Prostatectomy A prostatectomy is the surgical removal of all or part of the prostate gland . Abnormalities of the prostate, such as a tumour , or if the gland itself becomes enlarged for any reason, can restrict the normal flow of urine along the urethra . There are several forms of the operation: Transurethral resection of the prostate Also called a TURP, this is a cystoscope [A Resectoscope Rather, which has 30 degree of viewing angle, along with Resectoscopy Sheath & Working Element] is passed up the urethra to the prostate, where the surrounding prostate tissue is excised. This is a common operation for benign prostatic hyperplasia (BPH) and outcomes are excellent for a high percentage of these patients (80-90%). A more refined and safer operation is by means of a holmium(Nd:YAG) high powered "red" laser. A related laser procedure for relief of prostatic obstruction utilizes a potassium titanyl phosphate(KTP) laser to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative bloodloss, elimination of the risk of TUR-syndrome , the ability to treat larger glands, as well as treating patients who are actively being treated with anti-coagulation therapy for unrelated diagnoses. 3,4 Open Prostatectomy A surgical procedure involving a skin incision and enucleation of the prostatic adenoma, through the prostatic capsule (RPP-retropubic prostatectomy) or
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ProstatectomyA prostatectomy is the surgical removal of all or part of the prostate gland. Abnormalities of the prostate, such as a tumour, or if the gland itself becomes enlarged for any reason, can restrict the normal flow of urine along the urethra.
There are several forms of the operation:
Transurethral resection of the prostate
Also called a TURP, this is a cystoscope[A Resectoscope Rather, which has 30 degree of viewing angle, along with Resectoscopy Sheath & Working Element] is passed up the urethra to the prostate, where the surrounding prostate tissue is excised. This is a common operation for benign prostatic hyperplasia (BPH) and outcomes are excellent for a high percentage of these patients (80-90%). A more refined and safer operation is by means of a holmium(Nd:YAG) high powered "red" laser. A related laser procedure for relief of prostatic obstruction utilizes a potassium titanyl phosphate(KTP) laser to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative bloodloss, elimination of the risk of TUR-syndrome, the ability to treat larger glands, as well as treating patients who are actively being treated with anti-coagulation therapy for unrelated diagnoses.3,4
Open Prostatectomy
A surgical procedure involving a skin incision and enucleation of the prostatic adenoma, through the prostatic capsule (RPP-retropubic prostatectomy) or through the bladder (SPP-suprapubic prostatectomy). Reserved for extremely large prostates.
Laparoscopic Radical Prostatectomy
a laparoscopic or four small incisions are made in the abdomen, and the entire prostate for prostate cancer.
Robotic-assisted Laparoscopic Radical Prostatectomy see also [3] da Vinci (Robot-assisted) Prostatectomy is the #1 choice for treatment of
localized prostate cancer* in the United States:Laparoscopic robotic arms are controlled by a surgeon. The robot gives the surgeon much more dexterity than conventional laparoscopy while offering the same advantages over open prostatectomy: much smaller incisions, less pain, less bleeding, less risk of infection, faster healing time, and shorter hospital stay.[1]. While the cost of such procedures is high, costs are declining rapidly [2]. The manufacturer of the da Vinci Surgical System, used for robotic-assisted prostatectomy, claims that this is now the number one treatment choice for prostate cancer in the United States[.[3]]
an incision is made in the perineum, midway between rectum and scrotum, and the prostate is removed. Radical prostatectomy is one of the key treatments for prostate cancer.
Radical retropubic prostatectomy
an incision is made in the lower abdomen, and the prostate removed, by going behind the pubic bone (retropubic). Radical prostatectomy is one of the key treatments for prostate cancer.
Medical Encyclopedia: Prostatectomy Home > Library > Health > Medical Encyclopedia
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PurposePrecautionsPreparation
AftercareRisks
Normal resultsResources
Definition
Prostatectomy is surgical removal of part of the prostate gland (transurethral resection, a procedure performed to relieve urinary symptoms caused by benign enlargement), or all of the prostate (radical prostatectomy, the curative surgery most often used to treat prostate cancer).
Description
TURP
This procedure does not require an abdominal incision. With the patient under either general or spinal anesthesia, a cutting instrument or heated wire loop is inserted to remove as much prostate tissue as possible and seal blood vessels. The excised tissue is washed into the bladder, then flushed out at the end of the operation. A catheter is left in the bladder for one to five days to drain urine and blood. Advanced laser technology enables surgeons to safely and effectively burn off excess prostate tissue blocking the bladder opening with fewer of the early and late complications associated with other forms of prostate surgery. This procedure can be performed on
an outpatient basis, but urinary symptoms do not improve until swelling subsides several weeks after surgery.
Radical prostatectomy
RADICAL RETROPUBIC PROSTATECTOMY. This is a useful approach if the prostate is very large, or cancer is suspected. With the patient under general or spinal anesthesia or an epidural, a horizontal incision is made in the center of the lower abdomen. Some surgeons begin the operation by removing pelvic lymph nodes to determine whether cancer has invaded them, but recent findings suggest there is no need to sample them in patients whose likelihood of lymph node metastases is less than 18%. A doctor who removes the lymph nodes for examination will not continue the operation if they contain cancer cells, because the surgery will not cure the patient. Other surgeons remove the prostate gland before examining the lymph nodes. A tube (catheter) inserted into the penis to drain fluid from the body is left in place for 14–21 days.
Originally, this operation also removed a thin rim of bladder tissue in the area of the urethral sphincter—a muscular structure that keeps urine from escaping from the bladder. In addition, the nerves supplying the penis often were damaged, and many men found themselves impotent (unable to achieve erections) after prostatectomy. A newer surgical method called potency-sparing radical prostatectomy preserves sexual potency in 75% of patients and fewer than 5% become incontinent following this procedure.
