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A prostatectomy is the surgical removal of all or part of the prostate gland. Enlargement of the prostate, commonly through benign prostatic hyperplasia (BPH), but sometimes through abnormalities such as a tumour, or from other causes, can restrict the normal flow of urine along the urethra, causing discomfort and difficulty voiding. Early preventive medical intervention with medications such as finasteride may forestall urinary restriction, making surgery unnecessary. Once a significant urinary restriction develops, however, it increases risks of obstructive uropathy, and even poses serious kidney damage from obstructive nephropathy if left untreated.
There are several forms of the operation:
This is used for benign prostatic hyperplasia (BPH), and sometimes for symptomatic relief in prostate cancer. 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%).
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 is a newer technique that uses bipolar current to remove the tissue.1 2 Bipolar TURP allows saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-TURP hyponatremia (TUR syndrome) and reducing other complications. As a result bipolar Turp is also not subject to the same surgical time constraints of conventional TURP.
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) "green" 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 blood loss, elimination of the risk of post-TURP hyponatremia (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.
This procedure uses ionized vapour that heats up by low voltage electricity and semi-spherical button to vaporize the prostate tissue from inside and only leave a 2-3 mm shell. This procedure is considered to be the least intrusive of all techniques currently available and has less post-operative complications and a short convalescence.3
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).
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.
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.4 SPP may be indicated for use with large patients and prostates because of the surgical time constraints associated with conventional TURP.
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 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.5 The cost of this procedure is higher, whereas long-term functional and oncological superiority has yet to be established.678
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.9
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.10
Remedies to the problem of post-operative sexual dysfunction include:11
- Intraurethral suppositories
- Penile injections
- Vacuum devices
- Penile implants
- Starkman JS, Santucci RA (2005). "Comparison of bipolar transurethral resection of the prostate with standard transurethral prostatectomy: shorter stay, earlier catheter removal and fewer complications.". BJU Int. 95 (1): 69–71. doi:10.1111/j.1464-410X.2005.05253.x. PMID 15638897.
- Bipolar versus Monopolar TURP: A Prospective Controlled Study at two Urology Centers. 2010.
- 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.
- Center for the Advancement of Health; August 29, 2005; Robot-assisted Prostate Surgery Has Possible Benefits, High Cost 
- 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 
- Bolenz, C.; Gupta, A.; Hotze, T.; Ho, R.; Cadeddu, J.; Roehrborn, C.; Lotan, Y. (2010). "Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer.". European Urology 57 (3): 453–458. doi:10.1016/j.eururo.2009.11.008. PMID 19931979.
- Barocas, D. A.; Salem, S.; Kordan, Y.; Herrell, S. D.; Chang, S. S.; Clark, P. E.; Davis, R.; Baumgartner, R. et al. (2010). "Robotic Assisted Laparoscopic Prostatectomy Versus Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer: Comparison of Short-Term Biochemical Recurrence-Free Survival". The Journal of Urology 183 (3): 990–996. doi:10.1016/j.juro.2009.11.017. PMID 20083261.
- 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.
- John P. Mulhall, M.D., Saving Your Sex Life: A Guide for Men with Prostate Cancer, Chicago, Hilton Publishing Company, 2008, p. 69.
- John P. Mulhall, M.D., Saving Your Sex Life: A Guide for Men with Prostate Cancer, Chicago, Hilton Publishing Company, 2008
- The Basics of the Prostatectomy Procedure Explained
- National Prostate Cancer Coalition
- Prostatectomy - slideshow by The New York Times