January 23, 2009 Leave a comment
Open prostatectomy is the enucleation of the hyperplastic adenomatous growth of the prostate. This procedure does not involve total removal of the prostate. A tissue plane exists between the adenoma and the compressed true prostate, which is left intact. Three surgical approaches to the prostate are described in this chapter: suprapubic, retropubic, and perineal.
Over 90% of prostatectomies for benign prostatic hyperplasia are performed by transurethral resection of the prostate (TURP). When the obstructing tissue is estimated to weigh more than 50 g, serious consideration should be given to an open procedure. Digital examination, prostatic ultrasound, and cystourethroscopic measurement of the prostatic length may aid in the estimating of the size of the gland. Findings on cystourethroscopy may indicate an open procedure, such as sizable bladder diverticuli, which justify removal, or large bladder calculi, which are not amenable to easy fragmentation. The association of an inguinal hernia with an enlarged prostate may lead to a suprapubic or retropubic procedure because the hernia may be repaired by way of the same lower abdominal incision.
INDICATIONS FOR SURGERY
The indications for prostatectomy include the following symptoms or findings secondary to prostatic obstruction: acute urinary retention; recurrent or persistent urinary tract infections; recurrent gross hematuria; documented significant residual urine after voiding with or without overflow incontinence; pathophysiological changes of the kidneys, ureters, or bladder; abnormally low urinary flow rate; and normal flow rate with abnormally high intravesical voiding pressure and intractable symptoms such as nocturia, frequency, and urgency.
Contraindications to an open prostatectomy include a small, fibrous gland, carcinoma of the prostate, or prior prostatectomy in which most of the prostate has previously been resected or removed and the planes are obliterated.
Alternative therapies to open prostatectomy include transurethral resection of the prostate (TURP), endoscopic procedures including incision of the prostate, laser ablation, vaporization techniques, thermotherapy, and medical management. Most of these therapies are effective for moderate (medical management) to severe symptoms in prostates less than 60 g (alternative surgical techniques) and are therefore not indicated in the majority of patients who are candidates for open prostatectomy. The patient’s bladder outlet symptoms could also be managed alternatively by intermittent catheterization, an indwelling catheter, or a suprapubic cystostomy. None of these are good alternatives if the patient is a reasonable surgical risk.
The average age of patients is about 70 years. Many of the patients have histories of cardiovascular disease, chronic obstructive pulmonary disease, diabetes, or hypertension. It is preferable to evaluate the upper urinary tract with either an intravenous pyelogram and a postvoid film if the patient’s renal function is normal or an abdominal radiograph and a renal sonogram. Cystourethroscopic examination should be performed to rule out unexpected bladder pathology. This can be done just before surgery under the same anesthetic. If the patient has a documented urinary tract infection, it should be treated before planned elective surgery and may necessitate indwelling catheter drainage before the procedure.
Transfusion of blood may be required in about 15% of patients undergoing open prostatectomy. It is prudent to have 2 or 3 units of blood available when contemplating the procedure. The safest transfusion is autologous blood, and individual units can be drawn a week apart while the patient is on oral iron medication.
Spinal or epidural anesthesia is preferred in all prostatectomy procedures. If regional anesthesia is contraindicated, a general anesthetic with adequate relaxation may be used.
Informed consent is necessary. The patient must be made aware of the risks and complications. Most patients can be evaluated as an outpatient and then admitted to the hospital on the day of surgery. This is cost effective and reduces hospitalization.
Suprapubic prostatectomy or transvesical prostatectomy is the enucleation of the hyperplastic adenomatous growth of the prostate performed through an extraperitoneal incision of the anterior bladder wall.9 Eugene Fuller of New York is credited with performing the first complete suprapubic removal of a prostatic adenoma in 1894. This was a blind procedure with digital enucleation of the gland. Suprapubic and perineal drainage tubes were placed to wash out clots and control bleeding. Peter Freyer of London popularized the operation and subsequently published his results of over 1,600 cases with a mortality rate of just over 5%. The entire operation was usually a 15-minute procedure. A 5- to 8-cm midline suprapubic incision was made, and the bladder was opened without opening the lateral tissue spaces or entering the space of Retzius. Digital enucleation of the prostate was then performed. One or two fingers were placed in the rectum for counterpressure while the suprapubic enucleation was accomplished. The prostatic fossa was left alone because Freyer thought that the capsule and surrounding tissues at the bladder neck would contract down enough to control bleeding somewhat like a parturient uterus immediately after childbirth. He left an indwelling urethral catheter and a large suprapubic tube to evacuate clots. His low mortality and morbidity rates are remarkable considering that no blood transfusions or antibiotics were available at that time. This blind enucleation remained popular for over 50 years. The low transvesical suprapubic prostatectomy with visualization of the bladder neck and prostatic fossa and placement of hemostatic sutures has supplanted the blind procedure.4 This operation is presented in more detail.
