Transvesical adenomectomy

1. Definition:
Open surgery performed by a scalpel incision on the abdomen to remove a benign prostate tumor (adenoma or benign prostatic hypertrophy) that, by increasing, causes an obstacle to the bladder emptying.

The peculiarity of the transvesical adenomectomy is that the adenomatous tissue is removed by practicing an opening at the level of the bladder rather than by opening the prostate capsule (retropubic adenomectomy). This type of surgery results in a better exposure of the bladder and bladder neck.

2. Indications:
The indication for open (rather than endoscopic) surgery typically results from excessive prostate volume and the concomitant presence of:
Bulky bladder diverticulum.
Ankylosis of the hips, which prevents the patient from being properly positioned for endoscopic surgery.

3. Contraindications:

• Small prostate.
• Previous adenomectomy for which an endoscopic intervention is best indicated
• Prostate cancer established

4. Description of the technique:
The patient may be subject to adenomectomy in general or local-regional anesthesia (introduction of lumbar spine anesthetic substances that allow complete patient consciousness). With the scalpel you perform an incision of the skin on the abdomen from the navel to the pubis or alternatively a transverse incision over the pubis through which you get to the bladder. This is engraved and once inside his cavity the bladder neck and the prostate gland are identified. After an incision with the scalpel of the bladder neck to identify the prostate adenoma (the benign prostatic cancer to be removed), the surgeon will perform an enucleation maneuver using the index finger and, if necessary, scissors and scalpel, leaving in place the rest of the prostate gland. At the end of the surgery, a special “3-way” urethral catheter is to be applied, which allows a proper “bladder wash” through a continuous irrigation (cystoclysis). At the end, a small tube for abdominal drainage (a warning of any bleeding or urine collecting in the area near the affected area) is left, which is connected with a collection bag.

5. Pre- and post-surgery
Before the intervention is desirable:

• An ultrasound assessment of the high urinary system as well as the bladder and the prostate gland.
• Prior to surgery, those medications that might help bleed should be suspended: such as anticoagulants or aspirin-like pain medicines.
• Parenteral antibacterial prophylaxis is always suggested.
• If the post-surgery course is regular, the patient can start feeding and mobilizing early (after 12-24 hours).
• The suspension of continuous irrigation (cystoclysis) will vary depending on the urine characteristics (persistence or not of macroematuria).
• The pelvic drainage tube is generally removed after 4 days from the surgery along with the bladder catheter unless complications occur.
• Patients can be discharged after 4-5 days and return for the medications and the stitches removal. A residual linear cutaneous scar will remain.

6. Duration of surgery:
Overall 1-2 hours (including preoperative, anesthetic and awakening times)

7. Type and length of hospitalization:
The hospitalization is of an ordinary type. Postoperative usually lasts from 5 to 7 days.

8. Results:
Removal of adenoma-induced bladder obstruction in order to allow bladder emptying at low pressures (effortless) to avoid complications for the bladder and / or the urinary system (ureters and kidneys).

9. Benefits:
The adenomectomy open surgery performed on the patient with an excessive volume increase in the prostate gland provides the patient with an improvement of the urination dynamics with favorable surgery times and modes. For the surgeon, the main advantage is to be able to quickly remove a massive prostate adenoma under direct vision without the risks of prolonged endoscopic prostate resections. To this it must be added the possibility of solving, in one operation, any other pathology (bladder diverticulum, bladder calculus).

10. Disadvantages:

1. The main disadvantage is that of all the surgical procedures that require scarring with longer healing times and therefore with greater degeneracy than the endoscopic techniques.
2. The greatest risk of intraoperative hemorrhage that requires transfusion with regard to endoscopic techniques.

11. Side Effects:

1. Excessive frequency of urinations and the inability to postpone them, with possible urinary loss, are normal symptoms after surgery. They are related to bladder irritability. Usually this symptom ceases after a few weeks or at most after a few months (depending on the preoperative bladder status). If the extent of the problem requires it, medications can be given to help the recovery of a normal urination dynamics.
2. Retrograde ejaculation, i.e. sperm passage, at ejaculation, into the bladder, rather than outside as usual. It is due to the loss of the bladder neck closure mechanism (which is observed after all the surgery performed for the IPB), and implies the inability to procreate while maintaining the erection normal. This condition occurs in 80-90% of the transfected adenomectomy patients.

12. Complications:

1. Hemorrhage during or after surgery requiring blood transfusions is more frequent than endoscopic technique (19% versus 8.8% of TURP).
2. Urinary incontinence (urinoma) may be a complication of the immediate post-surgery and consists in passing urine through the suture points applied to the bladder. Usually it is caused by a malfunction of the urethral catheter. Prevention of this complication is carried out by continuous monitoring of the correct drainage of the catheter and flow of the irrigation fluid. The problem, however, resolves spontaneously once an adequate drainage of decanted liquids is induced.
3. Urinary incontinence after transvesical adenomectomy is observed in about 2-3%. It is mostly a “stress” incontinence, or is highlighted when there is a sudden increase in intra abdominal pressure (coughing, sneezing, laxation, weight lifting). Only 0.3% of the cases have total incontinence. Such type of incontinence is usually related to a lesion of the external urethral sphincter and, depending on the severity, it can be corrected by endoscopic or ultimately prosthetic surgery.
4. Acute epididymitis (painful swelling of the epididymis).
5. Sclerosis of the bladder neck (scar trauma after surgery) is observed in 2-3% of cases and occurs after about 6-12 weeks after the operation. Symptoms are those of inguinal bladder obstruction. This complication, however, can be corrected with endoscopic surgery that involves bumping into the bladder.
6. Fever and wound infection (linked to urine release immediately after surgery) are rare events whose frequency has been minimized by using the spy drainage tube and antibiotic prophylaxis.
7. General complications are: deep venous thrombosis, pulmonary embolism, myocardial infarction, and cerebral stroke. Each of these affects about 1% of cases and the overall mortality resulting from intervention is close to zero. All are related to coagulation turbines that can be prevented to some extent by the use of thromboembolic prophylaxis and / or the use of elastic stockings and early mobilization.

13. Attentions to be placed on discharge:
If the post-surgery course is regular, the patient is usually resigned after about 5/6 days from the surgery. In the case of urinary tract infections or bleeding, the Patient should increase the amount of water and consult a physician for appropriate therapy.