Simple Prostatectomy – Open

Why is it done?

For those large benign prostates where a TURP would be too time consuming, and too dangerous.
Generally, prostates over 200cc
Not commonly performed in Australia
This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
Step-up therapy could have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar and can be used as a first line in these huge prostates as long as the sexual side effects have been discussed.
Prostate cancer would have been excluded by doing a PSA, and when indicated, with a 3T MRI scan.
An alternative: A 2 staged-TURP can also be performed to dis-obstruct a huge prostate. Either Bipolar resection or Laser can be utilized
It provides a quicker solution with more marked side-effects and risks

Patients will receive a general anesthesia,
Prophylactic anti-biotic is given.
An indwelling catheter is placed.
A lower midline incision is made (or alternatively a horizontal Pfannenstiel-incision), The retropubic space of Retzuis is entered
A Millen-procedure is done where the prostate capsule and lower part of the bladder is incised in the longitudinal aspect
The bladder neck mucosa is cut and freed from the prostate away from the ureters as to prevent injury.
With blunt dissection the apex of the prostate is freed from with the urethra and each lobe is delivered separately.
Copious bleeding is possible in this phase, and this is where a cell-saver usage is critical to prevent blood transfusions with donor blood.
Hemostatic sutures are placed over bilateral prostatic vascular pedicles to stop the bleeding.
Sutures are placed to assist in reducing the cavity left after enucleation
The bladder neck is pulled down into the cavity to assist with hemostasis.
Prostate capsule and bladder are closed in 2 layers over a 3-way irrigation catheter
A drain is left for a couple of days
You may have continuous Antibiotics over the next few days.

Complications

Blood loss 400-1200cc, usually less
Wound infections
The first 6 weeks are the worst with frequency and urgency as a result
Stress incontinence may occur and will improve over the next 12 months (12%)
Complete incontinence at 12 months (2%)
Erectile dysfunction (bladder neck stenosis 5 % requiring intermittent self-dilatation
Retrograde ejaculation with Infertility
Testicular pain similar to vasectomy for up to a week
Possibility of bowel injury

Post-operative review: