Indications For Open Prostatectomy

There are a number of factors that should prompt the serious consideration of suprapubic transvesical prostatectomy. These include the following: (1) adenomas > 75 g; (2) transition zone hyperplasia associated with a large, prominent subtrigonal component; (3) presence of a physiologically relevant diverticulum; (4) multiple large bladder calculi; (5) confounding orthopedic problems such as severe spinal stenosis and fusion/ankylosis of the hip joints; (6) large scrotal hernia or massive hydrocele; (7) rigid or semirigid penile prosthesis; (8) multiple urethral strictures; (9) trigonal distortion resulting from trauma or previous surgery that places the ureteral orifices in close proximity to the bladder neck; (10) expectations/prejudices of the patient; and (11) skill/experience of the surgeon (1).

Ideally, simple perineal prostatectomy warrants consideration in those patients with large, low-lying prostates who are capable of withstanding prolonged exaggerated lithotomy. Preferably, patients selected for posterior capsulotomy by means of perineal exposure should be free of significant perineal or anorectal disease and never have had surgery in that area. Achieving perineal access is also attractive in those patients with large glands who have undergone previous pelvic surgery. This approach is also attractive because it allows exposure of the prostate at its most superficial location, allows exposure of the prostate beneath the pelvic venous plexus and peritoneal reflection, minimizes the risk of bleeding from periprostatic veins and significant ileus, provides the most direct and dependent route for drainage of extravasated urine and blood, and allows a postoperative course associated with minimal pain and reduced analgesic requirements (3).

There are two major reasons for the infrequent use of simple perineal prostatectomy for the management of BPH. First, there is a general attrition of perineal surgical skills. Second, this approach has been historically associated with a 15% risk of impotence and is therefore unattractive to potent patients. The well-appreciated anatomy of the cavernous nerves and their relationship to the dorsolateral prostatic capsule permits the successful preservation of these neurovascular bundles in skilled hands (3).

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