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

CLINICS 2012;67(12):1415-1418 DOI:10.6061/clinics/2012(12)11 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 Clı́nicas da Faculdade de Medicina da Universidade de São Paulo, General Surgery, Division of Urology, São Paulo, SP/Brazil. 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. Marmiroli R, Antunes AA, Reis ST, Nakano E, Srougi M. Standard surgical treatment for benign prostatic hyperplasia is safe for patients over 75 years: Analysis of 100 cases from a high-volume urologic center. Clinics. 2012;67(12):1415-1418. Received for publication on June 12, 2012; First review completed on July 26, 2012; Accepted for publication on August 20, 2012 E-mail: Tel.: 55 11 3255-6372 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). 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). Copyright ß 2012 CLINICS – This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. No potential conflict of interest was reported. 1415 Benign prostatic hyperplasia and elderly Marmiroli R et al. CLINICS 2012;67(12):1415-1418 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. Incidental carcinoma of the prostate was present in 6% of cases (5% T1a and 1% T1b). One case had incidental urothelial bladder cancer. Even though patients who presented complications had larger prostates, higher PSA levels and higher rates of hypertension, diabetes and coronary disease, no variable was statistically associated with the occurrence of complications (Table 1). DISCUSSION This study demonstrates that traditional surgical treatments for BPH can be performed in patients older than 75 years with acceptable complication rates and good functional results. No variable was statistically associated with the occurrence of complications; therefore, no comorbidity taken alone can be considered an absolute contra-indication for these procedures. With the increase in the number of aging males in most populations, an improved understanding of the clinical characteristics of this selected population is important for improving surgical outcomes. On average, patients with BPH who are candidates for surgical treatment are older than before. Choi et al. (18) compared the characteristics of patients who underwent surgery in 1985 to 1989, in 1995 to 1999 and in 2005 to 2009. The mean ages of the men were 65.4, 65.9 and 69.3 years, respectively. Likewise, the prevalence of hypertension, a history of surgery, and "other complications" (e.g., stroke, cancer and cardiac conditions) increased significantly over time. The prevalence of hypertension increased from 22% in the first period to 43% in t (...truncated)