Enucleation of a Giant Prostatic Hyperplasia in Ghana: A Case Report and Mini Literature Review

Herein we report a patient with a prostatic hyperplasia weighing exactly 700 g which was successfully removed at the Brong Ahafo Regional Hospital theatre in Ghana by Pfannesteil Transvesical Simple Prostatectomy. A prostatic hyperplasia of enormous size is very uncommon and to the best of our knowledge, only ten of such cases have been previously reported. The case report presented here constitutes the eleventh heaviest prostate reported in medical literature and also forms the first case report of giant prostatic hyperplasia from Ghana.


Introduction
Benign prostatic hyperplasia (BPH) in males has been shown to be commonly associated with the ageing process [1] [2]. As a man ages, the enlarged prostate usually produces obstructive and irritative lower urinary tract symptoms. The size of the prostate is independent of symptoms [3] and smaller size may produce symptoms whereas bigger size may not. In some people, the prostate enlarges massively (weighing more than 500 g) consequently developing into a giant prostatic hyperplasia (GPH) [4] [5]. Despite its undesirable effects, re-in passing urine and stools. He experienced symptoms of straining on micturition, weak stream, intermittency and incomplete emptying of the bladder. He also complained of frequency and nocturia.
He suffered an episode of acute retention of urine about a week prior to presentation and was rushed to a peripheral health facility and consequently to our facility for further management. Examination of the patient revealed a massive prostate enlargement weighing exactly 700 g. The prostate's large size and the relative lack of symptoms prior to patient presentation further explained the fact that symptoms do not necessarily correlate with the size of the prostate. To the best of our knowledge, this is the eleventh largest benign prostatic hyperplasia presented in medical literature. Though our patient could not survive in this case, we provide recommendations and suggestions to advance surgical treatment.

Case Report
This is an 88-year-old male retired civil servant with no history of alcohol or tobacco use and no known history of any chronic condition. He was in his usual state of health till about 2 weeks prior to presentation when he complained of difficulty in passing urine and stools. He experienced symptoms of straining on micturition, weak stream, intermittency and incomplete emptying of the bladder. He also complained of frequency and nocturia. He suffered an episode of acute retention of urine about a week prior to presentation and was rushed to a peripheral health facility. A suprapubic catheter was passed to relieve the obstruction after a failed urethral catheterization, but he was subsequently noticed to have experienced an episode of heamaturia and was referred to our facility (Brong Ahafo Regional Hospital in Sunyani, Ghana) for expert urological care on 1 st March 2018.
Examination revealed an elderly male, conscious, alert but confused. He was not pale, not febrile and had no bipedal edema. He had no prior history of any chronic condition, and this was the first episode of acute retention of urine. He also had no known family history of BPH or prostate cancer. Pupils were about 2 mm in size and reacted directly and consensual to light. Tone and reflexes in both upper and lower limbs were normal but power in the lower limbs could not be objectively assessed. The abdomen was soft, full, non-tender with a huge suprapubic mass. His blood pressure was 130/70 mmHg, pulse was 96 beats-per-minute and jugular veinous pressure was not raised. The first and second heart sounds were present and normal with apex beat in the Left 6 th intercostal space, anterior axillary line. Respiratory rate was 22 cycles/minute, air entry was adequate bilaterally and breath sound was vesicular with no added sounds. Digital rectal examination revealed good anal hygiene and normal sphincter tone. The prostate was enlarged (about 12 cm × 15 cm) with a smooth surface, well defined edges, firm consistency, non-tender, non-obliterated median sulcus and a mobile rectal mucosa over the surface of the prostate. An initial impression of Urine retention

Surgery
Patient was operated upon 7 th March 2018. Under sterile condition and spinal anaesthesia, patient was well draped, pfannesteil incision was made through the fascia ( Figure 1 & Figure 2). Rectus muscles retracted longitudinally through it fibres, bladder opened in transverse to expose huge adenomatosed prostate occupying the whole bladder wall ( Figure 3). Enucleation with the right index finger with support of the left index finger in the rectum was made. Findings were giant lobed prostate tissue ( Figure 4). A 3 Way 22F silicon catheter was placed at the fossa of the enucleated prostate and its balloon inflated with 40 ml distilled water to achieve haemostasis. It served the purpose of continuous bladder drainage. Massively distended bladder was closed in 2 layers with vicryl 2 ( Figure 5). Drainage tube was placed in the pelvis. Rectus muscle apposed with vicryl 0 and fascia with nylon 2, subcutaneous layer with vicryl 2/0 and skin with nylon 2/0.

