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Retropubic Simple Prostatectomy: Steps of the Millin Technique

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 Millin's Simple Prostatectomy

The most common indication for surgical therapy of BPH is moderate to severe symptoms of BPH, which cannot be controlled with medication and lower the quality of life of the patients. Furthermore, surgical therapy is indicated:

• After recompensation of postrenal kidney failure
• Recurrent urinary retention
• Recurrent urinary tract infections
• Recurrent hematuria
• Huge bladder diverticula

Retropubic adenomectomy of the prostate is indicated for the surgical treatment of benign prostatic hyperplasia with 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 transvesical simple prostatectomy for large bladder stones or bladder diverticula.

Contraindications to Retropubic Prostatectomy

Prostate cancer, low life expectancy, coagulation disorders, untreated urinary tract infection.

Surgical Technique of Millin's 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 irrigation catheter

Surgical Approach:

• 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 the prostatic urethra is visible. Retract the catheter.
• The mucosa over the lateral lobes is incised, leaving a small strip of the 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 positions are done (do not incorporate the ureteric orifices).
• Major bleeding should be stopped now; discrete bleeding is controlled with electrocautery or suture ligatures.
• The irrigation catheter is readvanced into the bladder and blocked with 50 ml.

Wound Closure:

• Continuous 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 Care after Retropubic Prostatectomy

General measures: pain management, consider patient-controlled analgesia. Early mobilization and exercises to prevent thrombosis and pneumonia. Thrombosis prophylaxis. Laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

• After surgery: continuous bladder irrigation, excessive bleeding may be controlled by increasing the catheter block or gentle catheter traction. If unsuccessful, proceed with transurethral coagulation of the prostate to control bleeding.
• First day: reduce or stop the continuous irrigation, patient ambulation.
• Second day: reduce the catheter balloon to 30 ml. Remove the wound drainage (if <75 ml/24 h drainage).
• Third to fifth day: removal of the irrigation catheter. Consider cystography to ensure a watertight closure of the capsulotomy.

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
• Ureteral injury.
• Bladder neck sclerosis, urethral stricture
• Surgical site infections
• Urinoma
• Thrombosis, pulmonary embolism

References

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

  Deutsche Version: transvesikale Adenomektomie