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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 27  |  Issue : 3  |  Page : 242-247

Management of a giant prostatic enlargement: Case report and review of the literature


1 Department of Surgery, Urology Unit, College of Medicine, University of Lagos; Department of Surgery, Urology Unit, Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, Nigeria
2 Department of Surgery, Urology Unit, Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, Nigeria

Date of Submission06-Apr-2020
Date of Decision08-May-2020
Date of Acceptance10-May-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Rufus Wale Ojewola
Department of Surgery, Urology Unit, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Surulere, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_69_20

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  Abstract 


Giant prostatic enlargement often referred to as giant prostatic hyperplasia (GPH) is a rare condition described as a massive prostatic enlargement >500 g. Up until now, the total number of GPH reported worldwide in medical literature is < 30. To the best of our knowledge, only one case of a giant prostate has been reported in Nigeria. We report a case of a giant prostatic enlargement treated by open simple retropubic prostatectomy in a 73-year-old man who was suffering from lower urinary tract symptoms and persistent visible (gross) haematuria necessitating repeated blood transfusions. Transrectal ultrasound (TRUS) scan revealed a markedly enlarged prostate measuring 565 ml with a suspicious nodule and prostate-specific antigen level of 48.5 ng/ml. He had a 20-core TRUS-guided prostatic biopsy which showed benign prostatic hyperplasia. We performed a retropubic open simple prostatectomy for complete enucleation of the adenoma. Specimen weighed 512.5 g with dimensions of 17 cm × 16 cm and a volume of 528 ml. Histological examination showed prostatic fibromuscular hyperplasia with a focus of adenocarcinoma. The patient had an uneventful post-operative recovery and was discharged within a week post-surgery. Urethral catheter was removed after 2 weeks with satisfactory outcome.

Keywords: Benign prostatic hyperplasia, giant prostatic enlargement, giant prostatic hyperplasia, prostatectomy


How to cite this article:
Ojewola RW, Tijani KH, Fatuga AL, Onyeze CI, Okeke CJ. Management of a giant prostatic enlargement: Case report and review of the literature. Niger Postgrad Med J 2020;27:242-7

How to cite this URL:
Ojewola RW, Tijani KH, Fatuga AL, Onyeze CI, Okeke CJ. Management of a giant prostatic enlargement: Case report and review of the literature. Niger Postgrad Med J [serial online] 2020 [cited 2020 Oct 28];27:242-7. Available from: https://www.npmj.org/text.asp?2020/27/3/242/289919




  Introduction Top


Benign prostatic hyperplasia (BPH) is the most prevalent benign tumour in elderly men, and its incidence is age related.[1] Many patients with BPH will only manifest with lower urinary tract symptoms (LUTS), but an appreciable percentage will also suffer other BPH-related complications that will make them seek urological intervention.[2] Giant prostatic enlargement popularly referred to as giant prostatic hyperplasia (GPH) is a terminology used specifically for massively enlarged prostate glands with measured weight >500 g.[3] It has been demonstrated that BPH usually accompanies ageing process in men.[4] As a man advances in age, the enlarged prostate typically causes storage and voiding LUTS. There is no positive correlation between size of the prostate and presence and severity of symptoms. Small-sized prostate may produce symptoms, whereas big-sized ones may not.[5] We report our experience of successful removal of a symptomatic GPH by open simple retropubic prostatectomy.


  Case Report Top


A 73-year-old male presented at the Accident and Emergency Unit of the Lagos University Teaching Hospital, Lagos, on 5 November 2019 with complaints of progressively worsened voiding and storage LUTS of 6-month duration that eventually culminated in an episode of acute urinary retention (AUR) 3 weeks before presentation. This was successfully relieved by urethral catheterisation in a private hospital. There was a history of recurrent episodes of painless visible haematuria in the past. He gave a history of transfusion once in the past during an episode of haematuria. He developed another episode of haematuria a week after catheterisation with associated weakness, dizziness, palpitation and easy fatigability though no fainting spells. This necessitated referral to our centre. There was neither history of any chronic medical condition nor positive family history of prostatic diseases.

