Transvesical (Suprapubic) Prostatectomy 
Leul Shigut and David R. Jeffcoach 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
The goal of transvesical prostatectomy is to 
remove the hypertrophic transitional zone of the 
prostate to reduce urinary obstruction.  It is not a 
surgical procedure for malignant lesions. 
Appropriate history (including functional 
status inquiry) and physical examination are done 
prior to any investigation. Physical exam always 
includes digital rectal exam. Enlarged lateral lobes 
can be easily felt and the rectal mucosa should move 
freely over the prostate. Any nodularity or fixation of 
the rectal mucosa should alert you to the possibility 
of prostatic cancer and core needle biopsy should be 
done before proceeding with the admission.  
In a young patient, one with history of 
multiple sexual partners, or previous purulent 
urethral discharge, rule out urethral stricture with a 
retrograde urethrogram. Rarely, a stricture at the 
membranous urethral will have the same appearance 
as benign prostatic hypertrophy. 
Preoperative workup includes: 
● Imaging: ultrasound helps assess the size of the 
prostate. It is also an invaluable tool when 
assessing the residual urine, to look for bladder 
wall 
changes, 
back 
pressure 
effects 
(hydronephrosis,) and findings concerning for 
cancer 
(nodularity, 
capsular 
invasion, 
lymphadenopathy.) 
● In high-resource settings, uroflowmetry is done 
to assess the flow rate of urine. Results 
<10ml/sec indicate a definite peak obstruction 
and deserve intervention.  
● Complete 
blood 
count, 
blood 
type 
and 
crossmatch, urinalysis, fasting serum glucose, 
serum creatinine, and prostate-specific antigen.  
● Electrocardiogram and echocardiogram can be 
ordered depending on the physical status of the 
patient.  
 
After the above two evaluations, if the patient 
has only frequency of micturition with a residual 
urine volume of <150ml and no evidence of back 
pressure (hydroureter) on ultrasound, the patient 
likely suffers from non-prostate related urinary 
retention. Uroflow, if available confirms the 
diagnosis if >15ml/sec. The patient can be reassured 
and advised to avoid heavy alcohol consumption 
which may be the cause.  Another important point is 
to avoid postponing micturition. 
If the patient does not fulfill the criteria for 
surgery or is deemed unfit for surgery for various 
reasons, there are two classes of drugs available:  
● 5α-reductase inhibitors, such as finasteride. 
These help in prevention of hyperplasia of the 
prostate. Dosing is 5mg daily for 6 months. 
Typically the patient must take the medicine for 
1-2 weeks before seeing any improvement, and 
full effect can take up to 6 months.  
● α-adrenergic 
blockers: 
tamsulosin 
(most 
selective,) alfuzosin, and terazosin. The latter 
two are primarily antihypertensives, with 
increased urine flow as a side effect. These help 
relax the internal sphincter for better drainage of 
the bladder. They are typically not used for 
prostate larger than 80cc because of the possible 
side effect of acute urinary retention. Typically 
α-blockers are effective immediately after 
beginning use.  
 
Suprapubic Prostatectomy is performed in 
the following steps:  
● Abdominal incision and entry into the retropubic 
(extraperitoneal) space 
● Opening of the bladder and placement of 
retractors 
● Incision in the mucosa between the urethral 
orifice and the ureteric orifices 
● Blunt dissection and enucleation of the prostate 
● Placement of hemostatic sutures in the capsule 
● Passage of the 3-way foley catheter and 
beginning bladder irrigation 
● 2-layered closure of the bladder 
● Closure of the fascia and skin 
 
Steps: 
1. Patients typically receive spinal anesthesia for 
the procedure unless otherwise contraindicated. 
2. Through a foley catheter, inflate the bladder with 
180 – 240 cc sterile saline mixed with iodine and 
then remove the catheter. This helps to both 
reduce infection rates and distend the bladder, 
Transvesical (Suprapubic) Prostatectomy 
Leul Shigut and David R. Jeffcoach 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
making 
identification 
and 
incision 
less 
challenging. 
3. Make sure to clip and not shave any pubic hair. 
4. The patient is prepared and draped in the supine 
position from the xiphoid process to the mid-
thigh including testicles and penis including the 
glans.  
5. As with all pelvic surgeries, a right handed 
surgeon may prefer to stand on the left side of the 
patient; this will aid during enucleation of the 
adenoma. But this is not mandatory. 
6. A lower midline longitudinal skin incision is 
made below umbilicus for a length of 8 cm to the 
pubic symphysis.  
 
A vertical incision below the umbilicus can be used to approach 
the extraperitoneal bladder. A Pfannensteil incision is also 
acceptable. In all of the following pictures, the patient’s head 
is towards the top of the pictures.  
 
