Open Simple Prostatectomy

Open simple prostatectomy removes the hyperplastic transition-zone adenoma while leaving the surgical capsule (peripheral zone) behind — the open counterpart of transurethral enucleation, reserved for large and very large glands where a purely endoscopic resection is impractical. Two open routes exist: suprapubic (transvesical), entering through the bladder, and retropubic (Millin), entering directly through the prostatic capsule. Selection among all BPH surgical options is driven largely by gland size and is covered in the Functional Urology / BPH-LUTS topic; the endoscopic alternatives are on the Endoscopic Management of BPH page.

Indications

• General BPH-surgery indications (identical to the endoscopic options): symptoms refractory to or intolerant of medical therapy, or a complication — refractory retention, recurrent UTI, recurrent bladder stones, recalcitrant gross haematuria, renal insufficiency (GFR < 60 for ≥ 3 months), or progressive bladder dysfunction. An asymptomatic diverticulum or an elevated PVR alone is not an indication.
• Reserved for the large gland. Simple prostatectomy is the option for large (> 80–150 g) and very large (> 150 g) prostates. Historically an open operation was advised above a 75 g transurethral-resection ceiling (expert opinion, to avoid TUR syndrome and excessive bleeding); bipolar TURP and laser enucleation have pushed that size threshold up considerably, so the AUA now bases the choice on the patient's anatomy, the surgeon's experience, and a discussion of the risks and benefits.
• Approach-specific pointers: the suprapubic (transvesical) route is preferred with a prominent intravesical (median-lobe) component or when the bladder must be entered anyway — bladder calculi or a large, narrow-necked diverticulum. The retropubic (Millin) route gives direct vision of the fossa and better control of the prostatic vessels at the bladder neck, without opening the bladder.

Preoperative Workup

• Evaluation: postvoid residual, urinalysis and urine culture (urine sterile at surgery), PSA (biopsy if elevated or the DRE is suspicious), AUA symptom score, and urodynamics if indicated. Size the prostate with transrectal ultrasound, remembering that DRE and TRUS overestimate — judge the transition-zone volume, not just the total. Treat retention beforehand with clean intermittent catheterisation (preferred — it preserves detrusor function better than an indwelling catheter) and treat any UTI.
• Anaesthesia/medical: general (preferred) or spinal, with cardiac clearance; CBC, chemistry, and coagulation studies; stop agents that affect coagulation. Transfusion rates are low but blood loss can be significant, so have typed and cross-matched blood available. A bowel prep/enema covers the small risk of rectal injury (retropubic).
• Antibiotic prophylaxis (AUA, open entry into the urinary tract): a first- or second-generation cephalosporin; with penicillin allergy, an aminoglycoside plus either metronidazole or clindamycin; second-line, a fluoroquinolone or ampicillin–sulbactam.

Comparing the Two Open Approaches

Feature	Suprapubic (transvesical)	Retropubic (Millin)
Access	Anterior cystotomy — enucleate through the open bladder	Transverse capsulotomy — enucleate directly through the capsule, bladder not opened
Bladder-neck vessel control	Indirect — hemostatic sutures at 5 & 7 o'clock (fossa inspected with lighting/retractors, but exposure less direct)	Direct vision of the fossa and vessels
Best suited for	Prominent intravesical/median lobe; concurrent bladder calculi or diverticulum	Large gland without a large intravesical lobe; when direct fossa visualisation is wanted
Trade-off	Cystotomy to close; fossa worked partly by feel	Apical dissection close to the sphincter; posterior-capsule tear risks the rectum

Suprapubic (Transvesical) Prostatectomy

1. Position and fill. Supine with the ASIS over the table break, slightly flexed in modified Trendelenburg. Place an 18-Fr Foley (balloon 10 cc), fill the bladder with 200–300 cc of saline, and clamp it to aid exposure; a headlight helps light the fossa later.
2. Incision and space of Retzius. A Pfannenstiel or lower-midline incision (the authors now use lower midline almost exclusively); avoid carrying a transverse incision too far laterally (hernia risk) and beware the inferior epigastric vessels. Open the anterior rectus fascia, separate the rectus bellies, open the transversalis fascia, and develop the space of Retzius; place a self-retaining retractor.
3. Cystotomy. Open the bladder transversely ~2–3 cm above the bladder neck between two 2-0 absorbable stay sutures — not too low, or the prostatic capsule tears. Enlarge the opening, empty and pack the dome, and expose the trigone. Identify both ureteric orifices (indigo carmine or methylene blue if needed) and remove any vesical calculi.
4. Enucleate the adenoma. Incise the bladder epithelium circumferentially around the protruding adenoma with cutting current, then place an index finger in the fossa and crack the anterior commissure with anterolateral pressure. Develop the plane between the surgical capsule and the adenoma, keeping pressure on the adenoma to avoid capsular tears; sweep side to side until the lobes free. Divide the urethra sharply, just proximal to the distal apex (pinch between two fingers), avoiding traction on the distal urethra to spare the sphincter. Deliver the adenoma with a four-pronged tenaculum or lobe forceps. Unusual adherence to the capsule should raise suspicion of carcinoma.
5. Hemostasis. Place figure-of-8 or Halsted mattress sutures of 2-0 chromic/absorbable at the 5 and 7 o'clock positions, 1 cm deep and 1 cm caudad, to capture the main prostatic arteries entering there — avoiding the ureteric orifices — and leave them uncut. Tack the vesical epithelium over the fossa rim (prevents an obstructing membrane and bladder-neck contracture); excise a V-wedge from the 6 o'clock position if the bladder neck is small or fibrous. Insert a 22–24 Fr Foley (30-mL balloon) and apply traction. For refractory bleeding use hemostatic agents, O'Conor capsular plication, or a Malament purse-string partition of the bladder neck.
6. Close. Close the bladder in two or three layers (mucosa with running 3-0/4-0 chromic, muscle with interrupted Lembert 2-0 chromic/absorbable), leave drains near the bladder neck, and use a three-way catheter or cystostomy tube for irrigation.

