John J. Bauer, M.D.
www.flinturology.com Urology Services, Inc.
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Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions
Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.
This procedure is performed for an extremely enlarged prostate from a benign tumor called an adenoma or Benign Prostatic Hyperplasia (BPH).
Benign Prostatic Hyperplasia (Prostate Enlargement)
Generally, prostate growth is negligible between puberty and middle age. When a man reaches about 40 years of age, however, hormonal changes may cause the prostate to begin growing again. This non-cancerous (benign) growth is called "hyperplasia."
Not all men experience this enlargement; in those who do, the condition is not always progressive. Studies have found enlarged prostates in about 40% of men over age 55, rising to 70% in men over 70, and to 80% over age 80 and beyond.
When the prostate enlarges, the surrounding tissue prevents it from expanding. This squeezes the gland inward, causing it to pinch the urethra and restrict the flow of urine from the bladder. The more the prostate grows, the more the urethra is constricted and the harder the bladder muscles must squeeze to force urine out. This can cause the muscles of the bladder wall to grow thicker, stronger and more irritable, creating a need to urinate frequently, even when the bladder contains only a small amount of urine.
Over time, this can cause urinary tract infections (UTI's), difficulty in starting or sustaining urination or an inability to empty the bladder completely (urinary retention). Occasionally, a complete blockage of the urethra results, causing a serious condition called acute urinary retention.
Open Prostatectomy
If the prostate is greatly enlarged, if the bladder has been damaged and must be repaired, or if the patient has other complications prohibiting transurethral surgery, an open surgical procedure called a prostatectomy (removal of the prostate) may be necessary.
With this procedure, the patient is anesthetized and the surgeon makes an external incision, either in the lower abdomen or in the perineum (the area between the rectum and the scrotum), depending upon the location of the enlarged portion of the prostate. The surgeon then removes the enlarged prostate tissue from inside the gland. An open prostatectomy in which the surgeon accesses the prostate from the abdomen and cuts through the bladder to is called a suprapubic approach; surgery through the prostatic capsule to remove the adenoma is called a retropubic approach. (Both approaches are described on this page.)
Your pre-operative appointments
Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.
Change In Health Status
Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.
Pre-Operative Medication Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:
Your operation occurs near the bowels so your preparation involves an intermediate-level bowel prep, as follows.
Pre-Operative Diet Instructions
Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:
Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.
Pre-Operative Cleaning Instructions (bathing and showering instructions)
Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:
On The Day Of Surgery
The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.
After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.
Time To Arrive For Your Surgery
During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.
ARRIVAL TIME:
WHERE TO ARRIVE:
The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.
Indications:
Patient is a male with lower urinary tract irrative or obstructive voiding symptoms that has not responded adequately to medical therapy. The size of the prostate on transrectal ultrasound is of sufficient weight that would potentially require a stage TURP or have a higher likelihood of complications if a trans-urethral procedure was completed. If patient has an incidental diverticulum or bladder stones these entities will be dealt with during the open prostatectomy.
Alternatives:
Alternatives are watchful waiting, continued oral medical therapy in combination with finasteride, transurethral resection of the prostate (TURP), staged TURP, chronic indwelling catheter or suprapubic catheter drainage, laser therapy, microwave therapy, ultrasound therapy and thermotherapy.
Risks/Complications:
The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.
The specific risks of this procedure include, but are not limited to: impotence, incontinence, retrograde ejaculation, bladder neck contracture, life-threatening bleeding requiring invasive vascular occlusion techniques, urinary tract infection, prolonged Foley catheter drainage or suprapubic tube placement, prolonged gross hematuria, may find prostate cancer on the pathology specimens and require further surgery, radiation or hormonal therapy for this entity, damage to bladder, sphincter muscle, ureters and additional procedures to correct these complications. You may require resection of a diverticulum or removal of bladder stones if found incidentally during the procedure.
To view the actual printable form for this surgery, click here: Counseling Note for Open Prostatectomy. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.
Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.
There are two types of Open Prostatectomy: Open Retropubic Prostatectomy and Open Suprapubic Prostatectomy.
Open Retropubic Prostatectomy
Indications:
Male with clinically symptomatic large volume BPH
Sample Procedure Dictation:
Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 24 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the umbilicus to the symphysis pubis coagulating all bleeders as the where encountered. The rectus fascia was divided the length of the incision and the space of Retsius was developed bluntly to expose the bladder, prostate, and obturator fossa. The obturator lymph nodes were palpated for normality. All nodes were normal in character. The pelvic gutters were bluntly exposed. The pre-prostatic fat was removed from the anterior prostate with bovie coagulation; a 0-chromic figure eight suture was placed around the superficial dorsal veins at the level of the bladder neck to control back bleeding. Two transverse rows of interrupted 0-chromic sutures were placed in the anterior prostate approximately 1cm apart to control bleeding. The endopelvic fascia was then entered bilaterally to expose the puboprostatic ligaments. Bilateral 0-chromic sutures were pre-placed for the running closing sutures for the prostatic capsule. The prostatic capsule was bovied transversely to the prostate proper and sharp dissection was performed to allow a blunt finger dissection of the prostatic adenoma from the apex to the base of the prostate. The distal urethra was then sharply divided with Jorgenson scissors and the remaining prostatic attachments were sharply divided to remove the adenoma. The prostate fossa was then packed with a hot water laden sponge and pressure was applied with a Dever retractor for 10 minutes to allow for prostatic capsule contraction. The specimen was inspected for completeness of resection and sent for permanent pathologic review. The hot sponges were then removed and bleeders were tied with 0-chromic sutures. Bilateral 0-chromic sutures were placed in the 5 and 7 o'clock base positions to control the bleeding from the prostatic pedicle vascular structures. The base of the prostate was re-epithelialized with the bladder mucosa using 2-0 chromic sutures.
