Adenomectomy and trans-bladder diverticulectomy with litholopaxy
When is this procedure indicated?
Trans-vesical prostate adenomectomy (ATV) is the surgical treatment of benign prostatic hyperplasia (BPH) with cervical-urethral obstruction and consequent dysuric symptoms during emptying and/or filling, indicated in patients with large prostate volumes. This type of surgery could be indicated in case prostatic hypertrophy is associated with the presence of large bladder diverticula and/or endovesical stones. In the latter case, ATV would be associated with contextual litholapaxy and/or bladder diverticulectomies.
How is it performed?
Trans-bladder prostate adenomectomy (ATV) is performed under epidural or general anesthesia depending on the judgment of the anesthesiologist. This surgical technique consists of removing the innermost portion of the prostate (the so-called prostate adenoma) while leaving the external prostate capsule in place, through a small incision in the bladder wall. If bladder diverticula and/or endovesical stones are present, the removal of the prostate adenoma would be combined with the removal of the stones (litholapaxis) and the exeresis of the diverticula at the level of the collar of the diverticulum with subsequent closure of the bladder breaches (bladder diverticulectomy). The procedure generally takes 1 hour and involves a transverse incision on the lower abdomen. At the end of the surgery a bladder catheter is left in place for a period usually ranging from 3 to 5 days in the absence of complications. A drainage tube is also left in place for approximately 2-4 days.
Histological examination is always carried out on the prostate tissue removed during the operation; according to the results of the histological examination, subsequent checks will be recommended.
Hospitalization lasts on average 5-7 days, except for complications. Once the catheter is removed, resumption of spontaneous urination is typically characterized by the presence of bloody urine and the need to urinate frequently (this picture usually improves markedly during the first post-operative month).
- Macrohaematuria with anaemia and need for haemotransfusion.
- Urinary tract infections.
- Transient dysuric symptoms (burning on urination).
- Transient stress urinary incontinence. Present when abdominal pressure increases, such as during a cough or when lifting weights.
- Acute urinary retention on bladder catheter removal.
The most common long-term complication in patients undergoing this type of surgery is retrograde ejaculation. This condition, which occurs in about 90% of cases, consists in the disappearance of seminal fluid discharge during orgasm, while maintaining orgasmic sensitivity and erectile function. Seminal fluid collected in the bladder is subsequently expelled with the first urination. The rest of the long-term complications consist of rare events and are essentially represented by:
- Stenosis of the urethra or bladder neck with need for re-intervention.
- Definitive urinary incontinence.