199

SUPRAPUBIC PROSTATECTOMY 20The most difficult part of an

open prostatectomy, whether bya suprapubic or retropubic ap-proach, is the control of bleedingafter the enucleation of the pros-tate gland.

CONTROL OF BLEEDING BEFOREPROSTATE GLAND ENUCLEATION

With precautionary maneuverssuch as (1) temporary hypogastricartery ligation, (2) ligation of thedeep dorsal venous complex, and(3) stitch ligation of the prostaticpedicles before the actual proce-dure, we have had good control ofbleeding after the prostate glandhas been enucleated.

Temporary Hypogastric ArteryLigation

Although temporary ligation ofthe hypogastric artery will notprevent bleeding after enucleationof the prostate gland, the maneu-

ver will lessen the bleeding so thatthe surgeon has an acceptablefield of visualization.

FIG. 20-1. As in radical retropubicprostatectomy (see p. 170), retro-peritoneal pockets are createdfirst. The malleable blade is usedto retract these pockets, and thehypogastric artery is isolated.

Rather than using bulldogclamps, we prefer to use vesselloops looped twice around thevessel and then tied. These vesselloops are easily removed after themain steps of the operation havebeen completed.

Ligation of DorsalVenous Complex

Although ligation of the dorsalvenous complex has been cited asproviding improved hemostasisfor retropubic prostatectomy forbenign disease,1 we have foundthis maneuver useful for thesuprapubic approach as well.

Bladder

Prostate gland

Incisedendopelvic fascia

Dorsal venouscomplex

Iliac vessels

Hypogastricartery

20-1

Dorsal venouscomplex

Puboprostaticligament

Urethra

Prostategland

200 Critical Operative Maneuvers in Urologic Surgery

As for radical retropubic pros-tatectomy (see p. 172), the surgeonfirst isolates the deep dorsal ve-nous complex (see Fig. 20-1).

FIG. 20-2. After opening the en-dopelvic fascia bilaterally, the sur-geon does not divide the pubo-prostatic ligaments as is done inradical prostatectomy.

FIG. 20-3. The surgeon establishesa plane between the deep dorsalvenous complex and the urethraand then passes a suture (0 Vicryl)around the complex and the pubo-prostatic ligaments as one unit.2

Two ties are usually sufficientfor good hemostasis.

Ligation of Prostatic Pedicles

FIGS. 20-4, 20-5, AND 20-6. The pros-tatic pedicles are located at the in-ferior junction between the blad-der and the prostate gland at the5- and 7-o’clock positions.

The seminal vesicles are medialand posterior to these pedicles,whereas the rectum is posterior tothe seminal vesicles.

After palpating and visualiz-ing the vesicoprostatic junction,the surgeon places a figure-of-eight stitch (0 absorbable) at thisjunction almost parallel to therectum.3-5

20-2

20-3

Prostategland

Pubicsymphysis

Puboprostaticligaments

Puboprostaticligaments

Finger-Pinching ofDorsal Venous Complex

Chapter 20 Suprapubic Prostatectomy 201

20-4

20-5

20-6

From Bensimon H: Urologic surgery, New York,1991, McGraw-Hill.

Lateral View

Prostategland

Bladder

Rectum

Prostaticpedicle

Openedbladder

Prostategland

Prostatic pedicle(lateral to

seminal vesicle)

Seminalvesicle

Oblique View

Bladder

Prostategland

Ligature of rightprostatic pedicle

Sponges(4 or 5)

Prostategland

Stentin ureteralorifice

Retractor blade

Median lobe ofprostate gland

StentUreteral

orifice

Median lobeof prostate gland

Incision overmedian lobeof prostategland

Ureteralorifice

Traction stitches

Trigone ofbladder

202 Critical Operative Maneuvers in Urologic Surgery

EXPOSURE OF BLADDER ANDPROSTATE GLAND ENUCLEATION

Rather than immediately enu-cleating the prostate gland afterthe bladder is opened, we preferfirst to obtain the best exposure ofthe bladder and to define the mostproximal dissection, thus protect-ing the ureters. This approach willalso facilitate the placement ofhemostatic stitches once the pros-tate gland has been removed.

