BENIGN PROSTATE SURGERY II RETROPUBIC
In general, urologists develop an aptitude for one type of prostatectomy and may favor this method. However, no single operative approach is applicable to all cases, so most urologists select the operation that is most suitable to a given case. For surgical treatment of benign prostatic hyperplasia (BPH), an open prostatectomy technique developed in 1945 is the retropubic approach, which in reality is a variation of the suprapubic approach.
Unlike the suprapubic approach (see Plate 4-14) in which the bladder is
entered, the retropubic prostatectomy involves directly incising the anterior
prostatic capsule instead. Retropubic prostatectomy is technically more
difficult than the suprapubic approach and requires more retraction in a deeper
wound. This approach is suitable for large prostates in which the hyperplasia
involves mainly the lateral lobes and not median lobe extension into the
bladder. If an individual is obese, retropubic exposure may be more difficult.
If bladder pathology coexists (tumors or stones) the retropubic approach is
less desirable, because visualization of the bladder cavity is difficult. It is
also not recommended for small glands or for prostate cancer.
The surgical approach through the skin and rectus muscles to the
prevesical space of Retzius is similar to that of the suprapubic procedure.
However, instead of entering the bladder, the anterior surface of the prostatic
capsule beneath the symphysis pubis is exposed. It may be necessary to divide
the puboprostatic ligaments while removing the areolar tissue from the anterior
surface of the prostate. The prostatic capsule is easily identified by the
overlying plexus of Santorini (see Plate 2-6), as these veins arborize over the
surface of the prostatic capsule. After ligating these veins, a transverse (or
vertical) incision is made into the prostatic capsule, exposing the adenoma.
Using the tip of the index finger, a cleavage plane is easily developed between
the adenoma and the surgical (false) capsule (see Plate 4-7) formed by the
compressed normal prostatic tissue. Further access can be obtained by insertion
of a finger from the other hand into the rectum to elevate the prostate. The
adenoma is shelled from the capsule and brought up through the prostatic
incision, where it is then peeled and freed from the bladder neck. If the
bladder neck is small, a wedge of tissue is removed and the bladder mucosa
advanced into the prostatic fossa so that a secondary bladder neck contracture
does not develop later.
Visualization of the prostatic fossa following removal of the adenoma
allows control of bleeding under direct vision. To aid hemostasis, a Foley
catheter is inserted per urethra and the balloon inflated in the prostatic
fossa. The prostatic capsule is then tightly closed with a continuous
absorbable suture without the need for a suprapubic catheter. Closure of the
lower abdominal wound is the same as with the suprapubic prostatectomy with a drain to the space of Retzius. The urethral catheter may be
removed after 4 to 7 days.
The retropubic approach has slightly lower morbidity and a faster
recovery than the suprapubic procedure because the bladder is not entered.
Opening the bladder is associated with more discomfort, dysuria, frequency, and
urgency postoperatively than if it is avoided. Excellent anatomic exposure of
the prostate is afforded by the retropubic approach, unlike with the suprapubic approach. Because of this, complete enucleation of the adenoma and
precise transection of the urethra are possible, lowering the recurrence rate
and aiding the return of continence. Secondary hemorrhage is uncommon, and the
urine clears relatively rapidly after the retropubic procedure. Again, because
this is an “open” procedure, the retropubic prostatectomy may not be indicated
for severely debilitated patients, as it is associated with a low (1%) but measurable
mortality rate.
