Suprapubic Transvesical Prostatectomy

Following the induction of satisfactory general or regional anesthesia, the operating table should be gently flexed in the modified Trendelenburg position. Care must be taken to avoid injudicious flexion that might induce a sacral stretch injury. When properly performed, this simple position change facilitates exposure within the narrow male pelvis and permits more facile mobilization of the peritoneal reflection. At this point, thigh-high anti-embolism stockings should be placed along with pneumatic sequential compression boots and heel protectors. The patient is comfortably secured to the table once these preliminary steps have been completed. The abdomen and genitalia are shaved and then prepped and draped in sterile standard fashion. It is our preference to prepare the penis and genitalia into the sterile operative field. Once this has been established, a 22-Fr Foley catheter is inserted and the balloon is inflated to 30 mL. Using a piston-tipped syringe, the bladder is then filled to approx 200 to 300 mL. The catheter is then clamped to maintain bladder distension. It is useful for the operating surgeon and/or the assistant to wear a fiberoptic headlight, which facilitates visualization of the prostatic fossa after enucleation.

A sterile marking pen is then used to delineate the line of intended incision. With respect to the latter, a transverse (Pfannenstiel) or lower midline incision may be used depending on the need for adjunctive procedures (i.e., diverticulectomy, concomitant inguinal hernia repair), the patient's body habitus, and the presence of previous surgical scars. If a transverse approach is chosen, the incision should be placed approximately two finger-breadths above the pubic symphysis in a suitable skin crease. Care must be taken to avoid extending the transverse incision too far laterally to decrease the risk of postoperative hernia. Awareness of potential injury to the underlying inferior epigastric vessels is important. We prefer the transverse approach whenever feasible given the superior cosmetic quality of the healed incision. The remainder of this discourse will be predicated on that operative approach.

After creation of the skin incision, the subcutaneous tissues are incised with electrocautery. Larger bleeding vessels that may be encountered with the transverse approach are delineated with blunt dissection, clamped, severed, and tied with 3-O or 4-O Vicryl sutures. The anterior fascia is then further delineated with sharp and blunt dissection. At this point the surgeon has the option of securing wound towels to the subcutaneous tissues using 3-O silk sutures. The approach to the fascia can be facilitated using small self-retaining retractors. A fresh scalpel is used to score the fascia in the midline aspect of the established wound. The fascial incisions are generally extended to the lateral border of each rectus abdominis muscle. At this point, it is necessary to raise the superior and inferior fascial flaps. This is done easily using three Kocher clamps applied equidistantly at each edge. The assistant provides gentle uplift, and the surgeon provides counter traction on the underlying rec-tus muscles. Using the Bovie, the superior flap is raised to a point halfway to the umbilicus. The inferior flap is raised to the pubic symphysis. The exposed rectus abdominis muscles are then separated one from the other in the midline aspect. Careful sharp and blunt dissection permits mobilization of the rectus muscle bellies and good exposure to the underlying umbilicoprevesical fascia. The latter is gently uplifted and incised. At this point, the peritoneal reflection is identified and gently reflected from the dome of the nicely distended bladder. Obtaining good exposure of the bladder in the space of Retzius is important, along with optimal identification of the bladder neck and prostate. However, injudicious dissection over the vesicle neck is unnecessary. Further exposure is provided by the use of a Balfour retractor. The padded blades are placed gently alongside and under each rectus muscle belly. Additional exposure of the bladder, bladder neck, and anterior prostatic surface can be facilitated by the careful placement of small-medium malleable retractors.

In general, it is our preference to establish a transverse incision approx 2 to 3 cm above the bladder neck. The placement of stay sutures of 2-O chromic catgut above and below the line of intended incision is helpful. This approach to the bladder is quite useful in that it optimizes exposure of the prostatic fossa and causes minimum disruption of the bladder neck and prostatic capsule. In theory, the latter developments are somewhat more likely if a vertical incision is chosen. The initial stay sutures are uplifted, and the bladder muscle is incised using electrocautery. The underlying mucosa is then easily identified and entered. The instilled fluid is then evacuated. The transverse incision can be extended with a careful spreading maneuver or with electrocautery. In any event, appropriately spaced 2-O chromic catgut sutures are placed in equidistant fashion along the superior and inferior bladder flaps. We tag the true midline sutures and the lateral sutures with straight clamps for identification purposes. If necessary, these sutures can be placed in figure-eight fashion and tied for additional hemostasis. A padded malleable or Deaver retractor is then placed in the bladder dome to optimize exposure. Indigo carmine is administered intravenously to facilitate exposure of the ure-teral orifices. Baby malleable retractors can be used to optimize exposure within the bladder. At this point, it should be emphasized that

