Comparative study between modified Freyer's prostatectomy, classical Freyer's prostatectomy and Millin's prostatectomy.
Classical Freyer's method was modified in which, prostatic fossa was packed after the enucleation of the gland for hemostatic purpose; and the pack and suprapubic drain were brought out laterally. The pack was removed after 48-72 hours postoperatively and catheter was introduced per urethrum for early closure of suprapubic ostomy. Fifty such cases of Modified Freyer's prostatectomy were compared with cases of classical Freyer's prostatectomy (n = 25) and Millin's prostatectomy (n = 25). The duration of surgery and requirements for perioperative blood transfusion were found to be less with our method.
Prostatectomy has undergone many modifications since the original description by Freyer. Amongst all these, following 3 techniques are commonly employed :
1. Freyer's suprapubic transvesical prostatectomy,
2. Millin's retropubic extravesical prostatectomy and
3. McCarthey's Transurethral resection
Transurethral resection (TUR) of the prostate, is the most favoured method; however, it can only be practised by a trained surgeon or urologist and requires a well-equipped set up. In India, majority of the patients with benign enlargement of the prostate are managed by general surgeons. Individuals with high-risk for anaesthesia, surgery and blood transfusion pose problems for surgeons, especially at a less equipped centre.
The major complication of prostatectomy is haemorrhage following enucleation of the gland. One of the methods to achieve haemostasis is "intra-operative packing of the prostatic fossa". This pack method of haemostasis with some modifications was followed by us for 50 cases subjected to Freyer's prostatectomy, and the results of this method were compared with the classical Freyer's prostatectomy and Millin's prostatectomy.
Comparison amongst these methods with reference to the technique, duration of surgery, preoperative blood requirements and post-operative complications are presented in this paper.
The study was carried out in patients with benign enlargement of prostate attending our hospital between January 1987 and January 1989. The patients were randomly divided in 3 groups as follows:
i. Group A (n = 50)
ii. Group B (n = 25) and
iii. Group C (n-25)
All the patients were evaluated clinically and were subjected to baseline investigations, in addition to the urine analysis and urine culture. Cystoscopy was performed in all the cases.
In patients with acute and/or chronic retention of urine, perurethral catheterisation was carried out and appropriate anti-microbial therapy was instituted after collecting the urine for culture and antibiotic sensitivity. Estimated size of the prostate gland ranged between 40-75 gms (57.5 gms) as assessed by Urologic services of the hospital during cystoscopy. Associated medical illness e.g. hypertension, diabetes mellitus, ischaemic heart disease were controlled. Patients who had undergone previous suprapubic cystostomy or having associated intravesical pathology, were not considered for retropubic prostatectomy.
The patients from Group A were subjected to Modified Freyer's prostatectomy (pack method). Briefly, the steps are outlined as follows
a) Enucleation of the prostate was performed as in classical Freyer's prostatectomy.
b) The prostatic fossa was packed with a roller pack, which was brought out along with the suprapubic Malecot's Catheter through a laterally placed stab incision on the abdominal wall, beyond the rectus muscle.
c) The bladder was closed in the usual manner and wound was closed after placement of corrugated retropubic drain. (See Fig. 1 below)
The patients from Group B underwent classical Freyer's prostatectomy and those from Group C Millin's prostatectomy.
Group A : Retropubic drain was removed after 48 hours. The pack was removed when the urine was clear i.e. after 48-72 hours and at the same time a Foley's catheter was introduced pre-urethrum. Malecot's catheter was removed on the 5th post-operative day and Foley's catheter was maintained till 9th or 10th post-operative day or till the suprapubic ostomy is closed.
The post-operative management followed in Group B and Group C was standard.
Post-operatively, patients of all the three groups received ampicillin and getamicin. Later on, depending upon the report of postoperative urine culture and antibiotic sensitivity, changes were made in therapy.
Following points were noted down for comparison of 3 operative techniques:
1. Age and associated medical conditions,
2. Intra-operative blood loss,
3. Duration of surgery,
4. Post-operative complications,
5. Post-operative hospital stay and
6. Mortality rate.
In all the three groups the median age of the patients were found to vary between 59 and 60 years. The associated medical diseases are illustrated in [Table - 1]. In Group A, especially incidence was 64% as compared to 40% lows: each in Group B and C.
The operative time of Group A patients ranged between 30-60 minutes with an average of 45 minutes. In Group B and C average time was 1.38 hr. (range: ½ hr-3 hr) and 1.62 hr (range: 1 hr-2 ½ hr) respectively. This difference between the operative time is statistically significant (p <0.01.)
The blood loss on an average was 150 ml. (range: 100-250 nil) in Group A, 400 ml in Group B (range: 100-1500 nil) and 540 ml. in Group C (range: 200-3800 ml) respectively. This difference was also statistically significant (p ).
In Group A, 22% patients required blood transfusions, as against 72% each from Group B and C. The details are illustrated in [Table - 2].
Post-operative complications were as follows:
a) Reactionary haemorrhage: It was seen in 4 patients (16%) from group B and 2 (8%) from Group C. Obviously, there was no question of reactionary haemorrhage in Group A.
b) Secondary haemorrhage: It was observed in 3 patients (6%) of Group A and 2 (8%) of Group B. There was no incidence of secondary haemorrhage in Group C.
c) Clot retention: It was found in 2 patients (8%) from Group B and one (4%) from Group C. This complication was not seen in Group A.
d) Re-exploration: 2 cases of group B and one case of group C had to undergo re-exploration either for uncontrollable reactionary haemorrhage or clot-retention but none of the patients in Group A required the same.
e) Urinary tract infection: Urinary infection on the basis of positive post-operative urine culture was present in 40% patients of Group A (n = 20) as well as of Group B (n = 10) and 28% of Group C (n = 5); however this difference was not statistically significant.
f) Wound infection: Incidence of postoperative wound infection was 40% in Group A, 52% in Group B and 20% in Group C. However this difference was also not statistically significant.
g) Incontinence: Incidence of incontinence was 24% (n = 12) in Group A as compared to 72% in Group B (n-18) and 32% in Group C (n = 8) respectively.
Duration of hospital stay was 10.4 days for patients from Group A, 12.25 days for Group B and 9.32 days for Group C.
There was no rise in the incidence of post-operative morbidity and mortality. Three patients from Group A, 1 from Group B and none from Group C died during the postoperative period.
In spite of availability of the various techniques for prostatectomy, haemorrhage still remains a major concern for surgeons. It is common in patients with benign enlargement of prostate to have age related associated medical diseases. Some of the diseases may be severe enough to preclude the patient from undergoing prolonged surgery and anaesthesia. Especially in this group of cases, an easy technique, short procedure and rapid control of bleeding is essential. In the earlier prostatectomies performed, packing of the prostatic fossa with a roller gauze was a routine procedure for haemostasis. This was commonly practised in Europe as well as in United States of America, as late as in 1949. Various modifications to achieve haemostasis like haemostatic stitches and bladder neck plication of the prostatic capsule or compression with bags are practised in Freyer's prostatectomy,. In Millin's prostatectomy, haemostasis is under vision, but is technically more difficult, at times uncontrollable as compared to Freyer's prostatectomy.
In comparison with the classical Freyer's prostatectomy and Millin's prostatectomy, our modified method was found to be more quick and resulted in reduction in blood loss. This also reduced the requirement of blood transfusion. The postoperative complications like reactionary haemorrhage, clot retention were absent following our modification hence re-exploration was never required. We therefore feel that this method is more suitable for patients with high-risk for anaesthesia and surgery and can easily be practised in a rural set up.