Simple Prostatectomy: Procedure, Outcomes, Recovery, and Modern Alternatives

Simple (open) prostatectomy = enucleation of the hyperplastic adenoma (transition zone) via a lower abdominal incision (retropubic or suprapubic), leaving the surgical capsule and peripheral zone intact. Indicated for BPH with prostate >80–100g, large median lobe, bladder stones/diverticula, or failed MIST.

Surgical Steps (Retropubic / Freyer)

1. Midline or Pfannenstiel incision → prevesical space (Retzius) entered.
2. Prostate capsule incised at apex; plane developed between adenoma and surgical capsule.
3. Adenoma enucleated digitally or with enucleator — "shelling out" the orange.
4. Hemostasis of prostatic fossa (suture, electrocautery, hemostatic agents).
5. Urethral reconstruction if apical mucosa violated.
6. Two-way catheter (22–24 Fr) + suprapubic tube (optional) → continuous bladder irrigation (CBI) until clear.
7. Drains (suction) × 24–48h.

Outcomes and Risks

Metric	Simple Prostatectomy	TURP	HoLEP
IPSS improvement	~80%	~75%	~85%
Qmax gain	+15–20 mL/s	+12–15 mL/s	+18–22 mL/s
Blood loss	500–1000 mL	200–300 mL	100–200 mL
Transfusion	5–15%	<1%	<1%
Incontinence (1 yr)	2–5%	1–2%	1–3%
Erectile dysfunction	5–15%	5–10%	3–8%
Hospital stay	2–4 days	1–2 days	1–2 days
Retreatment at 10 yr	<5%	10–15%	<5%

Recovery Timeline

• Catheter 3–7 days (longer if urethral repair).
• No heavy lifting (>10 lb) × 6 weeks.
• Return to desk work 2–3 weeks; manual labor 6–8 weeks.
• Pelvic floor PT starts post-catheter — accelerates continence.

Modern Context

HoLEP and robotic simple prostatectomy now offer similar adenoma removal with less morbidity. Open simple prostatectomy remains valuable where laser/robot unavailable or for massive glands (>200g). Shared decision-making with urologist is essential.