Minimally invasive simple prostatectomy for a case of giant benign prostatic hyperplasia

Abstract

Dear Editor, We would like to present a rare case of giant prostatic hyperplasia (GPH), which is defined as a prostate weight over 200 g for Easterners1 or 500 g for Westerns.2 Only 14 cases of GPH exceeding 500 g had been reported in the English literature by 2015 (Supplementary Table 1). To the best of our knowledge, this is the first report of removing a GPH exceeding 500 g by using minimally invasive laparoscopic technique. Reported cases of giant prostate enlargement exceeding 500 g in English literature. A 52-year-old man was admitted to our hospital with long-standing symptoms of difficult defecation or elongation of defecation with dejecta turning small, which became worse during the past 3 months. However, he just had mild hesitant urination, without manifesting significant LUTS. The IPSS was 4. The routine laboratory investigations and the sex hormone levels were within the normal limits except total PSA (69.96 ng ml−1). An imaging-urodynamic study showed that the volume of the bladder was 360 ml and the state of bladder outlet obstruction was mild, with a maximum flow rate of 18 ml s−1 and no residual urine. CT scans showed that the prostate was abnormally enlarged, measuring 10.8 cm × 9.6 cm × 10.6 cm and almost occupying the whole pelvic cavity. The rectum was severely pressed posteriorly, and the bladder and seminal vesicles were displaced anteriorly (Figure 1a). Urography revealed passable filling of the bladder with a little higher position beyond the pubic symphysis. No urethral stenosis, ectasia, or atresia was found when voiding (Figure 1b). Two prostate biopsies were consistent with the diagnosis of BPH.Figure 1: Imaging data and the removed prostatic specimen. Preoperative (a and b) and postoperative (c and d) imaging data. CT (a) show that the whole pelvic cavity is occupied by a giant prostate. Urography (b) reveals passable filling of the bladder with no urethral stenosis, ectasia, or atresia. CT (c) re-examinations show that the pelvic wound heals well and the bladder is in place. Cystoscopic urography (d) shows normal bladder containment with no urethral stenosis. (e) The final gross prostatectomy specimen measuring 11 cm × 13 cm. (f) The removed prostatic specimen weighing 524.2 g. (g) Histological observation shows a predominance of glandular hyperplasia with numerous dilated glands (H and E, ×200).The “gold standard” for surgical treatment of BPH is transurethral resection of the prostate. Conventional open prostatectomy remains an effective and durable procedure for the treatment of symptomatic BPH with a large prostate volume (>80 ml).3 With the advent of minimally invasive simple prostatectomy (MISP) in recent years, the laparoscopic approach for the treatment of large prostatic adenoma was first proposed by Mariano et al.4 in 2002. Recently, a European-American multi-institutional analysis5 provided the largest outcome analysis reported for MISP for large BPH. Their results confirmed that simple prostatectomy could be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings where specific surgical expertise and technology are available. However, the median overall prostate volume was only 100 ml. How about MISP for GPH? In 2010, Singh et al.6 reported successful removal of the largest (384 g) case of cancer prostate by robotic MISP in the literature. From this point of philosophy, we introduced laparoscopic simple prostatectomy as the premier technique for the treatment of the present case. Based on preparation with a detailed exploration of the imaging data, we finished most of the procedure by the laparoscopic operation (Supplementary Figure 1). However, due to the huge volume of the prostate, it was impossible to complete the dissection using the pure laparoscopic method even though the bladder wall was longitudinally cut apart. At the end of the operation steps, finger assistance of one hand was indispensable for reaching the apex of the prostate