Last updated: 02/17/2009

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.

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.

Suprapubic prostatectomy

Suprapubic prostatectomy (also called transvesical prostatectomy) is a procedure to remove the prostatic overgrowth via a different surgical route. The suprapubic approach utilizes an incision of the lower anterior (front) bladder wall. The primary advantage over the retropubic approach is that the suprapubic route allows for direct visualization of the bladder neck and bladder mucosa. Because of this, the procedure is ideally suited for persons who have bladder complications, as well as obese men. The major disadvantage is that visualization of the top part of the tumor is reduced. Additionally, with the subrapubic approach, hemostasis (stoppage of bleeding during surgery) may be more difficult due to poor visualization after removal of the tumor.

Using a scalpel, a lower midline incision is made from the umbilicus to the pubic area. A cystotomy (incision into the bladder) is made, and the bladder inspected. Using electrocautery (a special tool that produces heat at the tip, useful for hemostasis or tissue excision) and scissors, dissection proceeds until the prostatic tumor is identified and removed. After maintaining hemostasis and arterial blood supply to the prostate, the incisions to the bladder and abdominal wall are closed.