General physical examination revealed an elderly man who was conscious and alert but markedly pale. His pulse rate was 110 bpm with blood pressure of 119/56 mmHg, respiratory rate of 24cpm and oxygen saturation of 96% on room air. Abdominal examination revealed a non-tender huge suprapubic mass of about 20-week size [Figure 1]. Kidneys, liver and spleen were not palpably enlarged. He had an indwelling size 20Fr urethral Foley catheter draining blood-stained urine. Prostate examination revealed a markedly enlarged prostate with benign features. An initial impression of bleeding BPH with symptomatic anaemia was made. The differential diagnoses in this patient were prostate and bladder cancers.
Figure 1: The straight arrow shows suprapubic swelling from the giant hyperplastic prostatic gland, whereas the curved arrow shows haematuric urine in the indwelling silicone urethral catheter

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Full blood count revealed severe anaemia with packed cell volume of 15.6%, whereas white blood count and platelets were essentially normal. Renal function test showed renal impairment with creatinine and urea values of 301.8 μmol/L and 12.4 mmol/L, respectively, and the prostate-specific antigen (PSA) was elevated, 48.5 ng/ml. Both transrectal ultrasound (TRUS) and pelvic ultrasound scans revealed a markedly enlarged prostate (125 mm × 98 mm × 89 mm = 565 ml) and (118mm x 97mm x 88mm= 524ml), respectively with significant intravesical protrusion, irregular outline and heterogeneous glandular echotexture. A hypoechoic nodule measuring 33 mm × 26 mm was seen in the left peripheral zone of the base of the prostate gland. A nodule was seen to demonstrate internal vascularity on colour Doppler interrogation. Abdominopelvic ultrasound also showed thickened urinary bladder with bladder wall thickness of 17 mm and mild bilateral hydronephrosis. There was no bladder diverticulum or stone. Haematuria was managed conservatively with continuous bladder irrigation and transfusion of three pints of whole blood. Repeat renal function was normal with creatinine and urea levels of 114 μmol/L and 6.8 mmol/L, respectively, after 2 weeks of continuous bladder drainage. He later had a 20-core TRUS-guided prostate biopsy which ruled out malignancy.

He had another episode of total and persistent painless haematuria within 2 weeks. For this, he was urgently worked up for open simple retropubic prostatectomy which he had on 26 November 2019 after a written consent was obtained. Findings at surgery include a highly vascular and markedly trilobar prostate enlargement with massive median lobe protrusion into the bladder as well as a thickened bladder wall with numerous blood vessels [Figure 2]. Haemostatic stitches were applied to the dorsal venous complex, the lateral pedicles as well as other prominent blood vessels on the prostate and the bladder neck. In addition, other prominent vessels on the bladder were coagulated with diathermy before a transverse capsulotomy was performed. The hugely enlarged prostate was enucleated in three main pieces, and prostatic fossa was packed with gauze for 15 min. Haemostasis was secured, and a three-way 22Fr haematuric catheter was inserted. A watertight capsulorrhaphy was carried out and a pelvic drain inserted and secured. Wound was closed in layers; catheter balloon was inflated with 60 cc of sterile water and bladder irrigation commenced on the table. The operation lasted about 90 min with an estimated blood loss of about 700 ml. An immediate weighing of the specimen showed a weight of 512.5 g [Figure 3] with dimensions of 17 cm × 16 cm and a volume of 528 ml measured by volume displacement technique. Post-operative condition was satisfactory. Haematuria cleared completely after 4 days of bladder irrigation, and the patient was transfused with three units of whole blood in the post-operative period. He was discharged home on indwelling catheter on the 7th day. He had his urethral catheter removed on the 14th day at the outpatient clinic, and the patient voided without any difficulty. He was reviewed again after 6 weeks, and he continued to have satisfactory voiding with normal continence.
Figure 2: The arrow shows the massive pelvic mass with prominent blood vessels extending from the true pelvis to the suprapubic and lower abdominal region after application of haemostatic stitches

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Figure 3: Enucleated prostatic adenoma specimens on weighing scale with weight of 512.5 g and length of 17 cm

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The enucleated prostate was sent for histopathology. Macroscopic examination showed three firm nodular pieces of greyish-white tissue with accompanying tiny fragments ranging in size from 3 cm × 2 cm × 1 cm to 9 cm × 8 cm × 7 cm. Cut sections showed greyish-white surfaces with areas of haemorrhage. Microscopy showed sections of prostatic tissue with fibrocollagenous stroma within which are glands lined by the inner basal layer and outer columnar layer with a focus of glands lined by a single layer of columnar cells with no basal layer. Also present were areas of infarction. A histological diagnosis of BPH with a focus of invasive adenocarcinoma [International Society of Urological Pathology (ISUP) grade1 (Gleason 3+3=6)] was made.


