Prostate surgery

Prostate surgery is a surgery, which is performend on prostate gland and leads to reduction of the size, or removal of whole gland. This operation is done for benign conditions that cause urinary retention, as well as for prostate cancer and other cancers of the pelvis.

There are two main types of prostatectomies. 

1.    A simple prostatectomy (also known as a subtotal prostatectomy) is when only part of the prostate is removed. Simple prostatectomies are typically only done for benign conditions. 

2.    A radical prostatectomy (Pic. 1), the removal of the entire prostate gland, the seminal vesicles and the vas deferens, is performed for malignant cancer. 

There are multiple ways the operation can be done: as an open surgery (with a large incision through the lower abdomen), laparoscopically with the help of a robot (a type of minimally invasive surgery), through the urethra or through the perineum.

Open surgery

In an open prostatectomy, the prostate is accessed through a large single incision through either the lower abdomen or the perineum. Further descriptive terms describe how the prostate is accessed anatomically (Pic. 2) through this incision (retropubic vs. suprapubic vs. perineal). A retropubic prostatectomy describes a procedure that accesses the prostate by going through the lower abdomen and behind the pubic bone. A suprapubic prostatectomy describes a procedure cuts through the lower abdomen and through the bladder to access the prostate. A perineal prostatectomy is done by making an incision between the rectum and scrotum on the underside of the abdomen.

Laparoscopic radical prostectomy

Laparoscopic radical prostatectomy (LRP) is a modern form of radical prostatectomy, an operation for prostate cancer. Contrasted with the original open form of the surgery, laparoscopic radical prostatectomy does not make a large incision. Instead, laparoscopic radical prostatectomy is minimally invasive and relies on modern technologies, such as fiber optics and miniaturization. Laparoscopic radical prostatectomy is not a new treatment for prostate cancer. It is a modern form of the oldest treatment for prostate cancer. The procedure takes at least five hours and as long as eight hours for the average urologist, without a bilateral lymph node dissection, compared to 2.5–3 hours when done by an open technique with an incision, with a completed lymph node dissection. 

Transurethral resection of the prostate

Transurethral resection of the prostate (commonly known as a TURP, plural TURPs, and rarely as a transurethral prostatic resection, TUPR) is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. This is considered the most effective treatment for BPH. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 80-90% of BPH patients.

Robotic assisted prostatectomy

Robotic-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 RALRP (robotic-assisted laparoscopic radical prostatectomy 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. The cost of this procedure is higher, whereas long-term functional and oncological superiority has yet to be established.

Urology, which is responsible for treatment of urinary tract including prostate, is a discipline, which is constantly evolving through new technological and modern approaches. New techniques leads to reduction of complications and reducing the time of convalescence.

Symptoms

The most common causes for prostate surgery are benign prostate hyperplasia and prostate cancer.

Symptomes of benign prostate hyperplasia include:

• urinate frequently
• waking at night to urinate
• urgency (compelling need to void that cannot be deferred)
• involuntary urination
• including involuntary urination at night
• urge incontinence (urine leak following a strong sudden need to urinate)
• urinary hesitancy (a delay between trying to urinate and the flow actually beginning)
• intermittency (not continuous)
• involuntary interruption of voiding
• weak urinary stream
• straining to void
• a sensation of incomplete emptying
• terminal dribbling (uncontrollable leaking after the end of urination, also called post-micturition dribbling)
• dysuria (pain while urinating)
• increased risk of urinary tract infection

Symptoms of prostate cancer are:

• frequent urination
• nocturia (increased urination at night)
• difficulty starting and maintaining a steady stream of urine
• hematuria (blood in the urine)
• dysuria (painful urination)
• difficulty achieving erection
• painful ejaculation

Associated diseases

• prostate cancer
• benign prostate hyperplasia

Complications

Any surgical procedure has risks associated with it. Complications that occur in the period right after any surgical procedure, including a prostatectomy, include a risk of bleeding, a risk of infection at the site of incision or throughout the whole body, a risk of a blood clot occurring in the leg or lung, a risk of a heart attack or stroke, and a risk of death.

Long term complications that are common and specific to a prostatectomy include the following:

• Bleeding (most common). Bleeding may be reduced by pre-treatment with an anti-androgen such as finasteride (a medication used for the treatment of benign prostatic hyperplasia) or flutamide (treatment of prostate cancer).
• Retrograde ejaculation (the entry of semen into the bladder instead of going out through the urethra during ejaculation) due to injury of preprostatic (internal) sphincter system. This is one of the most frequent complications of the procedure. 
• Urinary incotinence. Patients who undergo a prostatectomy have an increased risk of leaking small amount of urine immediately after surgery and for the long-term. Things associated with an increased risk of urinary incontinence at 12 months after surgery include higher age, higher BMI, more comorbidities, and larger prostates, as well as experience and technique of the surgeon.
• Clot retention and clot colic.
• TURP Syndrome: Hyponatremia and water intoxication (symptoms resembling brain stroke in an elderly presenting patient) caused by an overload of fluid absorption (e.g. 3 to 4 Litres) from the open prostatic sinusiods during the procedure. This complication can lead to confusion, changes in mental status, vomiting, nausea, and even coma. 
• Bladder neck stenosis.
• Bladder wall injury such as perforation (rare).
  

Risk factors

The risk factors for the most common causes of prostate surgery are:

• age - chance of cancer is rapidly higher after the age of 50
• race - cancer more occures in african- american men
• geography- cancer is most common in north america, northwestern europe and australia
• family history- in some cases cancer may runs in families
• diet - high-fat diet could have efect on cancer developement
• obesity increases risk of cancer
• inflammation of the prostate- very often there is an inflammatory tissue in samples with cancer
• sexually transmitted infections leads to inflammation of the prostate

Prevention

Healthy lifestyle, such as eating lot of vegetables, fishes and low fat meat combine with excescise can help in prevention of cancer and benigh prostate hyperplasia. After the age of 50, every man should have digital rectal examination once a year.

Surgical removal of the prostate contains an increased likelihood that patients will experience erectile dysfunction. Impotence is common when nerve-sparing techniques are not used. Although erection and ejaculation are affected, penile sensation and the ability to achieve orgasm remain intact. Continence and potency may improve depending on the amount of trauma and the patient's age at the time of the procedure, but progress is frequently slow. Potency is greatly affected by the psychological attitude of the patient. The sensation of orgasm may be altered and no semen is produced, but there may be a few drops of fluid from the bulbourethral glands.

On the other hand nerve-sparing surgery reduces the risk of erectile dysfunction. Nerve-sparing surgery attempts to protect the cavernous nerves of penis, which control erection. These nerves are very fine and fragile and run next to the prostate and may be destroyed during surgery, leading to impotence. If the cancer is clinically unlikely to have spread beyond the prostate, nerve-sparing surgery should be offered to minimize impotency and to speed up urinary control.

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.

Following a prostatectomy, patients will not be able to ejaculate semen due to the nature of the procedure, resulting in infertility.

Following a prostatectomy, patients will not be able to ejaculate semen due to the nature of the procedure, resulting in the permanent necessity of assisted reproductive techniques in case of desires of future fertility. Preservation of normal ejaculation is possible after TUR-Prostatectomy, open or laser enucleation of adenoma and laser vaporisation of prostate.

Once the prostate and vesicles are removed, even if partial erection is achieved, ejaculation is a very different experience.

Very few surgeons will claim that patients return to the erectile experience they had prior to surgery. 

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

• medications
• intraurethral suppositories
• penile injections
• vacuum devices
• penile implants