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

2. 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.

3. 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.

6. 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

7. 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

8. Suprapubic surgical steps:

13. Retropubic surgical steps:

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

21. 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

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

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

24. c. Modified Denis  Non-absorbable purse string

26. 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

27. 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

28. 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

29. 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

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

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

32. 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.

33. THANK YOU