RADICAL PERINEAL PROSTATECTOMY. This procedure is just as curative as radical retropubic prostatectomy but is performed less often because it does not allow the surgeon to spare the nerves associated with erection or, because the incision is made above the rectum and below the scrotum, to remove lymph nodes. Radical perineal prostatectomy is sometimes used when the cancer is limited to the prostate and there is no need to spare nerves or when the patient's health might be compromised by the longer procedure. The perineal operation is less invasive than retropubic prostatectomy. Some parts of the prostate can be seen better, and blood loss is limited. The absence of an abdominal incision allows patients to recover more rapidly. Many urologic surgeons have not been trained to perform this procedure. Radical prostatectomy procedures last one to four hours, with radical perineal prostatectomy taking less time than radical retropubic prostatectomy. The patient remains in the hospital three to five days following surgery and can return to work in three to five weeks. Ongoing research indicates that laparoscopic radical prostatectomy may be as effective as open surgery in treatment of early-stage disease.
Cryosurgery
Also called cryotherapy or cryoablation, this minimally invasive procedure uses very low temperatures to freeze and destroy cancer cells in and around the prostate gland. A catheter circulates warm fluid through the urethra to protect it from the cold. When used in connection with ultrasound imaging, cryosurgery permits very precise tissue destruction. Traditionally used only in patients whose cancer had not responded to radiation, but now approved by Medicare as a primary treatment for prostate cancer, cryosurgery can safely be performed on older men, on patients who are not in good
enough general health to undergo radical prostatectomy, or to treat recurrent disease. Recent studies have shown that total cryosurgery, which destroys the prostate, is at least as effective as radical prostatectomy without the trauma of major surgery.
— David A. Cramer
Definition
Prostatectomy is surgical removal of part of the prostate gland (transurethral resection, a procedure performed to relieve urinary symptoms caused by benign enlargement), or all of the prostate (radical prostatectomy, the curative surgery most often used to treat prostate cancer).
Purpose
Benign Disease
When men reach their mid-40s, the prostate gland begins to enlarge. This condition, benign prostatic hyperplasia (BPH) is present in more than half of men in their 60s and as many as 90% of those over 90. Because the prostate surrounds the urethra, the tube leading urine from the bladder out of the body, the enlarging prostate narrows this passage and makes urination difficult. The bladder does not empty completely each time a man urinates, and, as a result, he must urinate with greater frequency, night and day. In time, the bladder can overfill, and urine escapes from the urethra, resulting in incontinence. An operation called transurethral resection of the prostate (TURP) relieves symptoms of BPH by removing the prostate tissue that is blocking the urethra. No incision is needed. Instead a tube (retroscope) is passed through the penis to the level of the prostate, and tissue is either removed or destroyed, so that urine can freely pass from the body.
Malignant Disease
Prostate cancer is the single most common form of non-skin cancer in the United States and the most common cancer in men over 50. Half of men over 70 and almost all men over the age of 90 have prostate cancer, and the American Cancer Society estimates that 198,000 new cases will be diagnosed in a given year. This condition does not always require surgery. In fact, many elderly men adopt a policy of "watchful waiting," especially if their cancer is growing slowly. Younger men often elect to have their prostate gland totally removed along with the cancer it contains—an operation called radical prostatectomy. The two main types of this surgery, radical retropubic prostatectomy and radical perineal prostatectomy, are performed only on patients whose cancer is limited to the prostate. If cancer has broken out of the capsule surrounding the prostate gland and spread in the area or to distant sites, removing the prostate will not prevent the remaining cancer from growing and spreading throughout the body.
Potential complications of TURP include bleeding, infection, and reactions to general or regional anesthesia. About one man in five will need to have the operation again within 10 years.
Open (incisional) prostatectomy for cancer should not be done if the cancer has spread beyond the prostate, as serious side effects may occur without the benefit of removing all the cancer. If the bladder is retaining urine, it is necessary to insert a catheter before starting surgery. Patients should be in the best possible general condition before radical prostatectomy. Before surgery, the bladder is inspected using an instrument called a cystoscope to help determine the best surgical technique to use, and to rule out other local problems.
Description
Turp
This procedure does not require an abdominal incision. With the patient under either general or spinal anesthesia, a cutting instrument or heated wire loop is inserted to remove as much prostate tissue as possible and seal blood vessels. The excised tissue is washed into the bladder, then flushed out at the end of the operation. A catheter is left in the bladder for one to five days to drain urine and blood. Advanced laser technology enables surgeons to safely and effectively burn off excess prostate tissue blocking the bladder opening with fewer of the early and late complications associated with other forms of prostate surgery. This procedure can be performed on an outpatient basis, but urinary symptoms do not improve until swelling subsides several weeks after surgery.
Radical Prostatectomy
Radical Retropubic Prostatectomy
This is a useful approach if the prostate is very large, or cancer is suspected. With the patient under general or spinal anesthesia or an epidural, a horizontal incision is made in the center of the lower abdomen. Some surgeons begin the operation by removing pelvic lymph nodes to determine whether cancer has invaded them, but recent findings suggest there is no need to sample them in patients whose likelihood of lymph node metastases is less than 18%. A doctor who removes the lymph nodes for examination will not continue the operation if they contain cancer cells, because the surgery will not cure the patient. Other surgeons remove the prostate gland before examining the lymph nodes. A tube (catheter) inserted into the penis to drain fluid from the body is left in place for 14–21 days.
Originally, this operation also removed a thin rim of bladder tissue in the area of the urethral sphincter—a muscular structure that keeps urine from escaping from the bladder. In addition, the nerves supplying the penis often were damaged, and many men found themselves impotent (unable to achieve erections) after prostatectomy. A newer surgical method called potency-sparing radical prostatectomy preserves sexual potency in 75% of patients and fewer than 5% become incontinent following this procedure.