Retropubic (Millin) Prostatectomy

First described by Millin in 1945, this uses a transverse capsular incision that gives better control of the prostatic vessels at the bladder neck.

1. Position and expose. Supine, table flexed and in Trendelenburg, with DVT prophylaxis. Place a Foley (balloon 30 mL) and palpate it to find the bladder neck. Enter through a low-midline infraumbilical (or Pfannenstiel) incision into the space of Retzius; a right-handed surgeon stands on the patient's left. Place a self-retaining retractor with a moist lap pad over the bladder.
2. Capsular sutures and incision. Tease the areolar/fatty tissue off the anterior prostate. Place parallel rows of 0-chromic sutures transversely — one near the bladder neck, one near the apex — deep through the capsule into the adenoma to control surface bleeders, with lateral stay sutures to prevent tearing. Hemostasis can be improved by ligating the dorsal venous complex and the lateral pedicles (figure-of-8 at the seminal-vesicle junction). Make the transverse capsulotomy between the suture rows, using sponge-stick compression and fulguration to keep a dry field, down to the adenoma.
3. Enucleate. Identify the capsule–adenoma plane; a Babcock on the lower capsular lip and Metzenbaum scissors start the separation, then blunt finger dissection frees the adenoma laterally, posteriorly, and superiorly. Divide the apex to the membranous urethra under direct vision with sharp dissection to protect the sphincter, remove the adenoma, and pack the fossa with warm moist gauze for 5 minutes. Do not tear the posterior capsule — a rectal injury is closed in two layers (with omental interposition; a diverting colostomy if there is fecal spillage or no bowel prep).
4. Trigonise the bladder neck. After the pack is removed, control fossa bleeders and place figure-of-8 sutures at 5 and 7 o'clock for the urethral arterial branches. Identify the ureteric orifices (indigo carmine, or ureteric catheters if they sit near the edge), then suture the posterior bladder-neck lip to the posterior prostatic capsule with 2-0 chromic, bringing the bladder neck as far distal as possible and excising excess tissue. Trigonisation aids hemostasis, widens the vesico-prostatic junction, hastens epithelialisation, and reduces post-adenectomy stricture and catheter duration.
5. Close the capsule. Place a 22–24 Fr three-way catheter, then close the anterior capsule with two 0-chromic continuous sutures. Inflate the balloon to 20–30 mL (more if the neck is wide) and pull it to the bladder neck to tamponade the fossa (gentle traction if there is haematuria). Leave a Penrose or Jackson-Pratt drain in the space of Retzius and run continuous bladder irrigation.

Vesicocapsular Variant

An alternative that incises the anterior bladder wall and prostatic capsule as one continuous opening — it carries a higher risk of urinary leak and of the incision extending down into the urethral sphincter. A vertical bladder-neck incision is made between stay sutures, the adenoma is enucleated bluntly, the capsule is opened down the midline to expose the apex, and closure uses a purse-string of the bladder plus an imbricating outer layer.

Postoperative Care

• Suprapubic: release Foley traction within 12 hours and remove the urethral catheter on postoperative day 2–3; a suprapubic tube (if used) comes out around day 6–7 after a voiding trial (often sooner). If voiding fails and the suprapubic tract has closed by 48–72 hours, reinsert a urethral catheter. Watch for postobstructive diuresis after relief of chronic retention — monitor fluid balance, blood pressure, and electrolytes.
• Retropubic: run continuous bladder irrigation until the urine is clear; remove the drain when output is minimal and the Foley at 3–5 days (replace the Foley if drain output persists after removal). Continue DVT prophylaxis and antibiotics until the catheter is out.

Complications

• Bleeding — may need endoscopic fulguration if tamponade fails (tamponade itself prevents the capsule from retracting).
• Postobstructive diuresis — salt-and-water loss after relief of chronic obstruction; strict fluid/electrolyte monitoring.
• Retrograde ejaculation — occurs in the majority; new-onset impotence or incontinence is uncommon.
• Bladder-neck contracture — uncommon, and unlike post-TURP contracture it usually responds well to dilation; urethral stricture in a few.
• Rectal injury (retropubic, from a posterior-capsule tear) — two-layer closure with omental interposition, occasionally a diverting colostomy.
• Infective — wound infection, UTI, epididymo-orchitis, and osteitis pubis are all rare.