THE PATIENT UNDERGOING PROSTATE SURGERY
Prostate surgery may be indicated for the patient with BPH or prostate cancer. The objectives before prostate surgery are to as-sess the patient’s general health status and to establish optimal renal function. Prostate surgery should be performed before acute urinary retention develops and damages the upper urinary tract and collecting system or, in the case of prostate cancer, before cancer progresses.
Several approaches can be used to remove the hypertrophied por-tion of the prostate gland: transurethral resection of the prostate (TURP), suprapubic prostatectomy, perineal prostatectomy, retropubic prostatectomy, and transurethral incision of the prostate (TUIP) (Table 49-3). In these approaches, the surgeon removes all hyperplastic tissue, leaving behind only the capsule of the prostate. The transurethral approaches (TURP, TUIP) are closed procedures; the other three are open procedures (ie, a sur-gical incision is required). The procedure chosen depends on the underlying disorder, the patient’s age and physical status, and pa-tient preference.
TURP, the most common procedure used, can be carried out through endoscopy. The surgical and optical instrument is intro-duced directly through the urethra to the prostate, which can then be viewed directly. The gland is removed in small chips with an electrical cutting loop (Fig. 49-4A). This procedure, which re-quires no incision, may be used for glands of varying size and is ideal for patients who have small glands and those who are con-sidered poor surgical risks.
This approach usually requires an overnight hospital stay. Strictures are more frequent, and repeated procedures may be necessary because the residual prostatic tissue can grow back. TURP rarely causes erectile dysfunction, but it may cause retro-grade ejaculation because removing the prostatic tissue at the bladder neck can cause the seminal fluid to flow backward into the bladder rather than forward through the urethra during ejaculation.
Suprapubic prostatectomy is one method of removing the gland through an abdominal incision. An incision is made into the bladder, and the prostate gland is removed from above (see Fig. 49-4B). Such an approach can be used for a gland of any size, and few complications occur, although blood loss may be greater than with the other methods. Another disadvantage is the need for an abdominal incision, with the concomitant hazards of any major abdominal surgical procedure.
Perineal prostatectomy involves removing the gland through an incision in the perineum (see Fig. 49-4C ). This approach is prac-tical when other approaches are not possible and is useful for an open biopsy. Postoperatively, the wound may easily become con-taminated because the incision is near the rectum. Incontinence, impotence, and rectal injury are more likely with this approach.
Retropubic prostatectomy, another technique, is more common than the suprapubic approach. The surgeon makes a low ab-dominal incision and approaches the prostate gland between the pubic arch and the bladder without entering the bladder (see Fig. 49-4D). This procedure is suitable for large glands located high in the pelvis. Although blood loss can be better controlled and the surgical site is easier to visualize, infections can readily start in the retropubic space.
Transurethral incision of the prostate (TUIP) is another proce-dure used in treating BPH. An instrument is passed through the urethra (see Fig. 49-4E ). One or two incisions are made in the prostate and prostate capsule to reduce the prostate’s pressure on the urethra and to reduce urethral constriction. TUIP is indicated when the prostate gland is small (30 g or less) and is an effective treatment for many cases of BPH. TUIP can be performed on an outpatient basis and has a lower complication rate than other in-vasive prostate procedures (Mebust, 1998).
Laparoscopic radical prostatectomy is a method recently devel-oped in France. Although not yet widespread in the United States, it is anticipated that this procedure will be widely used in place of more extensive surgery for patients with localized prostate cancer. The laparoscopic approach provides better visu-alization of the surgical site and surrounding areas. Preliminary data suggest that patients who undergo this procedure have less bleeding and reduced need for blood transfusion, a shorter hos-pital stay, less postoperative pain, and more rapid return to nor-mal activity compared to open radical prostatectomy (Rassweiler, Sentker, Seemann et al., 2001). Further research is needed to as-sess long-term outcomes.
Complications depend on the type of prostatectomy performed and may include hemorrhage, clot formation, catheter obstruc-tion, and sexual dysfunction. All prostatectomies carry a risk of impotence because of potential damage to the pudendal nerves. In most instances, sexual activity may be resumed in 6 to 8 weeks, the time required for the prostatic fossa to heal. During ejacula-tion, the seminal fluid goes into the bladder and is excreted with the urine. (The anatomic changes in the posterior urethra lead to retrograde ejaculation.) A vasectomy may be performed during surgery to prevent infection from spreading from the prostatic urethra through the vas and into the epididymis.
After total prostatectomy (usually for cancer), impotence al-most always results. For the patient who does not want to give up sexual activity, options are available to produce erections suffi-cient for sexual intercourse: prosthetic penile implants, negative-pressure (vacuum) devices, and pharmacologic interventions.