FIG. 20-7. The placement of fouror five sponges within the bladderwith a malleable blade retractedcephalad and fixed to the Balfourretractor will provide a good fieldfor the initial maneuvers (A).

The ureteral orifices are identi-fied, and a feeding tube or stent isplaced within if needed (B).

A traction stitch (0 Prolene) isplaced into the median lobe of theprostate gland with multiple bitesfor better maneuverability (C).When the traction stitch is re-tracted distally, the space betweenthe ureters and the median lobe isbetter identified.

FIG. 20-8. The urothelium above,the median lobe, and the prostaticcapsule are incised via electro-cautery. With scissors the surgeoncan now establish a clean plane ofproximal bladder dissection aswell as define the base of the pros-tate gland within the prostaticcapsule.

FIG. 20-9. At this point the sur-geon has the option of continuingthe dissection with the index fin-ger to either go around the base ofthe prostate gland toward the pros-tatic apex (1) or break the anteriorcommissure, start the dissection atthe prostatic apex, and work to-ward the base (2).

We prefer to work from thebase toward the prostatic apexwhile encircling the urethra andcutting the urethra flush againstthe apical tissues.

When enucleating the prostategland, the surgeon should applyfinger pressure against the pros-tate surface and not on the capsu-lar side to avoid false passage andcapsular lacerations.

20-7

A

B

C

Sharp Dissection of Median Lobe of Prostate Gland

Frontal View

Stent inureteral orifice

Sharp dissectionof median lobeof prostate gland

Lateral View

Stent inureteral orifice

Tractionstitch

2

1

Ureteralorifice

Proximalmedian lobedissection

Distal anteriorand laterallobe dissection

Verumontanum

Urethra

Chapter 20 Suprapubic Prostatectomy 203

20-8

20-9

Stent inureteralorifice

Prostaticfossa afterenucleation

Nasal speculum

Stent inureteral orifice

Prostatic pedicleposterior to bladderand lateral toseminal vesicle

Hemostaticstitches

Prostaticfossa

Hemostaticstitch through

prostatic fossa

Ureteralorifice

Prostatic fossaafter enucleation

Openedbladder

Depth ofhemostatic

stitch at7-o’clockposition

Frontal View(with Section of Bladder Removed)

204 Critical Operative Maneuvers in Urologic Surgery

CONTROL OF BLEEDING AFTERPROSTATE GLAND ENUCLEATION

The most important maneuver insuprapubic open prostatectomy isthe control of bleeding within theprostatic fossa after enucleation.

FIG. 20-10. By placing a long nasalspeculum or a narrow Deaver re-tractor into the prostatic fossa, thesurgeon can better visualize theregion for hemostatic stitch place-ment.

FIGS. 20-11 AND 20-12. Allis clampsapplied at the 5- and 7-o’clock po-sitions of the proximal prostaticfossa and the bladder edgesshould incorporate at least a 1 to 2cm depth of the tissues. While ap-plying cephalad traction withclamps, the surgeon can place arunning stitch into the 5- and 7-o’clock positions (0 absorbable or2-0 Vicryl).

Before placing these stitches,the surgeon should have a goodsense of the location of the pros-tatic pedicles, seminal vesicles,and rectum.

Fearful of injuring the rectum,surgeons generally tend to takeexcessively shallow suture bites,which have no effect on hemosta-sis. With experience, the surgeonlearns the proper depth of eachbite of the stitch.

20-10

20-11

20-12

Bladder

Ureteralorifice

Prostaticfossa

Malamentstitch

Stent inureteral orifice

Foley catheter

Abdominal skin

Prostaticfossa

Stitchcrossed

Malament Stitch

Prostaticfossa

PlicationstitchProstatic

fossa

Stent inureteralorifice

Chapter 20 Suprapubic Prostatectomy 205

Alternately, if necessary, thesurgeon can actually palpate andcheck for the appropriate depth ofstitch placement by palpating inthe rectum with (1) a finger, (2) aninflated rectal catheter, or (3) asponge stick.