Transvesical Suprapubic Prostatectomy

Fig. 1. Circumferential incision of the bladder neck prior to enucleation of prostatic adenoma. Exposure is facilitated by placement of a medium malleable or Deaver retractor in the superior aspect of the bladder. Additionally, the use of small malleable or Deaver retractors adjacent to the bladder neck greatly enhances visualization. Electrocautery is used to initiate the incision through the mucosa overlying the intruding adenoma at the level of the bladder neck. Sharp dissection can be used subsequently to further free the adenoma from the surrounding tissue. Care must be taken to avoid injury to the bladder neck and trigone. (Reprinted with permission from ref. 13.)

Fig. 1. Circumferential incision of the bladder neck prior to enucleation of prostatic adenoma. Exposure is facilitated by placement of a medium malleable or Deaver retractor in the superior aspect of the bladder. Additionally, the use of small malleable or Deaver retractors adjacent to the bladder neck greatly enhances visualization. Electrocautery is used to initiate the incision through the mucosa overlying the intruding adenoma at the level of the bladder neck. Sharp dissection can be used subsequently to further free the adenoma from the surrounding tissue. Care must be taken to avoid injury to the bladder neck and trigone. (Reprinted with permission from ref. 13.)

procedures to be done in conjunction with the prostatectomy (removal of bladder stones, diverticulectomy, preperitoneal repair of an inguinal hernia) should be performed before enucleation of the adenoma.

Careful inspection of the bladder, especially with respect to the location of the trigonal complexes and identification of associated bladder disease, is important before initiating enucleation of the obstructing adenoma. Scoring the mucosa circumferentially around the protruding adenoma with electrocautery prevents excessive tearing during enucleation

Enucleation Prostate

Fig. 2. Finger enucleation of the prostatic adenoma. This maneuver is accomplished by using the index finger inserted into the prostatic urethra. The anterior commissural tissue is then cracked by gentle manipulation using the ip of the index finger. The proper plane is then established between each component of the adenoma and the surgical capsule on the lateral aspects, respectively (Reprinted with permission from ref. 13.)

Fig. 2. Finger enucleation of the prostatic adenoma. This maneuver is accomplished by using the index finger inserted into the prostatic urethra. The anterior commissural tissue is then cracked by gentle manipulation using the ip of the index finger. The proper plane is then established between each component of the adenoma and the surgical capsule on the lateral aspects, respectively (Reprinted with permission from ref. 13.)

of the prostate. The instrument can be used on the fulguration mode and applied repetitively for deeper penetration. At this point, fine scissors can be used to separate the mucosa from the underlying adenoma. Alternatively, careful use of the cutting current can accomplish this goal as well (Fig. 1) (13).

The enucleation should be initiated by inserting the index finger into the prostatic fossa and cracking the anterior commissure using antero-lateral pressure against the larger adenoma. Using the fingernail as a wedge is helpful (Figs. 2, 3) (13,14). A sweep and roll maneuver should be used, with the tip of the index finger within the cleavage plane between the surgical capsule and the adenoma. The lateral sweeping maneuvers should be alternated and pressure should be exerted primarily against the adenoma. It is preferable to initiate the enucleation of each lobe before proceeding to definitive detachment of either lobe. Each lobe

Finger Prostatic Enucleation

Fig. 3. Depiction of the lateral plane of cleavage the adenoma and surgical capsule. This plane is best developed by using the tip of the index finger to initiate a sweep and roll maneuver. This should be done sequentially on one side and then the on other to establish the optimal plane of cleavage for each component of the adenoma. This should be done thoroughly before any attempt is made to sever the urethra and evacuate the adenoma. (Reprinted with permission from ref. 14.)