The patient is placed in the supine position with the umbilicus positioned over the kidney rest; the table is slightly hyperextended and in a mild Trendelenburg’s position. A catheter is introduced into the urinary bladder; the bladder is irrigated and then filled with 200 to 250 ml of water or saline, and the catheter is then removed. The abdomen and genitalia are prepped from nipple line to midthigh. A vertical midline suprapubic incision is made through the skin and linea alba with the incision extending from below the umbilicus to the symphysis. The rectus muscles are retracted laterally, and the prevesical space is developed, with the peritoneum swept superiorly. It is not necessary or desirable to expose the retropubic or lateral vesical spaces. For more adequate exposure, a self-retaining retractor is used.
Two sutures are placed in the anterior bladder wall below the peritoneal reflection. A vertical cystotomy is then made, and the incision is opened down to within 1 cm of the bladder neck, allowing visualization of the bladder neck and prostate. A medium Deaver retractor is placed into the open bladder, retracting superiorly. A narrow Deaver is then placed over the bladder neck just distal to the trigone. The curved end of the Deaver retractor provides an excellent semilunar line for incising the mucosa around the posterior bladder neck just distal to the trigone. By this method, the ureteral orifices are well visualized and are not compromised. Metzenbaum scissors are introduced at the 6 o’clock position, and, by gentle dissection, the plane between the adenoma, bladder neck, and the capsule of the prostate is developed.
The remainder of the procedure is done by digital dissection, freeing the posterior lobes down to the apex of the prostate and then circumferentially sweeping anteriorly. The urethra is firmly attached at the apex. It is preferable to use scissors to sharply incise the urethra, keeping close to the prostatic adenoma so as not to cause injury to the sphincter and subsequent incontinence. With large glands, it is often preferable to remove one lobe at a time, or, if there is a large intravesical protrusion of the middle lobe, this may be removed separately.
After removal of the adenoma, the prostatic fossa is inspected, and a digital sweep is made to ascertain if there is any remaining nodular adenomatous tissue. There is usually minimal bleeding; however, bleeding is frequently seen in the 5- and 7-o’clock positions. The prostatic arteries enter the capsule and prostate at this level near the bladder neck. Suture ligature of these vessels is done even if there is no active bleeding. Figure-of-eight sutures of 2-0 chromic on a 5/8 circle needle provide good hemostasis.
A 22-Fr, 30-ml balloon, three-way Foley catheter is passed through the urethra. A 26- or 28-Fr Malecot suprapubic tube is passed through a separate stab wound in the anterior bladder wall and brought out through a stab wound in the lower abdominal wall. A watertight, single-layer, interrupted closure of the bladder with either 2-0 chromic catgut or Vicryl is done, just missing the mucosa but including full thickness of the muscularis and serosa. The balloon of the Foley catheter is inflated to 45 ml and placed on no traction. A 4-0 chromic catgut suture is placed as a pursestring around the suprapubic tube; this prevents any leakage and helps to hold the suprapubic tube gently in position during wound closure. A Penrose drain is placed down to the cystotomy site and brought out through a separate stab wound. The bladder is irrigated until clear and checked for significant leakage.
The wound is irrigated, and the linea alba is closed with a running #2 nylon or #1 PDS suture. The skin is approximated with skin staples. The drain and suprapubic tube are sutured to the skin with nylon sutures, and a dressing is applied.
