Overview

Simple (open) prostatectomy differs from radical prostatectomy in that the

former consists of enucleation of a hyperplastic prostatic adenoma, and the
latter involves removal en bloc of the entire prostate, the seminal vesicles, and
the vas deferens. This article reviews the indications for open prostatectomy,
discusses the various approaches for this procedure, weighs the advantages
and disadvantages of each approach, and provides a brief outline of standard
surgical technique.
When medical and minimally invasive options for benign prostatic
hyperplasia (BPH) have been unsuccessful, the more invasive treatment
options for BPH should be considered, such as transurethral resection of the
prostate (TURP) or open prostatectomy. Patients who present for open
(simple) prostatectomy are typically age 60 years or older.
The advantages of open (simple) prostatectomy over TURP include the
complete removal of the prostatic adenoma under direct visualization in the
suprapubic and retropubic approaches. However, these procedures do not
obviate the need for further prostate cancer surveillance because the posterior
zone of the prostate remains as a potential source of carcinoma formation.
Open (simple) prostatectomy has 3 different approaches: retropubic,
suprapubic, and perineal. Simple retropubic prostatectomy is the enucleation
of a hyperplastic prostatic adenoma through a direct incision of the anterior
prostatic capsule. Simple suprapubic prostatectomy is the enucleation of the
hyperplastic prostatic adenoma through an extraperitoneal incision of the
lower anterior bladder wall. [1]
Indications for Open (Simple) Prostatectomy
The indications for either TURP or open (simple) prostatectomy include the
following:
 Acute urinary retention
 Persistent or recurrent urinary tract infections
 Significant hemorrhage or recurrent hematuria
 Bladder calculi secondary to bladder outlet obstruction
 Significant symptoms from bladder outlet obstruction that are not
responsive to medical or minimally invasive therapy
 Renal insufficiency secondary to chronic bladder outlet obstruction

Advantages of retropubic prostatectomy

Advantages of the retropubic technique over the suprapubic approach include
the following:
 Superb anatomic prostatic exposure
  Direct visualization of the adenoma during enucleation to ensure
complete removal
 Precise division of the prostatic urethra, optimizing preservation of urinary
continence
 Direct visualization of the prostatic fossa after enucleation for hemorrhage
control
 Minimal to no surgical trauma to the bladder
Advantages of suprapubic prostatectomy
The major advantage of the suprapubic approach over the retropubic
approach is that it permits better visualization of the bladder neck and ureteral
orifices and is therefore better suited for patients with the following conditions:
 Enlarged, protuberant, median prostatic lobe
 Concomitant symptomatic bladder diverticulum
 Large bladder calculus
 Obesity (to a degree that makes access to the retropubic space more
difficult)
Advantages of simple perineal prostatectomy
Advantages of perineal prostatectomy include the following:
 Ability to treat clinically significant prostatic abscess and prostatic cysts
 Less postoperative pain
 Ability to avoid the retropubic space
With regard to the last point, above, retropubic or suprapubic surgery is more
difficult in patients who have had prior retropubic surgery.
Contraindications to Open (Simple) Prostatectomy
Open (simple) prostatectomy is contraindicated in the presence of prostate
cancer. If cancer is suspected, a formal prostate biopsy should be performed
before surgery is considered.
If cystoscopy findings indicate that the obstructing adenoma primarily involves
the median lobe, the suprapubic approach may be preferred to the retropubic
technique, because the suprapubic procedure optimizes anatomic exposure.
In addition, retropubic prostatectomy offers only limited access to the bladder,
which is an important consideration if a bladder diverticulum requiring excision
coexists or if a large bladder calculus must be directly removed.
The perineal approach can be contraindicated in patients in whom sexual
potency remains important. In this procedure, the perineal neurovascular
anatomy is invaded more extensively than it is in the other available open
techniques.
