eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Simple Prostatectomy: Treatment

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
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Aug 17, 2009

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.

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