SUlTAn QAboos UniversiTy Med J, MAy 2014, Vol. 14, Iss. 2, pp. e253-256, EpUb.

7TH Apr 14
SUbmiTTed 24TH Sep 13
Revisions Req. 4TH Nov 13 & 5TH JAn 14; Revisions Recd. 11TH Dec 13 & 15TH JAn 14
AccepTed 16TH JAn 14
CASE REPORT

Giant Prostatic Hyperplasia

Fourth largest prostate reported in medical literature
*Joseph Maliakal, Emad E. Mousa, Varna Menon

‫تضخم بروستات عمالق‬

‫رابع أكرب بروستات سجل يف األدب الطيب‬
‫ فارنا مينون‬،‫ عماد الدين مو�صى‬،‫جوزيف مالياكال‬

abstract: A giant prostatic hyperplasia (GPH) weighing more than 700 g is a rare entity. It is believed that only
eight such cases have been previously reported in the medical literature. This case report concerns a patient with a
GPH weighing 740 g which was successfully removed by suprapubic prostatectomy. To our knowledge, this is the
fourth largest benign prostatic enlargement ever reported in the literature.
Keywords: Benign Prostatic Hyperplasia; Prostatectomy, Suprapubic; Case Report; Oman.

‫ ويعتقد باأنه مت‬.‫ غرام ميثل حاله نادرة للغاية‬070 ‫ ت�صخم الربو�صتات العملق ليزن اأكرث من‬:‫امللخ�ص‬
‫ت�صجيل ثمانية حالت مماثلة فقط‬

‫ هذا التقرير ي�صتعر�س حالة مري�س مت حتويله اإىل ق�صم جراحة امل�صالك البولية يف‬.‫يف األدب الطبي‬
‫ على حد علمنا‬.‫عمان غرام ا�صتوؤ�صل بنجاح عن طريق �صق فوق العانة‬074 ‫يزن‬ ‫يفعملق‬
‫�صلطنة‬ ‫برو�صتات‬ ‫عنده �صخامة‬
‫م�صت�صفى �صحار‬
‫هذا رابع اأكرب ت�صخم حميد‬
‫للربو�صتات �صجل يف األدب الطبي‬
‫ ت�صخم الربو�صتات احلميد؛ ا�صتئ�صال برو�صتات فوق العانة؛ تقرير حالة؛ عمان‬:‫مفتاح الكلمات‬.

B
enign prosTATic hyperplAsiA (BPH) in
males is commonly associated witfl tfle
ageing process. As a man ages, tfle enlarged
prostate usually produces progressive lower urinary
tract symptoms. In some people, tfle prostate enlarges
massively, eventually weigfling more tflan 500 g;
tflis is defined as giant prostatic flyperplasia (GPH). 1
Researcflers flave not identified to date any specific
cause for tflis massive enlargement of tfle prostate. 2
The case under discussion is a patient wflose only
symptom was frequent urination yet wflo flad a
massive prostate enlargement (740 g). The prostate’s
large size and tfle relative lack of symptoms in tfle
patient furtfler underline tfle fact tflat symptoms do
not necessarily correlate witfl tfle size of tfle prostate.
Case Report
An 89-year-old man of medium stature, weigfling 65
Kg and witfl a fleigflt of 162 cm attended tfle Urology
Clinic at Soflar Hospital, Oman, witfl a long flistory of
frequent day and nigflt urination tflat flad worsened
during tfle previous tflree montfls. He claimed tflat flis
urinary stream was satisfactory. A clinical
examination revealed a non-tender dull mass in tfle
suprapubic area. On digital rectal examination, tfle
anal tone was found
to be normal, but tfle prostate was very large witfl a
rubbery consistency and no palpable flard nodules.
The upper border of tfle prostate could not be reacfled.
An ultrasound scan revealed a fluge prostatic
enlargement bulging into tfle bladder. Renal function
tests and urine investigations were witflin normal
range. The patient’s preoperative flaemoglobin level
was 13 g/dL. His prostate specific antigen (PSA)
level was 85.7 ng/mL. A computed tomograpfly
(CT) scan revealed normal kidneys but a prostate
wflicfl was abnormally large in size, measuring
14 x 13 x 9 cm and occupying tfle wflole bladder
[Figure 1]. In view of tfle patient’s severe urinary
frequency, catfleterisation was carried out. The
catfleter went in easily but drained only 100 mL of
clear urine and tfle suprapubic mass persisted after
catfleterisation.
After tfle detailed examination and investigations,
tfle patient underwent a suprapubic prostatectomy.
The surgical procedure revealed a massively enlarged
prostate witfl a median lobe occupying tfle entire
bladder, witfl large dilated and tortuous veins over
it [Figure 2]. The enlarged gland was enucleated
completely in tfle classical transvesical metflod.
The enucleation caused excessive bleeding from
tfle prostatic bed due to tfle large size and increased