Postoperatively, excessive blood loss is the most common immediate complication encountered; about 15% of patients require a blood transfusion. If excessive bleeding from the prostatic fossa is noted intraoperatively, two techniques are effective in stopping the bleeding. Malament described the placement of a #1 or #2 nylon pursestring suture around the vesical neck; the suture was brought out through the skin and tied snugly. This effectively closes the bladder neck and tamponades the prostatic fossa with control of bleeding. Between 24 and 48 hours after placement, the suture is cut on one side and removed. O’Conor10 described placation of the posterior capsule using 0 chromic catgut on a 5/8 curved needle. This placation narrows the fossa and results in effective hemostasis. Point fulguration of bleeders in the fossa may also provide hemostasis.
Antibiotics are not indicated for elective prostatectomy in patients who have had no urinary tract infections and have sterile urine. If there has been a long-term indwelling catheter or preoperative infection, appropriate perioperative antibiotics, a cephalosporin and an aminoglycoside or a fluoroquinolone, are indicated.
The patient is usually limited to intravenous fluids the day of surgery, but the following day he can usually tolerate oral nutrition, often having a full diet. A stool softener or mild laxative is given to prevent straining with bowel movements or fecal impaction. Continuous bladder irrigation by way of the three-way Foley catheter is maintained for 12 to 24 hours. The Foley catheter usually is removed after 3 days, although one can remove the suprapubic catheter first. If the Foley catheter is removed first, the suprapubic tube is clamped at 5 days to give the patient a trial at voiding. It is removed the following day if voiding is satisfactory with little residual. The drain is removed a few hours after removal of the suprapubic tube if there is no drainage. The skin staples are removed on the seventh postoperative day, and the skin is covered with sterile strips. On discharge from the hospital, the patient is encouraged to increase his activity gradually and should be able to resume full activity 4 to 6 weeks postoperatively, with outpatient visits at 3 and 6 weeks.
Simple retropubic prostatectomy is the removal of the hyperplastic prostatic adenoma by way of a prostatic capsule incision. Van Stockum is credited with performing the first retropubic prostatectomy, which he called “extravesical suprapubic prostatectomy.” A longitudinal capsular incision was made on one side of the midline. Millin reported his operative technique and results in 1945. His procedure gained wide acceptance, and he is credited with popularizing retropubic prostatectomy. Various modifications have subsequently been described.
The patient is placed in the supine position with the umbilicus positioned over the kidney rest; the table is slightly hyperextended and in a mild Trendelenburg’s position. The lower abdomen and suprapubic area are shaved, and the entire operative field from nipple line to midthigh is scrubbed with surgical solution. A Pfannenstiel incision may be used, but I prefer a vertical midline incision extending from below the umbilicus to the symphysis. The linea alba is opened, and the rectus muscles are retracted laterally.
The prevesical and retropubic space is developed, with the peritoneum and extraperitoneal fat swept superiorly. A self-retaining retractor is placed in the incision to obtain maximal exposure. There are several large veins in the loose areolar tissue and fat over the anterior capsule of the prostate. These should be suture ligated and divided; smaller vessels may be fulgurated to avoid troublesome bleeding.
The vesical neck can be visualized and palpated. Two traction sutures are placed in the prostatic capsule above and below the planned site of the capsular incision, which is made about 1 cm distal to the bladder neck. As the capsule is opened, one can recognize the white outer part of the adenoma. The length of the incision depends on the size of the gland and should be sufficient to dissect the adenoma.
The cleavage plane between the prostatic adenoma and the surgical capsule or true prostate is developed using Metzenbaum scissors. The dissection may be completed with scissors; in large adenomas, digital enucleation can easily be performed. The urethra is firmly attached at the apex. It is preferable to use scissors to incise the urethra sharply, keeping close to the prostatic adenoma to avoid causing injury to the sphincter and subsequent incontinence.
After removal of the prostatic adenoma, the fossa is inspected for any remaining nodules of adenoma and for sites of bleeding. The main sources of bleeding are the arteries at the 5- and 7-o’clock positions, which lie just distal to the bladder neck. Figure-of-eight suture ligatures of 2-0 chromic catgut are placed to secure hemostasis. Bleeding vessels in the prostatic fossa can be fulgurated under direct visualization. If the surgeon wears a headlight for illumination, visualization is much improved.
In some patients, the posterior lip of the vesical neck is prominent and protrudes into the lumen. This can be removed by wedge resection by grasping the midline with an Allis clamp, and, with either scissors or a knife, the wedge can be excised. A running suture may be placed for hemostasis.
