Laparoscopic retropubic extraurethral adenomectomy

Introduction

Benign prostatic hyperplasia (BPH) is a polyethological disease that occurs due to the proliferation of periurethral adenomatous tissue of the prostate gland, leading to the obstruction of the lower urinary tract and deterioration of the quality of life of the male population. According to international statistics, BPH is observed on average in 80.0% of men over 60 years of age and is a common cause of hospitalization in a urological clinic [1]. Medicine therapy is effective only in the initial stages of the disease, but surgical treatment is indicated with progression of the disease [2]. The most widely used minimally invasive surgery techniques are transurethral enucleation, vaporization, and prostate vapor resection using mono- and bipolar electrodes, holmium, thulium, or diode lasers [3].

The choice of the optimal technique for the treatment of prostate hyperplasia, despite the development of minimally invasive technologies, still attracts the attention of urologists. Transurethral operations are limited by prostate volume and the correspondence of the urethral lumen with the diameter of the resectoscope. Therefore, adenomectomy methods continue to be used, such as transvesical adenomectomy according to Fedorov-Freyer, retropubic adenomectomy according to Millin, and laparoscopic retropubic and transvesical adenomectomy. Each of the above-mentioned methods has its advantages, disadvantages, and limitations [4][5]. However, they all violate the continuity of the vesicourethral segment and result in the removal of the prostatic urethra.

Anatomically, the prostatic part of the urethra extends from the bladder neck to the distal part of the seminal tubercle. It is represented by the proximal and distal sections, the boundary of which is the seminal tubercle. At the same time, the circular fibers of the vesicular sphincter, which play a role in urinary retention, are believed to also cover the prostatic urethra almost throughout its length (Fig. 1) [6]. At the same time, the specified sphincter squeezes the urethra during ejaculation and prevents retrograde ejaculation. The muscle fibers of the urethral sphincter cover the distal part of the prostatic urethra, descending lower to the membranous part (Fig. 1, green arrows).

The mucous membrane in this department is histologically represented by a transitional epithelium and its own mucosal plate. The transitional epithelium is formed by several layers of cubic cells. The own plate of the mucosa consists of loose fibrous connective tissue with the presence of small arterial vessels, nerve stems, and Littre glands of a cluster-tubular structure. It should be noted that there is no muscle plate in the urethral mucosa. The submucosal base is well expressed throughout the prostatic part of the urethra. The muscular membrane is characterized by the presence of two layers of smooth muscle tissue. The inner layer is longitudinally arranged bundles of muscle tissue, and the outer layer is characterized by a circular arrangement of muscles.

Considering the anatomical and functional features of the prostatic urethra described above and the organ-preserving tendencies accepted in modern surgery, the tactics of maximum saving of this part of the urethra seem relevant. The issue of urethra-preserving adenomectomy has been considered in the scientific works of Sergienko et al. (2012) since 1977 with the use of postlobular and intravesical extraurethral techniques [7]. The results showed significant advantages of these techniques compared to transurethral and incision operations with a decrease in the frequency of complications and the timing of postoperative recovery [8]. Considering the pace of development of modern urology, it has currently become possible to apply the technique of extraurethral retropubic adenomectomy by means of the videolaparoscopic technique. In the foreign literature, there are separate works describing the urethra-preserving variant of adenomectomy with the DaVinci robotic complex [9].

The study aimed to evaluate the possibilities of performing extraurethral adenomectomy with preservation of the prostatic urethra with laparoscopic access, determining its advantages and disadvantages.

Materials and methods

The authors of this study developed a laparoscopic version of retropubic extraurethral adenomectomy based on the St. Luke’s Simferopol Clinical Multidisciplinary Medical Center. Thirty-five surgeries were performed from 2019 to 2021 using this technique. In the preoperative period, patients underwent a standard examination, including ultrasound, a blood test for prostate-specific antigen (PSA), an assessment on the International Prostate Symptom Score (IPSS) scale, the International erectile Function Index (IIEF), the Quality of Life (QoL) index due to urination disorders.