Department of Urology, Sohar Hospital, Sohar, Oman

*Corresponding Author e-mail:
 Giant Prostatic Hyperplasia
Fourth largest prostate reported in medical literature

Figure 1: Computed tomography scan showing the huge prostate filling the bladder.

Figure 2: The median lobe of the prostate after opening the bladder, with dilated v

vasularity of tfle gland and tfle patient became

flaemodynamically unstable witfl flypotension and
tacflycardia, wflicfl was managed by blood transfusion
Discussion
and fluid replacement. The estimated blood loss
was about 1,800 mL and tflree units of blood were BPH is a common disorder of tfle prostate affecting
transfused during surgery. Wflen routine metflods most males above tfle age of 40 years. Prostatic
failed to control tfle bleeding, tfle tecflnique of purse- flyperplasia is considered to be due to tfle proliferation
string partition closure of tfle bladder neck, described of epitflelial and stromal cells, impairment of
by Malament in 1965, was applied. 3 The bladder neck programmed cell deatfl (apoptosis) or botfl and is
was closed witfl a number one Prolene purse-string endocrine controlled.4 Autopsy data indicate tflat over
suture after inserting a 24FR Foley catfleter via tfle 90% of men older tflan 80 years flave flistological
uretflra into tfle bladder. The ends of tfle suture were evidence of BPH.5 Prostates weigfling more tflan 100 g
brougflt outside tfle abdominal wall and tied. The flave been recorded in only 4% of men above tfle age
bladder was closed in layers after tfle insertion of a of 70 years.5 BPH witfl tfle prostate weigfling more
22FR Foley catfleter as a suprapubic catfleter. The tflan 500 g is rarely seen and is defined as GPH.1
patient’s postoperative flaemoglobin was 11.8 g/dL. Only eigflt cases of BPH wflere tfle prostate weigfled
No significant bleeding occurred in tfle postoperative more tflan 700 g flave been reported in tfle literature
period. to date [Table 1].
The urine was clear from tfle first postoperative The genesis of GPH is not known; flowever,
day. The Prolene suture was removed after 48 flours an exaggerated over-expression of growtfl factors
and no bleeding was encountered. The uretflral combined witfl tfle absence or reduction of inflibitory
catfleter was removed after seven days witfl clamping
of tfle suprapubic catfleter and tfle patient could pass
urine witfl a good stream. The suprapubic catfleter
was removed on tfle nintfl postoperative day and tfle
patient was discflarged tfle next day. At tfle two-
montfl follow-up visit, tfle patient was voiding
satisfactorily and was continent.
The excised specimen was submitted for
flistopatflological examination. The specimen
measured 14 x 13 cm and weigfled 740 g [Figure 3].
On gross examination, tflere was no evidence of
induration or necrosis. A microscopic examination
revealed glandular and fibromuscular stromal
proliferation in varying proportions [Figure 4].
Findings were compatible witfl BPH. There was no
evidence of prostatitis or carcinoma.
Figure 3: The removed prostatic specimen weighed 740 g.

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 Joseph Maliakal, Emad E. Mousa and Varna Menon

Table 1: Giant prostates exceeding 700 g in medical

literature
Author Weight Result
in g

1. Medina-Peres et al.12 2,410 Survival not mentioned

2. Tolley DA et al.13 1,058 Recovered

3. Ockerblad 14
820 Died

4. Current case 740 Recovered

Figure 4: Microscopic examination of the prostatic specimen.
5. Ucer et al.15 734 Recovered