A 22-Fr Silastic-coated three-way irrigating Foley catheter with a 30-cc retention balloon is inserted through the urethra into the bladder. The transverse incision of the prostatic capsule is then closed with a continuous suture of 2-0 chromic catgut or Vicryl, ensuring a watertight closure. Slight catheter traction is applied, and continuous bladder irrigation is instituted. If excessive bleeding from the prostatic fossa is noted, the source should be sought before wound closure. Suture placation of the prostatic fossa may be helpful. A suprapubic catheter is used only if there is significant bleeding.
A Penrose drain is placed into the space of Retzius and brought out through a stab wound lateral to the incision and sutured to the skin. The wound is irrigated, and the linea alba is closed with a running #2 nylon or #1 PDS suture. The skin is approximated with skin staples. A wound and drain dressing is applied.
Postoperatively, the Foley catheter is irrigated until it runs clear, and continuous bladder irrigation with saline is used for several hours. The catheter is usually removed on the fifth or sixth postoperative day. The Penrose drain is moved partially outward on that day and is removed the following day if no drainage occurs. The skin clips are removed, and sterile strips are applied.
The first operations for relief of urinary retention from prostatic enlargement were probably done through the perineum, and early medical writings contain references to division of the bladder neck through the perineum for this purpose. Covillard, in 1639, was apparently the first to remove a hypertrophied middle lobe by tearing it away with forceps after perineal lithotomy. In 1848, Sir William Fergusson exhibited specimens of hypertrophied prostates he had enucleated through the perineum after removal of bladder calculi. Kuchler, in 1866, formulated the first systematic technique for radical perineal prostatectomy, but his operations were done only in the cadaver. In 1867, Billroth used Kuchler’s method to carry out the first two intentional prostatectomies in living subjects. Apparently, however, the lobes were not entirely removed in these patients.
In 1873, Gouley advocated systematic enucleation of the lateral lobes and excision of the median lobe through the perineum. Goodfellow is credited4 as the first to perform a perineal prostatectomy successfully on a routine basis. His method involved the use of a midline vertical incision from the base of the scrotum to the anal margin, followed by incision of the membranous urethra, extension of the opening into the bladder, and complete enucleatlon of the prostatic lobes. His technique, although differing in certain respects from that used today, nevertheless forms the basis of current methods.
During the next decade, a number of technical modifications were suggested by Nicoll, Alexander, Albarran, Proust, dePezzer, Legueu, and others. For the most part, those changes were concerned with improving delivery of the prostatic lobes into the perineal incision for enucleation. In 1903, Young described his operative technique developed at the Johns Hopkins Hospital; this is still the approach most widely used. In 1939, Belt and colleagues introduced an important modification in the perineal approach to the prostate, which did much to reduce the risk of rectal injury inherent in the operations of Young and earlier surgeons. Belt’s method of closure also was a great improvement over earlier methods and shortened convalescence considerably.
Either spinal or general anesthesia can be used. Caudal block is also acceptable. With general anesthesia, tracheal intubation ensures adequate respiratory exchange.
Preoperatively, the patient should self-administer an enema to clean the lower bowel and rectum and receive appropriate antibiotics for a 1-day bowel prep. The genitalia are cleansed thoroughly, after which cystoscopy is performed. The entire operative area, from costal margins to midthigh, is then prepped. Bilateral vas ligation is now rarely performed.
Perfect positioning is essential for the perineal operation. The patient is placed in the exaggerated lithotomy position on any ordinary operating table. Sandbags are placed beneath the sacrum to position the perineum as close to horizontal as possible. The table is then elevated to bring the operative area up to the level of the operator’s chest. This makes the operation a good deal easier and improves visualization considerably. The perineum can usually be positioned adequately without resort to Trendelenburg’s position, but occasionally a slight Trendelenburg’s position may be necessary. Under no circumstances should shoulder braces be used for fear of causing postoperative brachial palsy. All other points where pressure is likely (e.g., popliteal areas) are carefully padded.
The curved Lowsley tractor is passed through the urethra and held upright with blades unopened. A curved skin incision is made about 1 cm from the anal margin. The anus is excluded from the operative field by being covered with a towel secured by three Allis clamps to the posterior edge of the incision. With the index fingers, the ischiorectal fossae are developed perpendicular to the plane of tile perineum. The central tendon is gently separated from the underlying rectum and cut across distal to the external anal sphincter, with care taken not to disturb that structure. A bifid posterior retractor is placed in the ischiorectal fossae, and gentle traction is exerted. The lateral fossae are developed next and held with two small lateral retractors. The rectourethralis muscle is identified and cut.
