 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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