PITFALLS IN OPEN PROSTATIC SURGERY FERRY SAFRIADI Hasan Sadikin Hospital Center Medical School of University of Padjadjaran MABI, July 8 2010

INTRODUCTION: Prostatic surgery is the most one to do in the urology field. Benign Prostate Hyperplasia (BPH) is suffered 50% > 60 years old and 100% in 80 years old. By 1/3-1/2 is a symptomatic BPH. Open prostatectomy has become an infrequently performed procedure in cities with urological facilitation except in certain indication.

General indications for surgery: Recurrent urinary retention Recurrent or persistent urinary tract infection No response to medical therapy Recurrent gross hematuria of prostatic origin Pathophysiologic changes of the kidneys Bladder calculi secondary to obstruction Indications for open prostatectomy Prostate weigh ≥ 80 gram, bladder diverticula and bladder stone.

Open prostatectomy techniques: a. Suprapubic/transvesical (Freyer) b. Retropubic (Millin) c. Perineal Suprapubic approach suited for pts with; - large median lobe - bladder diverticulum - large bladder calculi Disadvantages: - reduced visualization of apex urinary incontinence. - hemostasis may be more difficultbleeding

Advantages of retropubic approach: - excellent anatomic exposure of the prostate - direct visualization during enucleation - precise transection of a urethra distally preserve urinary continence - easier to control bleeding - minimal or no surgical trauma to the bladder Disadvantage of retropubic approach: no direct access to the bladder

Suprapubic surgical steps:

Retropubic surgical steps:

Complications: Bleeding Persistent urinary leak Incontinence Erectile dysfunction Retrograde ejaculation Bladder neck contracture Epididymitis Non urologic: deep vein thrombosis, pulmonary embolus.

Management to complication prevention: Bleeding (0,8-35%) Source of bleeding: - a/v prostate, fossa prostatica, dorsal vein complex (depend on technique) Treatment steps: - packing the capsule with gauze - hemostatic figure of 8 at the 5 and 7 o’clock - dorsal complex ligation - lateral pedicle ligation - traction

If hemostasis is not adequate: a. Malament maneuver  absorbable purse string at bladder neck

O’connor stich  absorbable plication stich placed in posterior capsule

c. Modified Denis  Non-absorbable purse string

Dorsal complex and lateral pedicle ligation; Using a 0 chromic for dorsal complex and 2-0 chromic for lateral pedicle Catheter traction Catheter balloon should be inflated ≥ 30cc Clot retention (0,8-6,7%) Prevented by continuous irrigation

2. Persistent urinary leak (1-2%) Source: cystostomy or capsulotomy (>48hours)  anatomical obstruction or poor detrusor function Treatment: - bladder drainage - repeat voiding trial - utilizing perivesical fat

Urinary incontinence Type: urge, stress or total Urge incontinence (7,7%)bladder instability Stress/total: disruption of external sphincter  extensive traction or tearing prostate apex Preventive: Sharp dissection of urethra at the apex

Erectile dysfunction-retrograde ejaculation 80-90% pts retrograde ejaculation post surgically  resection or disruption of the internal sphincter It is reduced by preserving of the bladder neck. ED (3-5%) is more common in older pts Perineal approach is more frequent as ED’s cause. Factors: age, comorbidities, preexisting ED  (-) the prostate capsule has been left intact

5. Bladder neck contracture (0. 2-6 5. Bladder neck contracture (0.2-6.1%) Suprapubic > Retropubic small opening at the bladder neck at the end of the operation Treatment: bladder neck dilatation bladder neck incision

Edidymitis (2.6%) Risk: long term indwelling catheter chronic UTI DVT (0.3-0.7%) Diagnosed by Color doppler flow imaging

a meticulous technique. CONCLUSION Suprapubic and retropubic prostatectomy are usually used for open prostatic surgery. It is suitable for large prostate volume, bladder diverticula and bladder stone. Pitfalls and complications can be avoided by appropriate diagnosis and recognizing a meticulous technique.

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