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Prostatectomy

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Prostatectomy
ICD-9-CM60.2-60.6
MeSHD011468

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 (TURP)

Main article: Transurethral resection of the prostate

A cystoscope [a resectoscope which has a 30 degree 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%).

Conventional (monopolar) TURP

The conventional TURP method in tissue removal utilizes a wire loop with electrical current flowing in one direction (thus monopolar) through the resectoscope to cut the tissue. A grounding ESU pad and irrigation by a nonconducting fluid is required to prevent this current from disturbing surrounding tissues. This fluid (usually glycine) can cause damage to surrounding tissue after prolonged exposure, resulting in TUR syndrome, so surgery time is limited.

Bipolar TURP

Bipolar TURP is a newer technique that uses bipolar current to remove the tissue. Bipolar TURP allows saline irrigation and eliminates the need for an ESU grounding pad thus preventing TUR syndrome and reducing other complications. As a result bipolar Turp is also not subject to the same surgical time constraints of conventional TURP.

Laser prostate surgery

Another surgical method utilizes laser energy to remove tissue. With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high powered "red" or potassium titanyl phosphate(KTP) 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.

Open prostatectomy

In an open prostatectomy the prostate is accessed through an incision that allows manual manipulation and open visualization through the incision. The most common types of open prostatectomy are radical retropubic prostatectomy (RRP) and radical perineal prostatectomy (RPP).

Radical retropubic prostatectomy

Main article: radical retropubic prostatectomy

With RRP, an incision is made in the lower abdomen, and the prostate is removed, by going behind the pubic bone (retropubic).

Radical perineal prostatectomy

Main article: radical perineal prostatectomy

In RPP an incision is made in the perineum, midway between the rectum and scrotum through which the prostate is removed. This procedure has become less common due to limited access to lymph nodes and difficulty in avoiding nerves.

Suprapubic transvesical prostatectomy

Another type of open prostatectomy is suprapubic transvesical prostatectomy (SPP) where an incision is made in the bladder. SPP remains a common surgical treatment for BPH in Africa but has largely been supplanted by TURP in the West for this application.[1] SPP may be indicated for use with large patients and prostates because of the surgical time constraints associated with conventional TURP.

Laparoscopic radical prostatectomy

Main article: Laparoscopic Radical Prostatectomy

This is a laparoscopic procedure involving four small incisions made in the abdomen used to remove the entire prostate for treatment of prostate cancer.

Computer-assisted laparoscopic radical prostatectomy (CALP)

Computer-assisted instruments are inserted through several small abdominal incisions and controlled by a surgeon. Some use the term 'robotic' for short, in place of the term 'computer-assisted'. However, procedures performed with a computer-assisted device are performed by a surgeon, not a robot. The computer-assisted device gives the surgeon more dexterity and better vision, but no tactile feedback compared to conventional laparoscopy. When performed by a surgeon who is specifically trained and well experienced in CALP, there can be similar advantages over open prostatectomy, including smaller incisions, less pain, less bleeding, less risk of infection, faster healing time, and shorter hospital stay.[2] The cost of this procedure is higher, whereas long-term functional and oncological superiority has yet to be established.[3][4][5]

Sexual effects of prostatectomy

Surgical removal of the prostate risks an increased likelihood that patients will experience erectile dysfunction. Nerve-sparing surgery reduces the risk that patients will experience erectile dysfunction. However, the experience and the skill of the nerve-sparing surgeon, as well as any surgeon are critical determinants of the likelihood of positive erectile function of the patient.[6]

Remedies to post-operative sexual dysfunction

Very few surgeons will claim that patients return to the erectile experience they had prior to surgery. The rates of erectile recovery that surgeons often cite are qualified by the addition of Viagra to the recovery regimen.[7]

Remedies to the problem of post-operative sexual dysfunction include:[8]

  • Medications
  • Intraurethral suppositories
  • Penile injections
  • Vacuum devices
  • Penile implants

References

  1. ^ Nthumba, P.M.; Bird, P.A. (November/December 2006). "Suprapubic Prostatectomy with and without Continuous Bladder Irrigation in a Community with Limited Resources". East and Central African Journal of Surgery. 12 (2): 53–58. ISSN 1024-297X. Retrieved 13 March 2010. {{cite journal}}: Check date values in: |date= (help)
  2. ^ Center for the Advancement of Health; August 29, 2005; Robot-assisted Prostate Surgery Has Possible Benefits, High Cost [1]
  3. ^ 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]
  4. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.eururo.2009.11.008, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.eururo.2009.11.008 instead.
  5. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.juro.2009.11.017, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.juro.2009.11.017 instead.
  6. ^ John P. Mulhall, M.D., Saving Your Sex Life: A Guide for Men with Prostate Cancer, Chicago, Hilton Publishing Company, 2008, p. 56, 58, Table 1: Factors Predicting Erectile Function Recovery after Radical Prostatectomy, p. 65.
  7. ^ John P. Mulhall, M.D., Saving Your Sex Life: A Guide for Men with Prostate Cancer, Chicago, Hilton Publishing Company, 2008, p. 69.
  8. ^ John P. Mulhall, M.D., Saving Your Sex Life: A Guide for Men with Prostate Cancer, Chicago, Hilton Publishing Company, 2008

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