October 31, 2014


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Open prostatectomy

An open prostatectomy is the operation of choice when the prostate is very large - e.g.>80 grams-(since transurethral surgery cannot be performed safely in these men). However, it carries a greater risk of life-threatening complications in men with serious cardiovascular disease, since the surgery is more extensive than TURP or TUIP.

In the past, open prostatectomies for BPH were carried out either through the perineum (the area between the scrotum and the rectum)-called perineal prostatectomy--or through a lower abdominal incision. Perineal prostatectomy has largely been abandoned for the treatment of BPH due to the higher risk of injury to surrounding organs, though it is still used for prostate cancer. Two types of open prostatectomy for BPH-suprapubic and retropubic-employ an incision extending from below the umbilicus (navel) to the pubis. A suprapubic prostatectomy involves opening the bladder and removing the enlarged prostatic nodules through the bladder. In a retropubic prostatectomy, the bladder is pushed upward and the prostate tissue is removed without entering the bladder. In both types of operation, one catheter is placed in the bladder through the urethra, and another through an opening made in the lower abdominal wall. The catheters remain in place for three to seven days after surgery. The most common immediate postoperative complications are excessive bleeding and wound infection (usually superficial). More serious potential complications include heart attack, pneumonia, and pulmonary embolus (blood clot to the lungs). Breathing exercises, leg movements in bed, and early ambulation are aimed at preventing these complications. The recovery period and hospital stay are longer than for transurethral prostate surgery.

RETROPUBIC AND SUPRAPUBIC OPEN PROSTATECTOMY

Misop Han, M.D., M.S. Alan W. Partin, M.D., Ph.D. Modified from Han and Partin -
Chapter 89, Campbell-Walsh Urology 9th Edition, 2006,
Editors: Wein, Kavoussi, Novick, Partin and Peters., Elsevier Inc.

INTRODUCTION: The treatment options for bladder outlet obstruction due to benign prostatic hyperplasia (BPH) have been expanded dramatically over the past two decades with the development of medical and minimally invasive therapies. Minimally invasive procedures include visual laser ablation of the prostate (VLAP), transurethral electrovaporization of the prostate (TVP), transurethral needle ablation (TUNA), transurethral microwave thermotherapy (TUMT), interstitial laser coagulation (ILC) and transurethral incision of the prostate (TUIP). However, these approaches are usually reserved for men with moderate symptoms and a small to medium-sized prostate gland.

INDICATIONS: For patients with acute urinary retention, persistent or recurrent urinary tract infections, severe hemorrhage from the prostate, bladder calculi, severe symptoms unresponsive to medical therapy and/or renal insufficiency as a result of chronic bladder outlet obstruction, transurethral resection of the prostate (TURP) or open prostatectomy are indicated. When compared with TURP, open prostatectomy offers the advantages of lower retreatment rate, more complete removal of the prostatic adenoma under direct vision and avoids the risk of dilutional hyponatremia (the TURP syndrome) that occurs in approximately 2% of patients undergoing TURP. The disadvantages of open prostatectomy, as compared with TURP, include the need for a lower midline incision and a resultant longer hospitalization and convalescence period. In addition, there may be an increased potential for perioperative hemorrhage.

SURGERY DISCUSSION: Open prostatectomy can be performed by either the retropubic or suprapubic approach. In Retropubic prostatectomy, the enucleation of the hyperplastic prostatic adenoma is achieved through a direct incision of the anterior prostatic capsule. This approach to open prostatectomy was popularized by Terrence Millin, who reported the results of the procedure on twenty patients in Lancet in 1945.

The advantages of this procedure over the suprapubic approach are

  1. excellent anatomic exposure of the prostate,
  2. direct visualization of the prostatic adenoma during enucleation to ensure complete removal,
  3. precise transection of the urethra distally to preserve urinary continence,
  4. clear and immediate visualization of the prostatic fossa after enucleation to control bleeding, and
  5. minimal to no surgical trauma to the urinary bladder.

The disadvantage of the retropubic approach, as compared with the suprapubic prostatectomy, is that direct access to the bladder is not achieved. This may be important when one considers excising a concomitant bladder diverticulum or removing bladder calculi. The suprapubic approach also may be the preferred method when the obstructive prostatic enlargement includes a large intravesical median lobe. Suprapubic prostatectomy, or transvesical prostatectomy, consists of the enucleation of the hyperplastic prostatic adenoma through an extraperitoneal incision of the lower anterior bladder wall. This approach to open prostatectomy was first carried out by Eugene Fuller in New York in 1894; it was later popularized by Peter Freyer in London, England, who described the procedure in 1900 and later reported the results of his first 1000 patients in 1912.

The major advantage of this suprapubic procedure over the retropubic approach is that it allows direct visualization of the bladder neck and bladder mucosa.

As a result, this operation is ideally suited for patients with

  1. a large median lobe protruding into the bladder,
  2. a clinically significant bladder diverticulum or
  3. large bladder calculi.

It also may be preferable for obese men, in whom it is difficult to gain direct access to the prostatic capsule and dorsal vein complex (. The disadvantage, as compared with the retropubic approach, is that direct visualization of the apical prostatic adenoma is reduced. As a result, the apical enucleation is less precise, and this factor may affect postoperative urinary continence. Furthermore, hemostasis may be more difficult because of inadequate visualization of the entire prostatic fossa after enucleatioin.

SUMMARY: Open prostatectomy, whether performed via a retropubic approach or a suprapubic approach, is an excellent treatment option for

  1. men with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia causing a markedly enlarged prostate gland,
  2. individuals with a concomitant bladder condition, such as a bladder diverticulum or large bladder calculi and
  3. patients who cannot be placed in the dorsal lithotomy position for a transurethral resection of the prostate gland.

With improved surgical technique, these procedures can be routinely performed in a precise manner with minimal hemorrhage. Efficacy, in terms of durable improvement in symptom score and peak urinary flow rate, is superior than other treatment options available for the obstructing prostate gland, including transurethral resection of the prostate. Meanwhile, complications are minimal and the length of hospitalization has been markedly reduced. For most patients, the length of hospital stay is three days or less. Thus, for the properly selected individual, an open prostatectomy is a highly effective and well-tolerated operation.

 

 

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