Open Adenomectomy and Laparoscopic Variants

Open Adenomectomy and Laparoscopic Variants

Prostate adenomectomy is the removal of prostate adenoma.

This ablation may be surgical (open) or endoscopic. However the use of the term adenomectomy synonymous with surgical removal of the adenoma. This can be carried out by transvesical hypogastric or retropubic route. The perineal, sacrococcygeal or coccypereal pathways were discontinued. The transurethral pathway is that of endoscopic resection.

Whatever the route chosen first and the technique used, prostatic adenomectomy only removes the pathological tissue of the adenoma and leaves the healthy peripheral prostatic tissue in place, stopping at the plane of cleavage which separates them , And thus does not merit the term prostatectomy too often used erroneously. Its purpose is to restore urges without hindrance. It respects the striated sphincter of the urethra but removes the smooth sphincter included in the adenoma, thus creating retrograde ejaculations. But it does not alter the erectile function in any way. His complications, now very limited, were the hemorrhage of the per- and peri-operative period, the infection, and the disorders of continence afterwards.

 

In rare cases where the prostate has become too large, transurethral resection (RTUP or TURP) is not recommended. In this case, it is advisable to prefer open surgery: high adenomectomy.

The surgeon performs an incision in the lower abdomen to remove the adenomatous hypertrophy of the prostate blocking the urethra while retaining the hull of the prostate gland.

 

Incision hypertrophie adénomateuse de la prostate

 

Several variants of this operation are commonly practiced and in particular one distinguishes the transvesical adenomectomy and the adenomectomy retro pubis.

adenomectomie-top-image

 

Transvesical prostate adenomectomy performs surgical removal of the prostatic adenoma through the transvesical hypogastric route.

The operation opens the hypogastric abdominal wall and then the bladder by cystotomy; It crosses the bladder cavity and opens the bladder floor to allow the enucleation of the adenoma and its removal.
This enucleation is performed on the finger by the surgeon.

enucleation prostate doigt

 

It is intended in principle for adenomas of large volume, not amenable to endoscopic resection. Techniques have evolved over the years: the initial intervention was that of FREYER, totally abandoned in favor of open surgical adenomectomies. These allow for the net scissors section of the supra-montanal urethra, hemostasis and repair of the lining of the lodge, and finally the haemostasis of the prostatic chamber itself, which may involve numerous variants Techniques, the most practiced being the technique of HRYNTSCHAK.

There are other variants such as the DENIS technique which involves a cervixing of the bladder neck.

This transvesicular adenomectomy is the open technique most often performed in France.

 

adenomectomie

The Anglo-Saxons more willingly practice the technique of MILLIN. In this retro-pubic adenomectomy the surgeon approaches the prostate directly behind the pubis without opening the bladder. To do this, it incises the suprogonal hypogastric abdominal wall, passes forward of the bladder without opening it, approaches the anterior surface of the prostate, incises the capsule and enucleates the adenoma, then repairs the prostatic shell on drainage.

Generally, this adenomectomy, whatever the technique used, requires longer hospitalization than a TURP, but the likelihood that the tissues will repel or that problems subsequently reappear is less.

The bladder catheter should be maintained at least five days after surgery.

An alternative to this open surgery is adenomectomy by laparoscopy, possibly assisted by the DA VINCI robot. It makes it possible to carry out the same excision of the adenoma as by the open way, but with the aid of mini-incisions.

The intraoperative blood loss and the risk of post-operative bleeding are also reduced compared to the conventional highway. The establishment of a continuous postoperative irrigation system is no longer necessary.

The technical difficulty of the procedure, the lengthening of the operative time and the necessity at the end of the procedure to perform an incision of a size equivalent to that of the conventional open pathway in order to remove the adenoma from the enucleated prostate, limits the Number of followers of this laparoscopic surgery.

The important cost of the intervention if it is performed in robotic surgery compared to the adenomectomy rating is another important brake to the diffusion of this technique.