eMedicine Specialties > Urology > Benign Prostatic Hypertrophy
Simple Prostatectomy
Updated: Aug 17, 2009
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.
Numerous 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), alfuzosin (Uroxatral), and, more recently, silodosin (Rapaflo), as well as 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.
Minimally invasive procedures exists for patients with recalcitrant or more advanced degrees of outlet obstruction, 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.1 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.
In patients in whom 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 (simple) prostatectomy. TURP is typically performed when the prostate size measures less than 75 g, while a simple prostatectomy is often reserved for prostates larger than 75 g. 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 Millin first reported his experience with 20 patients.2
Fuller first performed suprapubic prostatectomy in 1894. By 1912, Freyer, who reported his results with 1000 patients, had popularized the procedure.3
Simple perineal prostatectomy for the treatment of lower urinary tract obstruction secondary to BPH 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.
More recently, urologists have explored minimally invasive methods for the simple prostatectomy. In 2002, Mariano et al4 described a technique for laparoscopic prostatectomy, and, in 2008, Sotelo et al5 reported their experience with the robotic-assisted laparoscopic simple prostatectomy.
Indications
The indications for 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 not responsive to medical or minimally invasive therapy
- Renal insufficiency secondary to chronic bladder outlet obstruction
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.
Open (simple) prostatectomy is contraindicated in the presence of prostate cancer. If cancer is suspected, a formal prostate biopsy should be performed prior to considering surgery.
Open prostatectomy has 3 different approaches, including retropubic prostatectomy, suprapubic prostatectomy (open, laparoscopic, or robotic), 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 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)
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.
More on Simple Prostatectomy |
 Overview: Simple Prostatectomy |
| Workup: Simple Prostatectomy |
| Treatment: Simple Prostatectomy |
| Follow-up: Simple Prostatectomy |
| References |
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References
Fabian KM. [The intra-prostatic "partial catheter" (urological spiral) (author's transl)]. Urologe A. Jul 1980;19(4):236-8. [Medline].
Millin T. Retropubic prostatectomy: a new extravesical technique report on 20 cases. 1945. J Urol. Feb 2002;167(2 Pt 2):976-9; discussion 980. [Medline].
Freyer P. One thousand cases of total enucleation of the prostate for radical cure of enlargement of that organ. Br Med J. 1912;2:868.
Mariano MB, Graziottin TM, Tefilli MV. Laparoscopic prostatectomy with vascular control for benign prostatic hyperplasia. J Urol. Jun 2002;167(6):2528-9. [Medline].
Sotelo R, Clavijo R, Carmona O, Garcia A, Banda E, Miranda M, et al. Robotic Simple Prostatectomy. J Urol. February 2008;179(2):513-5. [Medline].
Bajoria S, Agarwal SA, White R, et al. Experience with the second generation UroLume prostatic stent. Br J Urol. Mar 1995;75(3):325-7. [Medline].
Baumert H, Ballaro A, Dugardin F, Kaisary AV. Laparoscopic versus open simple prostatectomy: a comparative study. J Urol. May 2006;175(5):1691-4. [Medline].
Blew BD, Fazio LM, Pace K, D'A Honey RJ. Laparoscopic simple prostatectomy. Can J Urol. Dec 2005;12(6):2891-4. [Medline].
Dall'Oglio MF, Srougi M, Antunes AA, Crippa A, Cury J. An improved technique for controlling bleeding during simple retropubic prostatectomy: a randomized controlled study. BJU Int. Aug 2006;98(2):384-7. [Medline].
Djaladat H, Mehrsai A, Saraji A, Moosavi S, Djaladat Y, Pourmand G. Suprapubic prostatectomy with a novel catheter. J Urol. Jun 2006;175(6):2083-6. [Medline].
Elder JS, Gibbons RP, Correa RJ Jr, Brannen GE. Morbidity of radical perineal prostatectomy following transurethral resection of the prostate. J Urol. Jul 1984;132(1):55-7. [Medline].
Gibbons R. Radical perineal prostatectomy. In: 7th ed. Campbell's Urology. Vol 2. Philadelphia, Pa: WB Saunders; 1998:2589-604.
Guazzoni G, Montorsi F, Coulange C, et al. A modified prostatic UroLume Wallstent for healthy patients with symptomatic benign prostatic hyperplasia: a European Multicenter Study. Urology. Sep 1994;44(3):364-70. [Medline].
Hinman F. Atlas of Urologic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:414-25.
Hudson P. Perineal prostatectomy. In: Campbell's Urology. Vol 3. 4th ed. Philadelphia, Pa: WB Saunders; 2327-60.
Mireku-Boateng AO, Jackson AG. Prostate fossa packing: a simple, quick and effective method of achieving hemostasis in suprapubic prostatectomy. Urol Int. 2005;74(2):180-2. [Medline].
Oesterling J. Retropubic and suprapubic prostatectomy. In: Campbell's Urology. Vol 2. 7th ed. WB Saunders; 1998:1529-40.
Partin AW, Yoo J, Carter HB, et al. The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol. Jul 1993;150(1):110-4. [Medline].
Rehman J, Khan SA, Sukkarieh T, et al. Extraperitoneal laparoscopic prostatectomy (adenomectomy) for obstructing benign prostatic hyperplasia: transvesical and transcapsular (Millin) techniques. J Endourol. May 2005;19(4):491-6. [Medline].
Reiner WG, Walsh PC. An anatomical approach to the surgical management of the dorsal vein and Santorini's plexus during radical retropubic surgery. J Urol. Feb 1979;121(2):198-200. [Medline].
Sotelo R, Spaliviero M, Garcia-Segui A, et al. Laparoscopic retropubic simple prostatectomy. J Urol. Mar 2005;173(3):757-60. [Medline].
Szutzman R. Textbook of Operative Urology. WB Saunders; 1998:532-6.
van Velthoven R, Peltier A, Laguna MP, Piechaud T. Laparoscopic extraperitoneal adenomectomy (Millin): pilot study on feasibility. Eur Urol. Jan 2004;45(1):103-9; discussion 109. [Medline].
Walsh PC, Oesterling JE. Improved hemostasis during simple retropubic prostatectomy. J Urol. Jun 1990;143(6):1203-4. [Medline].
Weldon VE, Tavel FR, Neuwirth H, Cohen R. Patterns of positive specimen margins and detectable prostate specific antigen after radical perineal prostatectomy. J Urol. May 1995;153(5):1565-9. [Medline].
Williams G, Coulange C, Milroy EJ, et al. The urolume, a permanently implanted prostatic stent for patients at high risk for surgery. Results from 5 collaborative centres. Br J Urol. Sep 1993;72(3):335-40. [Medline].
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
