ISI Impact Factor (2004): 1.096

Editor-in-Chief
Prof. Yi-Fei WANG,

Evaluation for Madigan's prostatectomy in patients with benign prostatic hyperplasia

Li-Min LIAO¹, Bing-Yi SHI¹, Chun-Quan LIANG¹, Werner SCHÄFER²

¹Department of Urology, Beijing Sanlingjiu Hospital, Beijing 100091, China
²Urologische Klinik der RWTH Aachen, Aachen, Germany

Asian J Androl  2001 Mar; 3: 33-37

Keywords: prostatic hyperplasia;  prostatectomy; urodynamics

Abstract

Aim: To comparatively evaluate the efficacy and post-operative complications of the Madigan's prostatectomy (MPC) and suprapubic prostatectomy (SPPC). Methods: A total of 43 patients with benign prostatic hyperplasia were divided into two groups: 21 underwent MPC and 22, SPPC. In all the patients, the international prostate symptom score (IPSS) and urinary pressure-flow studies were assessed before and 6 months after operation. The International Continence Society (ICS) nomogram, Abrams-Griffiths (AG) number and linear passive urethral resistance relation analysis (L-PURR) were used to diagnose and grade bladder outlet obstruction (BOO). The IPSS and the urodynamic parameters before and after operation, as well as the advantages and post-operative complications were recorded and compared. Results: Patients of both the MPC and SPPC groups had a significant improvement in IPSS and urodynamic parameters. Obstruction was relieved in 81.0% of MPC and 86.4% of SPPC patients. MPC has the advantages of the absence of postoperative hematuria and post-catheter stricture, a shorter period of hospitalization, and lower incidence of retrograde ejaculation and erectile dysfunction. Conclusion: Both MPC and SPPC can effectively relieve BOO. MPC has certain advantages and a lower incidence of complications as compared with SPPC.

1 Introduction

Benign prostatic hyperplasia (BPH) is a popular disease in elderly men. In the 1970s, the suprapubic prostatectomy (SPPC) was one of the conventional operative methods for BPH. In 1990, Dixon et al^[1] first reported the employment of Madigan prostatectomy (MPC). In this operation the hypertrophic adenomatous tissue was removed outside the urethra which is thus retained intact. Preservation of urethral intactness gives the method an enormous advantage over the conventional operative procedures. The urine will not leak out from and the blood at the operation site will not leak into the urinary tract. In MPC, postoperative catheter drainage is ordinarily not used or used only for a short period of time as bladder irrigation is not compulsory. Furthermore, preservation of the bladder neck will prevent the occurrence of retrograde ejaculation commonly seen in transurethral resection of prostate (TURP)^[2-4].

2 Materials and methods

2.1 Patients

From 1991 to 1996 a total 43 patients, aged 58-82 (mean 63) years, with BOO resulted from BPH, underwent surgical intervention with either MPC (21 cases) or SPPC (22 cases). All the patients had been subjected to a screening program consisting of digital rectal examination, urine culture, transrectal prostatic ultrasonography, renal ultrasonography, urethrocystoscopy, and the determination of prostate specific antigen and sedimentation rate before surgical intervention; those patients with neurogenic bladder or urethral dysfunction were excluded.

2.2 Surgery and observation

The MPC was performed according to Dixion et al^[1] and SPPC according to the conventional procedure. Before the operation and 6 months after that, subjective (IPSS questionnaire) and objective (urodynamic data) evaluation were accessed. The IPSS questionnaire consists of 7 questions with a maximal score of 5 for each question. The presence of retrograde ejaculation and erectile dysfunction (ED) were also inquired. The urodynamic study, consisting of uroflowmetry, urethral pressure profilometry (UPP), Stress UPP (SUPP), filling cystometry-electromyography and voiding pressure-flow study, was performed using the Dantec Menuet Advanced Urodynamic System. The methods, definitions and units used in the urodynamic study were based on the standards recommended by ICS^[11]. The bladder was catheterized with a 8F catheter with two lumens: one used for medium rate bladder filling with saline at room temperature and the other for pressure recording. The rectum was catheterized with an 8F catheter with a balloon to record the rectal pressure. The pressures in the bladder and rectum and the flow rate were measured with external pressure transducers and flowmeter. The detrusor pressure was calculated by subtraction of the rectal pressure from the intravesical pressure. Throughout the study the pelvic floor electromyography was recorded by self-adhesive electrodes to indicate the behavior of pelvic floor muscles during voiding. Before cystometry with the patient in the supine position, the bladder was emptied through the transurethral catheter and then filled at a speed of 30 mL per minute with sterile saline at room temperature. During the filling phase, the vesical and rectal pressures were examined every minute when asking the patient to cough. At the maximal cystometric capacity (MCC), the patients were asked to stand up to enter the voiding phase. The pressure and flow data were recorded and analyzed by the urodynamic computer program with a flow delay time correction of 0.7 second. Uroflowmetry, UPP and SUPP were done according to the standards recommended by ICS^[11]. The post-voiding residual volume (PVR) was measured by transabdominal ultrasonography. Stress incontinence (SIC) was diagnosed according to the standard of ICS^[11].

