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.