  Discussion Top


BPH is a well-known cause of bladder outlet obstruction (BOO) and can cause visible haematuria.[6] It is regarded as an endocrine event secondary to the proliferation of epithelial and stromal cells, impairment of programmed cell death or both.[7] Aetiology of prostatic development and growth shows that prostatic size increases slowly in a regular fashion with ageing.[8] Very rarely, the prostate enlarges immensely and eventually gives rise to a GPH.[1]

Although very large or massive prostatic enlargements have been encountered in urological practice before, the term 'GPH' was coined by Fishman and Merrill to characterise glands weighing more than 500 g when they reported successful surgical removal of a 526 g prostate in 1993.[3] GPH is a rare phenomenon, with only 16 cases documented in the medical literature till 2014.[9] In some earlier reports, few giant prostates were not accounted for because of non-uniform terminologies used in reporting such as massive, huge or markedly enlarged prostate. After the report of the 17th case by Khan et al.[9] in 2014, few more have been reported and attempts have been made in this study to include the newly reported as well as other giant prostates excluded in the earlier reports as a result of the use of different terminology other than GPH. Conversely, a good number of researchers erroneously used the term GPH for prostates <500 g but usually >200 g in their reports. With a thorough search of medical literatures, only 29 prostates met the criterion of GPH including three patients who were diagnosed with imaging studies but were not offered any surgical treatment. This makes the current case to be the 30th reported giant prostate in medical history [Table 1].
Table 1: Giant prostatic enlargement/hyperplasia in medical literature

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The biggest prostate in medical literature used to be the surgically resected 2410g prostate in a 57-year-old man with LUTS reported by Medina Pérez et al.[7] in 1997. However, Domínguez et al.[10] reported the case of a 72-year-old man with magnetic resonance imaging (MRI) diagnosis of a GPH with a prostatic volume of 3987 ml in 2016. Their patient had mild LUTS which remained stable over a period of 10-year follow-up and therefore required no form of surgical treatment. In essence, the prostate weight of 2410 g reported by Medina Pérez et al. is still the biggest prostate ever removed surgically in medical literature. To the best of our knowledge, only one case of GPH has been reported in Nigeria till date. Akpo and Akpo[33] reported the successful enucleation of a 510 g prostate with 14 cm × 14 cm in dimension in 2010. The volume of the enucleated prostate was not stated. In the current case, the prostate was slightly bigger at a weight of 512.5 g, 17 cm × 16 cm in dimension and actual volume of 528 ml making this to be the biggest prostate ever reported in Nigeria and the 28th biggest giant prostate reported in the medical history.

'The pathophysiology of GPH is not fully understood. Hypotheses suggest a combination of disruption in normal stromal-epithelial paracrine signalling, an imbalance between androgenic, cytokine and peptide growth signalling, a reduction in apoptosis and a proliferation in stromal and epithelial cells which result in significant prostate enlargement. Specifically, mutations of proto-oncogenes such as Ras and c-erbB2, as well as the downregulation of the p53 suppressor gene, can lead to the abnormal and continuous cellular proliferation'.[6]

BPH can be symptomatic or asymptomatic. When symptomatic, it usually manifests as LUTS or complications of BOO. The severity of symptoms is, however, independent of prostatic size as small-sized prostate may produce symptoms, whereas big-sized one may not.[35] The prevalence rate of visible haematuria in men with clinical BPH is approximately 2.5%, and it is rarely seen as an initial presentation.[36] However, GPH has been associated with recurrent bleeding. Although not common, GPH can cause massive haematuria leading to haemodynamic instability. This may necessitate immediate resuscitation and urgent definite treatment of the enlarged prostate. This is particularly common with GPH.[18],[23] Like many others with GPH, our patient had many episodes of visible haematuria and multiple blood transfusions. He was operated for recalcitrant haematuria and AUR. Furthermore, unclear is the exact aetiology of bleeding in men with enlarged prostates. Increased microvessel density and overexpression of vascular endothelial growth factor are possible mechanisms for this.[37] Another common presentation of GPH as seen in this index case is suprapubic swelling raising a suspicion of chronic urinary retention or bladder tumour.

Prostatic volume can be measured either by transrectal or pelvic ultrasound, computerised tomography (CT) scan or MRI. In this index patient, transrectal and pelvic ultrasound scans gave values of 565 and 524 mls, respectively as his prostatic volume. We did not carry out a CT scan or MRI for financial reason. When necessary, biopsies to rule out malignancy before initiating definitive therapy are of paramount importance because of its potential influence on treatment decisions.[18] Although we are of the opinion that the increase in the PSA level of our patient was due to the massive prostatic size and recent haematuria of prostatic origin, we performed a 20-core transrectal biopsy of the prostate on account of additional TRUS findings of suspicious hypoechoic nodule. Histologic findings were, however, in keeping with benign prostatic adenoma. Most of the GPH reported earlier were associated with abnormally elevated PSA level.[9],[18],[33]

