Retro-pubic / Suprapubic Open Prostatectomy (Robotic Assisted available)

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. More recently a Robotic Assisted technique has been used for these large prostates

Still commonly used in the rest of the world especially third world countries.

Why is it done?

• This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
• Symptoms include: a weak stream, nightly urination, frequent urination, inability to urinate, (LUTS) kidney failure due to the weak urination (obstruction), bladder stones, recurrent bladder infections.
• Medication such as Flomaxtra, Xatral Minipress etc. should always be given as a first resort.
• Step-up therapy should 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.
• Prostate cancer first needs to be ruled out by doing a PSA, and when indicated, with a 3T MRI scan of the prostate with an abnormal PSA with a possible prostate biopsy of any suspicious lesions.
• A staged-TURP can also be performed to dis-obstruct a huge prostate. Either Bipolar resection or Laser can be utilised.
• Patient informed decision is vital.
• It provides a quicker solution with more marked side-effects and risks.

How is it done?

• Patients will receive a general anaesthesia, unless contra-indicated.
• Prophylactic anti-biotics is given.
• An indwelling catheter is placed.
• A lower midline incision is made ( or alternatively a horizontal Pfannensteil-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 eneucleation.
• The bladder neck is pulled down into the cavity to assist with hemostasis.
• Prostate capsule and bladder is 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.

What next?

• You will spend up to 5-7 nights in hospital.
• You will have a catheter for that time.
• A drain for 2-3 days.
• You will a trial without the catheter on the 5th day.
• You will be discharged as soon as you can completely empty your bladder.
• You may initially suffer from urge incontinence and dysuria (irritable voiding) and will improve within the next 6 weeks.
• Allow for 6 weeks for stabilization of symptoms.
• There may be some blood in your urine. You can remedy this by drinking plenty of fluids until it clears.
• A ward prescription will be issued on your discharge, for your own collection at any pharmacy.
• A follow-up appointment will be scheduled for 6 weeks. Remember there is no pathology due to vaporisation.
• Don’t hesitate to ask Jo if you have any queries.
• DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Side-effects

• Blood loss requiring blood transfusion.
• Infection.
• Prolonged hospital stay.
• Retrograde ejaculation in more than 90% of patients. Therefore if you have not completed your family, this procedure is not for you unless absolutely necessary.
• Infertility as a result of the retrograde ejaculation.
• Stress incontinence especially in the elderly and the diabetic patients.
• Patients with Multiple Sclerosis, Strokes and Parkinsons have a higher risk of incontinence and risks should be discussed and accepted prior to surgery.
• Less chance of growth of prostate lobes usually within 3-5 years requiring a second procedure.
• NB! Each person is unique and for this reason symptoms vary!

Remember

You still have a peripheral zone of your prostate and regular PSA reviews are required up to the age of 75.

(This could be seen as controversial).

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