|Year : 2022 | Volume
| Issue : 4 | Page : 432-438
The modified suprapubic prostatectomy technique is associated with improved hemostasis and decline in blood transfusion rate after open suprapubic prostatectomy compared to the freyers technique
AO Obi1, CJ Okeke2, AO Ulebe2, UU Ogbobe2
1 Department of Surgery Alex Ekwueme Federal, University Teaching Hospital; Department of Surgery Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
2 Department of Surgery Alex Ekwueme Federal, University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Submission||04-Apr-2021|
|Date of Acceptance||05-Jan-2022|
|Date of Web Publication||19-Apr-2022|
Dr. A O Obi
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital Abakaliki, PMB 102, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Open suprapubic prostatectomy is attended by significant perioperative haemorrhage and need for blood transfusion. Aim: To share our experience on how the adoption of a modified suprapubic prostatectomy technique has led to improved hemostasis and decline in the blood transfusion rate after open suprapubic prostatectomy in our center. Patients and Methods: This was a retrospective study comparing two open prostatectomy techniques. The patients in group 1 had Freyer's suprapubic prostatectomy while the patients in group 2 had a modified suprapubic prostatectomy technique. The groups were compared for the effectiveness of hemostasis using change in packed cell volume, clot retention, blood transfusion, and requirement of continuous bladder irrigation. Results: Both groups were similar concerning age, body mass index (BMI), total prostate-specific antigen (PSA), prostate volume, presence of comorbidities, duration of surgery, and duration of follow-up. The clot retention rate was 34% in group 1 versus 16.4% in group 2, P = 0.030. The clot retention requiring bladder syringe evacuation occurred in 32.1% of the patients in group 1 versus 14.8% in group 2, P = 0.048. The mean change in the packed cell volume (PCV) in group 1 was 8.0 ± 5.3 versus 6.9 ± 3.5 in group 2, P = 0.175. The blood transfusion rate in group 1 was 40.0% versus 13.3% in group 2, P = 0.040. The complication rate in group 1 was 67.2% versus 41.9% in group 2, P = 0.004. A general decline in blood transfusion was noted from January 2011 to December 2019. Conclusion: The modified suprapubic prostatectomy technique was associated with better hemostasis compared to the standard Freyer's prostatectomy technique. It should be a worthwhile addition to the numerous modifications of the original Freyer's suprapubic prostatectomy technique.
Keywords: Blood transfusion, Freyer's prostatectomy, hemostasis, modified suprapubic prostatectomy technique
|How to cite this article:|
Obi A O, Okeke C J, Ulebe A O, Ogbobe U U. The modified suprapubic prostatectomy technique is associated with improved hemostasis and decline in blood transfusion rate after open suprapubic prostatectomy compared to the freyers technique. Niger J Clin Pract 2022;25:432-8
|How to cite this URL:|
Obi A O, Okeke C J, Ulebe A O, Ogbobe U U. The modified suprapubic prostatectomy technique is associated with improved hemostasis and decline in blood transfusion rate after open suprapubic prostatectomy compared to the freyers technique. Niger J Clin Pract [serial online] 2022 [cited 2022 May 22];25:432-8. Available from: https://www.njcponline.com/text.asp?2022/25/4/432/343448
| Introduction|| |
Benign prostatic hyperplasia (BPH) is the commonest benign tumor in men. The treatment options for BPH have evolved over the years from the earliest open surgical techniques of Freyer and Millins and their modifications,,,,, to the current less invasive surgical options such as transurethral resection of the prostate (TURP) and Holmium laser enucleation of the prostate (HoLEP). The central focus in the evolution of newer treatments for BPH and modifications of older techniques has been to reduce patient morbidity, reduce perioperative blood loss, and the need for blood transfusion.
Open suprapubic prostatectomy (OSP), also known as Freyer's prostatectomy, was described by Peter Freyer in 1900. It has traditionally been a bloody surgery attended often with significant perioperative blood loss, clot retention (CRE), and the need for blood transfusion (BT).,, Several modifications of Freyer's original technique aimed at improving hemostasis have been described.,,,,, None of these has completely resolved the problem of hemorrhage associated with OSP and BT rates ranging from 0 to 57.1% have been documented.,,,
BT is fraught with many challenges and risks ranging from non-availability in developing countries to transmission of infectious diseases. It is also an additional cost to the surgery fee.
In 2010, a modified suprapubic prostatectomy (MSP) technique was described,, which was shown to be associated with a reduction in perioperative blood loss, and therefore, avoidance of BT. We adopted this technique as our preferred method for OSP in 2016. In this paper, we share our experience of how this technique has resulted in improved hemostasis and reduction in BT after OSP in our hands. We compare the outcomes concerning hemostasis between Freyer's prostatectomy,, which was our technique before 2016, and the (modified suprapubic prostatectomy) MSP technique.
| Patients and Methods|| |
This was a retrospective study comparing two patient groups which underwent OSP using two different techniques from June 2011 to December 2019. The study was approved by our institution's research and ethics committee. The first group of patients was operated on using Freyer's technique, from June 2011 to May 2016. The second group was operated on using the MSP technique from May 2016 to December 2019. All the surgeries were done by the first author, who had 19 years of post-fellowship experience at the time of writing the manuscript. The groups were compared for the effectiveness of hemostasis using the following parameters: perioperative blood loss as determined by a change in the packed cell volume (PCV), clot retention episodes (CREs), CREs requiring bladder syringe evacuation, BT rate, and requirement for continuous bladder irrigation (CBI).
A predesigned proforma was used to collect the patients' demographic and clinical data. The data collected included the patient's age, body mass index (BMI), international prostate symptom score (IPSS), quality of life score (QOL), total prostate-specific antigen (PSA), transabdominal ultrasound determined prostate volume, postvoid residual urine volume (PVR), presence of diabetes mellitus (DM), hypertension (HTN), other associated pathologies, duration of surgery, clot retention (CRE), CREs requiring bladder syringe evacuation, BT, duration of admission, complications, and duration of follow-up. A change in PCV was determined by subtracting postoperative day 2 PCV from preoperative PCV. The number of pints of blood transfused in the perioperative period was taken into consideration in determining the change in PCV. In this calculation, it was assumed that a pint of blood will raise the PCV by three digits. Thus, for every pint of blood transfused, three digits were added to the change in PCV.
Indications for surgery
The indications for surgery were severe and bothersome lower urinary tract symptoms despite medical therapy for BPH; the IPSS score ≥20, patients dependent on the urethral or suprapubic catheter for voiding. Also, the presence of complications such as recalcitrant hematuria, recalcitrant urinary tract infection, vesical stones, and features of obstructive uropathy such as vesical diverticular, hydronephrosis, and deranged serum urea and creatinine.
Preoperative workup included estimation of PCV, total PSA, serum electrolytes, urea and creatinine, platelet count, retroviral screening, urine cultures, blood sugar, chest X-ray, electrocardiogram (ECG), and abdomino-pelvic ultrasound scan. The patients with PSA above 4 ng/mL had a prostate biopsy to rule out prostate cancer. A minimum PCV of 30 was ensured before surgery except in emergencies. A minimum of one pint of blood was grouped and cross-matched for each patient. We ensured sterile urine, normal platelet count and normal serum electrolytes, urea, and creatinine before surgery. The patients with comorbidities such as DM, HTN, or chronic obstructive airway disease (COAD), were referred to the relevant specialists for treatment before surgery. Antiplatelet medications were withdrawn for at least 10 days before surgery.
MSP was performed as previously described., After enucleation of the prostate, hemostasis was achieved by suturing the bladder mucosa to the prostatic capsule, from 1 o'clock to the 11 o'clock position of the bladder neck, using 2/0 vicryl running sutures. In the original description, the bladder neck is narrowed to the size of the surgeon's index finger by placing interrupted vertical sutures at the 12 o'clock position of the bladder neck. In our modification, we do not narrow the bladder neck further by placing interrupted vertical sutures at the 12 o'clock position, except to prevent the urethral catheter balloon (inflated to 40 mL) from slipping into the prostatic fossa when it is put under traction. A size 22 F, two-way silicone catheter is inserted to drain the bladder following which the bladder is closed in two layers. The retropubic space is not drained. The abdominal wound is closed in layers in a standard fashion.
In the Freyer's prostatectomy, bladder neck hemostatic sutures are placed at the 5 and 7 o'clock positions with additional hemostatic sutures to any bleeding points. The bladder neck is not narrowed. A three-way size 22 F urethral catheter or a combination of a two-way size 22 F urethral and size 22 F suprapubic catheter is used to drain the bladder. The bladder is closed in two layers. The retropubic space is drained routinely. The abdominal wound is closed in layers in the standard fashion.
Postoperative management in both groups was essentially the same with a few differences. Patients in both groups were continued on intravenous fluids, intravenous antibiotics, and analgesics. Our threshold hemoglobin level for postoperative BT was 9 g/dL. The decision for intraoperative BT was based on the sucker volume, assessment of the degree of pallor, and taking into consideration the patients' preoperative haemoglobin (HB).
In group 2, the urethral catheter was placed under traction. The traction was maintained at two points; at the penile meatus using a salvaris gauze and at the thigh using a thigh strap. The salvaris gauze was removed at 2 h postop while the thigh strap was removed at 24 h postop. There was no catheter traction in group 1.