To study the effectiveness of extraurethral retropubic laparoscopic adenomectomy (euLAE), intraoperative, early, and late postoperative complications, the duration of patient's stay in the hospital, the duration of bladder catheterization and the time of complete recovery from urination were evaluated. Uroflowmetry and transrectal ultrasound (TRUS) data were compared before surgery, 3 and 6 months after surgery, and the quality of urination was assessed on the IPSS scale.

Key stages of laparoscopic retropubic extraurethral adenomectomy. An Olympus ENDOEYE 3D (Olympus Medical Systems Corp., Shinagawa City, Tokyo, Japan) laparoscopic device is used. Laparoscopic trocars are installed: an optical trocar of 10 mm under the navel, a trocar of 5 mm on the left along the pararectal line, a trocar of 5 mm on the right along the pararectal line, a trocar of 5 mm on the left in the iliac region, and a trocar of 5 mm on the right in the iliac region. Access to the prostate is standard transperitoneal laparoscopic. Isolation of tissues of the retropubic space and the anterior surface of the prostate, preservation of the dorsal vascular complex without its ligation. Transverse "arc-shaped" incision of the capsule along the anterior surface of the prostate. First, the fibrous capsule is dissected and then the entire surgical capsule is dissected to the adenomatous nodes. This method provides sufficient access to isolate both the adenomatous lobes and the prostatic urethra, starting from the bladder neck. This is followed by alternate isolation of the adenomatous lobes, sequential intersection of the anterior and posterior commissures (in the presence of the middle lobe, the latter is removed in one block from one of the lateral ones), and separation of the prostatic urethra from the adenomatous tissues (Fig. 2).

Considering that the prostatic part of the urethra is represented by a thin wall, its partial marginal wound may occur in some patients during isolation of the adenomatous nodes. Defects are sutured on a Foley catheter installed at the beginning of the operation until tightness is created (Fig. 3). After the removal of the adenomatous nodes, a cavity remains around the urethra (Fig. 4). Next, a "frame" is created that supports the prostatic urethra due to the corrugated seams of the posterolateral surface of the capsule with a simultaneous decrease in the space from the removed lobes. The inner walls of the capsule are stitched to reduce the volume of the cavity and stabilize the prostatic urethra (Fig. 5).

The preservation of the prostatic urethra provides the best indicators of urination quality both in the early and long-term postoperative period [10]. The surgery technique discussed makes it possible to completely preserve the external and internal urethra sphincter zone, which can be damaged during transurethral operations, especially with large volumes of adenomatous nodes [11]. Patients have no elements of urinary incontinence due to the preservation of the urethra and muscle elements of the sphincters.

Statistical analysis. Statistical data analysis of the data obtained was carried out using the IBMÒ SPSS Statistics 25 data analysis package (SPSS:  IBM Company, IBM SPSS Corp., Armonk, NY, USA). When processing data for the indicators studied, the median and interquartile intervals (Me [LQ – UQ]) were calculated. The statistical significance of the results obtained was evaluated based on a two-sample t-test with different variances, the values of which were less than 0.001 (p < 0.001).

Results

Intraoperative parameters, the duration of irrigation and catheterization of the bladder, as well as information on hospital bed-days are presented in Table 1.

TRUS confirmed that the prebladder cavity was not formed after the surgery, and the preserved prostatic part of the urethra was clearly traced, which was absent after standard retropubic adenomectomy or transurethral operations (Fig. 6).

Due to preservation of the integrity of the vesicourethral segment and prostatic urethra, it is possible to create a tighter urethra, which significantly reduces the duration of rehabilitation. None of the patients had hematuria in the early postoperative period, making it possible to reduce the intensity of bladder flushing to 10 – 30 drops per minute. The bladder irrigation system could be turned off early, sometimes immediately after the end of the surgery, contributing to the early activation of the patient.

