BPH is a pathologic process that can cause lower urinary tract symptoms. Etiology of prostatic growth demonstrates that prostate size increases slowly and steadily with aging.1
However, cause and effect links have not been established. The term “giant prostatic hyperplasia” was defined by Fishman and Merrill2
as exceeding 500 g. In this case, preoperative MRI revealed a 580 mL prostate, and actual weight was 475 g.
Although we thought that the increment in the PSA level was probably due to the enlarged prostate adenoma, we performed a biopsy (ten specimens) to rule out prostatic cancer. The result showed no malignant cells.
Surgical treatment for men with BPH is reserved for those who do not respond well to medical therapy or who have complications such as urinary retention. In this case, we considered that there was a surgical indication since macrohematuria continued and he was suffering from lower urinary tract symptoms.
Transurethral resection of the prostate, the gold-standard surgery, is usually applicable to a BPH of up to moderate size (<50–80 mL).3
On the other hand, the surgical treatment options for BPH have dramatically changed over the past two decades with the development of minimally invasive therapies. They include holmium laser enucleation of the prostate, transurethral electrovaporization of the prostate, transurethral microwave thermotherapy, and others.3
However, these techniques are also performed for patients with slightly to moderately enlarged prostates. Rocco et al stated that 100 g is regarded as the limit of weight for those minimally invasive procedures.4
European Association of Urology guidelines also show that open prostatectomy is the treatment of choice for large prostatic glands more than 80–100 mL5
Since 2002, new minimally invasive simple prostatectomy techniques have been reported. McCullough et al published the data that laparoscopic simple prostatectomy for patients with BPH was less invasive compared to open prostatectomy.6
They stated that men who underwent laparoscopic prostatectomy had less postoperative catheter time and a shorter hospital stay, although a longer operation time. As for the prostate size, the average preoperative prostatic volume was 111.3 ± 35.3 cm in the laparoscopic group.6
It was thought that patients with severely enlarged adenoma were not treated with laparoscopic surgery. In 2008, robotic simple prostatectomy was first reported by Sotelo et al.7
Furthermore, Vora et al summarized the studies of robotic simple prostatectomy.8
In summary, robotic surgery provides all the merits of laparoscopy with a potentially shorter learning curve. Urinary flow rate, postvoid residual urine, and IPSS scores were also improved by robotic prostatectomy. Operation time and estimated blood loss were similar to those seen in the laparoscopic group. However, Sutherland and colleagues reported that they could not successfully perform robot-assisted simple prostatectomy for a man with severe prostatomegaly (260 g), although a maximal limit was not placed on prostatic adenoma size during the preoperative evaluation.9
These two papers indicated that both laparoscopic and robotic simple prostatectomy would not be feasible for severely enlarged prostate.
Thus, we considered that simple prostatectomy was the recommended treatment for men with enlarged prostate, including giant hyperplasia. In this case, as the estimated prostate volume based on MRI was 580 mL, we performed retropubic open prostatectomy. Operation time was short, and no major complication occurred.
To the best of our knowledge, this is the 15th-heaviest adenoma ever reported in the English-language literature.10
Simple open prostatectomy was performed in all 15 cases. We believe that open surgeries are recommended for giant prostatic hyperplasia.