The dorsal vein complex was then isolated with the mixter clamp and #2-vicryl was used to tie the deep dorsal vein complex without division of the puboprostatic ligaments. The complex was then bovied and divided over the mixter clamp. Bleeding was controlled with a figure eight suture just above the urethra and below the pubis.
The 24 Fr 3-way Foley catheter was placed through the urethra and bladder neck with approximately the weight of the prostate adenoma in cc's injected into the balloon. Gentle traction on the Foley was placed and the prostate capsule was closed in a running fashion with the pre-placed 0-chromic sutures. A 15mm Jackson-Pratt drain was placed through a separate stab incision in the pelvis. The operative site was inspected for possible bleeders, which were clipped if found. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain was secured and the Foley was tapped with gentle traction. Brisk continuous bladder irrigation was applied. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR) with the epidural used for pain control. The patient arrived to the RR in stable condition and without complications. The CBI was then turned down to 250cc/hr with a medium rose urinary efflux.
Open Suprapubic Prostatectomy
Indications: Male with clinically symptomatic large volume BPH with A large intravesical lobe, diverticulum or bladder stone.Sample Procedure Dictation:
Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 24 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the umbilicus to the symphysis pubis coagulating all bleeders as the where encountered. The rectus fascia was divided the length of the incision and the space of Retsius was developed bluntly to expose the bladder, prostate, and obturator fossa. The obturator lymph nodes were palpated for normality. All nodes were normal in character. The pelvic gutters were bluntly exposed. The pre-prostatic fat was removed from the anterior prostate with bovie coagulation; a 0-chromic figure eight suture was placed around the superficial dorsal veins at the level of the bladder neck to control back bleeding. The bladder was then entered using the bovie in a midline vertical fashion with 0-chromic stay sutures. The apex of the incision was supported with a figure eight 2-0 vicryl suture to prevent tearing the bladder neck and pre-placed for bladder closure. Eight French feeding tubes were placed into the ureters bilaterally to avoid ureteral damage.
The bladder stone was removed without difficulty or the bladder diverticulum was resected without difficulty and closed in a two-layer fashion with 2-0 vicryl sutures.
The bladder mucosa was bovied to the prostate proper avoiding the ureteral orifices. Sharp dissection was performed to allow a blunt finger dissection of the prostatic adenoma from the base to the apex of the prostate. The distal urethra was then sharply divided with Jorgenson scissors and the remaining prostatic attachments were sharply divided to remove the adenoma. The prostate fossa was then packed with a hot water laden sponge and pressure was applied with a Dever retractor for 10 minutes to allow for prostatic capsule contraction. The specimen was inspected for completeness of resection and sent for permanent pathologic review. The hot sponges were then removed and bleeders were tied with 0-chromic sutures. Bilateral 0-chromic sutures were placed in the 5 and 7 o'clock base positions to control the bleeding from the prostatic pedicle vascular structures. The base of the prostate was re-epithelialized with the bladder mucosa using 2-0 chromic sutures.
The dorsal vein complex was then isolated with the mixter clamp and #2-vicryl was used to tie the deep dorsal vein complex without division of the puboprostatic ligaments. The complex was then bovied and divided over the mixter clamp. Bleeding was controlled with a figure eight suture just above the urethra and below the pubis.
The 24 Fr 3-way Foley catheter was placed through the urethra and bladder neck with approximately the weight of the prostate adenoma in cc's injected into the balloon. Gentle traction on the Foley was placed and the bladder was closed in a two layer running fashion with the pre-placed 2-0 vicryl suture. A 15mm Jackson-Pratt drain was placed through a separate stab incision in the pelvis. The operative site was inspected for possible bleeders, which were clipped if found. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain was secured and the Foley was tapped with gentle traction. Brisk continuous bladder irrigation was applied. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR) with the epidural used for pain control. The patient arrived to the RR in stable condition and without complications. The CBI was then turned down to 250cc/hr with a medium rose urinary efflux.
To the family and friends of patients undergoing surgery.
SCHEDULED STARTING TIME OF SURGERY:ESTIMATED LENGTH OF SURGERY:
You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.
The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.
We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.
Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.
Activity
Diet
Medication
Catheter and Wound Care
Bowel Movements
When to Contact your Doctor
Contacting Your Physician
Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.
Specific post-operative instructions for your individual surgery:
Frequently Asked Questions after surgery
This section is under construction.