What are the four approaches in prostate surgery?

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emedicine.medscape.com - Simple Prostatectomy: Overview, Preparation, Technique

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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

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

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)

Ability to treat clinically significant prostatic abscess and prostatic cysts

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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.

emedicine.medscape.com - Simple Prostatectomy: Overview, Preparation, Technique

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