The indications for a suprapubic prostatectomy for benign disease are the same as for the retropubic approach, namely symptomatic bladder outlet obstruction from benign prostatic hyperplasia (BPH) or urinary retention along with a markedly enlarged prostate gland. In years past, the size limit for transurethral resection (TUR) procedures of 75 g was imposed by expert opinion. At sizes above that somewhat modest limit, an open prostatectomy was recommended to avoid the challenges of TUR syndrome, including excessive blood loss and inadvertent injury to the rhabdosphincter. With the development of bipolar transurethral resection of the prostate (TURP) and several types of transurethral laser methods, the size at which the open prostatectomy should be considered has increased dramatically. This new reality is supported by the most recent AUA Clinical Guidelines in which “the choice of open prostatectomy should be based on the patient’s individual presentation including anatomy, the surgeon’s experience and discussion of the potential benefit and risks for complications”. The suprapubic approach may be preferred in cases involving a prominent intravesical component of the prostate or when direct access to the bladder is required, such as with bladder calculi or a large, narrow-necked bladder diverticulum.
Preoperative evaluation should include measurement of postvoid residual, a urinalysis and urine culture, prostate specific antigen (PSA), AUA symptom score, and urodynamics if indicated. Urinary retention should be treated with indwelling or clean intermittent catheterization (CIC) preoperatively, and any urinary tract infection should be treated with antibiotics.
The preference of CIC over indwelling catheter for management of retention is supported by limited data suggesting that CIC preserves detrusor function better than long-term continuous drainage. The prostate size should be measured with transrectal ultrasonography, and in cases of an elevated PSA or suspicious prostate examination findings, a prostate biopsy should be performed to rule out adenocarcinoma. Overestimation of prostate size using digital rectal examination (DRE) or transrectal ultrasonography is a common occurrence, and one should be mindful of the volume of the transition zone alone as compared with the total volume of the prostate.
The procedure requires either a general or spinal anesthetic (general is preferred), and preoperative cardiac clearance should be obtained. Preoperative laboratory studies should include a complete blood count, chemistry panel, and coagulation studies if indicated. Medications and allergies should be reviewed, and any medications that affect coagulation should be discontinued before surgery provided the overall medical status allows as such. Although transfusion rates are low, this procedure has the potential for significant blood loss, and typed and cross-matched blood products should be available for intra- and postoperative transfusion if necessary. When anticoagulation cannot be discontinued, then the surgeon must carefully balance the risks of multiple smaller staged procedures (i.e., several laser TURPs) versus a more time-efficient open prostatectomy in which excessive blood loss is likely.
Instruments to be provided include a prostatectomy set with lobe forceps or a four-pronged tenaculum, Allis clamps, three Deaver retractors, a Omni or other self-retaining retractor (Balfour or Buchwalter), 2-inch vaginal packing (several rolls tied together), and a cystoscopy set. Perform cystoscopy if not already done.
Antibiotic prophylaxis should be administered before surgery. The AUA guidelines on antimicrobial prophylaxis for open urologic procedures involving entry into the urinary tract are as follows. The first choice is a first- or second-generation cephalosporin. If there is a penicillin allergy, an aminoglycoside plus either metronidazole or clindamycin can be used. Second-line choices include fluoroquinolones or ampicillin–sulbactam. Intravenous antibiotics should be discontinued after surgery and then urine cultures used to help in antibiotic selection to be given just before decatheterization.
Positioning and Prep ( Fig. 69.1 )
After the induction of satisfactory general or regional anesthesia, position the patient supine with the anterior superior iliac spine located over the break in table or kidney rest. The table should be slightly flexed in the modified Trendelenburg position to facilitate exposure of the male pelvis and retraction of the peritoneal reflection. Shave the patient from above the umbilicus to the pubis; prep with chlorhexidine gluconate and isopropyl alcohol skin prep (Chloraprep); and scrub and drape using towels, clamps, and a laparotomy drape. Place an 18-Fr Foley catheter, fill the balloon with 10 cc of saline, fill the bladder with 200 to 300 cc of saline, and clamp to facilitate exposure of the bladder. Use of a fiberoptic headlight may aid visualization of the prostatic fossa after enucleation.
Incision and Exposure
A transverse (Pfannenstiel) or lower midline incision may be used depending on the patient’s build and presence of previous surgical scars. The authors preferred a transverse incision in the past but use the lower midline approach almost exclusively. Please reference Chapter 75 for details regarding this incision. With regard to the former, extending the incision too far laterally should be avoided to decrease the risk of postoperative hernia. Awareness of potential injury to the underlying superficial inferior epigastric vessels is important with either incision. Expose and incise the anterior rectus fascia in the same direction and same length as the skin incision. In the case of the transverse incision, grasp the superior flaps of rectus fascia with Kocher clamps on either side of the midline. Using the Kocher clamps for retraction, separate the rectus muscle bellies from the fascia with blunt finger dissection and electrocautery ( Fig. 69.2 ). Repeat this on the inferior aspect of the incision to the symphysis pubis. Separate the rectus muscle bellies in the midline and retract them laterally using electrocautery to open the underlying transversalis fascia. Use sponge sticks or fingers and a lap pad to gently develop the space of Retzius anterior to the bladder by pushing the peritoneal reflection superiorly and perivesical tissue laterally and posteriorly ( Fig. 69.3 ). Avoid injuring the deep inferior epigastric vessels during this maneuver. Place a padded self-retaining retractor when ample room is exposed.
Cystotomy and Exposure
Select a site on the anterior surface of the bladder, approximately 2 to 3 cm superior to the bladder neck, to open the bladder. Determine if the bladder is sufficiently distended (add or remove saline if necessary) and remove the Foley catheter. Place stay sutures of 2-0 synthetic absorbable suture (SAS) inferior and superior to the planned incision. Avoid placing these too low to prevent tearing the prostatic capsule. Open the bladder transversely with a knife or electrocautery between the stay sutures ( Fig. 69.4 ). Immediately enlarge the opening by inserting a Mayo clamp and spreading. Empty the bladder contents with suction. Insert two fingers and stretch the opening wider (this technique is preferred as fewer vessels are injured). After cursory inspection of the interior of the bladder, pack the dome with lap pads and retract using the bladder blade attachment for the self-retaining retractor or a wide Deaver retractor. Expose the trigone and bladder neck using narrow Deaver retractors placed on either side. Identify the ureteral orifices using an intravenous chromagen dye (i.e., indicarmine or methylene blue if necessary), remove any vesical calculi, and more closely inspect the bladder mucosa.
Dissection and Removal of the Adenoma
Identify and palpate the adenoma protruding at the bladder neck. Incise the bladder epithelium circumferentially around the protruding adenoma using the cutting current of the Bovie ( Fig. 69.5 ). Separate the epithelium from the adenoma using curved scissors. Remove the retractors and shift the patient into Trendelenburg position.