7. Electrocautery is used to dissect through the 
subcutaneous tissue. The linea alba is incised, 
allowing the rectus abdominis muscles to be 
separated in the midline. The transversalis fascia 
is incised sharply or with electrocautery to 
expose the space of Retzius. 
 
Following division of the linea alba between the rectus muscles, 
the transversalis fascia is seen. This is divided taking care to 
avoid entering the peritoneum. The fat around the bladder is 
then seen.  
 
8. Identify the bladder by clearing any peritoneal fat 
off of it bluntly, sweeping in a cranial direction. 
Place two anchoring stitches of 1-0 chromic on 
the bladder wall. 
 
Once the bladder is identified, place two traction sutures before 
opening it.  
 
9. Care should be taken to not inadvertently enter 
the peritoneum during this step.  If there is 
confusion, use a small 22G needle to aspirate the 
bladder to ensure you are entering the correct 
space. 
10. Perform your cystotomy for a length of 4-5cm in 
craniocaudal direction and remove the instilled 
fluid from the bladder.  
Transvesical (Suprapubic) Prostatectomy 
Leul Shigut and David R. Jeffcoach 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Make a longitudinal incision in the bladder, going slowly by 
layers to assure hemostasis. 
 
11. Insert a small self-retaining retractor inside the 
bladder and expose the bladder fully. Place a 
gauze at the dome of the bladder then a narrow 
Deaver retractor can be placed over top which 
can be used to retract the bladder cephalad. The 
gauze will help move redundant bladder tissue 
cephalad. An additional small Richardson 
retractor can be placed over the bladder neck and 
used to further expose the trigone. 
12. Explore the bladder cavity for any lesions, ulcers, 
stones, or diverticuli. Identify both ureteric 
orifices. 
 
In this photo, the small self-retaining retractor has not yet been 
placed in the bladder. The narrow Deaver retractor is crucial 
to retract the mucosa away from the trigone and ureteric 
orifices, so that they are seen more easily. A folded gauze can 
be placed behind this retractor so that it pulls the mucosa in a 
cranial direction more effectively.  
 
13. Develop the appropriate plane between the 
adenoma and the prostate capsule using 
electrocautery in a circular incision in the bladder 
mucosa cranial to the urethral orifice, between 
the adenoma and the ureteric orifices.. This is 
done so that the mucosa is not torn as blunt 
enucleation is performed.  
 
The mucosa is divided along this Yellow dotted line, so that 
when blunt enucleation is performed the mucosa is less likely to 
tear into the ureteric orifices, which are cranial to this line. 
Source: Nthumba PM, Bird PA. East Centr Afr J Surg 
2007;12:2 53-58  
 
14. Place the index finger into the prostatic urethra. 
15. “Finger fracture” the adenoma against the pubic 
bone by pushing anteriorly. This move will start 
to dissect the adjacent adenoma off of the 
capsule. With the same finger move side to side 
and continue blunt dissection of the transitional 
prostate. Be gentle but firm while doing this. 
Resist the urge to grab and pull the adenoma, as 
this has shown to increase post operative 
incontinence.  
Transvesical (Suprapubic) Prostatectomy 
Leul Shigut and David R. Jeffcoach 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Insert a fingertip into the urethral orifice and move it gently 
from side to side until a plane starts to develop. Then follow this 
plane on one side of the capsule until you have completed a 
semi-circle. Return to the anterior aspect of the capsule and 
dissect the other side in a similar fashion. Source: Primary 
Surgery Vol. 1 : Non Trauma 
https://global-help.org/products/primary-surgery/  
 
16. Complete the dissection using the index finger 
until only the distal urethra attachment remains; 
this will finally be cut using curved scissors and 
the adenoma freed. Avoid passing your fingertip 
into the urethra below the prostate, this can cause 
stricture.  
 
Bluntly enucleate all of the prostate until only the distal urethra 
remains. In this illustration, another finger is inserted in the 
rectum as a “guide” but this is not necessary. Source: Primary 
Surgery Vol. 1 : Non Trauma 
https://global-help.org/products/primary-surgery/  
 
17. Dealing with a difficult enucleation: Sometimes 
the adenoma will be adherent to the prostatic 
fossa, making it difficult for enucleation. There 
are various reasons for this, such as missed 
diagnosis of prostatic cancer or repeated prostatic 
infection. If one encounters difficult enucleation, 
use a sponge forceps to grasp the adenoma and 
complete the dissection using diathermy. 
 
Typical appearance of a hypertrophic prostate gland after blunt 
enucleation. Sometimes the two lateral lobes will remain 
connected to each other after enucleation, other times, as here, 
they will be removed separately.  
 
