Open Prostatectomy Health Article

Definition

Open prostatectomy is a procedure for removal of an enlarged prostate gland.

Purpose

The primary indication for open prostatectomy is benign prostatic hyperplasia (BPH), a condition whereby benign or noncancerous nodules grow in the prostate gland. The prostate gland is composed of smooth muscle cells, glandular cells, and cells that give the gland structure (stromal cells). A dense fibrous capsule surrounds the prostate gland. The glandular cells produce a milky fluid that mixes with seminal fluid and sperm to make semen. The prostate gland also produces a hormone (dihydrotestosterone) that has a major impact on the gland's development.

Description

Open prostatectomy can be performed by either the retropubic or suprapubic approach. The preferred anesthesia for open prostatectomy is a spinal or epidural nerve block. Regional anesthesia can help reduce blood loss during surgery, and lowers the risk of complications such as pulmonary embolus and postoperative deep vein thrombosis. General anesthesia may be used if the patient has an anatomic or medical contraindication for regional anesthesia.

Demographics

The cause of BPH is not entirely known; however, the incidence increases with advancing age. Before 40 years of age, approximately 10% of males have BPH. A small amount of hyperplasia is present in 80% of males over 40 years old. Approximately 8–31% of males experience moderate to severe lower urinary tract symptoms (LUTS) in their fifties. By age 80, about 80% of men have LUTS. A risk factor is the presence of normally functioning testicles; research indicates that castration can minimize prostatic enlargement. It appears that the glandular tissues that multiply abnormally use male hormones produced in the testicles differently than the normal tissues do.

Approximately 5.5 million American males have BPH. It is more prevalent in the United States and Europe, and less common among Asians. BPH is more common in men who are married rather than single, and there is a strong genetic correlation. A man's chance for developing BPH is greater if three of more family members have the condition.

Retropubic prostatectomy

The retropubic prostatectomy is accomplished through a direct incision of the anterior (front) prostatic capsule. The overgrowth of glandular cells (hyperplastic prostatic adenoma) is removed. These are the cells forming a mass in the prostate because of their abnormal multiplication.

A cystoscopy is performed prior to the open prostatectomy. The patient lies on his back on the operating table, and is prepared and draped for this procedure. Following the cystoscopy, the patient is changed to a Trendelenberg (feet higher than head) position. The surgical area is shaved, draped, and prepared. A catheter is placed in the urethra to drain urine. An incision is made from the umbilicus to the pubic area. The abdominal muscle (rectus abdominis) is separated, and a retractor is placed at the incision site to widen the surgical field. Further maneuvering is essential to clearly locate the veins (dorsal vein complex) and the bladder neck. Visualization of the bladder neck exposes the patient's main arterial blood supply to the prostate gland. Once the structures have been identified and the blood supply controlled, an incision is made deep into the level of the tumor. Scissors are used to dissect the prostatic tissue (prostatic capsule) from the underlying tissue of the prostatic tumor. The wound is closed after complete removal of the prostate tumor and hemostasis (stoppage of bleeding) occurs.

The advantages of the retropubic prostatectomy include:

• Direct visualization of the prostatic tumor.
• Accurate incisions in the urethra, which will minimize the complication of urinary continence.
• Excellent anatomic exposure and visualization of the prostate.
• Clear visualization to control bleeding after tumor removal.
• Little or no surgical trauma to the urinary bladder.