The catheter was removed on the second to fourth day after surgery. Self-urination after catheter removal was observed in 100.0% of the cases. Three patients (8.0%) needed a day to eliminate the elements of dysuria. Urethrography in the fourth week after surgery showed that the urethra maintained its integrity throughout. Therefore, Table 2 shows the results of treatment 3 and 6 months after the execution of euLAE compared to the preoperative indicators. Patients maintained satisfactory urination quality 6 months after surgery and did not develop complications such as retrograde ejaculation and urethral strictures.

Discussion

The authors analyzed the literature data to compare the proposed method of performing euLAE with the open option of performing surgery using the Sergienko technique and standard laparoscopic adenomectomy (euLAE) without preserving the urethra [12]. The high traumatism of the lower middle access lengthens the rehabilitation process, being associated with postoperative complications. Blood loss in such surgery averages 350 ml, while in euLAE — 328 ± 125 ml. However, in most studies evaluating euLAE, a low percentage of bleeding and hemotransfusion is observed, which is achieved using precision enucleation techniques and selective coagulation of capsular blood vessels, as well as spontaneous thrombosis in veins under the influence of CO₂ [13]. In this study, intraoperative blood loss during euLAE was 150 ml. Additionally, with the open version of the operation according to the Sergienko method, in the immediate postoperative period, most patients have an admixture of blood in the urine for three to five days, requiring a constant irrigation system of the bladder. With euLAE, the irrigation system is turned off on the first day, and during the first eight hours after surgeries with euLAE, in some cases immediately after surgeries.

The urethral catheter in open surgery is removed on the third or fourth day, and the complete restoration of urination occurs only from twelfth to fourteenth day. With euLAE, due to the absence of a preserved urethra, the duration of catheter standing increases to 7.71 ± 3.63 days. According to the literature data, comparative studies of laparoscopic and open adenomectomy show that both surgical methods are comparable in functional results [14]. All the above operation methods show high efficiency with an increase in the maximum urine flow rate to 17 – 18 ml/s, an improvement in the QoL index, and a decrease in the total score on the IPSS scale. The results of the study show a similar improvement in the functional results of the operation. However, with retropubic euLAE, these indicators are achieved much earlier, almost immediately after catheter removal, which was removed on from second to fourth day.

According to Sergienko et al. (2012), the surgical wound healing occurs from twelfth to fourteenth day, and the transition to outpatient treatment is possible from fourteenth to sixteenth day [7]. With euLAE, the median hospital stay was five days, necessary for the complete restoration of urination. The frequency of early postoperative complications (bleeding, bladder blood tamponade, urinary tract infection, acute urinary retention) during open surgery according to various studies reaches 15.0 – 19.0%. During laparoscopic surgery, this indicator is reduced to 2.0 – 3.0%. The most common long-term complication of standard retropubic adenomectomy is retrograde ejaculation, which occurs in almost all (up to 86.0%) patients [15]. Postoperative urethral strictures are also a frequent complication. The preservation of the prostatic part of the urethra and reduction of the duration of urethral catheterization made it possible to avoid these complications in this study.

Thus, the technique of performing the retropubic euLAE combined the positive aspects of minimally invasive surgery, such as a shorter rehabilitation period and a reduction in the frequency of postoperative complications, as well as all the advantages of preserving the prostatic urethra — early catheter removal, absence of retrograde ejaculation and urinary incontinence.

Conclusion

Preservation of the urethral prostatic part during the implementation of the retropubic euLAE provides less trauma, the possibility of early activation of the patient and removal of the catheter in the shortest possible time, which reduces the risk of postoperative urethral strictures. Due to a significant reduction in the rehabilitation period, patients can be transferred to outpatient treatment earlier. The preservation of the urination quality and the absence of early and late postoperative complications, urinary incontinence after surgery, and retrograde ejaculation prove the effectiveness of the evaluated technique and the possibility of its application in practice.