transfusion [ ] and infection, and involving a greater length of stay in hospital [ ], so it is logical for fever to be more prevalent following this procedure [ ]. However, with the use of antibiotics for chemoprophylaxis, and dependent on pre- and postoperative care, this complication can be similar in both groups [ ].
Time to Catheter Removal
In most transvesical procedures, the catheter should remain in place for at least 1 week, but this period is shorter in transurethral procedures [ ]. M-TURP and B-TURP catheter removal times are similar [ ]. The duration of catheterization after TURP depends primarily on the color of the catheter effluent, but in most series it is less than 5 days [ , ].
Hospital Stay and Return Time to Work
Hospitalization duration is longer in patients who undergo open prostatectomy [ ], with a mean hospital stay between 6 and 10 days, and this is owing to a longer catheterization time [ ]. In a recent study, authors showed overnight admission rates in a series of cases with small- to medium-sized prostates who had undergone TURP dramatically differed from those found with open prostatectomy [ ].
Urinary Tract Infection
Some studies noted more incidence of UTI in TURP [ ]. It has been proposed that bacteriuria incidence varies from 9% to 26%, and septicemia incidence from 0.7% to 4% [ ], but overall, because of modern antibiotic prophylaxis policies, infection is about 6%–8% in open prostatectomy, similar to that detected after TURP [ ].
In a previous study, postsurgical epididymitis developed in 1.0% of the TURP group versus 3.2% of open prostatectomy group. This is in contradiction of two more recent studies, in which more cases of epididymitis were noted in TURP [ ]. There are also data showing similar rates of this complication [ ]. These discrepancies show the need for more robust RCTs in this field in the future.
Secondary operation is much more prevalent in TURP than open prostatectomy [ , ]. It is interesting to note that reoperation, in cases of surgery both for BPH and unrelated to BPH, is much more prevalent in monopolar TURP than bipolar TURP [ , , ].
AUA guidelines state that incontinence in TURP is about 3%, and 6% in open prostatectomy [ ]. In contrast, two studies showed that incontinence was more common after TURP [ , ]. It seems highly likely that this outcome is dependent on surgeon experience and patient selection. Again, it is interesting to know that it is somewhat more probable in M-TURP than B-TURP [ , ].
A very recent study showed TURP significantly reduced sexual function [ ]. The incidence rate of postoperative ED after prostatectomy was 12.5%, and was similar in both groups [ ]. It is proposed that open prostatectomy confers, not only a reduction of LUTS after the procedure, but also an improvement of erectile function; this improvement was related to the patient’s age [ ].
Bladder Neck Contracture
In AUA guidelines, both procedures are stated to carry about an 8% risk of contracture [ ], but in newer metaanalyses, this reaches less than 2% of patients, and most notably only about 0.5% in B-TURP [ , , ].
Tur syndrome occurred less than 2.5% of the time in a recent series in M-TURP, and is rarely reported in B-TURP [ , , ].