This procedure is just as curative as radical retropubic prostatectomy but is performed less often because it does not allow the surgeon to spare the nerves associated with erection or, because the incision is made above the rectum and below the scrotum, to remove lymph nodes. Radical perineal prostatectomy is sometimes used when the cancer is limited to the prostate and there is no need to spare nerves or when the patient's health might be compromised by the longer procedure. The perineal operation is less invasive than retropubic prostatectomy. Some parts of the prostate can be seen better, and blood loss is limited. The absence of an abdominal incision allows patients to recover more rapidly. Many urologic surgeons have not been trained to perform this procedure. Radical prostatectomy procedures last one to four hours, with radical perineal prostatectomy taking less time than radical retropubic prostatectomy. The patient remains in the hospital three to five days following surgery and can return to work in three to five weeks. Ongoing research indicates that laparoscopic radical prostatectomy may be as effective as open surgery in treatment of early-stage disease.
Cryosurgery
Also called cryotherapy or cryoablation, this minimally invasive procedure uses very low temperatures to freeze and destroy cancer cells in and around the prostate gland. A catheter circulates warm fluid through the urethra to protect it from the cold. When used in connection with ultrasound imaging, cryosurgery permits very precise tissue destruction. Traditionally used only in patients whose cancer had not responded to radiation, but now approved by Medicare as a primary treatment for prostate cancer, cryosurgery can safely be performed on older men, on patients who are not in good enough general health to undergo radical prostatectomy, or to treat recurrent disease. Recent studies have shown that total cryosurgery, which destroys the prostate, is at least as effective as radical prostatectomy without the trauma of major surgery.
Preparation
As with any type of major surgery done under general anesthesia, the patient should be in optimal condition. Most patients having prostatectomy are in the age range when cardiovascular problems are frequent, making it especially important to be sure that the heart is beating strongly, and that the patient is not retaining too much fluid. Because long-standing prostate disease may cause kidney problems from urine "backing up," it also is necessary to be sure that the kidneys are working properly. If not, a period of catheter drainage may be necessary before doing the surgery.
Aftercare
Following TURP, a catheter is placed in the bladder to drain urine and remains in place for two to three days. A solution is used to irrigate the bladder and urethra until the urine is clear of blood, usually within 48 hours after surgery. Whether antibiotics should be routinely given remains an open question. Catheter drainage also is used after open prostatectomy. The bladder is irrigated only if blood clots block the flow of urine through the catheter. Patients are given intravenous fluids for the first 24 hours, to ensure good urine flow. Patients resting in bed for long periods are prone to blood clots in their legs (which can pass to the lungs and cause serious breathing problems). This can be prevented by elastic stockings and by periodically exercising the patient's
legs. The patient remains in the hospital one to two days following surgery and can return to work in one to two weeks.
Risks
The complications and side effects that may occur during and after prostatectomy include:
Excessive bleeding, which in rare cases may require blood transfusion. Incontinence when, during retropubic prostatectomy, the muscular valve
(sphincter) that keeps urine in the bladder is damaged. Less common today, when care is taken not to injure the sphincter.
Impotence, occurring when nerves to the penis are injured during the retropubic operation. Today's "nerve-sparing" technique has drastically cut down on this problem.
Some patients who receive a large volume of irrigating fluid after TURP develop high blood pressure, vomiting, trouble with their vision, and mental confusion. This condition is caused by a low salt level in the blood, and is reversed by giving salt solution.
A permanent narrowing of the urethra called a stricture occasionally develops when the urethra is damaged during TURP.
There is about a 34% chance that the cancer will recur within 10 years of the procedure. In addition, about 25% of patients experience what is known as biochemical recurrence, which means that the level of prostate-specific antigen (PSA) in the patient's blood serum begins to rise rapidly. Recurrence of the tumor or biochemical recurrence can be treated with radiation therapy or androgen deprivation therapy.
Normal Results
In patients with BPH who have the TURP operation, urination should become much easier and less frequent, and dribbling or incontinence should cease. In patients having radical prostatectomy for cancer, a successful operation will remove the tumor and prevent its spread to other areas of the body (metastasis). If examination of lymph nodes shows that cancer already had spread beyond the prostate at the time of surgery, other measures are available to control the tumor.
Technology
Responding to spoken instructions, a specially engineered robot has assisted in more than 500 operations to remove the prostate glands of cancer patients. Used by surgeons in the United States and Europe, the AESOP system is the first surgical robot approved by the Food and Drug Administration (FDA). By positioning a slender optical tube (endoscope) that is passed through the patient's body, the robotic arm allows the surgeon to view the minimally invasive surgery on a video monitor and use both hands to improve surgical precision and results while minimizing side effects. Patients spend about 12 hours in the hospital and return to work within two days.
Early findings released by the Prostate Cancer Outcomes Study (PCOS) confirm that radical prostatectomy results in significant sexual dysfunction and some loss of urinary control. Initiated by the National Cancer Institute (NCI) in 1994, PCOS is the first systematic evaluation of how primary cancer treatments affect patients' quality of life.
Resources
Books
Beers, Mark H., MD, and Robert Berkow, MD, editors. "Prostate Cancer." Section 17, Chapter 233 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
Marks, Sheldon. Prostate Vancer: A Family Guide to Diagnosis, Treatment and Survival. Cambridge, MA: Fisher Books, 2000.
Wainrib, Barbara, et al. Men, Women, and Prostate Cancer: A Medical and Psychological Guide for Women and the Men they Love. Oakland, CA: New Harbinger Publications, 2000.
Periodicals
Augustin, H., and P. G. Hammerer. "Disease Recurrence After Radical Prostatectomy. Contemporary Diagnostic and Therapeutical Strategies." Minerva Urologica e Nefrologica 55 (December 2003): 251–261.
Gomella, L. G., I. Zeltser, and R. K. Valicenti. "Use of Neoadjuvant and Adjuvant Therapy to Prevent or Delay Recurrence of Prostate Cancer in Patients Undergoing Surgical Treatment for Prostate Cancer." Urology 62, Supplement 1 (December 29, 2003): 46–54.
Nelson, J. B., and H. Lepor. "Prostate Cancer: Radical Prostatectomy." Urologic Clinics of North America 30 (November 2003): 703–723.
