Three15 147 Simple Prostatectomy

Enucleation of the hyperplastic prostatic adenoma is achieved through a direct incision of the anterior prostatic pseudocapsule. 

• Advantages 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.

• Disadvantage of the retropubic approach, as compared with  the suprapubic prostatectomy
• - direct access to the bladder is not achieved.

Enucleation of the hyperplastic prostatic adenoma through an extraperitoneal incision of the lower anterior bladder wall.

• Advantage of this suprapubic procedure over the retropubic approach - 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 pseudocapsule and dorsal vein complex.

• Disadvantage, compared with the retropubic approach
• - direct visualization of the apical prostatic adenoma is reduced.
• - hemostasis may be more difficult because of inadequate visualization of the entire prostatic fossa after enucleation

• [@ Frey - Prey - Inside - मन्दिर भित्र पुजा 
• Milin - retro - घर पछाडी मिल्ने ]

• - Size > 75 gms. A simple prostatectomy on small glands carries a high complication rate.
• - when a patient presents with ankylosis of the hip or other orthopedic conditions that prevent proper positioning for TURP.
• - recurrent or complex urethral conditions, such as urethral stricture or previous hypospadias repair, to avoid the urethral trauma associated with TURP.
• - association of an inguinal hernia with an enlarged prostate suggests a simple procedure, because the hernia may be repaired by the same lower abdominal incision

Both retropubic and suprapubic simple prostatectomies are performed in the space of Retzius.

• Small fibrous glands
• Presence of significant prostate cancer
• Previous prostatectomy and pelvic surgery

Although a cystoscopic examination is not indicated for routine evaluation of obstructive voiding symptoms, one must estimate the size of the prostate adenoma preoperatively to schedule the patient appropriately. Cystoscopy may be a crucial component of that estimation. Moreover, in patients who have hematuria or a urethral stricture, or in whom one needs to evaluate a known bladder calculus or diverticulum, cystoscopy is indicated.

• Incision - lower midline incision from teh umbilicus to the pubic symphysis
• Expose space of Retzius
• Repair hernia if present 

Exposure of the prostate - displace the bladder posteriorly and superiorly.Periprostatic adipose tissue is genltly removed to expose superficial branch of the dorsal vein complex and puboprostatic ligaments.

The endopelvic fascia is incised bilaterally.

Complete control of the DVC

Control of main arterial blood supply of the prostate gland - a figure-of-eight suture is placed through the prostatovesicular junction just above the level of the seminal vesicles to control the main arterial blood supply to the prostate gland. When placing this suture, care must be taken to avoid entrapment of the neurovascular bundles located posteriorly and slightly laterally

Enucleation of the adenoma - transverse capsulotomy in the prostate 1.5 to 2.0 cm distal to the bladder neck. Metzenbaum scissors are used to develop the plane anteriorly between the prostatic adenoma and the prostatic pseudocapsule.

• With blunt dissection with the index finger, the prostatic adenoma is dissected free laterally and posteriorly. Metzenbaum scissors are used to divide the anterior  commissure to visualize the posterior urethra and  verumontanum. The index finger is then used to fracture the urethral mucosa at the level of the verumontanum. With this  last maneuver, extreme care is taken not to injure the external sphincteric mechanism.
• 

After removal of the left lateral lobe of the prostate, the right lateral lobe is excised with the aid of a tenaculum and Metzenbaum scissors. Finally, the median lobe is removed under direct vision.

After enucleation of the entire prostatic adenoma, a 0-chromic suture is used to place two figure-of-eight sutures to advance bladder mucosa into the prostatic fossa at the 5- and 7-o’clock positions at the prostatovesicular junction to ensure control of the main arterial blood supply to the prostate.



After placement of a urethral catheter and, if needed, a Malecot suprapubic tube, the transverse capsulotomy is closed with two running 2-0 chromic sutures. The two sutures are tied first to themselves and then to each other across the midline to create a watertight closure of the prostatic pseudocapsule.

• Incision - lower midline incision from teh umbilicus to the pubic symphysis
• Expose space of Retzius
• Repair hernia if present

Small, longitudinal cystotomy is made.

With adequate exposure of the bladder neck, a circular incision in the bladder mucosa is made distal to the trigone, using an electrocautery. 

 

Starting at the bladder neck posteriorly, Metzenbaum scissors are used to develop the plane between the prostatic adenoma and the prostatic pseudocapsule. 

Using the index finger, the prostatic adenoma is enucleated from the prostatic fossa.

 Cystotomy incision is closed in two layers using 2-0 absorbable sutures.

• Lower retreatment rate
• More complete removal of the prostatic adenoma under direct vision and
• Avoids the risk of dilutional hyponatremia (the TUR syndrome).

Urinary incontinence, erectile dysfunction, retrograde ejaculation, UTI, bladder neck contracture, urethral stricture, deep vein thrombosis, pulmonary embolus, and the need for blood transfusion