Standard surgical treatment for benign prostatic hyperplasia is safe for patients over 75 years: analysis of 100 cases from a high-volume urologic center

CLINICAL SCIENCE   Standard surgical treatment for benign prostatic hyperplasia is safe for patients over 75 years: analysis of 100 cases from a high-volume urologic center     Rafael Marmiroli; Alberto A. Antunes; Sabrina T. Reis; Elcio Nakano; Miguel Srougi Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, General Surgery, Division of Urology, São Paulo, SP/Brazil     ABSTRACT OBJECTIVES: In this study, we aimed to determine the complications of standard surgical treatments among patients over 75 years in a high-volume urologic center. METHODS: We analyzed 100 consecutive patients older than 75 years who had undergone transurethral prostatic resection of the prostate or open prostatectomy for treatment of benign prostatic hyperplasia from January 2008 to March 2010. We analyzed patient age, prostate volume, prostate-specific antigen level, international prostatic symptom score, quality of life score, urinary retention, co-morbidities, surgical technique and satisfaction with treatment. RESULTS: Median age was 79 years. Forty-eight patients had undergone transurethral prostatic resection of the prostate, and 52 had undergone open prostatectomy. The median International Prostatic Symptom Score was 20, the median prostate volume was 83 g, 51% were using an indwelling bladder catheter, and the median prostatespecific antigen level was 5.0 ng/ml. The most common comorbidities were hypertension, diabetes and coronary disease. After a median follow-up period of 17 months, most patients were satisfied. Complications were present in 20% of cases. The most common urological complication was urethral stenosis, followed by bladder neck sclerosis, urinary fistula, late macroscopic hematuria and persistent urinary incontinence. The most common clinical complication was myocardial infarction, followed by acute renal failure requiring dialysis. Incidental carcinoma of the prostate was present in 6% of cases. One case had urothelial bladder cancer. CONCLUSIONS: Standard surgical treatments for benign prostatic hyperplasia are safe and satisfactory among the elderly. Complications are infrequent, and urethral stenosis is the most common. No clinical variable is associated with the occurrence of complications. Keywords: Prostatic Hyperplasia; Prostatectomy; Transurethral Resection of Prostate; Aged; Quality of Life, Complications.     INTRODUCTION Benign prostatic hyperplasia (BPH) represents an increase in the total number of stromal and epithelial cells within the prostate gland. It is associated with bothersome lower urinary tract symptoms that affect the individual's quality of life and interfere with day-to-day activities. BPH is now one of the most common diseases in the elderly. According to histological studies, more than 50% of men will face this diagnosis by the age of 60 (90% by the age of 85) (1). Assuming that by the year 2030, 20% of the population of the United States will be older than 65 years (2), the rise in the incidence of lower urinary tract symptoms (LUTS) due to BPH makes it a public health question. LUTS involve an estimated annual impact of $1.1 billion of direct costs (excluding outpatient pharmaceuticals) and indirect costs of approximately 38 million hours of lost productivity by these patients (3). In recent decades, several new methods for treating BPH have been developed, both pharmaceutical and surgical. Several minimally invasive procedures are still favored by the international community due to their lower complication rates. However, it is necessary to remember that the perceived efficacy and long-term durability of these therapies remain to be proven; so far, the gold-standard treatments are still open prostatectomy (OP) and transurethral resection of the prostate (TURP) (4). Because BPH is associated with old age, OP and TURP are usually performed in patients with various comorbidities. Some studies have confirmed a direct effect of comorbidity on perioperative morbidity and mortality after these procedures (5,6). However, OP and TURP patient populations, especially in multicenter studies and meta-analyses with large numbers of patients, are generally approximately 65 to 75 years old (7,8). A better understanding of the clinical characteristics of patients over 75 years old is important for preventing complications and improving clinical outcomes. In this study, we aimed to determine the complications (both clinical and urological) of standard surgical treatments among patients over 75 years in a high-volume urologic center.   MATERIALS AND METHODS We analyzed a selected group of 100 consecutive patients older than 75 years who had undergone TURP or OP for BPH from January 2008 to March 2010. Exclusion criteria in this study were previous surgical treatment for BPH, diagnosis of prostate cancer and suspected neurogenic bladder. Preoperatively, all patients were subjected to anamnesis focused on urinary symptoms, according to the International Prostate Symptom Score (IPSS) and QOL (Quality Of Life) gradation. We also analyzed the available information from digital rectal examinations, prostate ultrasounds, prostate-specific antigen (PSA) levels, use of an indwelling bladder catheter due to urinary retention, presence of co-morbidities (arterial hypertension, diabetes and coronary diseases) and surgical technique. To analyze treatment outcome, patients were asked if they were satisfied with the treatment results. Urologic and non-urologic complications were recorded. It is important to note that all patients preoperatively attended an evaluation with specialists; patients who were considered to be at high risk of complications (cardiological or other) after an analysis of their global health status and comorbidities were not treated with surgery. Statistical analysis was performed using SPSS® 19.0 software for Windows® (IBM Incorporated, Armonk, New York), and significance was defined as p<0.05. All data are presented as median (range) unless specified otherwise. We determined the risk factors for complications using the chi-square and Student's-t tests.   RESULTS The median patient age was 79 years (75 to 91). Forty-eight patients were subjected to TURP and 52 to OP. Hypertension, diabetes and coronary disease were present in 69%, 24% and 26% of the cases, respectively. Median preoperative IPSS was 20 (8 to 31), and 51% of patients were using an indwelling bladder catheter. Median prostate volume was 83 g (24 to 417), and median PSA level was 5.0 ng/ml (0.2 to 60). After a median follow-up period of 17 months (1 to 40), 83% of patients were satisfied with the treatment. Overall, complications were present in 20% of cases. Regarding urological complications, 10% presented urethral stenosis, 2% had bladder neck sclerosis, 2% had urinary fistula, 2% had late macroscopic hematuria and 2% had persistent urinary incontinence. Among clinic (...truncated)