Surgical intervention becomes necessary when the patient develops acute or chronic urinary retention, recalcitrant gross haematuria, urinary tract infections, obstructive nephropathy, bladder stones or severe LUTS refractory to medical treatment'.[38] Currently, the European Association of Urology recommended transurethral resection of the prostate as appropriate treatment choice for patients with prostate volume of 30–80 ml and open surgery or transurethral holmium laser enucleation for prostate volume >80 ml.[39] Open surgical enucleation either through a suprapubic (transvesical) or retropubic approach is the recommended surgical technique for GPH. Although holmium laser enucleation has shown satisfactory results with large-sized prostates, there is no report of any successful treatment of GPH with this technique yet. More recently, laparoscopic simple prostatectomy and robotic simple prostatectomy have both been deployed to treat BPH and are considered less invasive than open simple prostatectomy. Furthermore, several studies have demonstrated the feasibility of these minimally invasive techniques for severely enlarged prostates. These techniques are associated with less post-operative catheter time, shorter hospital stay, less complications and comparable results to open prostatectomy.[31],[40],[41] Despite feasibility of minimally invasive treatment for severely enlarged prostate, only one study documented successful treatment of GPH of more than 500 g.[31] In most studies on laparoscopic and robotic prostatectomies, the average volume was <120 g with a range of 53–220 g. Bhatia et al.[28] also reported the successful treatment of a case of GPH with prostate arterial embolisation technique. They reported a reduction in prostate volume from 571 to 270 ml and successful trial of voiding without catheter with satisfactory improvement in patient's bothersome LUTS 6 weeks after such treatment. They opined that the minimally invasive as well as reduced morbidity could make this procedure an appealing procedure for massively enlarged prostates, especially for men with co-morbidities. It should be stated here, however, that laparoscopic and robotic surgeries are not readily available in a developing country like ours and open technique is still commonly the approach used for moderate to severely enlarged prostates. Our patient did not have any associated co-morbidity. The giant prostatic size, advanced age and presence of bleeding complication in this patient made open simple prostatectomy the preferred operation of choice. Initial resuscitation and optimisation were necessary in this patient before the definitive surgery could be performed when he became clinically stable.

In certain instances, surgical treatment of BPH has resulted in the death of patients due to haemorrhage, and this is more so in GPH.[13],[17],[19] Intraoperatively, application of haemostatic sutures to include other prominent vessels on the prostate and bladder neck in addition to the conventional haemostatic stitches to the dorsal venous complex and lateral pedicles, diathermisation of other prominent blood vessels on bladder and packing of the prostatic fossa for longer than the usual time for smaller prostates appeared to be three helpful techniques in reducing intraoperative haemorrhage in this index patient. In order to reduce intraoperative blood loss effectively, Egote et al.[23] recommended catheter balloon inflation at the base of enucleated prostate with traction in addition to continuous bladder irrigation to decrease oozing of blood from the prostatic fossa. This technique was utilised and produced a fantastic outcome in this case.

Following catheter removal after prostate surgery for BPH, patients should ideally be reviewed about four to 6 weeks in order to assess the success of treatment and untoward events. Patients with satisfactory voiding and without adverse events require no further re-assessment.[39] We reviewed our patient after 6 weeks of surgery. He had satisfactory voiding and urinary continence. Our patient will, however, require further follow-up beyond the recommended duration for BPH patients because of the focus of Gleason 3 + 3 = 6 adenocarcinoma reported on histopathology. Gleason 6 prostate cancer carries low risk in terms of morbidity and mortality. Clinical evidence suggests that a significant proportion of elderly men harbour it for years without symptoms.[42] This patient requires no treatment for prostate cancer for now and will thus be managed by watchful waiting. Until recently, watchful waiting usually stood for delay in the commencement of palliative treatment until the cancer causes symptoms. Recently, active surveillance is recommended for younger patients. This entails frequent monitoring and curative treatment if early evidence of cancer progression is detected during monitoring.[43]


  Conclusion Top


GPH is a rare entity of massive prostatic enlargement limited to individual case reports. They are commonly associated with LUTS and recurrent bleeding. Despite the giant prostatic size, surgical treatment should only be undertaken when indicated and the patient is fit for such. Open surgical techniques still appear to be the most commonly utilised surgical treatment modality. However, laparoscopic and robotic simple prostatectomy and prostatic artery embolisation are alternatives to open surgery where available. Meticulous haemostasis before enucleation can help reduce intraoperative blood loss.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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