BOO was diagnosed and graded according to the different parameters of pressure-flow study that included the maximal flow rate (Q_maxPF), detrusor pressure at the maximal flow rate (P_detQ_max), ICS nomogram^[9], Schaefer nomogram with linear passive urethral resistance relation analysis (L-PURR)^[8,12,13] and AG number (P_detQ_max-2Q_max)^[14]. Different criteria for the diagnosis and grading of BOO consisted of Schaefer L-PURR≥3, AG number≥40 and the obstructed area on ICS nomogram.

2.3 Data processing

3 Results

The changes in the urodynamic parameters and IPSS in patients 6 months after treatment are shown in Table 1 and Figure 1. The MPC group had a significant improvement in symptom scores and urodynamic parameters after operation. The IPSS, PVR, and P_detQ_max decreased significantly (P<0.01), the free Q_max and Q_maxPF increased significantly (P<0.01), and both the L-PURR and AG number showed a statistically significant improvement (P<0.01). Table 2 indicated that the incidence of pre-operative BOO was 90.5% with ICS or Scheafer nomogram, while post-operatively only 19.0% of the patients still had BOO and residual obstruction (RO).

As shown in Tables 3 and 4 and Figure 2, the bleeding volume, the duration of catheter drainage, the days of hospitalization as well as the incidences of bladder spasm, hemorrhage, infection, urethral stricture, retrograde ejaculation and ED were significantly lower in the MPC than in the SPPC group (P<0.05 or 0.01). There were no significant differences in prostatic volume and incidence of SIC between the two groups (P>0.05). The incidence of RO and the need of re-operation were higher in the MPC than in the SPPC group (P<0.05).

Table 1. IPSS and urodynamic parameters before and after operation in the 2 groups. ^cP<0.01, compared with the pre-treatment value.

	MPC (n=21)			SPPC (n=22)
	Pre-treatment	6 month post-treatment	Improvement	Pre-treatment	6 month post-treatment	Improvement
IPSS	25.2±5.1	5.0±1.5c	20.2±3.3	26.1±5.6	3.0±1.0c	23.1±3.1
PVR (mL)	113.4±21.5	14.8±11.2c	98.6±15.4	116.5±57.8	7.5±8.1c	109.0±38.1
Qmax(mL/s)	8.5±0.6	22.8±1.2c	14.3±0.8	8.1±0.5	26.1±1.2c	18.0±0.8
MCC (mL)	253.0±42.0	358.0±31.2	105.0±38.0	240.3±55.0	361.4±30.2	121.1±42.3
QmaxPF (mL/s)	8.0±0.5	21.7±1.0c	13.7±0.8	7.5±0.4	23.6±0.9c	16.1±0.7
PdetQmax(cmH2O)	143.9±8.2	37.8±6.1c	106.1±6.1	155.1±9.2	22.5±6.1c	132.6±8.2
L-PURR	5.2±2.5	1.6±0.8c	3.2±1.5	5.5±2.2	1.2±0.5c	4.3±1.3
AG number	127.9±1.0	-5.7±1.5c	133.6±0.9	140.1±0.8	-24.8±0.8c	164.9±0.9

Table 2. Classification and grading of BOO before and after operation in the 2 groups.

	MPC (n=21)				SPPC (n=22)
	Pre-treatment		6 month post-treatment		Pre-treatment		6 month post-treatment
	No.	%	No.	%	No.	%	No.	%
Schaefer nomogram
L-PURR≥III	19	90.5	4	19.0	20	90.9	3	13.6
L-PURR≤III	2	9.5	17	81.0	2	9.1	19	86.4
ICS nomogram
Obstructed	19	90.5	4	19.0	20	90.9	3	13.6
Equivocal	2	9.5	0	0	2	9.1	0	0
Unobstructed	0	0	17	81.0	0	0	19	86.4

Table 3. Post-operative complications in MPC and SPPC groups.

Table 4.  Comparison of certain clinical indices between MPC and SPPC groups.

Figure 1. The comparison of improvements for symptom scores and bladder outflow obstruction after operation in MPC and SPPC group.
Figure 2. The comparison of incidences of complications between MPC and SPPC groups. 
A: stress incontinence; B: residual obstruction; C: bladder spasm; D: hemorrhage;   E: infection; F: urethral stricture; G: retrograde ejaculation; H: erectile dysfunction; I: re-operation.

4 Discussion