 Prostate
Surgery
Enlarged Prostrate (BPH)
What is Enlarged Prostrate BPH)?
Located below the bladder the doughnut-shaped prostate gland surrounds the urethra, the
tube that carries urine and semen through the penis.
The prostate gland produces semen and aids the bladder in the flow of urine. After puberty
the prostate gradually grows from 10 – 12 cm to 25 – 30 cm. After 50 the prostate
begins to grow again. This is commonly caused by Benign Prostatic Hypertrophy (BPH) or enlarged
prostate, other causes can be prostatitis, and even prostate cancer. This process may be
related to hormonal changes brought on by aging.
Symptoms of BPH:
- A need to pass urine frequently
- Pain, burning, difficulty in stopping and starting urination
- A need to urinate during the night
- A constant feeling that the bladder isn't completely empty
- Prolonged emptying of the bladder
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- Irregular need to urinate
- Incomplete bladder emptying
- Incontinence or involuntary leakage of urine.
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If left untreated, BPH can be a progressive disease. It may lead to secondary
conditions that can be serious for example an increased risk of urinary tract infection
due to the bladder not emptying fully. Urinary bladder stones can then form from the crystallisation
of salts in the residual urine. Acute or chronic urinary retention can cause the bladder
to expand and may eventually progress to renal failure.
In the west 45% of men over the age of 46 can expect to suffer from the symptoms of BPH,
the majority of men over 55 will suffer some level of symptoms as they age.
Diagnosis
A blood test measures prostate specific antigen (PSA) levels. In increased level will require
further investigation. Also rectal examination and transrectal ultrasonography can provide
early cancer detection as can ultrasound examination of the testicles, prostate and kidneys.
For some men, the symptoms may be severe enough to require treatment.
Treatment
Lifestyle Changes:
- A high fiber and protein diet, low in fats and carbohydrates
- Annual prostate examination
- Weight – increased weight doubles the risk
- Lower alcohol and caffeine intake
Medication
Alpha-blockers relax muscles in the prostate and the bladder neck providing symptomatic
relief of BPH symptoms by decreasing the blockage of urine flow. Alpha-blockers may cause
ejaculation back into the bladder (retrograde ejaculation).
The 5a-reductase inhibitors, inhibit production of a hormone responsible for enlarging the
prostate. When used together with alpha blockers in patients with BPH there is less risk
of progression to acute urinary retention and need for surgery.
Surgery
- TURP (Transurethral resection of the prostate)
- Laser prostatectomy surgery – Green light laser surgery
TURP (Transurethral resection of the prostate)
What is TURP?
Transurethral resection of prostate (TURP) involves removing part of the prostate through
the urethra and is still frequently used to treat moderate to severe BPH. Today’s
surgeons are trying out a range of other less invasive procedures with varying success rates.
The procedure
Under general anaesthetic a thin cylindrical instrument (resectoscope) is inserted into
the urethra through the penis through the urethra enabling the surgeon to cut or burn away
excess prostate tissue to improve urine flow. The surgeon will try to remove only the interior
part of the gland leaving the exterior nerves intact.
After the procedure
For a few days the bladder will be drained with a catheter. Urination will be painful for
a few days.
Frequent urge to urinate is common during the early recovery period.
The patient can return to work in 2 - 4 weeks without heavy activity for 6 weeks. Sexual
activity may be resumed in 4 - 6 weeks.
TURP greatly relieves symptoms in nearly all men. Best effects are seen in men with larger
prostate glands and more pronounced symptoms. Men with severe bladder damage caused by BPH
often improve after TURP. Immediate relief is experienced with a stronger urine flow within
a few days.
Side effects:
Prolonged side effects of TURP may include:
- Semen entering the bladder (retrograde ejaculation)
- Reoccurring urinary tract infections
- A stricture or narrowing at the neck of the bladder
Further treatment may be required if the prostate gland re-grows or because
insufficient has been removed.
Radical Prostatectomy
What is a Radical Prostatectomy?
In Radical Prostatectomy the surgeon removes the entire prostate gland and surrounding tissue.
Surgery may completely remove prostate cancer; however, it is not possible to know beforehand
whether the cancer has spread beyond the prostate and is curable with surgery alone.
Prostate cancer often spreads to the nerves that surround the prostate, when these nerves
are removed erection dysfunction will occur.
In order to remove the prostate, the surgeon must cut the urethra and later reconnect it
to the bladder. The greater the surgeon's experience and skill, the lower the possibility
of incontinence.
The operation
Open Surgery
Under general anaesthesia an incision is made either in the lower belly or in the groin
between the anus and the penis. The most common method is the retropubic approach (the lower
belly) and is the treatment for prostate cancer. In this procedure, the surgeon may also
remove lymph nodes in the area so that they can be tested for cancer.
Laparoscopic Surgery
Under general anaesthesia the surgeon makes several small incisions in the lower abdomen.