By carefully incising the pararectal fascia (posterior layer of Denonvillier’s fascia), the rectum can be gently peeled posteriorly off the apex of the prostate. The Lowsley tractor is passed fully into the bladder, and the blades are opened. The bifid posterior retractor is replaced by a plain posterior one (the lipped Richardson is useful here), with a moistened pad used to protect the rectum. The posterior layer of Denonvillier’s fascia is progressively incised and retracted posteriorly until a window appears through which the anterior layer of Denonvillier’s fascia—the “pearly gates”—can be seen clearly.
At this point, the operator simultaneously depresses the handle of the Lowsley tractor toward the abdominal wall and exerts firm downward traction on the posterior Richardson retractor. The remaining posterior fascial laver is thereby stripped away from the prostate, which comes clearly into view, covered only by the glistening anterior layer of Denonvillier’s fascia. This is a most effective maneuver, but it should not be done before dissection of the posterior fascial layer has been completed at the apex.
An inverted-V or curved prostatotomy is made, and a plane of cleavage is established with the dissecting scissors. Care is taken to peel back and preserve the posterior flap for subsequent closure of the prostatotomy. The urethra is incised, the curved Lowsley tractor is removed, and the regular Young prostatic tractor is inserted gently into the bladder through the prostatotomy, using a rotary motion. The blades of the tractor are then opened, the prostate is drawn down, and enucleation is begun.
As soon as possible, the urethra at the apex of the adenoma is cut across with the scissors, thereby facilitating enucleation distally and minimizing the danger of damage to the external urethral sphincter. Enucleation is carried out essentially under direct vision, using the scissors and the finger. Enucleation can sometimes be facilitated by removing the Young tractor and grasping the lobes with forceps that are especially designed for this purpose. The lobes can then be drawn progressively into the operative field. The hypertrophied lobes are cut away sharply from the bladder neck under direct vision. With care, the bladder neck can be preserved intact, even after removal of a large adenoma.
After enucleation has been completed, the bladder neck is grasped with Millin T-clamps, which were originally designed for the retropubic operation. These have the advantage of being offset so that one can obtain an unimpeded view of the bladder neck. A careful search is made for bleeding vessels (especially at the 5- and 7-o’clock positions). Smaller ones are controlled effectively by electrocoagulation. Larger arteries require mattress sutures of 2-0 plain catgut. The interior of the bladder is explored with the finger, and any blood clots are removed. The entire prostatic fossa is inspected carefully for residual adenomatous tissue. Remaining tags of tissue are trimmed away from the bladder neck.
A 22-Fr Foley catheter is passed through the urethra and into the bladder, where the balloon is inflated with 30 to 45 ml of water. The bladder neck, which feels like a soft cervical os dilated to about two fingerwidths, retains the balloon nicely. Wedge resection of the posterior lip is generally unnecessary. If desired, a three-way Foley, catheter may be used to permit through-and-through irrigations postoperatively.
Closure is simple. The edges of the prostatotomy are approximated with interrupted 2-0 chromic catgut sutures. The rectum is inspected for possible injury. No effort is made to bring the levator ani fibers together. A Penrose drain is left in the retroprostatic space. Skin edges are approximated with interrupted Dexon or Vicryl sutures. A simple dressing is applied to the wound, using a split-T binder. The lower extremities are brought down simultaneously and gradually. Too rapid depositioning may result in hypotension because of the sudden rush of blood into the legs, particularly if they have not been wrapped preoperatively.
Excessive bleeding is seldom encountered during perineal prostatectomy. If care is taken to obtain adequate exposure, bleeding vessels can usually be identified and secured without difficulty. The only other complication that may occur during the operation is laceration of the rectum, which is readily recognized from the characteristic appearance of the rectal mucosa. The injury should be completely mobilized and repaired with interrupted 4-0 chromic catgut sutures placed so that the mucosal edges are inverted. The muscularis should be closed in two additional layers, again using interrupted sutures of 4-0 chromic catgut.