Patients in group 1 had (continuous bladder irrigation) CBI using normal saline as a routine until the urine was relatively clear. For patients on combined urethral and suprapubic catheter drainage, the suprapubic catheter was removed once the urine became relatively clear, usually by postoperative day 2. CBI was not done in group 2.
Patients with uneventful postoperative courses were usually discharged home on postoperative day 6 or 7 after removal of the catheter. They were seen in the clinic at 2 weeks, 4 weeks, 3 months, 6 months, and yearly, thereafter. At follow-up, the patients were evaluated by history and physical examination for any complications. At 1 month of follow-up, the IPSS, QOL, PVR, and visual observation of the voided stream were evaluated. Where indicated specific investigations were ordered to evaluate complications.
Data were analyzed using the IBM SPSS Statistics for Windows, version 25.0, Armonk, NY, USA: IBM Corp. Categorical data were analyzed using the Chi-square test, while the non-categorical data were analyzed using the Student's t-test. The P value < 0.05 was taken as significant.
| Results|| |
[Table 1] shows the key differences in the surgical technique between the Freyer's technique and the MSP technique.
|Table 1: Key differences in the surgical technique between the conventional (Freyer's) suprapubic prostatectomy technique (group 1) and the modified suprapubic prostatectomy technique (group 2)|
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[Table 2] shows the demographic and clinical parameters of the patients in both groups. The overall mean age of the 127 patients studied was 66.0 ± 7.9 years. The groups were similar for age, BMI, total PSA, prostate volume, DM, HTN, and duration of surgery. The groups were also similar with respect to postoperative PVR, IPSS, and QOL. The mean preoperative IPSS in group 1 was 27.7 ± 4.8 versus 29.5 ± 4.2 in group 2, P = 0.031. The mean duration of admission in group 1 was 8.4 (± 2.4) days versus 7.4 (± 1.6) days in group 2, P = 0.026. The complication rate in group 1 was 67.2% versus 41.9% in group 2, P = 0.004.
|Table 2: Comparison of the demographic and clinical parameters of the patients in both groups|
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[Table 3] depicts the parameters used in comparing the effectiveness of hemostasis between the two groups. Statistically significant differences were observed between the groups concerning BT, CRE, and CREs requiring bladder syringe evacuation. Thirty-four percent of the patients in group 1 had clot retention compared to 16.4% in group 2, P = 0.030. Also, 32.1% of the patients in group 1 versus 14.8% of the patients in group 2 had clot retention requiring bladder syringe evacuation, P = 0.048. The mean change in PCV in group 1 was 8.0 (± 5.3) versus the mean change in PCV of 6.9 (± 3.5) in group 2, P = 0.175. The BT rate in group 1 was 40.0% compared to 13.3% in group 2, P = 0.040. A total of 53 pints of blood were transfused in group 1 versus 13 pints in group 2, P = 0.000. A general decline in BT was noted from January 2011 to December 2019 [Figure 1].
|Figure 1: Bar chart showing declining blood transfusion from the year 2011 to 2019|
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|Table 3: Analysis of parameters used to evaluate the effectiveness of hemostasis in the two groups|
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There were two mortalities in group 1 (3.1%), none of which was due to hemorrhagic complications. There was no mortality in group 2.
Hypertension was the commonest associated pathology observed in both groups. The details of other associated pathologies are depicted in [Table 4].
There was no case of postoperative bladder neck stenosis in both groups as adjudged by the symptomatology, postoperative IPSS, visual evaluation of the voiding stream, and PVR.
The overall follow-up duration for both groups was 3.8 ± 3.1 months, range 1–21 months. The follow-up period in group 1 was 3.6 ± 2.8 months (range 4–28 months) and 4.1 ± 3.4 months (range 3–18 months) in group 2, P = 0.352.
| Discussion|| |
The overall mean age was 66.0 ± 7.9 years. The mean age of the patients in the two groups was similar [Table 2] and is in keeping with the mean age of the patients undergoing prostatectomy for BPH in other studies.,
The greatest challenge of OSP has been perioperative hemorrhage.,, Several ingenious modifications of Freyer's original description of OSP have been described in the literature. The purpose of these modifications has been to improve intraoperative hemostasis, and thereby, reduce perioperative hemorrhage and the need for BT. Despite these modifications, OSP has remained a bloody operation in most hands.
The key modifications to Freyer's OSP include those of Lower and Harris, who described the separation of the bladder neck from the prostatic fossa for control of the postoperative hemorrhage using an absorbable bladder neck suture. Hryntschak modified and popularized this technique in 1955. Other modifications include those of De la Pena and Alcina, Malament and Dennis, who describe various forms of partition sutures separating the bladder from the prostatic fossa.
