Retropubic (Millin) Prostatectomy

As previously stated, the patient is placed on the operating room table in the supine position in mild Trendelenburg. A lower midline incision is made and the space of Retzius developed. Initiate the Millin (transverse capsular) prostatectomy by locating the vesicle neck by palpation of the Foley balloon. Place a 1-0 absorbable suture deeply in the capsule of the prostate, just below the vesicle neck. Repeat this technique until a 4-cornered area is created, through which a transverse incision is made into the adenoma across the entire anterior surface while the bladder is retracted cephalad. Place the proximal capsule under tension and achieve hemostasis actively with full suction. Hemostasis can also be achieved by ligating the dorsal venous complex as well as ligating the prostatic arteries as they enter the prostaticovesical junction near the level of the seminal vesicles. Next, identify the plane between the adenoma and the capsule and sharply dissect. Once developed, manually explore this plane while the adenoma is enucleated under direct visualization. Carefully identify the apex of the prostate and sharply divide the urethra under direct visualization. Achieve hemostasis before placement of figure-of-8, 2-0 absorbable sutures at the 5- and 7-o'clock positions through the vesical neck and proximal capsule. Clearly identify the ureteral orifices before resecting a wedge of posterior vesical neck. Using a running 2-0 absorbable suture, evert and approximate the edges. Indigo carmine can be administered to decrease the risk of iatrogenic injury to the ureteral orifices. Introduce a large catheter into the urethra and inflate the balloon. Finally, close the capsule from both ends with 2 continuous 2-0 absorbable sutures. Foley traction may be used as needed for hemostasis. Place an external drain into the space of Retzius to prevent hematoma and urinoma formation. After that, irrigate and close the wound.

Surgical biopsy. During a surgical biopsy, a portion of the breast mass is removed for examination (incisional biopsy), or the entire breast mass may be removed (excisional biopsy, wide local excision or lumpectomy). A surgical biopsy is usually done in an operating room, with sedation and a local anesthetic. If the breast mass can't be felt, your radiologist may use a technique called wire localization to map the route to the mass for the surgeon. During wire localization, the tip of a thin wire is positioned within the breast mass or just through it. This is usually done right before surgery. During surgery, the surgeon will attempt to remove the entire breast mass, along with the wire. To help ensure that the entire mass has been removed, the tissue is sent to the hospital laboratory to check the edges (margins) of the mass. If it's determined in the laboratory that cancer cells are present in the margins (positive margins), some cancer may still be in the breast and more tissue must be removed. If the margins are clear (negative margins), it's more likely that all the cancer has been removed. At the time of the breast biopsy, a tiny stainless steel marker or clip may be placed in your breast at the biopsy site. This is done so that your doctor or surgeon can easily find the area biopsied, for future monitoring or in the event that a follow-up procedure is needed to remove more tissue.