Simple Prostatectomy

Simple (open) prostatectomy differs from radical prostatectomy in that the former consists of enucleation of a hyperplastic prostatic adenoma, and the latter involves removal en bloc of the entire prostate, the seminal vesicles, and the vas deferens. 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.

When medical and minimally invasive options for benign prostatic hyperplasia (BPH) have been unsuccessful, the more invasive treatment options for BPH should be considered, such as transurethral resection of the prostate (TURP) or open prostatectomy. Patients who present for open (simple) prostatectomy are typically age 60 years or older.

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

Open (simple) prostatectomy has 3 different approaches: retropubic, suprapubic, and perineal. Simple retropubic prostatectomy is the enucleation of a hyperplastic prostatic adenoma through a direct incision of the anterior prostatic capsule. Simple suprapubic prostatectomy is the enucleation of the hyperplastic prostatic adenoma through an extraperitoneal incision of the lower anterior bladder wall. ^[1]

Indications for Open (Simple) Prostatectomy

The indications for either 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 that are not responsive to medical or minimally invasive therapy

• Renal insufficiency secondary to chronic bladder outlet obstruction

Advantages of 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

Advantages of 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)

Advantages of simple perineal prostatectomy

Advantages of perineal prostatectomy include the following:

• Ability to treat clinically significant prostatic abscess and prostatic cysts

• Less postoperative pain

• Ability to avoid the retropubic space

With regard to the last point, above, retropubic or suprapubic surgery is more difficult in patients who have had prior retropubic surgery.

Contraindications to Open (Simple) Prostatectomy

Open (simple) prostatectomy is contraindicated in the presence of prostate cancer. If cancer is suspected, a formal prostate biopsy should be performed before surgery is considered.

If cystoscopy findings indicate that the obstructing adenoma primarily involves the median lobe, the suprapubic approach may be preferred to the retropubic technique, because the suprapubic procedure optimizes anatomic exposure.

In addition, retropubic prostatectomy offers only limited access to the bladder, which is an important consideration if a bladder diverticulum requiring excision coexists or if a large bladder calculus must be directly removed.

The perineal approach can be contraindicated in patients in whom sexual potency remains important. In this procedure, the perineal neurovascular anatomy is invaded more extensively than it is in the other available open techniques.

Disadvantages of open (simple) prostatectomy

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

A disadvantage to the use of suprapubic approach relates to reduced visualization of the apical prostatic adenoma and the potential complications of postoperative urinary incontinence and intraoperative bleeding.

Other Considerations

Other considerations include congestive heart failure, prostate size, and bladder pathology.

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.

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.

Positioning of Patients

In the retropubic (Millin) prostatectomy, the patient is placed on the operating room table in the supine position in mild Trendelenburg.

In the suprapubic approach, place the patient in a supine position on the operative table, with the umbilicus over the break of the table. Next, hyperextend the table slightly, placing the patient in a mild Trendelenburg position.

Complication Prevention

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

Although transrectal ultrasonography may help to document the prostate’s 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 and electrocardiography are indicated to investigate potential complications from possible preexisting conditions in patients older than age 60 years.

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

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.

A study by Pariser et al that examined the national trends of simple prostatectomy for BPH found that bleeding complications were common, but perioperative mortality was low and that patients who are older, black race, or have multiple comorbidities were at higher risk of complications. ^[2]

Surgical Overview

Open (simple) prostatectomy is an invasive surgical approach for the treatment of medically resistant or advanced lower urinary tract obstruction secondary to 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 the entire prostate and to the intravesical bladder.

Retropubic (Millin) Prostatectomy

As previously stated, 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. After that, 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. After that, hyperextend the table slightly, placing the patient in a mild Trendelenburg position. ^[3]

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 2 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. 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. ^{[4, 5, 6]}

In 2008, Sotelo et al published their initial experience with a robotic, suprapubic simple prostatectomy. ^[7] As with other laparoscopic cases, robotic assistance may prove to be very valuable and may increase the popularity of this minimally invasive approach.

A study by Pokorny et al presented the perioperative and short-term functional outcomes of robot-assisted simple prostatectomy in a large series of patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement (BPE) treated in a high-volume referral center. The data indicated good perioperative outcomes, an acceptable risk profile, and excellent improvements in patient symptoms and flow scores at short-term follow-up following RASP. ^[8]

A study by Wang et al that included 27 patients who underwent robotic-assisted urethra-sparing simple prostatectomy via an extraperitoneal approach reported short catheterization time, an acceptable risk profile, significantly improvements of voiding function and maintaining antegrade ejaculation following this urethral- sparing technique. ^[9]

Postsurgical Care

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.

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 for the patient in order to exclude carcinoma. With simple prostatectomy, the risk of prostate cancer development remains and patients must be monitored with DRE and PSA studies.

Complications of Simple (Open) Prostatectomy

Postoperative complications following suprapubic and retropubic prostatectomy include hemorrhage, urinary extravasation, and associated urinoma. ^[10]

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 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 or 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.

Patient Education

For patient education information, see eMedicineHealth's Men's Health Center. Also, see eMedicineHealth's patient education articles The Male Anatomy and Enlarged Prostate.