- 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.