Post Op Day 2
Patient complained of persistent hiccups. Suprapubic and urethral catheters were draining much clearer urine. Wound dressing was soaked, temperature was 35.4˚C, pulse was 80 beats/min and BP also measured 130/60 mmHg. Chest was clinically clear and respiration rate and, RBS measured 20 cycles/min and 8.4 mmol/L respectively. Plan was to; Continue treatment, stop continuous irrigation, change wound dressing, encourage patient to mobilize, administer IV Chlorpromazine 50 mg stat, then 25 mg 8 hourly for 72 hours.

Post Op Day 3
Patient was drowsy after the administration of stat dose of IV Chlorpromazine. Both urethral and suprapubic catheters were draining slightly blood-stained urine. Body temperature was 37.5˚C, Pulse measured 92 beats/min, BP measured 130/70 mmHg and respiration rate was 22 cycles/min but chest was clinically clear. GCS and RBS also measured 13/15 and 11.3 mmol/L respectively.
Plan was to; Stop IV Chlorpromazine, continue other medications, change wound dressing, hydration with IV fluids; IV Normal Saline-1.0 L, IV Ringers Lactate-1.0 L and IV Dextrose Saline-1.0 L

Post Op Day 4
Patient had regained full consciousness and had no complaints, dressing was

Post Op Day 7
Patient was doing well and was feeding and taking in oral fluids satisfactorily.
Mobilization was however not encouraging, dressing was soaked, temperature measured 37.6˚C, pulse was 98 beats/min, BP was 130/70 mmHg and respiration rate also measured 23 cycles/min. Examination revealed bronchial breath sounds on the right upper and middle zones of lungs.
Plan was to; Continue treatment, change wound dressing, continue physiotherapy, encourage adequate feeding and liberal oral fluid intake.

Post Op Day 8
Patient was doing well and was feeding and taking in oral fluids satisfactorily.

Post Op Day 9
Patient had suddenly tipped into a state of unconsciousness with a GCS of 6/15.
He had labored breathing, urine was still blood stained, temperature-37.6˚C, pulse-118 beats/minute, BP-130/80 mmHg and respiration rate measured 28 cycles/min with bronchial breath sounds on the right upper and middle zones.
Tone and reflexes were decreased and power in all limbs could not be objectively assessed. RBS also measured 12.5 mmol/L. An impression of a thromboembolic phenomenon was made with differentials of pulmonary embolism and cerebrovascular accident.
Plan was to; Pass a feeding tube, give intranasal oxygen at a flow rate of 4 L/hr, Start IV Fragmin 5000 IU daily for 72 hours, urgent CT scan of chest and brain, stop Tab tranexamic acid and continue other medications. About 2 hours after initiation of treatment, patient went into cardiac arrest. Cardiopulmonary resuscitation was started and after 6 cycles, there was still no cardiopulmonary activity. Patient was therefore declared biologically dead. An informed consent was obtained from the patient's family to report the case.

Discussion
BPH is a common disorder of the prostate affecting most males above the age of 40 years [2]. Prostatic hyperplasia is considered to be due to the proliferation of epithelial and stromal cells, impairment of programmed cell death (apoptosis) or both and is endocrine controlled [6]. Autopsy data (2010-2017) from our facility (Brong Ahafo Regional Hospital) indicate that over 90% of men older than 80 years have histological evidence of BPH. According to Maliakal et al., 2014, prostates weighing more than 100 g has been recorded in only 4% of men above the age of 70 years [7] and only 10 cases of BPH where the prostate weighed more than 700 g has been reported in medical literature to date [6]- [15] with the highest recorded by Medina-Peres et al., in 1997 [6]. In all of these cases only six

Conclusion and Recommendation
In certain cases, surgical treatment of prostate hyperplasia has ended fatally due to the after effects of haemorrhage. In order to tackle the risk of haemorrhage effectively, we recommend the technique of inflation of catheter balloon at the

Ethical Approval
Ethical clearance was sought form the Research Ethics Committee of the Brong Ahafo Regional Hospital.