Zimmerman, R. A., and D. G. Culkin. "Clinical Strategies in the Management of Biochemical Recurrence after Radical Prostatectomy." Clinical Prostate Cancer 2 (December 2003): 160–166.
Organizations
Cancer Research Institute. 681 Fifth Ave., New York, NY 10022. (800) 99CANCER. .
Zero — The Project to End Prostate Cancer. 1156 15th St., NW, Washington, DC 20005. (202) 463-9455. .
Prostate Health Council. American Foundation for Urologic Disease. 1128 N. Charles St., Baltimore, MD 21201-5559. (800) 828-7866. .
A prostatectomy is the surgical removal of all or part of the prostate gland. Abnormalities of the prostate, such as a tumour, or if the gland itself becomes enlarged for any reason, can restrict the normal flow of urine along the urethra.
There are several forms of the operation:
Transurethral resection of the prostate
Also called a TURP, this is a cystoscope[A Resectoscope Rather, which has 30 degree of viewing angle, along with Resectoscopy Sheath & Working Element] is passed up the urethra to the prostate, where the surrounding prostate tissue is excised. This is a common operation for benign prostatic hyperplasia (BPH) and outcomes are excellent for a high percentage of these patients (80-90%). A more refined and safer operation is by means of a holmium(Nd:YAG) high powered "red" laser. A related laser procedure for relief of prostatic obstruction utilizes a potassium titanyl phosphate(KTP) laser to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative bloodloss, elimination of the risk of TUR-syndrome, the ability to treat larger glands, as well as treating patients who are actively being treated with anti-coagulation therapy for unrelated diagnoses.3,4
Open Prostatectomy
A surgical procedure involving a skin incision and enucleation of the prostatic adenoma, through the prostatic capsule (RPP-retropubic prostatectomy) or
through the bladder (SPP-suprapubic prostatectomy). Reserved for extremely large prostates.
Laparoscopic Radical Prostatectomy
a laparoscopic or four small incisions are made in the abdomen, and the entire prostate for prostate cancer.
Robotic-assisted Laparoscopic Radical Prostatectomy see also [3] da Vinci (Robot-assisted) Prostatectomy is the #1 choice for treatment of
localized prostate cancer* in the United States:Laparoscopic robotic arms are controlled by a surgeon. The robot gives the surgeon much more dexterity than conventional laparoscopy while offering the same advantages over open prostatectomy: much smaller incisions, less pain, less bleeding, less risk of infection, faster healing time, and shorter hospital stay.[1]. While the cost of such procedures is high, costs are declining rapidly [2]. The manufacturer of the da Vinci Surgical System, used for robotic-assisted prostatectomy, claims that this is now the number one treatment choice for prostate cancer in the United States[.[3]]
Radical perineal prostatectomy
an incision is made in the perineum, midway between rectum and scrotum, and the prostate is removed. Radical prostatectomy is one of the key treatments for prostate cancer.
Radical retropubic prostatectomy
an incision is made in the lower abdomen, and the prostate removed, by going behind the pubic bone (retropubic). Radical prostatectomy is one of the key treatments for prostate cancer.
1. Ě‚ Center for the Advancement of Health; August 29, 2005; Robot-assisted Prostate Surgery Has Possible Benefits, High Cost [1]
2. Ě‚ Cost Analysis of Radical Retropubic, Perineal, and Robotic Prostatectomy; Scott V. Burgess, Fatih Atug, Erik P. Castle, Rodney Davis, Raju Thomas; Journal of Endourology 2006 20:10, 827-830 [2]
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Definition
Transurethral resection of the prostate (TURP) is a surgical procedure by which portions of the prostate gland are removed through the urethra.
Demographics
Prostate disease usually occurs in men over age 40. BPH eventually develops in approximately 80% of all men. Prostate cancer occurs in one out of 10 men. In the United States, more than 30,000 men die of prostate cancer each year.
Description
TURP is a type of transurethral surgery that does not involve an external incision. The surgeon reaches the prostate by inserting an instrument through the urethra. In addition to TURP, two other types of transurethral surgery are commonly performed, transurethral incision of the prostate (TUIP), and transurethral laser incision of the prostate (TULIP). The TUIP procedure widens the urethra by making small cuts in the bladder neck (where the urethra and bladder meet), and in the prostate gland itself. In TULIP, a laser beam directed through the urethra melts the tissue.
The actual TURP procedure is simple. It is performed under general or local anesthesia. After an IV is inserted, the surgeon first examines the patient with a cystoscope, an instrument that allows him or her to see inside the bladder. The surgeon then inserts a device up the urethra via the penis opening, and removes the excess capsule material that has been restricting the flow of urine. The density of the normal prostate differs from that of the restricting capsule, making it relatively easy for the surgeon to tell exactly how much to remove. After excising the capsule material, the surgeon inserts a catheter into the bladder through the urethra for the subsequent withdrawal of urine.
Diagnosis/Preparation
BPH symptoms include:
increase in urination frequency, and the need to urinate during the night difficulty starting urine flow a slow, interrupted flow and dribbling after urinating sudden, strong urges to pass urine a sensation that the bladder is not completely empty pain or burning during urination
In evaluating the prostate gland for BPH, the physician usually performs a complete physical examination as well as the following procedures:
Digital rectal examination (DRE). Recommended annually for men over the age of 50, the DRE is an examination performed by a physician who feels the prostate through the wall of the rectum. Hard or lumpy areas may indicate the presence of cancer.
Prostate-specific antigen (PSA) test. Also recommended annually for men over the age of 50, the PSA test measures the levels of prostate-specific antigen secreted by the prostate. It is normal to observe small quantities of PSA in the blood. PSA levels vary with age, and tend to increase gradually in men over age 60. They also tend to rise as a result of infection (prostatitis), BPH, or cancer.
