Step 7 Prostatic Adenomectomy

Semicircular movements using the J-hook electrocautery, harmonic scissors, or the suction-irrigation cannula progressively free the adenoma from the internal surface of the prostate capsule. At this point, the initial mucosal incision is completed cir-cumferentially. The left lateral lobe is dissected first, with the dissection proceeding distally in a largely avascular plane. Simultaneously, one assistant aspirates and coun-tertracts this region with the suction cannula. This enables the surgeon to clearly visualize and further develop the cleavage plane between the adenoma and the capsule. Hemostasis is secured continuously with electrocautery or harmonic scalpel by controlling any perforating tethering blood vessels. Large volume prostate adenomas are divided and extracted piecemeal. Specific care is taken at the prostate apex at its point of transection from the urethra to avoid injury to the external sphincter and possible avulsion (Figs. 4-6).

Every attempt is made to maintain good hemostasis constantly during dissection, such that enucleation proceeds under clear visualization. Adequate control of the main prostatic vessels can be achieved with either the harmonic scalpel and/or hemostatic figure-of-eight sutures placed at 4 and 8 o'clock position at the bladder neck. The contralateral lobe of the prostate is enucleated in a similar manner.

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