Fig. 3. Depiction of the lateral plane of cleavage the adenoma and surgical capsule. This plane is best developed by using the tip of the index finger to initiate a sweep and roll maneuver. This should be done sequentially on one side and then the on other to establish the optimal plane of cleavage for each component of the adenoma. This should be done thoroughly before any attempt is made to sever the urethra and evacuate the adenoma. (Reprinted with permission from ref. 14.)

should be freed laterally, then posteriorly across the midline and behind the middle lobe (if present). The mucosa should be pushed distally with the fingernail at the apex and either pinched off between the thumbnail and finger or occasionally divided sharply with scissors hugging the adenoma (Fig. 4) (14). In any event, the apex of the adenoma should be separated from the area adjacent to the external sphincter bilaterally, and both lateral lobes should be free before completing the enucleation. Traction on the distal urethra should be avoided while the capsule is being teased from the apex of the adenoma to avoid sphincter injury. In obese patients, enucleation may be facilitated by placing the fingers of the free hand or an assistant's hand in the rectum to push the prostate

Suprapubic Transvesical Prostatectomy

Fig. 4. Transection of the prostatic urethra. Once the adenoma has been thoroughly mobilized, the tether point represents the prostatic urethra. Pinching it off between the thumbnail and index finger is a useful maneuver. If adhesions are encountered and easy transection is not forthcoming, the surgeon can angulate the elbow or try standing with his or her back to the table. (Reprinted with permission from ref. 14.)

Fig. 4. Transection of the prostatic urethra. Once the adenoma has been thoroughly mobilized, the tether point represents the prostatic urethra. Pinching it off between the thumbnail and index finger is a useful maneuver. If adhesions are encountered and easy transection is not forthcoming, the surgeon can angulate the elbow or try standing with his or her back to the table. (Reprinted with permission from ref. 14.)

ventrally in a cephalad direction. The potential need for this maneuver should be anticipated preoperatively to permit adequate patient positioning. The adenoma should be separated with care from the bladder neck, especially posteriorly in the area of the ureteral orifices. A thyroid clamp is occasionally useful to grasp the adenoma and facilitate extraction (Fig. 5) (14). The sequence of the enucleation must be varied depending on the configuration of the adenoma and the ease of enucleation. At times, the median or subtrigonal lobe should be worked on first. In a large gland with multiple adenomas, sequential removal is preferable to the traumatic intact removal of the adenomatous growth. Obviously, unusual adherence of the adenoma to the capsule should increase suspicion of carcinoma.

Suprapubic Transvesical Prostatectomy

Fig. 5. Use of sponge or lobe forceps to grasp a large adenoma. Once the adenoma has been mobilized to near completion, grasping it with suitable forceps can facilitate extraction. During this process, any adherent mucosa should be trimmed with scissors. Following removal of the adenoma, the prostatic fossa should be inspected and palpated for residual tissue. The latter should be removed with additional blunt and sharp dissection. (Reprinted with permission from ref. 14.)

Fig. 5. Use of sponge or lobe forceps to grasp a large adenoma. Once the adenoma has been mobilized to near completion, grasping it with suitable forceps can facilitate extraction. During this process, any adherent mucosa should be trimmed with scissors. Following removal of the adenoma, the prostatic fossa should be inspected and palpated for residual tissue. The latter should be removed with additional blunt and sharp dissection. (Reprinted with permission from ref. 14.)

Once the adenoma has been enucleated, rapid control of bleeding is a paramount concern. Figure 6 shows the primary and secondary arterial supply to the prostate (15). The first and probably most strategic hemostatic maneuver at this point is to tightly pack the evacuated prostate fossa using a vaginal gauze roll or a Kerlex roll. Baby malleable retractors and an empty ring forceps can be used to facilitate this packing maneuver. Once established, compression should be left in place for approx 5 min. The pack can then be removed and, using optimal lighting, the prostatic fossa can be inspected. It may be possible at this point to spot fulgurate discrete bleeding vessels within the fossa. It is our preference to repetitively pack the fossa for 5-min intervals until hemo-stasis has been optimized and discrete bleeding areas better defined.

