eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Simple Prostatectomy

Brian J Miles, MD, Medical Director, Chief of Urology Service, Director of Education, Associate Professor, Department of Urology, St Luke's Episcopal Hospital; Program Director, Baylor College of Medicine
Mohit Khera, MD, MBA, MPH, Assistant Professor of Urology, Scott Department of Urology, Baylor College of Medicine; Robert J Cornell, MD, Staff Physician, Department of Urology, Baylor College of Medicine; John S Colen, MD, Resident Physician, Department of Urology, Baylor College of Medicine

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

See Intraoperative details.

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.

Workup

Laboratory Studies

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 ultrasound-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 cell count, coagulation studies, and at least a type and screen should be obtained in all patients prior to proceeding with an open (simple) prostatectomy.

Imaging Studies

Although transrectal ultrasonography may help document prostatic 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 is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years.

Other Tests

ECG is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years.

Diagnostic Procedures

Cystoscopy is useful for identifying the presence of urethral stricture disease, bladder calculi, diverticula, and a large median lobe. This information is useful in deciding whether to perform a suprapubic versus 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.

Treatment

Medical Therapy

A number of treatment options exist for benign prostatic hyperplasia (BPH). Consider medications that act at the level of the prostate and bladder neck. These include alpha-blockers, such as tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), and alfuzosin (Uroxatral), which relax prostatic and bladder neck smooth muscle. In addition, the 5-alpha-reductase inhibitors, finasteride (Proscar) and dutasteride (Avodart), decrease the size of the prostate. These medications have been shown to improve symptoms of lower urinary tract obstruction.

In patients with outlet obstruction that is recalcitrant (does not respond to medical treatment) or more advanced, minimally invasive procedures are available, including visual laser prostatic ablation, TUIP, and thermotherapy procedures, such as TUMT, TUEVP, and TUNA.

Surgical Therapy

The advantages of open (simple) prostatectomy over TURP include the complete removal of the prostatic adenoma under direct visualization in the suprapubic or retropubic approaches. 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.

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.

Open (simple) prostatectomy does have disadvantages when compared to TURP, however, and include the morbidity and longer hospitalization associated with the open procedure and the potential for greater intraoperative hemorrhage.

Preoperative Details

Exclude prostate cancer before performing prostatectomy in patients with symptomatic bladder outlet obstruction. All men should undergo preoperative PSA determination and routine DRE. Suspicions evoked by either screening modality should prompt a transrectal ultrasound-guided needle biopsy of the prostate before open (simple) prostatectomy is performed. Additionally, preoperative lower urinary tract studies likely 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.
Patients who present for open (simple) prostatectomy are typically aged 60 years or older. The comorbidities common to this patient population involve not only routine preoperative history, physical examination, and standard serum chemistries but also chest radiography and ECG to investigate potential complications of these potential preexisting conditions.
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.

Intraoperative Details

The retropubic (Millin) prostatectomy

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. Then, 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. Then, hyperextend the table slightly, placing the patient in a mild Trendelenburg position.
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 two 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. Both 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.

In 2008, Sotelo et al published their initial experience with a robotic suprapubic simple prostatectomy.⁵ As with other laparoscopic cases, robotic assistance may prove to be very valuable and may increase the popularity of this minimally invasive approach.

Postoperative Details

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.

Follow-up

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 to exclude carcinoma.

For excellent patient education resources, visit eMedicine's Prostate Health Center and Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Enlarged Prostate.

Complications

Postoperative complications following both suprapubic and retropubic prostatectomy include hemorrhage, urinary extravasation, and associated urinoma.
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 also 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 to 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.

Outcome and Prognosis

Open (simple) prostatectomy is an invasive surgical approach for the treatment of medically resistant or advanced lower urinary tract obstruction secondary to benign prostatic hyperplasia (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 both the entire prostate and the intravesical bladder. These procedures differ from radical prostatectomy, in which the entire prostate, seminal vesicles, and vas deferens are removed en bloc. With simple prostatectomy, the risk of prostate cancer in the future remains and patients must be monitored with DRE and PSA studies.

References

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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

Contributor Information and Disclosures

Author

Brian J Miles, MD, Medical Director, Chief of Urology Service, Director of Education, Associate Professor, Department of Urology, St Luke's Episcopal Hospital; Program Director, Baylor College of Medicine
Brian J Miles, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Association of Military Surgeons of the US, Society of Urologic Oncology, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mohit Khera, MD, MBA, MPH, Assistant Professor of Urology, Scott Department of Urology, Baylor College of Medicine
Mohit Khera, MD, MBA, MPH is a member of the following medical societies: American Medical Association, American Urological Association, and Texas Medical Association
Disclosure: Auxilium Honoraria Speaking and teaching; Coloplast Honoraria Speaking and teaching; American Medical Systems Honoraria Speaking and teaching

Robert J Cornell, MD, Staff Physician, Department of Urology, Baylor College of Medicine
Robert J Cornell, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

John S Colen, MD, Resident Physician, Department of Urology, Baylor College of Medicine
John S Colen, MD is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Michael Grasso, MD, Chairman, Department of Urology, Saint Vincent's Medical Center; Professor and Vice Chairman, Department of Urology, New York Medical College
Michael Grasso, MD is a member of the following medical societies: American Medical Association, American Urological Association, California Medical Association, and Endourological Society
Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

Further Reading

Clinical trials

Laser Prostatectomy Database and Registry

Dutasteride After Failure of Finasteride In the Management of Symptomatic Prostatic Enlargement/Hypertrophy (BPE/H)