If the results of the DRE and PSA tests are indicative of a significant prostate disorder, the examining
An enlarged prostate can cause urinary problems due to its location around the male urethra (A). In TURP, the physician uses a cystoscope to gain access to the prostate through the urethra (B). The prostate material that has been restricting urine flow is cut off in pieces, which are washed into the bladder with water from the scope (B). ( Illustration by GGS Inc.)
physician usually refers the patient to a urologist, a physician who specializes in diseases of the urinary tract and male reproductive system. The urologist performs additional tests, including blood and urine studies, to establish a diagnosis.
To prepare for TURP, patients should:
Select an experienced TURP surgeon to perform the procedure. Purchase a mild natural bulk-forming laxative. Wear loose clothing on the morning of surgery. Ask friends or family to be available for assistance after surgery. Schedule a week off from work. Get sufficient sleep on the night before surgery.
Aftercare
When the patient awakens in the recovery room after the procedure, he already has a catheter in his penis, and is receiving pain medication via the IV line inserted prior to surgery.
The initial recovery period lasts approximately one week, and includes some pain and discomfort from the urinary catheter. Spastic convulsions of the bladder and prostate are expected as they respond to the surgical changes. The following medications are commonly prescribed after TURP:
B&O suppository (Belladonna and Opium). This medication has the dual purpose of providing pain relief and reducing the ureteral and bladder spasms that follow TURP surgery. It is a strong medication that must be used only as prescribed.
Bulk-forming laxative. Because of the surgical trauma and large quantities of liquids that patients are required to drink, they may need some form of laxative to promote normal bowel movements.
Detrol. This pain reliever is not as strong as B&O. There may be wide variations in its effectiveness and the patient's response. It also controls involuntary bladder contractions.
Macrobid. This antibiotic helps prevent urinary tract infections. Pyridium. This medication offers symptomatic relief from pain, burning,
urgency, frequency, and other urinary tract discomfort.
When discharged from the hospital, patients are advised to:
Refrain from alcoholic beverages. Avoid sexual activities for a few weeks. Avoid driving a car for a week or more. Keep domestic activities to a minimum. Avoid weight lifting or strenuous exercise. Check their temperature and report any fever to the physician. Practice good hygiene, especially of the hands and penis. Drink plenty of liquids.
Risks
Serious complications are less common for prostate surgery patients because of advances in operative methods. Nerve-sparing surgical procedures help prevent permanent injury to the nerves that control erection, as well as injury to the opening of the bladder. However, there are risks associated with prostate surgery. The first is the possible development of incontinence, the inability to control urination, which may result in urine leakage or dribbling, especially just after surgery. Normal control usually returns within several weeks or months after surgery, but some patients have become permanently incontinent. There is also a risk of impotence, the inability to achieve penile erection. For a month or so after surgery, most men are not able to become erect. Eventually, approximately 40–60% of men will be able to have an erection sufficient for sexual intercourse. They no longer ejaculate semen because removal of the prostate gland prevents that process. This effect is related to many factors, such as overall health and age. Other risks associated with TURP include:
TURP syndrome effects 2–6% of TURP patients. Symptoms may include temporary blindness due to irrigation fluid entering the bloodstream. On very rare occasions, this can lead to seizures, coma, and even death. The syndrome may also include toxic shock due to bacteria entering the bloodstream, as well as internal hemorrhage.
Normal results
TURP patients usually notice urine flow improvement as soon as the catheter is removed. Other improvements depend on the condition of the patient's prostate before TURP, his age, and overall health status. Patients are told to expect the persistance of some pre-surgery symptoms. In fact, some new symptoms may appear following TURP, such as occasional blood and tissue in the urine, bladder spasms, pain when urinating, and difficulty judging when to urinate. TURP represents a major adaptation for the body, and healing requires some time. Full recovery may take up to one year. Patients are almost always satisfied with their TURP outcome, and the adaptation to new symptoms is offset by the disappearance of previous problems. For example, most patients no longer have to take daily prostate medication, and quickly learn to gradually increase the time between urinating while enjoying uninterrupted and more restful sleep at night.
Normal post-operative symptoms include:
urination at night and reduced flow mild burning and stinging sensation while urinating reduced semen at ejaculation bladder control problems mild bladder spams fatigue urination linked to bowel movements
To eliminate these symptoms, patients are advised to:
Exercise. Retrain their bladder Take all medications that were prescribed after TURP Inform themselves via support groups or pertinent reading Get plenty of rest to facilitate the post-surgery healing process
Morbidity and mortality rates
TURP reduces symptoms in 88% of BPH patients. TURP mortality rates are 0.2%, but they can be as high as 10% in patients over 80 years of age. Following surgery, inadequate relief of BPH symptoms occurs in 20–25% of patients, and 15–20%
require another operation within 10 years. Urinary incontinence affects 2–4%, and 5–10% of TURP patients become impotent.
Alternatives
Conventional surgical alternatives for BPH patients include:
Interstitial laser coagulation. In this procedure, a laser beam inserted in the urethra via a catheter heats and destroys the extra prostate capsule tissue.
Transurethral needle ablation (TUNA). This technique was approved by the FDA in 1996. It uses radio waves to heat and destroy the enlarged prostate through needles positioned in the gland. It is generally less effective than TURP for reducing symptoms and increasing urine flow.
Transurethral electrovaporization. This procedure is a modified version of TURP, and uses a device that produces electronic waves to vaporize the enlarged prostate.
Photoselective vaporization of the prostate (PVP). This procedure uses a strong laser beam to vaporize the tissue in a 20–50 minute outpatient operation.
Transurethral incision of the prostate (TUIP). In this procedure, a small incision is made in the bladder, followed by a few cuts into the sphincter muscle to release some of the tension.
Transurethral microwave thermotherapy (TUMT). TUMT uses microwave heat energy to shrink the enlarged prostate through a probe inserted into the penis to the level of the prostate. This outpatient procedure takes about one hour. The patient can go home the same day, and is able to resume normal activities within a day or two. TUMT does not lead to immediate improvement, and it usually takes up to four weeks for urinary problems to completely resolve.