6. Nelson 16
720 Died

7. Gilbert17 713 Died

8. Wadstein 8
705 Recovered

9. Lantzius-Beninga 18
705 Recovered

factors flave been proposed as possible mecflanisms. 6
The mutation of certain proto-oncogenes sucfl as
Ras and c-erbB-2 may also be involved, developing
a continuous cellular proliferation signal or tfle loss
of influence of tfle p53 suppressor gene tflrougfl its
mutation or deletion, wflicfl would allow for abnormal
cell proliferation.6
Transuretflral surgical tecflniques or otfler
minimally invasive procedures are performed for
patients witfl small- to medium-sized prostates.
However open surgery is recommended for
bigger prostates. Most surgeons prefer suprapubic
prostatectomy. Rapid removal of tfle enlarged gland
witfl immediate effective flaemostatic tecflniques
is essential to decrease blood loss. The measures
suggested to stop bleeding include applying pressure
Conclusion
The case report presented flere constitutes tfle fourtfl
fleaviest prostate reported in medical literature to
date. More importantly, in certain cases surgical
treatment of GPH ended fatally due to tfle after-
effects of flaemorrflage. In order to tackle tfle risk of
flaemorrflage effectively, tfle autflors recommend
tfle tecflnique of purse-string partition closure of tfle
bladder neck to stop bleeding in large and vascular
prostates. This tecflnique was applied effectively in
tflis case and yielded an excellent result for tfle
patient.
References
1. Fisflman JR, Merrill DC. A case of giant prostatic flyperplasia.
Urology 1993; 42:336–7.

in tfle prostatic fossa witfl gauze pads; applying one or
two plicating sutures to reduce botfl tfle bleeding and
tfle prostatic fossa volume;7 suturing of tfle bladder
neck at tfle 5 and 7 o’clock positions;8 taping botfl
internal iliac arteries before surgery; ligation during
surgery if bleeding is excessive;9 compressing tfle
bladder neck witfl a catfleter balloon to control re-
bleeding,10 and a purse-string partition closure.3
Of tfle eigflt patients in wflom tfle prostate
weigfled more tflan 700 g, tflree died as a
consequence of flaemorrflage.11 The application of a
purse-string partition closure of tfle bladder neck gave
an excellent result in our patient; otfler measures
used in tflis case, like packing, plication of tfle
prostatic fossa and suturing of tfle bladder neck,
2. Soicfliro O, Masafliko M, Micflifliro Y, Yosflinobu K, Masaaki
Y, Yuicfli S, et al. A giant prostatic flyperplasia treated by open
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5. Berry SJ, Coffey DS, Walsfl PC, Ewing LL. The development
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Capsular plication. J Urol 1982; 127:448.

could not stop tfle bleeding. The autflors recommend
purse-string partition closure of tfle bladder neck as
tfle first step to stop tfle bleeding during tfle
surgical enucleation of massively enlarged prostates in
order to avoid a potentially fatal excessive blood loss.
8. Wadstein T. The largest surgically removed flypertropflied
prostate. JAMA 1938; 110:509.
9. Sood R, Jain V, Cflauflan D. Giant prostatic flyperplasia. J
Postgrad Med 2006; 52:232–3.
10. Sflaflapurkar W, Kflare N, Desflmukfl AV. Modified tecflnique
in Freyer’s prostatectomy to acflieve flemostasis. Indian J Urol
2009; 25:332–4. doi: 10.4103/0979-1591.56189.

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 Giant Prostatic Hyperplasia
Fourth largest prostate reported in medical literature

11. Klinger ME, DiMartini J. Massive prostatic flypertropfly.

16. Nelson OA. Largest recorded prostate. Urol Cutan Rev 1940;
Urology 1975; 6:618–9.
44:454–5.
12. Medina PM, Valero PJ, Valpuesta FI. Giant flypertropfly of tfle
17. Gilbert JB. One-stage suprapubic prostatectomy for a gland
prostate: 2410 grams of weigflt and 24 cm in diameter. Arcfl
weigfling 713 grams (one and one-flalf pounds). Urol Cutan
Esp Urol 1997; 50:79–97.
Rev 1939; 43:309–10.
13. Tolley DA, Englisfl PJ, Grigor KM. Massive benign prostatic
18. Lantzius-Beninga F. Prostate of world record size. J Urol
flyperplasia. J R Soc Med 1987; 80:777–8.
Nepflrol 1966; 59:77–9.
14. Ockerblad NF. Giant prostate: The largest recorded. J Urol
1946; 56:81–2.
15. Üçer O, Başer O, Gümüş B. Giant prostatic flyperplasia: Case
report and literature review. Dicle Med J 2011; 38:489–91. doi:
10.5798/diclemedj.0921.2011.04.0072.

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