Prostate Arterial Supply

Fig. 6. Primary and secondary arterial supply to the prostate gland. The primary (inferior vesical) and secondary (middle rectal and pudendal) arteries are derived from the anterior division of the hypogastric artery. As depicted here, the urethral branches generally enter the bladder neck at the 5 and 7 o'clock positions, but this relationship is inconstant and variable. (Reprinted with permission from ref. 15.)

Fig. 6. Primary and secondary arterial supply to the prostate gland. The primary (inferior vesical) and secondary (middle rectal and pudendal) arteries are derived from the anterior division of the hypogastric artery. As depicted here, the urethral branches generally enter the bladder neck at the 5 and 7 o'clock positions, but this relationship is inconstant and variable. (Reprinted with permission from ref. 15.)

Patience with this particular phase of the procedure can greatly enhance a successful outcome.

Because the primary arterial supply enters at the 5 o'clock and 7 o'clock positions of the bladder neck, purposeful or anticipatory figure-eight 2-O chromic catgut sutures are placed in these positions (Fig. 7) (13). These sutures can also be used to anchor the bladder neck to the surgical capsule posteriorly. Persistent discreet bleeding can be fulgurated or controlled with interrupted figure-eight suture ligatures of 2-O chromic catgut. More diffuse but accessible oozing within the prostatic fossa can be treated with the careful application of the Argon beam photocoagulator. When using this approach, care must be taken to avoid contact with the bladder neck to prevent postoperative contracture. Plication of the capsule (Fig. 8) is a very simple and useful maneuver when bleeding persists even though no artery is obviously exposed (16). Two sutures of 0 chromic catgut on 5/8 curved needles are placed in the prostatic capsule, running from one side of the fossa to the other, to plicate these tissues. This simple approach induces immediate mechani-

Suprapubic Prostatectomy

Fig. 7. Placement of hemostatic sutures at the 5 and 7 o'clock positions of the bladder neck. 2-O chromic catgut sutures placed in figure-eight fashion generally control the urethral branches of the prostatovesicular artery, which enters in these locations. This maneuver is facilitated by the use of 5/8 curved genitourinary needles and optimal exposure. Care must be taken to avoid injury to the trigonal complex at this time. (Reprinted with permission from ref. 13.)

Fig. 7. Placement of hemostatic sutures at the 5 and 7 o'clock positions of the bladder neck. 2-O chromic catgut sutures placed in figure-eight fashion generally control the urethral branches of the prostatovesicular artery, which enters in these locations. This maneuver is facilitated by the use of 5/8 curved genitourinary needles and optimal exposure. Care must be taken to avoid injury to the trigonal complex at this time. (Reprinted with permission from ref. 13.)

cal contraction of these tissues, which facilitates hemostasis. In most instances, the use of hemostatic agents (oxidized cellulose, thrombin-soaked Gelfoam, fibrin glue) is unnecessary, but their use should be considered (along with prolonged packing) in extraordinary circumstances.

In the very unlikely event of severe persistent bleeding, consideration can be given to the insertion of a resectoscope and directed fulguration of bleeding vessels within the prostatic fossa using a rollerball electrode. Another infrequently needed adjunct is the placement of a Malament purse-string suture. This consists of a double-armed suture of 1-O or 2-O nylon placed through the mucosa and into the muscle and then carried around in both directions to cross in the midline and exit the entire bladder wall (Fig. 9; 14). Before the purse string is tied, a 24- or

Prostatic Fossa

Fig. 8. Hemostatic plication sutures. Persistent bleeding from the depths of the posterior prostatic fossa can be controlled by placing three transverse plication sutures of 0 chromic catgut. The sutures should engage the opposing lateral aspects of the fossa as well as the midzone component. Once tied, they induce an accordion-like affect, which facilitates hemostasis. (Reprinted with permission from ref. 16.)

Fig. 8. Hemostatic plication sutures. Persistent bleeding from the depths of the posterior prostatic fossa can be controlled by placing three transverse plication sutures of 0 chromic catgut. The sutures should engage the opposing lateral aspects of the fossa as well as the midzone component. Once tied, they induce an accordion-like affect, which facilitates hemostasis. (Reprinted with permission from ref. 16.)