The MSP technique, apart from improving hemostasis, also eliminated CBI.,,, The key elements of the MSP technique and Freyer's technique are shown in [Table 1]. The bladder neck traction in the MSP technique separates the prostatic fossa from the bladder cavity, and if properly applied, achieves the same purpose as the partition sutures previously mentioned. It also serves to tamponade the prostatic venous plexus and any arterial bleeders in the bladder neck that may have been missed. The sutural hemostasis in the MSP technique is based on Flocks' seminal, cadaveric dye injection study of prostatic blood supply. He showed that the prostatic arteries are distributed from the 7 to 11 o'clock and the 1 to 5 o'clock positions of the bladder neck. This contrasts with the traditionally held belief that prostatic arteries enter the prostate at the 5 and 7 o'clock positions only. Thus, to achieve maximal hemostasis, there is a need for the hemostatic sutures to encompass the 1 to 5 o'clock and the 7 to 11 o'clock positions of the bladder neck.
Our study shows important differences between the two groups in terms of the outcome measures of the hemostasis analyzed. We found statistically significant differences between the two groups both in the absolute numbers of patients that had CRE and the mean number of CREs [Table 3]. Some CREs subside spontaneously or on milking the urethral catheter while others require evacuation with the 60-mL bladder syringe. CREs requiring bladder syringe evacuation indicate a more severe perioperative hemorrhage. In this regard, the patients who had MSP had fewer episodes of CRE requiring bladder syringe evacuation both in the absolute number of patients affected and mean episodes of CRE requiring bladder syringe evacuation [Table 3]. The clot retention rate in the MSP group of 16.4% is higher than that reported by Okorie et al., This may be because our study population had higher prostate volumes and we deliberately looked out for CREs.
The mean change in the PCV was also lower in the MSP group compared to the Freyer's prostatectomy group, but the difference did not reach a statistical significance; 6.9 (± 3.5) versus 8.0 (± 5.3), P = 0.175. A change in PCV or hemoglobin is a simple and useful method of assessing blood loss after prostatectomy and has been used by several authors., Our mean change in the HB of 2.3 though higher than the 3.27 (HB 1.09) of Okorie et al., is lower than the 3.5 and 3.15 mg/dL reported by Adam et al. and Dall'Oglio et al., respectively, and similar to that of other OSP series., It is important to note that the mean prostate volume of 115.5 g in this study is much higher than the 85.9 g in the study by Okorie et al. High prostate volume above 100 g is associated with increased perioperative blood loss in simple prostatectomy.
Significant differences were also noted between the two groups with respect to BT [Table 3]. In group 1, 40% of the patients were transfused compared to 13.3% in group 2, P = 0.04. Likewise, 53 pints of blood were transfused in group 1 compared to 13 pints transfused in group 2, P = 0.04. A general decline in BT was observed from 2011 to 2019 as shown in [Figure 1]. The BT rates after OSP range from 0 to 57.1%.,,,, The BT rate of 13.3% in the MSP group though higher than that of Okorie et al., is lower than that of Mohyelden, Shaheen and Luttwak's and similar to that reported in several large series., There are obvious dangers of BT such as transfusion reactions, the transmission of infections like human Immunodeficiency virus HIV and hepatitis in addition to the additional surgical cost. Therefore, any modification in the surgical technique that reduces the BT rate is a welcome development.
Notably, all patients in group 2 were drained with size 22 F, two-way urethral catheters only and did not need to undergo CBI compared to the patients in group 1, who as a matter of protocol all had CBI using three-way urethral catheters or a combination of urethral and suprapubic catheters. This is also a measure of the effectiveness of hemostasis. At the onset, before we fully adopted the MSP technique, we used to place a suprapubic catheter (spigotted) as a safety valve should the urethral catheter get blocked by clots. The elimination of CBI in group 2 also meant significant cost savings in terms of nursing care and volume of normal saline that could have been used for postoperative bladder irrigation. On average, 20–30 L of normal saline is used for CBI, costing approximately N21,000 (54 USD), excluding the cost of additional nursing care.
Significant differences in the complication rate were observed between the two groups; 67.2% in group 1 compared to 41.9% in group 2, P = 0.004. This is not surprising considering the differences in CRE and BT rates. There were two deaths in group 1 giving a mortality rate of 3.1% and no mortality in group 2. None of the two mortalities observed in group 1 was related to hemorrhagic complications. The complication rate in the MSP group compares favorably with that reported in the other studies., The details of complications will be presented as a separate report.
The MSP technique was associated with better hemostasis compared to Freyer's prostatectomy technique in our hands, as evidenced by the comparative reduction in perioperative blood loss, CRE, BT rates, and elimination of CBI.
It is a useful technique particularly in low-resource countries because of the avoidance of CBI and less need for BT. It should be a worthwhile addition to the numerous modifications of Freyer's OSP technique.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]