Water-induced thermotherapy (WIT). WIT is administered via a closed-loop catheter system, through which heated water is maintained at a constant temperature. WIT is usually performed using only a local anesthetic gel to anesthetize the penis, and is very well tolerated. The procedure is FDA approved.
Balloon dilation. In this procedure, a balloon is inserted in the urethra up to where the restriction occurs. At that point, the balloon expands to push out the prostate tissue and widen the urinary path. Improvements with this technique may only last a few years.
BPH patients have experienced improved prostate health from the following:
Zinc supplements. This mineral plays an important role in prostate health because it decreases prolactin secretion and protects against heavy metals such as cadmium. Both prolactin and cadmium have been associated with BPH.
Saw palmetto. Saw palmetto has long been used by Native Americans to treat urinary tract disturbances without causing impotence. It shows no significant side effects. A number of recent European clinical studies have also shown
that fat soluble extracts of the berry help increase urinary flow and relieve other urinary problems resulting from BPH.
Garlic. Garlic is believed to contribute to overall body and prostate health. Pumpkin seed oil. This oil contains high levels of zinc and has been shown to
help most prostate disorders. Eating raw pumpkin seeds each day has long been a folk remedy for urinary problems, but German health authorities have recently recognized pumpkin seeds as a legitimate BPH treatment.
Pygeum bark. The bark of the Pygeum africanus tree has been used in Europe since early times in the treatment of urinary problems. In France, 81% of BPH prescriptions are for Pygeum bark extract.
Recent developments in BPH treatment options include:
The Urologix Targis TM System. This is a microwave device that uses the same heating method as TUMT. The procedure takes about an hour, and requires no anesthesia. The urologist inserts a flexible tube into the penis. This tube contains a unique microwave antenna that is able to generate very localized hot spots while cooling the surrounding areas. Diseased prostate tissue is destroyed with very little discomfort and a short recovery time. To date, men who have had this procedure have yet to develop impotence or incontinence.
The Dornier MedTech Urowave. This device is another proprietary microwave heating device, similar to the Targis System.
Transurethral alcohol treatment. This recent development is very promising for the treatment of BPH. The procedure involves injecting ethyl alcohol into the lateral and middle lobes of the prostate. The alcohol kills prostate tissue, which the body then absorbs. Early results are encouraging, and show that all patients (who were originally scheduled for TURP) were able to urinate freely after 24 hours. More studies are required to assess long-term outcomes.
Prostatic stents. Stents are wire devices shaped like small springs or coils. They are placed within the prostate channel to maintain its patency (keep it open). These devices are currently under investigation and are not yet FDA-approved.
Aromatase. This inhibitor drug suppresses excess levels of estrogen in the blood. In many men, estrogen is the primary growth-stimulating agent that causes prostatic overgrowth.
Transurethral Resection of the Prostate (TURP)
Transurethral Resection of the Prostate (TURP)
Prostate Cancer Information: Prostate Surgery and Prostatectomy
Prostate surgery or prostatectomy is the removal of the prostate gland. This
prostate cancer treatment is an invasive procedure that can be performed by a
single incision to the lower abdomen (retropubic) or perineum (perineal), or by a
series of small incisions (laparoscopic and robotic).
Surgery’s Role in the Treatment of Prostate Cancer
Prostate surgery is one of the oldest prostate cancer treatments. The premise:
“remove the cancerous organ to treat the patient.” Prostate surgery (the technical
term is prostatectomy) will help only those patients who have confined, localized
disease. The oldest type of surgery, the radical retropubic prostatectomy, uses
pelvic lymph node dissection (PLND) before surgery to ensure that the disease has
not metastasized out of the gland.
Radical prostatectomy is the removal of the entire prostate gland and possibly the
seminal vesicles and surrounding nerves and veins. The part of the urethra
travelling through the gland’s transition zone is also removed. The two ends of
remaining urethra are reattached in a connection called the anastomosis. Excising
part of the urethra may lead to a penile shrinkage or shortening.
Types of Prostate Surgery
There are three types of prostate surgeries: retropubic, perineal, and laparoscopic.
They are classified according to the incision site.
Retropubic
The retropubic incision is made in the center of the lower abdomen and could be
called open prostate surgery. The incision is from 8 to 10 centimeters long. The
advantages of this technique include PLND and nerve-sparing.
Perineal
The 4 centimeter perineal incision is made in the perineum which comprises
muscles and exterior skin between the scrotum and anal sphincter. Surgeons cannot
perform the PLND during this procedure but is considered acceptable because PSA
testing, DRE findings, and Gleason scoring are excellent indicators of lymph node
metastasis.
Laparoscopic and Robotic
The laparoscope is a slender, tube-like instrument which allows the surgeon to see
inside the abdominal cavity and excise the prostate through a series of small
incisions rather than a long single one. The robotic procedure uses the same
incisions and tools but a surgeon uses robotic arms controlled by a console to
perform the surgery remotely. From the patient’s point of view, the two are virtually
identical.
Sex After Prostate Surgery
All prostate cancer treatments affect sexual potency. Physically, several factors
affect the mechanics of the erection such as diversion the blood flow or the nerve
stimulations that trigger erections. Surgeons try to preserve nerve function through
the nerve-sparing technique.
Nerve-sparing prostatectomy can be used only for patients who have small,
localized tumors that do not touch the neurovascular nerve bundles. The technique
helps men regain erectile function more quickly afterwards if they were potent
beforehand. Only the open field of view available through an abdominal incision
allows a surgeon to spare nerve bundles. Patients considering the nerve-sparing
technique should find an experienced surgeon.
The History of the Prostatectomy
The radical perineal approach has been in use since the early 20th century. Not the
until the 1940’s did doctors begin to uses the radical retropubic approach. Both of
these approaches, however, engaged an unrefined surgical technique which
resulted in significant blood loss for the patient. Once surgeons began clamping
veins and refining surgical technique, patients immediately fared better. Until the
1980’s, the retropubic approach was the most commonly used.