26-Fr 30-mL catheter is inserted into the bladder and its balloon inflated. The purse-string sutures are then drawn up close to the neck of the bladder around the catheter (Fig. 10; 14). Following bladder closure, the needles are cut off at each end of the nylon sutures, which are then threaded on large straight cutting needles, passed out above the sym-physis, and tied over a button (or some other anchor) under slight tension. Under ideal circumstances, the Foley catheter would be removed on the second or third postoperative day, and the suprapubic catheter would be removed on the sixth or seventh postoperative day. The nylon purse string would then be removed to complete the process. In general, hemostasis is easy to achieve after simpler surgeries, and this particular maneuver should be required in only the most extreme circumstances.

Anchoring the bladder neck to the posterior aspect of the prostatic fossa facilitates hemostatis and helps prevent the formation of an obstructing membrane. This process of trigonalization of the prostatic fossa is illustrated in Figure 11. This maneuver also facilitates any sub-

Transvesical Prostatectomy

sequent catheter placement. Obviously, before completing this step, it should be determined whether the bladder neck is inordinately tight. If so, a V-shaped wedge can be removed from the 6-o'clock position (Fig. 12) (1). Once completed, the surgeon should proceed with the trigonalization step. Before bladder closure, a 24-Fr catheter is inserted in each urethra. The balloon is inflated to approx 60 to 70 mL, placed on general traction, and temporarily clamped. A separate opening is made in the dome of the bladder for the placement of a 28-Fr Malecot suprapubic catheter. Ultimately, that catheter will traverse the abdominal wall through another opening made in the superior fascial flap. It is helpful to gently anchor the Malecot catheter to the bladder wall using one or two 3-O or 4-O chromic catgut sutures. A two-layer bladder closure is initiated with interrupted figure-eight 2-O chromic catgut sutures, taking care to avoid injury to the hyperinflated Foley balloon (Fig. 13) (17). Once the bladder is closed, the catheter is unclamped and through and through irrigation is initiated to validate catheter patency and adequacy of hemostasis. In addition, it helps to determine the watertight integrity of the closure. Additional interrupted sutures can be placed if necessary. Bladder closure is facilitated by pairing the previously placed suture tags.

Before embarking on closure of the abdominal wall, drains should be placed. Some surgeons favor small-to-medium Penrose drains for this purpose. Others, including our group, prefer the use of closed suction sump drains. Generally, a single 7- or 10-mm flat-type sump drain is adequate for this purpose. We generally place it through an inferior opening. It should be positioned well away from the bladder suture line. It has been reported that inaccurate placement of sump drains may result in a risk for persistent urinary leakage, but this has not been our general experience (2).

Fig. 9. (previouspage) Placement of the Malament purse-string suture. In rare instances, severe persistent bleeding may prompt additional hemostatic procedure. Depicted here is placement of a purse-string suture around the bladder neck using a doubly armed suture of 1-O or 2-O nylon. The sutures are placed through the mucosa and into muscle and carried around the bladder neck in both directions exiting in the 12 o'clock orient position. (Reprinted with permission from ref. 14.)

Fig. 10. (previous page) Completion of the Malament circumferential purse-string suture. In this figure, a 24- or 26-Fr Foley catheter is inserted into the bladder. Its balloon is hyperinflated (60-70 mL). At that point, the respective ends of the purse-string are delivered through the anterior abdominal wall at the level of the symphysis. The sutures are then snugly tied over a bolster or button. (Reprinted with permission from ref. 14.)

Ligand Suture

Fig. 11. Trigonalization of the prostatic fossa. This can be accomplished using previously placed hemostatic sutures that are located at the 5 and 7 o'clock positions at the bladder neck. Alternatively, separate suture placement can be used for this maneuver. This simple approach aids in achieving hemostasis, facilitates appropriate healing, and prevents the development of a lip or ridge, which can be an obstructing element, particularly for catheter passage. (Reprinted with permission from ref. 8.)

Fig. 11. Trigonalization of the prostatic fossa. This can be accomplished using previously placed hemostatic sutures that are located at the 5 and 7 o'clock positions at the bladder neck. Alternatively, separate suture placement can be used for this maneuver. This simple approach aids in achieving hemostasis, facilitates appropriate healing, and prevents the development of a lip or ridge, which can be an obstructing element, particularly for catheter passage. (Reprinted with permission from ref. 8.)

