This operation is reserved for BPH where the prostate weighs over 50-75 g. It is also appropriate where there is concomitant benign bladder disease requiring treatment such as a symptomatic diverticulum or a large stone. Potential risks are urinary incontinence, erectile dysfunction, retrograde ejaculation and urinary tract infection. The advantages over TURP are complete removal of the gland (therefore no recurrence) and no risk of dilutional hyponatraemia. However, there is an increased risk of intraoperative haemorrhage and a longer hospital stay. Previous prostatectomy, prior pelvic surgery and prostate cancer are contraindications to the operation.
There are two possible approaches to enucleation of the prostate gland via open prostatectomy:
• retropubic - through a direct incision of the anterior prostatic capsule,
• suprapubic - through an extraperitoneal incision of the lower anterior bladder wall.
The retropubic approach allows excellent exposure and visualisation of the prostate and prostatic fossa during enucleation, ensuring complete removal and control of bleeding sites. There is minimal trauma to the bladder and precise transection of the urethra distally to preserve urinary continence. The suprapubic approach allows direct access to the bladder and bladder neck and is suited to patients with bladder pathology (diverticulum, stone) or a large "middle" lobe of prostate protruding into the bladder.
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