eMedicine Specialties > Urology > Benign Prostatic Hypertrophy
Simple Prostatectomy
Updated: Jan 29, 2007
Introduction
Simple retropubic prostatectomy is the enucleation of a hyperplastic prostatic adenoma through a direct incision of the anterior prostatic capsule.
Suprapubic prostatectomy is the enucleation of the hyperplastic prostatic adenoma through an extraperitoneal incision of the lower anterior bladder wall.
Simple perineal prostatectomy involves removal of bladder calculi through a perineal incision in the treatment of lower urinary tract obstruction.
A number of treatment options exist for benign prostatic hyperplasia (BPH). Medications that act at the level of the prostate and bladder neck include alpha blockers, such as tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), and alfuzosin (Uroxatral), and 5-alpha reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart). Each can decrease outlet resistance related to prostatic hyperplasia and improve symptoms of lower urinary tract obstruction. In patients with recalcitrant or more advanced degrees of outlet obstruction, minimally invasive procedures exist, including visual laser prostatic ablation, transurethral incision of the prostate (TUIP), and thermal procedures, such as transurethral microwave thermotherapy (TUMT), transurethral electrovaporization (TUEVP), and transurethral needle ablation (TUNA).
In 1980, Fabian first described the use of intraprostatic stents for the treatment of outlet obstruction secondary to BPH. Both temporary and permanent stents are available. Temporary stents are made of either biodegradable or nonabsorbable material. Depending on the type of material used, the nonabsorbable stents are removed every 6-36 months. Temporary stents should be considered in patients who would be high-risk surgical candidates as a short-term alternative to urethral or suprapubic catheter placement. Permanent intraprostatic stents, such as UroLume stents, are not generally used because of their high complication rate and poor efficacy. Complications seen with permanent intraprostatic stents include encrustation, migration, irritative voiding symptoms, painful ejaculation, and epithelial hyperplasia.
If medical and minimally invasive options for BPH have been unsuccessful, more invasive treatment options for BPH should be considered, such as transurethral resection of the prostate (TURP) or open prostatectomy. 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.
History of the Procedure
Simple retropubic prostatectomy dates to 1945, when Terrence Millin first reported his experience with 20 patients.
Eugene Fuller first performed suprapubic prostatectomy in 1894. By 1912, Peter Freyer, who reported his results with 1000 patients, had popularized the procedure.
Simple perineal prostatectomy for the treatment of lower urinary tract obstruction secondary to benign prostatic hypertrophy illustrates the developments in the approach to this common pathology. More than 2000 years ago, surgeons devised and used a median perineal incision for the removal of bladder calculi. In the first century CE, surgeons used a semielliptical incision in the perineum for partial removal of the prostate. Few records document the use of this procedure for several hundred years to follow.
Indications
The indications for TURP or open 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 not responsive to medical or minimally invasive therapy
- Renal insufficiency secondary to chronic bladder outlet obstruction
Consider open prostatectomy, using either the retropubic or suprapubic approach, when the prostate is larger than 50-70 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.
Open prostatectomy has 3 different approaches. These include retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy.
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
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, therefore, is 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)
Simple perineal prostatectomy
Advantages of the perineal prostatectomy approach include the following:
- Ability to avoid the retropubic space (prior retropubic surgery would make retropubic or suprapubic surgery more difficult)
- Ability to treat clinically significant prostatic abscess and prostatic cysts
- Less postoperative pain
Relevant Anatomy
Contraindications
Disadvantages of retropubic prostatectomy relate largely to the limited access to the bladder, which is an important consideration if a bladder diverticulum requiring excision coexists or when a large bladder calculus must be directly removed. Additionally, if cystoscopy findings indicate that the obstructing adenoma primarily involves the median lobe, the suprapubic approach may be preferred because this technique optimizes anatomic exposure.
The disadvantage of the suprapubic approach relates to reduced visualization of the apical prostatic adenoma and the potential complication of postoperative urinary incontinence and intraoperative bleeding.
The main contraindication and disadvantage to perineal enucleation prostatectomy is performing the procedure in patients for whom sexual potency remains important. This approach invades the perineal neurovascular anatomy more extensively than other available open techniques.
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References
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Further Reading
Keywords
simple prostatectomy, open prostatectomy, retropubic prostatectomy, simple retropubic prostatectomy, Millin prostatectomy, enucleation of a hyperplastic prostatic adenoma, suprapubic prostatectomy, simple perineal prostatectomy, benign prostatic hyperplasia, BPH, transurethral resection of the prostate, TURP, lower urinary tract obstruction, bladder outlet obstruction, urinary tract infections, recurrent hematuria, bladder calculi, renal insufficiency, laparoscopic simple prostatectomy, perineal enucleation prostatectomy