Today, the laparoscopic and robotic procedures are quickly becoming popular. Partly
because many doctors PLND is can be diagnosed with other testing. In this
procedure however conversion to the abdominal incision may be used if
complications arise during a laparoscope-assisted procedure
surgical treatment during which a surgeon inserts a
Author: Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of OhioContributor Information and Disclosures
Updated: Oct 3, 2006
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Introduction
For most of the 20th century, from 1909, when Hugh Hampton Young performed his first cold-cut
prostatic punch operation, until the late 1990s, when effective medical therapy and newer, less
invasive technologies for prostatic obstruction were developed, the premier treatment for
symptomatic benign prostatic hypertrophy (BPH) was transurethral resection of the prostate
(TURP). It was the first successful, minimally invasive surgical procedure of the modern era. To
this day, TURP remains the criterion standard therapy for obstructive prostatic hypertrophy and is
both the surgical treatment of choice and standard of care when other methods fail.
Since the advent of medical therapy for symptomatic prostatic hypertrophy with 5-alpha reductase
inhibitors and alpha-adrenergic blockers, the need for immediate surgical intervention in
symptomatic prostatic obstruction has been reduced substantially. However, alpha-blockers do not
modify prostate growth, and even the use of prostatic growth inhibitors such as finasteride
(Proscar) or dutasteride (Avodart) often fails to prevent recurrent urinary symptoms of BPH and
retention. In the past, these patients would almost certainly have undergone transurethral prostate
surgery years earlier.
The modern role of transurethral prostatectomy and the current status of urology residency training
in TURP was perhaps best stated by J. Curtis Nickel in a recent editorial.
The vascular anatomy of the prostate was accurately described in detail by Rubin Flocks in 1937.
The blood supply of the prostate comes primarily from branches of the inferior vesical artery, which
is a branch of the internal iliac artery (see Image 13). When the inferior vesical artery reaches the
prostate just at the vesicoprostatic border, it branches into 2 groups of arteries (see Image 14).
One penetrating group passes directly into the prostate toward the interior of the bladder neck.
Upon reaching the prostatic interior near the urethra, most of these branches turn distally and
parallel the prostatic urethra, while others supply the median lobe.
Vessels that parallel the prostatic urethra supply most of the blood to the hypertrophied lateral
lobes. The second large group of arteries follows the exterior of the prostatic capsule
posterolaterally, periodically giving rise to perforating vessels, and supplies the area around the
verumontanum.
Contraindications
Although TURP is the standard of care for the management of BPH, it is an elective procedure that
is not recommended for some patients. Most contraindications are relative, based on the
comorbidities of the patient and his ability to withstand the surgical procedure and anesthesia.
Some relative contraindications include unstable cardiopulmonary status and a history of
uncorrectable bleeding disorders. Patients with a recent myocardial infarction or coronary artery
stent placement should not have elective TURP surgery for a least 1 month because of the
increased risk of cardiovascular events and other complications. A reasonable minimum delay of 3
months is suggested, but waiting at least 6 months after any significant myocardial event is optimal
before performing an elective TURP.
Patients with myasthenia gravis, multiple sclerosis, or Parkinson disease in whom the external
sphincter is dysfunctional and/or the bladder is severely hypertonic should not have a TURP
because intractable incontinence invariably would result. Patients who have had major pelvic
fractures that involved damage to the external urinary sphincter also should not undergo a TURP
for similar reasons. Loss of the internal urinary sphincter from the TURP makes these patients
totally dependent on their external sphincter muscle function for continence. Should the external
sphincter be damaged, injured, or dysfunctional, they will have substantial problems with
incontinence.
Patients who have recently completed definitive radiation therapy for prostate cancer are not candidates for TURP because of the unacceptably high rate of urinary incontinence reported. If a TURP is absolutely necessary, it should be delayed at least 6 months after definitive radiation therapy. Alternatives to TURP in such a situation include drainage with a Foley or suprapubic catheter, intermittent self-catheterization, and various other less-invasive prostatic surgical procedures. Patients with prostate cancer who are considering brachytherapy (radioactive seed implantation) or cryotherapy as part of their definitive treatment should not undergo a TURP because the resected tissue would be necessary for optimal needle, probe, and seed placement. The patient is also at increased risk for
incontinence. Definition
This surgery involves removal of part or all of the prostate gland .
The prostate gland is a fibrous organ that surrounds the urethra at the base of the bladder in men. An enlarged prostate gland can compress the urethra, thus causing problems with urination. Prostate enlargement may be caused by prostate gland overgrowth (benign prostatic hypertrophy or hyperplasia) or prostate cancer.
Removal of the prostate gland can be performed in a number of different ways, depending on the size of the prostate and the cause of the prostate enlargement (such as prostate cancer).
The three most common procedures for surgically removing the prostate for benign disease include: transurethral resection of the prostate (TURP), suprapubic prostatectomy, and transurethral incision of the prostate (TUIP).
The decision regarding the type of prostatectomy to perform depends on the size of your prostate gland. Generally, for prostates less than 30 grams, TUIP is recommended.
For glands bigger than 30 grams and less than 80 grams (this number depends on the experience of the surgeon), TURP is performed. If the prostate is bigger than 80 grams, open prostatectomy is recommended.
Instruments : TURPTransurethral resection of the prostate is the gold standard treatment and most common surgical procedure for benign prostatic hyperplasia (BPH). TURP is performed using spinal or general anesthesia. A special kind of cystoscope (tubelike instrument) is inserted into the penis through the urethra to reach the prostate gland.
A special cutting instrument is inserted through the cystoscope to remove the prostate gland piece by piece. Blood vessels are cauterized (using heat to stop the bleeding) with electric current during the surgery.
A Foley catheter (artificial tube to remove urine from the body) is placed to help drain the bladder after surgery. The urine will initially appear very bloody, but will clear with time.
A bladder irrigation solution may be attached to the catheter to continuously flush the catheter, thus keeping it from becoming clogged with blood or tissue. The bleeding will gradually decrease, and the catheter will be removed within 1-3 days. You will remain in the hospital for 1 to 5 days.
