a.retropubic open prostatectomy with the fulguration of bladder diverticulum.

b.long-acting α-adrenergic antagonist and prophylactic antibiotics.

c.TURP followed by bladder diverticulectomy in 3 months.

d.TURP and partial cystectomy.

e.simple prostatectomy with bladder diverticulectomy.

5.The contraindications to simple prostatectomy include:

a.multiple cores of Gleason 8 prostate cancer.

b.bladder diverticulum.

c.large bladder calculi secondary to obstruction.

d.recurrent urinary tract infection.

e.acute urinary retention.

6.Both retropubic and suprapubic simple prostatectomies:

a.are performed in the space of Retzius.

b.are ideal for patients with a large, obstructive prostatic adenoma and a concomitant, small bladder tumor.

c.require no blood transfusion.

d.cause no trauma to the urinary bladder.

e.require control of the dorsal vein complex before the enucleation of an obstructive prostatic adenoma.

7.Compared with open simple prostatectomy, robot-assisted laparoscopic simple prostatectomy has:

a.quicker operative time.

b.longer hospital stay.

c.decreased need for blood transfusion.

d.shorter learning curve.

e.decreased need for anesthesia.

Answers

1.a. Removal of the prostatic adenoma under direct vision. When compared with TURP, simple prostatectomy offers the advantages of lower retreatment rate and more complete removal of the prostatic adenoma under direct vision and avoids the risk of dilutional hyponatremia (the TUR syndrome).

2.c. Easier management of a large median lobe and/or bladder calculi. The major advantage of suprapubic simple prostatectomy over the retropubic

approach is that it allows direct visualization of the bladder neck and bladder mucosa. As a result, this operation is ideally suited for patients with a large median lobe protruding into the bladder or a clinically significant bladder diverticulum.

3.d. Symptomatic bladder diverticulum. Suprapubic simple prostatectomy is ideally suited for patients with a large median lobe protruding into the bladder, a clinically significant bladder diverticulum that requires repair, or large bladder calculi. It also may be preferable for obese men, in whom it is difficult to gain direct access to the prostatic pseudocapsule and dorsal vein complex.

4.e. Simple prostatectomy with bladder diverticulectomy. Combined suprapubic simple prostatectomy and bladder diverticulum is the best option for the patient with a massive benign prostatic hyperplasia (BPH) and a symptomatic bladder diverticulum because of easy access to both prostatic adenoma and bladder diverticulum. If the prostatectomy is performed without the diverticulectomy, incomplete emptying of the bladder diverticulum and subsequent, persistent infection may occur.

5.a. Multiple cores of Gleason 8 prostate cancer. Contraindications to simple prostatectomy include a small fibrous gland, the presence of significant prostate cancer, and previous prostatectomy or pelvic surgery that may obliterate access to the prostate gland.

6.a. Are performed in the space of Retzius. Both retropubic and suprapubic simple prostatectomies are performed in the space of Retzius. The dorsal vein complex does not have to be controlled before the enucleation of an obstructive prostatic adenoma during suprapubic simple prostatectomy.

7.c. Decreased need for blood transfusion. Compared with open simple prostatectomy, robot-assisted laparoscopic simple prostatectomy can be performed with smaller incisions with shorter hospital stay and decreased risk for perioperative hemorrhage and blood transfusion.

Chapter review

1.Of the indications for simple prostatectomy—(a) acute urinary retention,

(b)recurrent or persistent urinary tract infections, (c) significant symptoms of bladder outlet obstruction not responsive to medical therapy, (d) persistent gross hematuria from the prostate, (e) pathologic changes of the kidneys secondary to prostatic obstruction, and (f) bladder calculi—the only absolute indication for prostatectomy is

pathologic changes of the kidneys secondary to prostatic obstruction. All the others are relative indications because they may on occasion be corrected without the need for prostatectomy.

2.One should not consider doing a simple prostatectomy for glands of less than 75 g. If a simple prostatectomy is planned and it is discovered intraoperatively that the prostate is less than 50 g, it is prudent to abort the procedure and perform a transurethral resection of the prostate instead, because performing an open prostatectomy on small glands carries an extremely high complication rate.

3.Simple prostatectomy should be considered in patients who cannot be placed in the lithotomy position and who have a sufficiently large gland that can be enucleated. Small fibrous glands, the presence of prostate cancer, previous prostatectomy, and pelvic surgery are contraindications to open simple prostatectomy.

4.Although a cystoscopic examination is not indicated for routine evaluation of obstructive voiding symptoms, one must estimate the size of the prostate adenoma preoperatively to schedule the patient appropriately. Cystoscopy may be a crucial component of that estimation. Moreover, in patients who have hematuria or a urethral stricture, or in whom one needs to evaluate a known bladder calculus or diverticulum, cystoscopy is indicated.

5.More than 10% of patients undergoing simple prostatectomy will require one or more units of blood either intraoperatively or postoperatively.

6.The risks of simple prostatectomy include urinary incontinence, erectile dysfunction, retrograde ejaculation, urinary tract infections, bladder neck contracture, urethral stricture, and the need for a blood transfusion.

7.Nonurologic complications include pulmonary embolus, myocardial infarction, and stroke.

8.A chromic suture placed at the 5-and 7-o'clock positions at the level of the bladder neck in the prostatic fossa may be used to secure the major arterial supply to the prostate and aids in hemostasis. If the bladder neck appears obstructive, a wedge is excised dorsally and the bladder mucosa advanced into the prostatic fossa and secured with 4-0 chromic suture.

9.A method of controlling persistent hemorrhage from the prostatic fossa that cannot be controlled by the hemostatic sutures or fulguration may be accomplished with the Malament suture. A nylon suture is placed in a purse-string fashion around the bladder neck, brought out through the

skin, and secured over the urethral catheter with the balloon inflated in the bladder, thus effectively tamponading the prostatic fossa. After several days the suture may be removed when hemostasis is adequate.

10.Following a suprapubic prostatectomy a Malecot suprapubic tube is placed. The proper flow of continuous irrigation is entering through the urethral catheter and exiting from the suprapubic tube.

11.Erectile dysfunction occurs in 5% and retrograde ejaculation in over 90%; 5% of patients develop bladder neck contractures.

12.A urethral catheter must be passed into the bladder before the skin incision is made.

13.The patient should be informed preoperatively that urgency and urge incontinence may occur for several months postoperatively.

14.Suprapubic simple prostatectomy is ideally suited for patients with a large median lobe protruding into the bladder, a clinically significant bladder diverticulum that requires repair, or large bladder calculi. It also may be preferable for obese men, in whom it is difficult to gain direct access to the prostatic pseudocapsule and dorsal vein complex.