Retropubic Prostatectomy

The retropubic prostatectomy approach uses a transverse capsular incision through the prostatic capsule, allowing better control of the prostatic vessels at the bladder neck after enucleation of the adenoma. This technique was first described in 1945 by Terence Millin and has remained relatively unchanged since it was first described. Other incisions through the prostatic capsule will also be described.

Preoperative Management

Most patients undergoing open prostatectomy are older with many comorbid medical conditions. Medical and, if necessary, cardiac evaluation should be considered in all cases. Upper tract evaluation and cystoscopy should be done in patients with a history of either gross or microscopic hematuria. A prostate specific antigen (PSA) test should be ordered on all patients, and biopsy should be done on those with elevated PSA.

A urine culture should be obtained before the operation, and the urine should be sterile at the time of surgery. In addition, preoperative antibiotic coverage should be used to prevent infection from skin flora. A bowel prep or enema should be given to patients to prevent stool contamination in case of rectal injury.

Positioning and Approach

The patient is placed in the supine position on the operating room table. The table should be placed in a flexed position to increase the space between the umbilicus and symphysis pubis, allowing for better exposure to the anterior surface of the bladder and prostate. In addition, the table should be placed in Trendelenburg position to displace the peritoneum and intraabdominal organs in a cephalad direction. Padding the lower back may help prevent nerve injury. Compression stockings or sequential compression devices should be applied to the lower extremities to prevent deep vein thrombosis (DVT). For those who are at high risk of DVT, oral or intravenous anticoagulants should be considered.

The abdomen and genitalia should be prepped under sterile conditions for surgery. Cystoscopy, if not done preoperatively, should now be done. A Foley catheter should be placed to drain the bladder and inflated with 30 mL of fluid. Palpation of the Foley balloon allows identification of the bladder neck.

Incision

Simple open retropubic prostatectomy is approached through a low midline infraumbilical incision that extends below the level of the symphysis pubis ( Fig. 70.1 ). Alternatively, a Pfannenstiel incision can be made. These incisions allow entry to the space of Retzius and access to the anterior surface of the prostate. A right-handed surgeon should stand on the patient’s left side.

After the skin incision, dissection should continue through subcutaneous tissue with electrocautery to the level of the anterior rectus sheath ( Fig. 70.2 ). The rectus sheath is opened in the midline, and the two bellies of the rectus muscle are retracted laterally. The loose fascia overlying the rectus muscle is incised to expose the extraperitoneal tissue overlying the bladder and prostate. The peritoneum is gently dissected away from the bladder. A self-retaining retractor (e.g., Balfour or Omni-Tract) is placed to retract the rectus muscles laterally and the bladder and peritoneum superiorly. A moist lap pad should be placed over the bladder and peritoneum retractor blade to prevent traction injury.

Transverse Capsular Incision (Millin Technique)

This technique differs in that the loose areolar and fatty tissue overlying the anterior surface of the prostate is gently teased away. The Foley balloon is palpated at the bladder neck, and parallel rows of 0-chromic sutures are placed transversely along the anterior prostate near the bladder neck and distally near the apex of the prostate. The sutures are placed deeply through the capsule into the adenoma ( Fig. 70.3 ). These sutures help control bleeding from vessels on the surface of the prostate. The middle sutures of each row are tagged with a small clamp. Separate sutures can be placed laterally at the edges of the planned incision to prevent lateral tearing of the prostate during enucleation. The Foley catheter is then removed.

Hemostasis can be improved by ligating the dorsal venous complex as is done before radical prostatectomy. In addition, the lateral pedicles can be ligated by placing figure-of-8 sutures at the posterolateral surface of the prostate at the junction of the seminal vesicles. These methods together should control most arterial and venous bleeding encountered during adenectomy.

Using a blade or cutting electrocautery, a transverse incision is made between and parallel to the suture lines over the anterior capsule ( Fig. 70.4 ). Larger prostates require a longer incision. Using a sponge stick, the upper portion of the capsule is compressed to stop bleeding vessels. The compression is slowly released to allow fulguration of vessels to maintain a dry field. In addition, suction is used to keep the surgical field dry. The incision is continued down to the level of the adenoma.

Enucleation of Adenoma

When the adenoma is reached, the plane between the capsule and the adenoma is identified. A Babcock clamp is placed on the lower lip of capsule, and Metzenbaum scissors are used to separate the adenoma from the capsule. Next, blunt dissection (finger) is used to further separate the adenoma circumferentially ( Fig. 70.5 ). After the adenoma are separated laterally, posteriorly, and superiorly away from the bladder, the apical portion is approached. Under direct vision, the adenoma proximal is divided to the membranous urethra with sharp dissection to prevent injury to the sphincter ( Fig. 70.6 ). After the adenoma is divided, it is removed from the surgical field, and it should be ensured that no tissue is left adherent to the capsule. After the adenoma has been completely removed, the prostatic fossa should be packed with a warm moist gauze pack for 5 minutes.