Disadvantages of open (simple) prostatectomy
Open (simple) prostatectomy does have disadvantages when compared with
TURP. These include the morbidity and longer hospitalization associated with
the open procedure and the potential for greater intraoperative hemorrhage.
A disadvantage to the use of suprapubic approach relates to reduced
visualization of the apical prostatic adenoma and the potential complications
of postoperative urinary incontinence and intraoperative bleeding.
Other Considerations
Other considerations include congestive heart failure, prostate size, and
bladder pathology.
The transurethral resection (TUR) syndrome of dilution hyponatremia is
unique to TURP and does not occur with open (simple) prostatectomy. The
incidence of TUR syndrome during a TURP is roughly 2%. Thus, in patients
with a greater risk of congestive heart failure caused by underlying
cardiopulmonary disease, open prostatectomy has a much smaller risk of
intraoperative fluid challenge.
Consider open (simple) prostatectomy, using either the retropubic or
suprapubic approach, when the prostate is larger than 75 g or larger than the
surgeon can resect reliably with TURP in 60-90 minutes.
In patients with concomitant bladder pathology that complicates their outlet
obstruction (eg, a large or hard bladder calculus, symptomatic bladder
diverticulum), open prostatectomy remains the procedure of choice.
Additionally, patients with musculoskeletal disease that precludes proper
patient positioning in the dorsal lithotomy position for TURP may benefit from
an open prostatectomy.
Preparation
Positioning of Patients
In the retropubic (Millin) prostatectomy, the patient is placed on the operating
room table in the supine position in mild Trendelenburg.
In the suprapubic approach, place the patient in a supine position on the
operative table, with the umbilicus over the break of the table. Next,
hyperextend the table slightly, placing the patient in a mild Trendelenburg
position.
Complication Prevention
Exclude prostate cancer before performing a prostatectomy in patients with
symptomatic bladder outlet obstruction. All men should undergo
preoperative prostate-specific antigen (PSA) determination and routine digital
rectal examination (DRE). Suspicions evoked by either screening modality
should prompt a transrectal, ultrasonographically guided needle biopsy of the
prostate to exclude the presence of carcinoma before open (simple)
prostatectomy is performed.
A urinalysis and urine culture, electrolyte study, complete blood count (CBC),
coagulation studies, and, at least, a type and screen should be obtained in all
patients prior to proceeding with an open (simple) prostatectomy.
Although transrectal ultrasonography may help to document the prostate’s
size, it is not indicated preoperatively and does not assist in the preoperative
screening for prostatic malignancy.
Imagery of the upper urinary tract is not performed routinely in patients with
outlet obstruction unless it is indicated for other reasons (eg, evaluation of
hematuria).
Chest radiography and electrocardiography are indicated to investigate
potential complications from possible preexisting conditions in patients older
than age 60 years.
Cystoscopy is useful for identifying the presence of urethral stricture disease,
bladder calculi, diverticula, and a large median lobe. This information is helpful
when the clinician is deciding whether to perform a suprapubic or a retropubic
prostatectomy.
Preoperative lower urinary tract studies may include a urinary flow rate with
documentation of postvoid residual and, possibly, a cystometrogram and
pressure or flow evaluation in patients with more complex conditions who may
have coexisting bladder instability or detrusor function abnormalities.
If anticoagulants (eg, aspirin, other nonsteroidal anti-inflammatory drugs
[NSAIDs], warfarin [Coumadin]) are required preoperatively, coordinate their
discontinuation with the ordering physician and correct any significant
coagulopathy before surgery.
Discuss potential risks of open (simple) prostatectomy with the patient
preoperatively, including urinary incontinence, erectile dysfunction, retrograde
ejaculation, urinary tract infection, and the need for a blood transfusion.
Additionally, as with all open pelvic procedures, the risk of deep vein
thrombosis and pulmonary embolus always exists.
