Open prostatectomy is surgery to remove an enlarged prostate that's causing urinary symptoms. With open prostatectomy, your doctor will remove your entire prostate through a cut (incision) beneath your navel. For most men, open prostatectomy generally requires a hospital stay of a few days, and a few weeks of recovery.
Open prostatectomy is one of several alternatives for treating an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). Other treatments include medications, transurethral resection of the prostate (TURP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), and laser surgery. Open prostatectomy is the most invasive of all treatments for enlarged prostate.
Indication
Open prostatectomy is a procedure to treat urinary symptoms caused by an enlarged prostate. These symptoms include:
Risks
Open prostatectomy can cause temporary problems right after surgery and can also cause long-term problems. Risks of open prostatectomy include:
Advantages of the retropubic technique over the suprapubic approach include the following:
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:
Advantages of the perineal prostatectomy approach include the following:
The disadvantage of the suprapubic approach relates to reduced visualization of the apical prostatic adenoma and the potential complication of postoperative urinary incontinence and intraoperative bleeding.
The main contraindication and disadvantage to perineal enucleation prostatectomy is performing the procedure in patients for whom sexual potency remains important. This approach invades the perineal neurovascular anatomy more extensively than other available open techniques.
In patients with outlet obstruction that is recalcitrant (does not respond to medical treatment) or more advanced, minimally invasive procedures are available, including visual laser prostatic ablation, TUIP, and thermotherapy procedures, such as TUMT, TUEVP, and TUNA.
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.
Open (simple) prostatectomy does have disadvantages when compared to TURP, however, and include the morbidity and longer hospitalization associated with the open procedure and the potential for greater intraoperative hemorrhage.
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. Both 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.
In 2008, Sotelo et al published their initial experience with a robotic suprapubic simple prostatectomy.[5 ]As with other laparoscopic cases, robotic assistance may prove to be very valuable and may increase the popularity of this minimally invasive approach.
For excellent patient education resources, visit eMedicine's Prostate Health Center and Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Enlarged Prostate.
Open prostatectomy is one of several alternatives for treating an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). Other treatments include medications, transurethral resection of the prostate (TURP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), and laser surgery. Open prostatectomy is the most invasive of all treatments for enlarged prostate.
Indication
Open prostatectomy is a procedure to treat urinary symptoms caused by an enlarged prostate. These symptoms include:
- · Frequent need to urinate
- · Increased frequency of urination at night (nocturia)
- · Stopping and starting again while urinating
- · Feeling like you can't completely empty your bladder
Risks
Open prostatectomy can cause temporary problems right after surgery and can also cause long-term problems. Risks of open prostatectomy include:
· Urinary incontinence. In some men, open prostatectomy causes loss of bladder control and an urgent need to urinate. In most cases, this gets better after several weeks to several months.Retropubic prostatectomy
· Dry orgasm. After prostatectomy, you can still have an orgasm during sex, but you'll ejaculate very little or no semen.
· Urinary tract infection. A urinary tract infection is more likely to occur the longer you have a catheter in place, and may require antibiotics or other treatment.
· Erectile dysfunction. In some cases, open prostatectomy causes erectile dysfunction — the inability to maintain an erection firm enough to have sex. In some men it can improve over time, but in many men it's permanent.
· Narrowing (stricture) of the urethra or bladder neck. This condition blocks the urethra, the tube that carries urine from your bladder, making urination difficult. It may require additional treatment to correct.
· Heavy bleeding. If you lose too much blood during surgery, you may require a blood transfusion. You may store your own blood ahead of time in case this occurs, or you may be given donor blood if needed. In some cases, the surgery area continues to bleed after the procedure and requires further treatment.
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
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 the perineal prostatectomy approach include the following:
- Ability to avoid the retropubic space (Prior retropubic surgery would make retropubic or suprapubic surgery more difficult.)
- Ability to treat clinically significant prostatic abscess and prostatic cysts
- Less postoperative pain
Contraindications
Disadvantages of retropubic prostatectomy relate largely to the limited access to the bladder, which is an important consideration if a bladder diverticulum requiring excision coexists or when a large bladder calculus must be directly removed. Additionally, if cystoscopy findings indicate that the obstructing adenoma primarily involves the median lobe, the suprapubic approach may be preferred because this technique optimizes anatomic exposure.The disadvantage of the suprapubic approach relates to reduced visualization of the apical prostatic adenoma and the potential complication of postoperative urinary incontinence and intraoperative bleeding.
The main contraindication and disadvantage to perineal enucleation prostatectomy is performing the procedure in patients for whom sexual potency remains important. This approach invades the perineal neurovascular anatomy more extensively than other available open techniques.
Workup
Laboratory Studies
- 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 ultrasound-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 cell count, coagulation studies, and at least a type and screen should be obtained in all patients prior to proceeding with an open (simple) prostatectomy.
Imaging Studies
- Although transrectal ultrasonography may help document prostatic 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 is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years.
Other Tests
- ECG is indicated to investigate potential complications of possible preexisting conditions in patients older than 60 years.
Diagnostic Procedures
- Cystoscopy is useful for identifying the presence of urethral stricture disease, bladder calculi, diverticula, and a large median lobe. This information is useful in deciding whether to perform a suprapubic versus 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.
Treatment
Medical Therapy
A number of treatment options exist for benign prostatic hyperplasia (BPH). Consider medications that act at the level of the prostate and bladder neck. These include alpha-blockers, such as tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), and alfuzosin (Uroxatral), which relax prostatic and bladder neck smooth muscle. In addition, the 5-alpha-reductase inhibitors, finasteride (Proscar) and dutasteride (Avodart), decrease the size of the prostate. These medications have been shown to improve symptoms of lower urinary tract obstruction.In patients with outlet obstruction that is recalcitrant (does not respond to medical treatment) or more advanced, minimally invasive procedures are available, including visual laser prostatic ablation, TUIP, and thermotherapy procedures, such as TUMT, TUEVP, and TUNA.
Surgical Therapy
The advantages of open (simple) prostatectomy over TURP include the complete removal of the prostatic adenoma under direct visualization in the suprapubic or retropubic approaches. 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.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.
Open (simple) prostatectomy does have disadvantages when compared to TURP, however, and include the morbidity and longer hospitalization associated with the open procedure and the potential for greater intraoperative hemorrhage.
Preoperative Details
- Exclude prostate cancer before performing prostatectomy in patients with symptomatic bladder outlet obstruction. All men should undergo preoperative PSA determination and routine DRE. Suspicions evoked by either screening modality should prompt a transrectal ultrasound-guided needle biopsy of the prostate before open (simple) prostatectomy is performed. Additionally, preoperative lower urinary tract studies likely 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.
- Patients who present for open (simple) prostatectomy are typically aged 60 years or older. The comorbidities common to this patient population involve not only routine preoperative history, physical examination, and standard serum chemistries but also chest radiography and ECG to investigate potential complications of these potential preexisting conditions.
- 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.
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. Both 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.
In 2008, Sotelo et al published their initial experience with a robotic suprapubic simple prostatectomy.[5 ]As with other laparoscopic cases, robotic assistance may prove to be very valuable and may increase the popularity of this minimally invasive approach.
Postoperative Details
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.Follow-up
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 to exclude carcinoma.For excellent patient education resources, visit eMedicine's Prostate Health Center and Men's Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Enlarged Prostate.
Complications
- Postoperative complications following both suprapubic and retropubic prostatectomy include hemorrhage, urinary extravasation, and associated urinoma.
- 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 also 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 to 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 non-urologic 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.
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