The abdominal cavity is then inflated so the surgeon can see and work. A lighted viewing
instrument called a laparoscope is inserted into one of the incisions. The surgeon uses
special instruments to reach and remove the prostate through the other incisions. Laparoscopic
surgery is associated with less blood loss and faster recovery.
Some tumours can be removed using a nerve-sparing technique, which means carefully cutting
around those nerves to leave them intact. Nerve-sparing surgery sometimes preserves the
man's ability to have an erection.
After Surgery
The patient will stay in hospital for 2 - 4 days. For 1 to 3 weeks the bladder will be drained
with a catheter. Urination will be painful for a few days. Bladder control can be poor for
a few months after the catheter is removed. The candidate will need instruction on how to
care for their catheter.
Frequent urge to urinate is common during the early recovery period
Follow-up care is important and may lead to early identification and treatment if the cancer
returns.
The follow up should include:
- Blood tests to monitor PSA (Prostate-specific antigen) levels
- Biopsies to examine suspect tissue when needed
When is a Radical Prostatectomy
required?
Generally when testing shows that cancer has not spread outside the prostate.
Before a radical prostatectomy a biopsy of the lymph nodes may be taken to find out whether
cancer is present. If cancer has spread to the lymph nodes the prostate is not removed.
Although occasionally radical prostatectomy is used to relieve urinary obstruction in men
with more advanced cancer, a TURP procedure is usually used for that purpose.
How effective is the treatment?
Radical prostatectomy is generally effective in treating prostate cancer that has not spread.
In such cases PSA levels will drop almost to zero. If cancer has spread, advanced cancer
may still develop even after prostate removal.
Urinary Incontinence
After one year 15% - 50% of men report urinary problems ranging from the need to wear urinary
incontinence pads to occasional dribbling.
HIFU treatment
A new technique called HIFU or High Intensity Frequency Ultrasound seems
to be producing excellent results where cancer has been detected.
The Prostrate is subject to sound waves liquefying the interior of the gland and enabling
it to be removed in the same way modern lipo-sculpture techniques are performed.
HIFU enables the surgeon to target the cancerous area, stopping the cancer
with or without damaging the exterior nerves of the prostrate. This reduces greatly the
chances of incontinence or erectile dysfunction.
The favoured methodology is to treat the patient in 2 sessions 18 months
apart, protecting the surrounding nerves from damage.
Typical Results from HIFU
Sometimes when the cancer has progressed it is necessary to treat in one
session. One treatment may damage the nerves possibly leading to incontinenece or erectile
disfunction problems.
The treatment can be administered on a day surgery basis, and results are
instant. Recovery is much faster than surgical solutions.
Recent results show that this treatment is fast becoming the treatment of
choice for surgeons especially when treating cancer.
Laser prostatectomy surgery – Green light
laser surgery
Newer techniques involving lasers in urology have emerged in the last 5-10
years such as Transurethral electrovaporization of the prostate (TVP), laser TURP, visual
laser ablation (VLAP), Transurethral microwave thermotherapy (TUMT), TransUrethral Needle
Ablation (TUNA).
With Laser prostatectomy surgery the surgeon uses microwaves or a laser to burn away the
interior of the gland leaving the exterior and nerves intact thus reducing the risk of incontinence.
Results show that Laser treatments are unsuitable where cancer is present and that scarring
caused by laser surgery doesn’t easily heal. Many surgeons have now discontinued Laser
based treatment in favour of HIFU.
Prostatitis
What is Prostatitis?
Prostatitis is an inflammation of the prostate caused by a bacterial infection spreading
from another area. Prostatitis can develop suddenly (acute), or gradually build up over
an extended period of time (chronic).
More common in men aged 20-35, men with multiple sex partners and men who engage in high-risk
sexual behaviours, acute prostatitis is caused by e coli, certain STD’s, sexual contact
with an infected person, a urinary tract infection, urethritis, epididymitis, urethral instrumentation,
trauma, bladder outlet obstruction, or from another infection elsewhere.
Symptoms of acute prostatitis:
- Fever associated with lower abdominal discomfort or perineal pain
- Pain and/or burning with urination, ejaculation, or a bowel movement
- Blood in the urine and/or semen
- An increased need to urinate
More common in men aged 30 to 50, Chronic prostatitis develops from urinary
tract infection, urethritis, epididymitis or from continued reoccurrence of acute prostatitis.
It may also be associated to hormonal changes of aging and also certain lifestyle influences
(excessive alcohol drinking, perineal injury, certain sexual practices).
Symptoms of chronic prostatitis:
- Recurrent urinary tract infections
- Pain in the lower back, perineal, pelvic floor, testacies
- Pain and/or burning with urination, ejaculation, or bowel movement
Treatment
Prostatitis is diagnosed by a rectal examination. The infected prostate is swollen, warm
and tender to touch. If antibiotic treatment is unsuccessful, surgery may be relevant.
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