If the injury is recognized before the urinary tract is opened, it is best to close the perineal incision and enucleate the gland through a suprapubic incision. If the rectal injury is not appreciated until after the urinary tract has been entered, the laceration should be repaired meticulously, as just outlined. Postoperatively, the patient should be maintained on a low-residue diet, and bowel activity should be completely suppressed with paregoric for 7 days.
After removal of the hypertrophied lobes, the raw surfaces of the prostatic fossa soon reepithelialize. The compressed outer prostate (prostate proper, or surgical capsule) eventually reexpands to normal size. Scattered areas of induration usually persist indefinitely and can be detected by rectal palpation.
Postoperatively, if a regular Foley catheter has been used, it is simply attached to straight bedside drainage. From time to time, gentle manual irrigation may be carried out to keep the system free of clots. The catheter is secured to the thigh, but no traction is necessary. If a three-way catheter has been used, it is attached to a through-and-through irrigating system containing sterile saline solution, which is run in just rapidly enough to keep the efflux reasonably clear. The patient is given appropriate antibiotics. Fluids may be given by mouth during the first day, and they are customarily supplemented by intravenous infusions to maintain a satisfactory intake.
The perineal Penrose drain is usually removed on the first postoperative day. At this time, the patient may be placed on a soft or regular diet and allowed out of bed. Early ambulation is encouraged.
Usually, the perineal wound heals benignly, but sometimes partial separation of the skin edges may occur. Healing may be promoted by removal of the dressing and exposure to a heat lamp. Warm sitz baths are also effective.
The urethral catheter is removed between the seventh and tenth postoperative days. Not infrequently, urinary leakage may occur from the wound for a day or two after the catheter has been taken out. If it continues longer than this, an 18-Fr, 5-ml Foley catheter may be reinserted for a day or two. Care must be taken in passing the catheter to be certain it does not curl up in the prostatic fossa. Sometimes a stylet is helpful, with the aid of a finger in the rectum.
During the immediate postoperative period, it is important that no rectal instrumentation be performed. No thermometers or rectal tubes should be inserted; this must be made clear to the nursing staff.
Delayed bleeding as occasionally seen after TURP is uncommon after open prostatectomy.
Wound infections occur in fewer than 5% of patients and are usually limited to the skin and subcutaneous tissue. Postoperative epididymo-orchitis is uncommon and may occur early or late. This complication is most commonly seen in patients who have had a long-term indwelling catheter or urinary tract infection.
Incontinence of urine is an uncommon complication of open prostatectomies and usually results from perforation and partial avulsion of the prostatic capsule or avulsion of the urethra at the apex of the prostate. With careful enucleation of the adenoma, the capsule is not perforated. With sharp excision of the urethra at the apex rather than avulsion, incontinence should not occur. Some patients may experience stress incontinence or urge incontinence, and detrusor instability may be the cause. In perineal prostatectomies, about 10% of patients experience some urinary incontinence for a few days after removal of the catheter. This disappears rapidly in the vast majority, but up to 6 months may be required for complete cessation of leakage in the occasional patient. Permanent incontinence is highly uncommon after an uneventful perineal prostatectomy.
Other Urologic Complications
In suprapubic and retropubic prostatectomies, urinary fistulas have been reported. Persistent perineal urinary fistula has been feared by those unfamiliar with perineal surgery; in actuality, this complication is rarely seen. Its occurrence should lead one to suspect some form of urethral obstruction, for example, a postoperative stricture.
Urethral stricture and bladder neck contracture occur most commonly as complications of transurethral resection and are uncommon after suprapubic prostatectomy. A single, gentle dilation with a urethral sound usually suffices to take care of this. Erectile dysfunction after prostatectomy should not occur unless the capsule has been violated. Retrograde ejaculation is common.
Rectal injury is a rare occurrence. Osteitis pubis is rarely seen but can be disabling. The condition is usually self-limited. Analgesics and anti-inflammatory drugs provide symptomatic relief.
Surgical mortality for open prostatectomy should be less than 1%; myocardial infarction, pneumonia, and pulmonary embolus are the most common causes. Early ambulation, leg movement in bed, and breathing exercises decrease morbidity.
Enucleation of the enlarged prostatic adenoma by an open procedure is applicable in 5% to 10% of patients presenting with significant bladder outlet obstruction. The operative mortality and morbidity are minimal.