What are the steps of an open prostatectomy?

Open Prostatectomy: Surgical Steps and Technique

Open prostatectomy involves surgical removal (enucleation) of the inner prostatic adenoma through either a suprapubic (transvesical) or retropubic incision in the lower abdomen, typically reserved for prostates larger than 80-100 mL. 1

Patient Positioning and Incision

• Position the patient supine with slight Trendelenburg positioning to optimize pelvic exposure 2
• Make a lower midline or Pfannenstiel incision in the suprapubic region, extending approximately 8-10 cm 2
• Dissect through subcutaneous tissue and fascia to expose the anterior bladder wall and retropubic space 2

Approach Selection: Retropubic vs. Transvesical

The choice between retropubic and transvesical approach depends on clinical criteria including prostate size, presence of bladder pathology (stones, diverticula), and surgeon preference. 2

Retropubic Approach (Millin Technique)

• Incise the anterior prostatic capsule transversely between the bladder neck and prostatic apex, staying above the dorsal venous complex 2
• Develop the plane between adenoma and surgical capsule using finger dissection, starting at the bladder neck 2
• Enucleate the adenoma bluntly by sweeping the finger circumferentially around the adenoma, separating it from the compressed peripheral zone 2, 3
• Divide the urethra distally at the apex after complete mobilization of the adenoma 2

Transvesical Approach (Freyer Technique)

• Open the bladder through a vertical cystotomy in the anterior bladder wall 1, 4
• Identify the bladder neck and prostatic urethra from within the bladder 4
• Incise the bladder neck mucosa circumferentially to develop the plane between adenoma and capsule 4
• Enucleate the adenoma digitally using finger dissection, working from superior to inferior 4
• Extract the adenoma through the cystotomy once completely mobilized 4

Hemostasis and Closure

• Achieve meticulous hemostasis of the prostatic fossa using figure-of-eight absorbable sutures (2-0 or 0 chromic/vicryl) placed at the 5 and 7 o'clock positions to control the prostatic vascular pedicles 2, 3
• Place additional hemostatic sutures as needed to control bleeding from the bladder neck and prostatic fossa 2
• Insert a three-way Foley catheter (22-24 Fr) with 30-60 mL balloon inflation for tamponade and continuous bladder irrigation 2, 3

For Retropubic Approach:

• Close the prostatic capsule with running absorbable suture if desired, though this is optional 2
• Place a drain in the retropubic space 2

For Transvesical Approach:

• Close the cystotomy in two layers with absorbable suture 4
• Place a suprapubic catheter in addition to the urethral catheter for some surgeons 4
• Place a drain near the cystotomy 4

Critical Technical Points

• The adenoma typically enucleates as a single piece weighing between 50-500 grams, with the plane of dissection following the natural cleavage between adenoma and surgical capsule 3, 5
• Digital assistance may be necessary for apical enucleation in 55% of cases to ensure complete removal 4
• Avoid injury to the external sphincter by staying within the prostatic capsule and not dissecting beyond the apex 2
• Ensure complete adenoma removal to prevent residual tissue and need for reoperation 3

Expected Outcomes and Complications

Open prostatectomy provides durable symptom improvement with AUA symptom scores decreasing from 18.5 to 4.0 within one month, maintained long-term. 3

Common Complications:

• Blood transfusion required in 27-36% of cases, representing the most common complication 1, 3
• Urethral stricture or bladder neck contracture in approximately 6% requiring dilation 1, 3
• Retrograde ejaculation in 61% of patients 1
• Erectile dysfunction in approximately 10% (though this may be pre-existing) 1
• Transient urinary incontinence in less than 10%, typically resolving within months 1
• Perioperative mortality less than 0.25% in contemporary series 1

Important Caveats:

• Reoperation rates are low at 1%, 6%, and 8.8% at 1,5, and 8 years respectively 1
• PSA levels decrease to less than 1 ng/dL postoperatively and remain stable long-term 3
• Hospital stay averages 3-5 days with catheter removal typically at 5-7 days once hematuria clears 2, 4