Malament Stitch

The purpose of the Malamentstitch is to compartmentalize theprostatic fossa from the bladderand thereby compress the bleed-ing surfaces of the fossa.6,7

FIG. 20-13. Using a 1-0 nylon orProlene stitch, the surgeon can usea pursestring or a running stitch 2cm apart to encircle the bladderneck (A). The stitch should be eas-ily movable and, as it comesthrough the prostatic capsule atthe 12-o’clock position, it shouldbe crossed and brought out to theskin with some tension (B).

This stitch should be under ten-sion to create a true tamponade ef-fect, and it should be removedwithin 5 to 10 hours postopera-tively. If this stitch is left in for aprolonged period (3 to 5 days), itcan lead to a bladder neck con-tracture.

The Foley catheter is best left infor a 10- to 14-day period to avoidcross adhesions at the bladderneck, whereas the suprapubictube can be removed as soon asthe bleeding has subsided and thelarge clot has been removed.

Plication Stitch of Prostatic FossaFIG. 20-14. The plication stitch es-

sentially obliterates the prostaticfossa while compressing potentialbleeding sites.8 Large bites withabsorbable sutures (e.g., 0 absorb-able) is the best choice.

The Foley catheter (24 Fr) withthe balloon inflated to 30 ml canbe placed under traction to com-press the prostatic fossa whetheror not the surgeon uses hemo-static stitches.

A

A

B

B

20-13

20-14

206 Critical Operative Maneuvers in Urologic Surgery

K E YP O I N T S

CONTROL OF BLEEDING BEFOREPROSTATE GLAND ENUCLEATION� The hypogastric artery is ligated

temporarily.� The dorsal venous complex is li-

gated.� Suture ligation of the prostatic

pedicles is performed.

PROSTATE GLAND ENUCLEATION� The bladder is exposed using a

malleable retractor blade.� The ureteral orifices are identi-

fied and stents are placed.� A traction stitch is placed in the

median lobe of the prostategland.

� Proximal bladder dissection isperformed via electrocautery in-cision in the prostatic capsule.

� Sharp and blunt dissection of theprostate base or distal dissectionat the prostatic apex is performed.

� Finger pressure is applied againstthe prostate surface during pros-tate gland enucleation.

CONTROL OF BLEEDING AFTERPROSTATE GLAND ENUCLEATION� A nasal speculum can be used for

improved exposure of the pros-tatic fossa.

� At the 5- and 7-o’clock positionsof the proximal prostatic fossa,running stitches can be placed.

� A 1-0 nylon Malament stitch canbe used to compress the bleedingsurfaces of the prostatic fossa.

� Plication stitches (0 chromic) canbe placed to obliterate the pros-tatic fossa.

P O T E N T I A LP R O B L E M S

� Capsular laceration during enucle-ation: Repair laceration and con-tinue with the operation

� Injury of ureteral orifice: Placestent

� Bleeding after enucleation of pros-tate gland: Consider all maneu-vers before and after enucleationas discussed

REFERENCES1 Walsh PC, Oesterling JE: Improved

hemostasis during simple retropubicprostatectomy, J Urol 143:1203, 1990.

2 Yu GW, Melograna FS, Miller HC:Surgical modifications for ligation ofdeep dorsal vein complex from theretropubic space, Urology 40:545,1992.

3 Bensimon H: Urologic surgery, NewYork, 1991, McGraw-Hill, pp 253-261.

4 Cockett ATK, Koshiba K: Manual ofurologic surgery: comprehensive manu-als of surgical specialties, vol 5, NewYork, 1979, Springer-Verlag.

5 Mayo G, Zingg EJ: Prostatectomy. InUrologic surgery: diagnosis, techniques,and postoperative treatment, New York,1976, John Wiley, pp 326-330.

6 Cohen SP, Kopilnick MD, RobbinsMA: Removable purse-string sutureof the vesical neck during suprapubicprostatectomy, J Urol 102:720, 1969.

7 Malament M: Maximal hemostasis insuprapubic prostatectomy, Surg Gy-necol Obstet 120:1307, 1965.

8 O’Connor VJ Jr: Suprapubic prosta-tectomy. In Glenn JF, editor: Urologicsurgery, Philadelphia, 1983, JB Lip-pincott, pp 853-860.