Sławomir Dutkiewicz, Maciej Fortuna
- Department of Urology, ATTIS Center, Warsaw and the Specialistic Hospital, Nowy Sącz, Poland
stercz, swoisty antygen sterczowy, łagodny rozrost stercza, adenomektomia, dolne drogi moczowe, zaleganie moczu w pęcherzu po mikcji
Introduction. Prostatectomy remains the definitive method of treatment of patients with benign prostatic hyperplasia (BPH), especially
- in those with markedly enlarged prostate. International Prostate Symptoms Score (IPSS) and post-void residual urine volume (PVR) are used to assess BPH stage. Determination of serum prostate specific antigen (PSA) level provides an additional estimate of prostatic volume and is a tool to detect prostatic cancer. We present the course of serum PSA values assessed before the operation and at regular intervals up to 5 years postoperatively.
Material and methods. 101 patients (pts) with BPH (mean age 62.5 yrs), underwent transvesical prostatectomy. Serum PSA was determined preoperatively and at regular intervals up to 60 months postoperatively. Also, suprapubic ultrasonography (USG) was used to assess prostatic volume and to determine PVR. All pts underwent physical examination and filled in the IPSS questionnaire.
Results. Baseline average PSA (before operation) was 4.2 ng/ml (range 1.9-8.1) and after 1 month stabilized at less than 1 ng/ml (mean 0.75 ng/ml; range 0.00 to 2.0 ng/ml) during the 5 yr. follow-up. However, PSA rise over 4 ng/ml approximately 3 yrs. postoperatively
- was found in 6 pts who were thus excluded from this study, despite biopsy negative for cancer, and in whom USG confirmed adenomatic tissue regrowth. Mean baseline PVR fell from 372 ml ±120 ml to 15,9 ml ±7 ml postoperatively (P<0.001) and achieved only trace levels thereafter. Similarly, average preoperative IPSS decreased from 24.5 to 2.8 1 month after the operation (P<0.001) and remained at this level throughout the follow-up.
Conclusions. 1. Following transvesical prostatectomy serum PSA decreases to less than 1.0 ng/ml by 1 month and remains at this level for up to 60 months postoperatively. 2. Open surgery of the prostate remains an effective therapeutic modality for BPH, particularly
- in pts with large prostates and a history of complete urine retention.
Surgical therapy of BPH (benign prostatic hyperplasia) remains the definitive treatment modality in patients with a markedly enlarged prostate and concomitant disorders such as acute urinary retention (AUR), bladder calculi, renal insufficiency secondary to bladder outlet obstruction or severe lower urinary tract symptoms (LUTS) refractory to medical management . Practically there are two most popular methods of open enucleation
of prostatic adenoma: the suprapubic and retropubic approach .
Serum PSA is a marker of prostate disease risk. The relationship
between prostate volume and serum PSA is established and PSA levels are transiently elevated in many clinical conditions [3,4]. It is well known that manipulation of the prostate can cause an increase in the PSA serum level [5,6,7].
It is also possible that PSA may be used as the cutoff for assessing postoperative prostate growth or the necessity of re-
treatment for instance occult malignancy.
Helfand B. et al  reported that PSA-like clinical tools had never been determined for open prostatectomy. However, they must have missed our previous study showing
that following prostatectomy PSA decreases to less than 1.0 ng/ml .
Prospective evluation of postprostatectomy PSA values.
Material and methods
This study included 101 men with BPH who underwent transvesical prostatectomy from January 1997 to January 2002 at a single institution: Department of Urology, the Specialistic Hospital in Nowy Sącz, Poland. Their age varied from 56 to 70 yrs. (mean 62.5 yrs). Indication for surgical treatment was markedly enlarged prostate (above 60 g), acute urinary retention
(AUR), urinary tract infection and severe LUTS refractory to medical management. Serum PSA was determined preoperatively
and at regular intervals (every 12 months) up to 60 months postoperatively.
Suprapubic ultrasound (USG) was also employed to determine
prostate size and PVR as well as IPSS questionnaire as tools to assess patients’ LUTS secondary to BPH. The pts received postoperative antibiotic prophylaxis (mean 7 to 10 days). Foley catheter drainage was continued until clear urine (7 days postoperatively
on the average). Suprapubic catheters (Malecot) were removed 2 to 5 days postoperatively. All excised tissue was sent for pathological examination. The means and standard deviations (±SD) were determined for all data and the student-t test was applied for the statistical analysis of the results.
Mean preoperative PSA was 4.2 ng/ml (range 1.9-8.1). 10-12 days and 1 month postoperatively it decreased to 1.4 ng/ml (range 0.2-2.8) and 0.75 ng/ml (range 0.0-2.0) respectively. Throughout follow-up in all pts PSA maintained at markedly reduced serum PSA (P<0.001) which further decreased to mean of 0.5 ng/ml (range 0.0-0.7ng/ml) after 60 months postoperatively
(fig. 1). However, six pts developed PSA >4 ng/ml approximately
3 years postoperatively. These patients were excluded from this study in spite of negative biopsy for cancer and in whom USG confirmed adenomatic tissue regrowth. The remaining
95 patients also demonstrated significant improvement in PVR and LUTS following surgical intervention. Preoperative average PVR was 372 ml ±120 ml compared to 15,9 ml ±7 ml assessed one month postoperatively (P<0.0001). Mean preoperatively
IPSS was 24.5 (range 17 to 30) and decreased to 2.8 (range 1 to 5; preoperative vs postoperative: P<0.001).
No major complications occurred intraoperatively. Three pts had transient urinary incontinence postoperatively which resolved
during following 5 months.
Prostatectomy has become less common with the advent of medical management and minimally invasive techniques for treatment of BPH. In pts with a markedly enlarged prostate the surgical mode of treatment still remains the preferred treatment [1,2]. Transvesical prostatectomy is an effective method of treating bladder outlet obstruction, especially in pts with large prostates and with a history of AUR. Also, significantly lower blood lose was associated with suprapubic than retropubic prostatectomy [1,9]. The first goal of BPH therapy is subjective improvement in LUTS which may be measured by IPSS, for instance. The results of our study demonstrate long term improvement in LUTS.
In our earlier report  and in our present study serum PSA decreased significantly following open surgery. Serum PSA of less than 1.0 ng/ml 1 month postoperatively was maintained at this level for up to 60 months. Long term reduction in PSA should be ascribed mainly to the excision of the adenoma. Of note, other factors like prostate cancer, urinary retention and catheterization, potentially producing PSA rise, were absent in the operated pts [3,5,6,7]. Our results are quite close to those found in our earlier report  and to those reported by Helfand B. et al . To the best of our knowledge the latter were not the first to indicate that following surgery (prostatectomy) serum PSA decreases to less than 1,0 ng/ml. The studied pts demonstrated
also significant improvement in PVR following surgical intervention. The present results are in keeping with those by Helfand et al . We agree with the authors’ opinion that PSA may be used as the cutoff for assessing postoperative growth and allows to define the need for re-treatment.
- Following transvesical prostatectomy serum PSA decreases to less than 1.0 ng/ml by 1 month and remains at this level for up to 60 months postoperatively.
- Transvesical prostatectomy is an effective therapeutic modality for BPH, especially in pts with large prostates and with a history of complete urine retention. The improvement in lower urinary tract symptoms and post-voit residual urine is maintained
for a long time.
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Slawomir A. Dutkiewicz
2, Lachmana str., app. 56
02-786 Warsaw, Poland
phone: +48 502 025 880