OPEN PROSTATECTOMYAlthough the transurethral approach is more commonly used, other surgical approaches to removal of the prostate gland (such as the transvesical, retropubic, and suprapubic approach) are sometimes used. The primary advantage of the transurethral approach is that it does not create an external incision. However, it is difficult to remove a large prostate using TURP.
To perform an open prostatectomy (sometimes called suprapubic or retropubic prostatectomy), an incision is made in the lower abdomen between the umbilicus (belly-button) and the penis through which the prostate gland is removed. This is a much more involved procedure and usually requires a longer hospitalization and recovery period.
Open prostatectomy is performed using general or spinal anesthesia. You will return from surgery with a Foley catheter in place. Occasionally, a suprapubic catheter will be inserted in the abdominal wall to help drain the bladder.
A bladder irrigation solution may be attached to the catheter to continuously flush the catheter, thus keeping it from becoming clogged with blood. A drainage tube may also be placed in the abdominal cavity to drain excess blood and fluids from the area.
Your urine may initially appear very bloody, but this should resolve in a few days. The Foley catheter and suprapubic catheters will remain in place for 5 days to a few weeks until the bladder has sufficiently healed.
TUIPTransurethral incision of the prostate (TUIP) is similar to TURP, but is usually performed in people who have a relatively small prostate. This procedure is usually performed on an outpatient basis and usually does not require a hospital stay.
A small incision is made in the prostatic tissue to enlarge the lumen (opening) of the urethra and bladder outlet, thus improving the urine flow rate and reducing the symptoms of BPH.
A Foley catheter may be placed to help drain the bladder after surgery. The catheter will usually remain in place for a few days after surgery. Another key advantage to the TUIP is the preservation of normal ejaculation.
Although orgasm is the same in both the TURP and TUIP, the TURP causes the ejaculate fluid to be projected into the bladder instead of out the penis. The TUIP usually continues to allow the ejaculate fluid to be expressed out the penis. Unfortunately, many patients are not candidates for this surgery due to configuration of their prostates.
NEWER TECHNIQUESTransurethral laser incision of the prostate (TULIP) and visual laser ablation (VLAP) are two newer procedures that use lasers to cut out or destroy the prostate tissue. These procedures are similar to the transurethral incision of the prostate (TUIP). Laser is being evaluated for use in removal of prostatic tissue because of the ability to easily control bleeding and decrease the amount of time required for healing.
Other treatments being investigated for treating the symptoms of prostate enlargement include: microwave therapy of the prostate, balloon dilation of the prostatic urethra, and placement of prostate stents that stretch open the narrowed urethral passage through the prostate gland.
These procedures have demonstrated short term efficacy in select patients, but have not had adequate long-term testing.
Symptoms of prostate enlargement and blockage (obstruction) include:
Frequent urination with small amounts of urine
Recent need to urinate at night (nocturia)
Difficulty starting a stream of urine
Slow stream of urine
Urine dripping out of urethra after urination (dribbling)
Feeling that bladder is never empty
An active urinary tract infection is another contraindication for TURP surgery. Usually, the surgery
can be rescheduled following a course of appropriate antibiotics.
Prostate Removal: Indications
Prostate removal may be recommended for:
inability to completely empty the bladder (urinary retention)
recurrent bleeding from the prostate
bladder stones (calculi) with prostate enlargement
extremely slow urination
stage A and B prostate cancer
increased pressure on the ureters and kidneys (hydronephrosis) from urinary
retention
Prostate surgery is not recommended for men who have:
blood clotting disorders
bladder disease (neurogenic bladder)
With the exception of skin cancer, prostate cancer is the most common type of cancer among men in the United States. Early detection may result from a blood test called a PSA (prostate-specific antigen), and/or a digital rectal exam. The digital rectal exam checks the rear surface of the prostate gland for any
abnormalities. A lump or hardness found during the exam might be a sign of prostate cancer
Prostatectomy - Series: Incision
There are two main surgical methods used for removing the prostate gland . The first method is called the "perineal" method. An incision is made in the perineum, which is the area between the base of the scrotum and the anus
The second surgical method of prostatectomy is called the "suprapubic" approach. An incision is made in the abdomen, just below the umbilicus, which extends downward to
the pubic bone The suprapubic approach allows for removal of the lymph nodes and the ability to perform a nerve sparing modification that might prevent impotence post surgery
An enlarged prostate gland compresses the urethra, causing problems with
urination. Prostate enlargement is caused by prostate gland overgrowth (benign
prostatic hypertrophy or hyperplasia) or in some cases, prostate cancer
Diagnostic TestsThe PSA blood test determines whether you have cancer of the prostate. The test measures how much of a protein essential to human reproduction, PSA (prostate-specific antigen), is in your blood. PSA turns your gelatinous pre-semen into a liquid, thus supporting ejaculation. If your PSA is below 4, most doctors agree that you needn't be tested again for a year. During annual tests, remember that it is normal for your reading to go up by a few tenths of a point every year. In general, only a drastic increase in PSA (an increase of at least 0.75 points or 20 percent) is considered a reason to worry. This test is recommended on an annual basis for all men over 50 (and for men above 45 if there is a family history of prostate problems).
A digital rectal examination (DRE) is a quick and safe screening technique in which a doctor inserts a
gloved, lubricated finger into the rectum to feel the size and shape of the prostate. The prostate should feel soft, smooth, and even. The doctor checks for lumps or hard, irregular areas of the prostate that may indicate the presence of prostate cancer. The
entire prostate
TURP - Series: Procedure
With an anesthetic (general anesthetic or spinal), a special kind of telescope, called a resectoscope is inserted through the urethra into the prostate. The resectosope is
used to remove the blocking portions of the prostate. Transurethral resection of the prostate (TURP) is the most common type of surgical procedure for benign prostatic hyperplasia (BPH)
cannot be felt during a DRE, but most of it can be examined, including the area where most prostate cancers are found.