The rectus diastasis can be obliterated with loosely tied interrupted figure-eight 2-O or 3-O monofilament absorbable suture. The fascia is reapproximated with 1-O or 2-O monofilament absorbable suture placed in interrupted figure-eight fashion. The subcutaneous tissues are irrigated with an antimicrobial solution and closed with running 3-O monofilament absorbable suture. The skin is generally closed with a running subcuticular suture of 4-0 Maxon. The suprapubic tube should be secured to the skin level with several 2-O silk sutures.

Suprapubic Prostatectomy

Fig. 12. Wedge resection of bladder neck. In some instances, the bladder neck will appear unduly snug following enucleation of the adenoma. In those cases, a ventrally directed wedge resection can be performed. When necessary, the wedge resection should precede retrigonalizing the posterior aspect of the prostatic fossa. (Reprinted with permission from ref. 1.)

Fig. 12. Wedge resection of bladder neck. In some instances, the bladder neck will appear unduly snug following enucleation of the adenoma. In those cases, a ventrally directed wedge resection can be performed. When necessary, the wedge resection should precede retrigonalizing the posterior aspect of the prostatic fossa. (Reprinted with permission from ref. 1.)

During the process of abdominal wall closure, periodic reassessment of catheter patency and hemostasis should be done. When the operation is completed, it is our preference to place the Foley catheter on a gentle traction and initiate a rather brisk, continuous irrigation with flow directed through the Foley catheter and out the suprapubic tube. The rate of infusion should be titrated to achieve a color that approaches crystal clear to light pink. In general, the irrigation is stopped on the first postoperative day. The Foley catheter is removed on the second or third

Suprapubic Prostatectomy

Fig. 13. Bladder closure. Before closing the transverse bladder incision in two layers with interrupted figure-eight sutures of 2-O chromic catgut, two catheters should be placed into the bladder proper. The first is a 24-Fr Foley catheter. Its balloon should be hyperinflated to about 70 mL and initially placed on gentle traction. The second catheter is a 28-Fr Malecot suprapubic tube. It should exit the superior aspect of the bladder. Following bladder closure, through and through irrigation is initiated to validate catheter patency and to assess the degree of hemostasis. That maneuver is performed periodically during the remainder of the closure. (Reprinted with permission from ref. 17.)

Fig. 13. Bladder closure. Before closing the transverse bladder incision in two layers with interrupted figure-eight sutures of 2-O chromic catgut, two catheters should be placed into the bladder proper. The first is a 24-Fr Foley catheter. Its balloon should be hyperinflated to about 70 mL and initially placed on gentle traction. The second catheter is a 28-Fr Malecot suprapubic tube. It should exit the superior aspect of the bladder. Following bladder closure, through and through irrigation is initiated to validate catheter patency and to assess the degree of hemostasis. That maneuver is performed periodically during the remainder of the closure. (Reprinted with permission from ref. 17.)

postoperative day. Barring complications, the suprapubic catheter is left indwelling for 7-10 d. In most instances, a cystogram is not required before its removal but should be considered in situations where bladder closure was tenuous. The drain maybe removed when clinically apparent drainage ceases or after removal of the suprapubic catheter. Of note, prolonged suprapubic drainage might be considered prudent in patients whose preoperative pressure-flow studies demonstrated profound detrusor hypocontractility.

If voiding is not resumed and the suprapubic site closed by 48-72 h, re-insertion of a urethral catheter may be necessary. In most instances, short-term catheter drainage will facilitate closure of the suprapubic tract. Persistent suprapubic drainage usually requires endoscopic and, at times, cystographic assessment to evaluate the possible presence of persistent obstructing tissue or foreign body. More remote causes within the context of the rule of fistulas may warrant consideration if supra-pubic drainage persists.

It is a good practice to obtain a urine culture one or two days before removing the final catheter. In most instances, the cultures will be negative. When infection is documented, appropriate antimicrobial agents should be provided before catheter removal. Patients with negative cultures are treated with oral antimicrobial therapy (nitrofurantin or fluoroquinolone) on the date of catheter removal and for two additional days.

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