18. Repair the bladder neck using 2.0 chromic suture. 
(Note- 
several 
methods 
are 
commonly 
employed.) 
a. Running locked fashion for a half-circle 
along the posterior circumference of the 
mucosa of the capsule edge 
b. Two separate stitches placed at 5 and 7 
o’clock, through the location of the 
arteries to the gland. 
Transvesical (Suprapubic) Prostatectomy 
Leul Shigut and David R. Jeffcoach 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Drawing of the surgeon’s view during closure of the bladder 
capsule. The two Blue circles represent the typical location of 
the blood vessels to the prostate: these are ligated either by a 
continuous semicircular suture through the cranial aspect of 
the capsule, or by individual ligation at these locations.  
 
19. Place a three-way urethral catheter through the 
urethra and inflate with 10cc so that the tip of the 
catheter and the balloon remains in the bladder. 
You may need to guide the tip into the bladder 
with one finger in the prostatic fossa. Do not 
inflate the balloon within the prostatic fossa, as 
this is theorized to prolong the duration of 
hematuria post operatively. If a 3-way catheter is 
not available, see “Pitfalls” below. 
 
Hemostatic suture of the capsule after prostatectomy. Note that 
the tip of the foley catheter is visible coming through the 
capsule. At times you will have to guide the catheter with your 
fingertip.  
 
20. Repair your cystotomy in two layers using 
absorbable 2.0 sutures. The first layer is a 
running mass closure incorporating the mucosa, 
submucosa and muscularis layers. The second 
layer involves only the outer muscular layer, 
inverts the previous suture line, and is done in 
either an interrupted or running manner. Ensure 
airtight closure by inflating the bladder with 
120cc saline. If any leak is identified, an 
additional suture is placed over the leak whilst 
taking care not to puncture the balloon.  
 
Closure of the bladder in 2 layers with absorbable sutures. We 
prefer to start the bladder irrigation immediately before 
beginning the first layer of bladder closure.  
 
21. Inflate the foley with additional 20cc saline, and 
place it on traction (this is optional and the 
surgeon might opt to leave the Foley catheter 
without traction) plus continuous irrigation.  
22. Approximate the rectus muscle (optional) 
23. Close the fascia in a running manner with slowly 
absorbable (PDS 1-0) or non-absorbable sutures. 
Transvesical (Suprapubic) Prostatectomy 
Leul Shigut and David R. Jeffcoach 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Closure of the fascia. Below the umbilicus, there is no posterior 
rectus sheath, so only closure of the anterior layer is necessary.  
 
24. Close the skin and place a sterile dressing.  
25. In the recovery area, the amount of irrigation 
fluid required is monitored. The traction on the 
foley catheter can be released on the following 
day. The patient is encouraged to ambulate and 
clear their secretions with adequate pulmonary 
exercises. The transurethral catheter is removed 
on postoperative day 3-5, after the urine remains 
clear without irrigation. Once the patient is able 
to void without any difficulty, appropriate 
discharge instructions are reviewed with the 
patient at this time in preparation for discharge.  
 
 
Pitfalls 
● While some blood loss is expected in the 
postoperative 
period, 
achieving 
adequate 
hemostasis while repairing the bladder neck 
allows you to avoid excessive amounts of 
bleeding. Excess bleeding also occurs if the 
bladder irrigation is neglected for too long. In 
both cases, sometimes blood clots will fill the 
bladder, making the irrigation no longer 
effective. 
Gentle 
irrigation 
and 
forceful  
aspiration of the catheter usually removes the 
clots if this problem is caught early. Be careful 
not to overfill the bladder and potentially burst 
the closure. Sometimes a return to the operating 
room for clot removal and better hemostasis is 
necessary.  
● If no 3-way catheter is available, a suprapubic 
foley or Malecot catheter can be incorporated 
into the bladder and abdominal wall closure: 
irrigation then occurs through one of the 
catheters and drainage through the other. On 
discharge, the suprapubic catheter can be 
clamped but must not be removed until the tract 
between the bladder and skin is mature, usually 
after 3-4 weeks.  
● Post op incontinence risk can be reduced by 
resisting the urge to yank on the adenoma during 
the enucleation step. Divide the urethra below the 
prostate sharply. Postoperative incontinence is 
usually temporary after this operation. Treatment 
is with condom catheterization and instructions 
on pelvic squeeze (“Kegel”) exercises.  
● Misdiagnosis of a urethral stricture as the main 
cause of obstruction can occur. Sometimes the 
patient will have concurrent enlargement of the 
prostate, causing you to think this is the problem. 
The presence of a stricture may not become 
apparent until you are attempting to catheterize 
the patient before surgery. Pay close attention to 
any history of failed catheterization. Recall that 
an enlarged prostate can make catheterization 
difficult as well, but it should always be possible 
to catheterize using a curved-tip catheter or a 
wire 
catheter 
guide 
(see 
“Urethral 
Catheterization.”)  
 
 
Leul Shigut, MD  
Soddo Christian Hospital 
Ethiopia 
 
David R. Jeffcoach, MD 
Soddo Christian Hospital 
Ethiopia 
 
February 2023 
