OPEN PROSTATECTOMY RETROPUBIC SUPRAPUBIC
Category: Urology
Abstract :
open prostatectomy - description Open prostatectomy can be performed by either the retropubic or suprapubic approach. The preferred anesthesia for open prostatectomy is a spinal or epidural nerve block. Regional anesthesia can help reduce blood loss during surgery, and lowers the risk of complications such as pulmonary embolus and postoperative deep vein thrombosis. General anesthesia may be u
open prostatectomy - description
Open prostatectomy can be performed by either the retropubic or suprapubic approach. The preferred anesthesia for open prostatectomy is a spinal or epidural nerve block. Regional anesthesia can help reduce blood loss during surgery, and lowers the risk of complications such as pulmonary embolus and postoperative deep vein thrombosis.
General anesthesia may be used if the patient has an anatomic or medical contraindication for regional anesthesia.
Retropubic prostatectomy
The retropubic prostatectomy is accomplished through a direct incision of the anterior (front) prostatic capsule. The overgrowth of glandular cells (hyperplastic prostatic adenoma) is removed. These are the cells forming a mass in the prostate because of their abnormal multiplication.
A cystoscopy is performed prior to the open prostatectomy. The patient lies on his back on the operating table, and is prepared and draped for this procedure. Following the cystoscopy, the patient is changed to a Trendelenberg (feet higher than head) position. The surgical area is shaved, draped, and prepared. A catheter is placed in the urethra to drain urine. An incision is made from the umbilicus to the pubic area. The abdominal muscle (rectus abdominis) is separated, and a retractor is placed at the incision site to widen the surgical field. Further maneuvering is essential to clearly locate the veins (dorsal vein complex) and the bladder neck. Visualization of the bladder neck exposes the patient’s main arterial blood supply to the prostate gland. Once the structures have been identified and the blood supply controlled, an incision is made deep into the level of the tumor. Scissors are used to dissect the prostatic tissue (prostatic capsule) from the underlying tissue of the prostatic tumor. The wound is closed after complete removal of the prostate tumor and hemostasis (stoppage of bleeding) occurs.
The advantages of the retropubic prostatectomy include:
• Direct visualization of the prostatic tumor.
• Accurate incisions in the urethra, which will minimize the complication of urinary continence.
• Excellent anatomic exposure and visualization of the prostate.
• Clear visualization to control bleeding after tumor removal.
• Little or no surgical trauma to the urinary bladder.
Suprapubic prostatectomy
Suprapubic prostatectomy (also called transvesical prostatectomy) is a procedure to remove the prostatic overgrowth via a different surgical route. The suprapubic approach utilizes an incision of the lower anterior (front) bladder wall. The primary advantage over the retropubic approach is that the suprapubic route allows for direct visualization of the bladder neck and bladder mucosa. Because of this, the procedure is ideally suited for persons who have bladder complications, as well as obese men.
The major disadvantage is that visualization of the top part of the tumor is reduced. Additionally, with the subrapubic approach, hemostasis (stoppage of bleeding during surgery) may be more difficult due to poor visualization after removal of the tumor.
Using a scalpel, a lower midline incision is made from the umbilicus to the pubic area. A cystotomy (incision into the bladder) is made, and the bladder inspected. Using electrocautery (a special tool that produces heat at the tip, useful for hemostasis or tissue excision) and scissors, dissection proceeds until the prostatic tumor is identified and removed. After maintaining hemostasis and arterial blood supply to the prostate, the incisions to the bladder and abdominal wall are closed.
Diagnosis / Preparation
The presence of symptoms is indicative of the disease. Age also has an associated risk for an enlarged prostate, and can help establish diagnostic criteria. Men must have a special blood test called the prostate specific antigen (PSA) and routine digital rectal examination (DRE) before surgery. If the PSA levels and DRE are suspiciously indicative of prostate cancer, a transrectal ultrasound guided needle biopsy of the prostate must be performed before open prostatectomy, to detect the presence of prostate cancer (carcinoma).
Additionally, preoperative patients should have lower urinary tract studies, including urinary flow rate and post void residual urine in the bladder. Because most patients are age 60 or older, preoperative evaluation should also include a detailed history and physical examination; standard blood tests; chest x ray; and electrocardiogram (EKG) to detect any possible preexisting conditions.
Aftercare
Open prostatectomy is a major surgical operation requiring an inpatient hospital stay of four to seven days. Blood transfusions are generally not required due to improvements in surgical technique. Immediately after the operation, the surgeon must closely monitor urinary output and fluid status. On the first day after surgery, most patients are given a clear liquid diet and asked to sit up four times. Morphine sulfate, given via a patient controlled analgesic pump (IV), is used to control pain.
On the second postoperative day, the urethral catheter is removed if the urine does not contain blood. Oral pain medications are begun if the patient can tolerate a regular diet.
On the third postoperative day, the pelvic drain is removed if drainage is less than 75ml/24 hr. The patient should gradually increase activity. Follow-up with the surgeon is necessary following discharge from the hospital. Full activity is expected to resume within four to six weeks after surgery.
Risks
Improvements in surgical technique have lowered blood loss to a minimal level. For several weeks after open prostatectomy, patients may have urgency and urge incontinence. The severity of bladder problems depends on the patient’s preoperative bladder status. Erectile dysfunction occurs in 3–5% of patients undergoing this procedure.
Retrograde (backward flow) ejaculation occurs in approximately 50–80% of patients after open prostatectomy. The most common non-urologic risks include pulmonary embolism, myocardial infarction (heart attack), deep vein thrombosis, and cerebrovascular accident (stroke). The incidence of any one of these potentially adverse effects is less than 1%.
Normal results
Normally, patients will not have the adverse effects of bleeding. Hematuria (blood in the urine) is typically resolved within two days after surgery. The patient should begin a regular diet and moderate increases in activity soon after surgery. His pre-surgical activity level should be restored within four to six weeks after surgery.
Morbidity and mortality rates
The overall rate of morbidity and mortality is extremely low. The overall mortality (death) rate for open prostatectomy is approximately zero.
Alternatives
For smaller prostates, treatment using medication may help to control abnormal prostatic growth. When the prostate gland is large (75 grams and bigger), surgery is indicated.
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