Retropubic Simple Prostatectomy (Millin)
fig. principle of retropubic simple prostatectomy, popularized by Millin:
A) sagittal section through the prostate adenoma
B) transverse capsulotomy and mobilization of the prostatic adenoma
C) situs after simple prostatectomy with hemostatic sutures at the bladder neck and closure of prostatic capsule. An irrigation catheter is blocked in the prostatic fossa.
Indications for Retropubic Simple Prostatectomy
Retropubic adenomectomy of the prostate is indicated for the surgical treatment of benign prostatic hyperplasia with very large adenoma (> 75 ml). The retropubic approach offers the advantage of better hemostasis and improved vision for the apical adenomectomy. The retropubic approach is not ideal for large middle lobes and significant obesity. Consider the transvesical suprapubic approach for large bladder stones or bladder diverticula.
Contraindications to Retropubic Prostatectomy
Prostate cancer, small prostate (prefer TURP), low life expectancy, coagulation disorders, untreated urinary tract infection.
Surgical Technique of Retropubic Simple Prostatectomy
Preoperative Patient Preparation
- Exclusion or treatment of a urinary tract infection
- Perioperative antibiotic prophylaxis
- General anesthesia or spinal anesthesia
- Supine position with slight hyperextension of the lumbar spine
- Disinfection and draping
- Insert a 22 CH urethral irrigation catheter
- Lower midline incision or Pfannenstiel incision
- Cut the linea alba
- After blunt dissection of the retropubic space, insert a wound retractor and a malleable blade to displace the bladder superiorly.
- Surgical exposure of the prostate is comparable to radical prostatectomy: incision of the endopelvic fascia, dissection of lateral aspects of the puboprostatic ligament, ligature of the dorsal venous plexus at the apex and near the bladder neck. In addition, the lateral prostate pedicles with significant arterial supply to the prostate are controlled with figure of eight sutures (do not incorporate the ureters).
Dissection of the Prostatic Adenoma:
- Transverse capsulotomy.
- Blunt dissection of the ventral aspect of the adenoma.
- The anterior commissure is sharply divided from the bladder neck to the apex, this separates the lateral lobes of the prostate anteriorly and a the prostatic urethra is visible. Retract the catheter.
- The mucosa over the lateral lobes is incised leaving a small strip of posterior prostatic urethra, now both lateral lobes can be bluntly dissected and removed.
- The median lobe is dissected bluntly, the overlying mucosa is incised at the level of the bladder neck before removal.
Hemostasis after Retropubic Prostatectomy:
- For significant bleeding, figure-of-eight sutures of the bladder neck at the 4 o'clock and 8 o'clock position are done (do not incorporate the the ureteric orifices).
- Major bleeding should be stopped now, other discrete bleeding sites are controlled with electrocautery or suture ligatures.
- The irrigation catheter is readvanced into the bladder and blocked with 50 ml.
- Optional: insert a suprapubic tube
- Continious closure of the capsulotomy using 2-0 vicryl.
- Irrigation of the wound cavity
- Insert a wound drainage (e.g. closed gravity system)
- Separate closure of fascia, subcutis and cutis
Postoperative Management after Retropubic Prostatectomy
- After surgery: continuous irrigation of the bladder, pain management via patient-controlled analgesia, exercises to prevent thrombosis and pneumonia. Excessive bleeding may be controlled by increasing the catheter block or by gentle catheter traction. If not successful, proceed with transurethral coagulation of the prostate to control bleeding.
- First day: reduce or stop the continuous irrigation, patient ambulation.
- Second day: reduction of the catheter balloon to 30 ml. Removal of wound drainage (if <75 ml/24 h drainage).
- Third to fifth day: removal of the irrigation catheter.
Complications of Retropubic Prostatectomy
- Bleeding: re-exploration (transurethral coagulation) and/or blood transfusion are seldom necessary
- Urinary incontinence, often due to overactive bladder.
- Erectile dysfunction
- Often retrograde ejaculation (80–90%)
- Urinary tract infections
- Bladder neck sclerosis, urethral stricture
- Wound infection
- Thrombosis, pulmonary embolism
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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