A study by Pariser et al that examined the national trends of simple
prostatectomy for BPH found that bleeding complications were common, but
perioperative mortality was low and that patients who are older, black race, or
have multiple comorbidities were at higher risk of complications. [2]
Technique
Surgical Overview
Open (simple) prostatectomy is an invasive surgical approach for the
treatment of medically resistant or advanced lower urinary tract obstruction
secondary to BPH. Patients with an exceedingly large prostate or with
concomitant bladder calculi or diverticula are ideal candidates for this
approach, as these techniques optimize exposure to the entire prostate and to
the intravesical bladder.
Retropubic (Millin) Prostatectomy
As previously stated, the patient is placed on the operating room table in the
supine position in mild Trendelenburg.
A lower midline incision is made and the space of Retzius developed.
Initiate the Millin (transverse capsular) prostatectomy by locating the vesicle
neck by palpation of the Foley balloon.
Place a 1-0 absorbable suture deeply in the capsule of the prostate, just
below the vesicle neck. Repeat this technique until a 4-cornered area is
created, through which a transverse incision is made into the adenoma across
the entire anterior surface while the bladder is retracted cephalad.
Place the proximal capsule under tension and achieve hemostasis actively
with full suction. Hemostasis can also be achieved by ligating the dorsal
venous complex as well as ligating the prostatic arteries as they enter the
prostaticovesical junction near the level of the seminal vesicles.
Next, identify the plane between the adenoma and the capsule and sharply
dissect.
Once developed, manually explore this plane while the adenoma is
enucleated under direct visualization. Carefully identify the apex of the
prostate and sharply divide the urethra under direct visualization.
Achieve hemostasis before placement of figure-of-8, 2-0 absorbable sutures
at the 5- and 7-o'clock positions through the vesical neck and proximal
capsule.
Clearly identify the ureteral orifices before resecting a wedge of posterior
vesical neck. Using a running 2-0 absorbable suture, evert and approximate
the edges.
Indigo carmine can be administered to decrease the risk of iatrogenic injury to
the ureteral orifices.
Introduce a large catheter into the urethra and inflate the balloon.
Finally, close the capsule from both ends with 2 continuous 2-0 absorbable
sutures.
Foley traction may be used as needed for hemostasis. Place an external drain
into the space of Retzius to prevent hematoma and urinoma formation. After
that, irrigate and close the wound.
Suprapubic Prostatectomy
With the suprapubic approach, place the patient in a supine position on the
operative table, with the umbilicus over the break of the table. After that,
hyperextend the table slightly, placing the patient in a mild Trendelenburg
position. [3]
After preparing and draping the patient in the standard fashion, introduce a
urethral catheter into the bladder, through which the bladder is filled to
approximately 250 mL with sterile water or saline before the catheter is
removed.
Make a vertical midline incision from below the umbilicus to the pubic
symphysis. Alternatively, a low Pfannenstiel incision can be made. Dissect
between the laterally retracted rectus abdominus, developing the prevesical
space extraperitoneally.
Neither the retropubic nor the lateral vesical spaces are necessarily entered.
Below the peritoneal dissection, place 2 stay sutures in the anterior bladder
wall, make a vertical cystotomy, and carry it within 1 cm of the bladder neck,
allowing visualization of the bladder neck and prostate. A transverse stay
suture may be placed to prevent caudal extension of the cystotomy.
Retract the superior bladder edge cranially and retract the inferior portion
distal to the trigone in a caudal direction to display the posterior bladder neck.
The urethral orifices are now well visualized and protected as the bladder
neck mucosa is incised just distal to the trigone.
After circumferentially incising the bladder mucosa over the prostate, using
sharp and blunt dissection, develop the plane between the adenoma and the
prostatic capsule.
Perform a gentle blunt digital dissection, completing the remaining dissection
both posteriorly and circumferentially around the prostatic apex and urethra.
The prostatic urethra is separated at the apex by carefully pinching 2 fingers
together. Make every effort not to tear the prostate or sphincter at this level.
Following gross enucleation of the adenoma, manually inspect the prostatic
fossa and remove any remaining nodular adenoma.
Bleeding within the prostatic fossa can be controlled with electrocautery or
suture ligatures.
Pass a 22F, 30-mL, 3-way catheter per urethra (and, in select patients, an
additional suprapubic tube through a separate anterior cystostomy).
Close the bladder in full-thickness through the serosa using a double layer of
interrupted 2-0 chromic or Vicryl suture.
Inflate the catheter balloon to prevent retraction into the prostatic fossa and
drain the space of Retzius.
Laparoscopic and Robotic Simple Prostatectomy
In 2002, Moreno was the first to describe a laparoscopic simple prostatectomy
for BPH. Since then, several others have described extraperitoneal
laparoscopic prostatectomies for obstructing BPH. The transvesical and
transcapsular (Millin) techniques have been performed laparoscopically. Most
investigators have found laparoscopic simple prostatectomy to be a feasible
alternative to the open (simple) technique. However, this technique has a
steep learning curve and requires significant laparoscopic expertise. [4, 5, 6]
In 2008, Sotelo et al published their initial experience with a robotic,
suprapubic simple prostatectomy. [7] As with other laparoscopic cases, robotic
assistance may prove to be very valuable and may increase the popularity of
this minimally invasive approach.
A study by Pokorny et al presented the perioperative and short-term functional
outcomes of robot-assisted simple prostatectomy in a large series of patients
with lower urinary tract symptoms (LUTS) due to large benign prostatic
enlargement (BPE) treated in a high-volume referral center. The data
indicated good perioperative outcomes, an acceptable risk profile, and
excellent improvements in patient symptoms and flow scores at short-term
follow-up following RASP. [8]
A study by Wang et al that included 27 patients who underwent robotic-
assisted urethra-sparing simple prostatectomy via an extraperitoneal
approach reported short catheterization time, an acceptable risk profile,
significantly improvements of voiding function and maintaining antegrade
ejaculation following this urethral- sparing technique. [9]
Post-Procedure
Postsurgical Care
Postoperative care of patients who have had an open (simple) prostatectomy
parallels care following most major open surgical procedures. Because the
need for postoperative blood transfusions is minimized through improvements
in understanding of the relevant surgical anatomy and advancements in
operative technique, most patients are discharged comfortably on the second
day following surgery. For the surgeon, the most significant concern is to
observe drain output and fluid status immediately after surgery, as patients
generally ambulate and tolerate a regular advancement of their diet by the first
day following surgery.
Monitor the patient in the clinic after surgery. If the Foley catheter was not
removed during the hospitalization, a voiding trial can be performed on an
outpatient basis.
Review pathology and schedule follow-up examinations for the patient in order
to exclude carcinoma. With simple prostatectomy, the risk of prostate cancer
development remains and patients must be monitored with DRE and PSA
studies.
Complications of Simple (Open) Prostatectomy
Postoperative complications following suprapubic and retropubic
prostatectomy include hemorrhage, urinary extravasation, and associated
urinoma. [10]
Infectious processes, including cystitis and epididymo-orchitis, may also
occur, but only rarely when prophylactic antibiotics are administered.
Because the risk of injury to the external urinary sphincter is minimal with
these procedures, stress urinary incontinence and total urinary incontinence
are rare.
Coincident erectile dysfunction and bladder neck contracture have been
reported postoperatively in approximately 2%-3% of patients following
suprapubic prostatectomy.
Depending on the degree of preoperative urge incontinence, postoperative
urge incontinence may be present for weeks or months.
Retrograde ejaculation has been reported in up to 80%-90% of patients after
surgery and is a common phenomenon after these procedures.
Finally, as with any significant pelvic surgery, the risk of nonurologic
complications exists, including deep vein thrombosis, pulmonary embolus,
myocardial infarction, and cerebral vascular accident. The incidence of these
complications, however, is low and reflects the comorbidities of the patient
population being treated.