 | This articlerelies excessively onreferences toprimary sources. Please improve this article by addingsecondary or tertiary sources. Find sources: "Prostatectomy" – news ·newspapers ·books ·scholar ·JSTOR(November 2020) (Learn how and when to remove this message) |
| Prostatectomy | |
|---|---|
 Anatomy of theprostate | |
| ICD-9-CM | 60.2–60.6 |
| MeSH | D011468 |
Prostatectomy (from theGreekπροστάτηςprostátēs, "prostate" andἐκτομήektomē, "excision") is thesurgical removal of all or part of theprostate gland. This operation is done forbenign conditions that cause urinary retention, as well as forprostate cancer and for other cancers of thepelvis.
There are two main types of prostatectomies. Asimple prostatectomy (also known as a subtotal prostatectomy) involves the removal of only part of the prostate. Surgeons typically carry out simple prostatectomies only forbenign conditions.[1] Aradical prostatectomy, the removal of the entire prostate gland, theseminal vesicles and thevas deferens and pelvic lymph nodes, is performed for cancer.[2]
There are multiple ways the operation can be done forbenign prostatic hyperplasia (BPH): with open surgery (via a large incision through the lower abdomen),laparoscopically with the help of arobot (a type of minimally invasive surgery), through theurethra or through theperineum.
Laser prostatectomy or holmium laser enucleation of the prostate (HoLEP), is a minimally invasive surgery to treat BPH. The holmium laser is used to enucleate and remove excess prostate tissue that is blocking the urethra into urinary bladder. Amorcellator is then used to cut the prostate tissue into smaller pieces before extracting it from the body. HoLEP can be an option for men who have a severely enlarged prostate.[3]Due to the decreased risk of bleeding and recurrence of obstruction, HoLEP has started to replacetransurethral resection of the prostate (TURP) operations, even for patients who have a smaller prostate. The procedure started to be extremely popular in Western countries and has recently gained popularity in the Middle East, including Jordan,[4] Egypt, and Saudi Arabia.
Other terms that can be used to describe a radical prostatectomy include:
Indications for removal of the prostate in a benign setting include acute urinary retention, recurrent urinary tract infections, uncontrollablehematuria, bladder stones secondary to bladder outlet obstruction, significant symptoms from bladder outlet obstruction that are refractory to medical or minimally invasive therapy, andchronic kidney disease secondary to chronic bladder outlet obstruction.[6]
A radical prostatectomy is performed due to malignant cancer. For prostate cancer, the best treatment often depends on the risk level presented by the disease. For most prostate cancers classified as "very low risk" and "low risk," radical prostatectomy is one of several treatment options; others include radiation, watchful waiting, and active surveillance. For intermediate and high risk prostate cancers, radical prostatectomy is often recommended in addition to other treatment options. Radical prostatectomy is not recommended in the setting of knownmetastases when the cancer has spread through the prostate, to the lymph nodes or other parts of the body.[7] Prior to deciding the best treatment option for higher risk cancers, imaging studies such as CT, MRI or bone scans are done to see whether the cancer has spread outside of the prostate.
These would be same as the contraindications for any other surgery.[citation needed]
There are several ways a prostatectomy can be done:
In an open prostatectomy, the prostate is accessed through a large single incision through either the lower abdomen or the perineum. In retropubic prostatectomies, an incision is made in the lower abdomen and the prostate is accessed from behind the pubic bone. For a suprapubic prostatectomy, the surgeon makes an incision through the lower abdomen and 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.
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 incomputer-assisted laparoscopy (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.[8][9] The cost of this procedure is higher, while long-term functional and oncological superiority have yet to be established.[10][11][12]
A prostatectomy has similar complications that can occur in the period right after any surgical procedure. This includes 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.
Severe irritation takes place if a latexcatheter is inserted in the urinary tract of a person allergic to latex. That is especially severe in case of a radical prostatectomy due to the open wound there and the exposure lasting e.g. two weeks. Intense pain may indicate such situation.[13]
Men can experience changes in their sexual responses after radical prostatectomy, including impairments to sexual desire, penile morphology[vague] and orgasmic function.[14][15] A 2005 article in the medical journalReviews in Urology listed the incidence of several complications following radical prostatectomy: mortality <0.3%, impotence >50%, ejaculatory dysfunction 100%, orgasmic dysfunction 50%, incontinence <5–30%, pulmonary embolism <1%, rectal injury <1%, urethral stricture <5%, and transfusion 20%.[16]
Surgical removal of the prostate increases the likelihood that patients will experienceerectile dysfunction. Radical prostatectomy is associated with a greater decrease in sexual function thanexternal beam radiotherapy. Nerve-sparing surgery reduces the risk that patients will experience erectile dysfunction. However, the experience and the skill of the nerve-sparing surgeon are critical determinants of the likelihood of positive erectile function of the patient.[17][better source needed]
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.[18] Preservation of normal ejaculation is possible after a TURP, open or laser enucleation of adenoma and laser vaporisation of prostate. However,retrograde ejaculation is a common problem. Preservation of ejaculation is the aim of some new techniques.[19] Once the prostate and vesicles are removed, even if partial erection is achieved, ejaculation is a very different experience, with little of the compulsive release that is common to ejaculation with those organs intact.
Prostatectomy patients have an increased risk of leaking small amounts of urine immediately after surgery, and for the long-term, often requiringurinary incontinence devices such as condom catheters or diaper pads. A large analysis of the incidence of urinary incontinence found that 12 months after surgery, 75% of patients didn't need a pad, while 9–16% did. Factors associated with increased risk of long-term urinary incontinence include older age, higher BMI, more comorbidities, larger prostates surgically excised, as well as experience and technique of the surgeon.[20]
Surgical management options for urinary incontinence secondary to prostatectomy include implantation ofperineal slings andartificial urinary sphincters.[21] Although there are limited data on the long-term outcomes in males, perineal slings are offered for mild-to-moderate post-prostatectomy incontinence.[22][23] In a retrospective study the success rate of perinealsling placement in urinary incontinence following prostatectomy achieved 86% at a median follow-up of 22 months.[24] Artificial urinary sphincters are offered for moderate-to-severe urinary incontinence in males and have shown good long-term efficacy and safety.[23][22][25][26] The use of artificial urinary sphincters for post-prostatectomy incontinence is recommended by theEuropean Association of Urology and International Consultation on Incontinence.[22][23]
Transurethral injection of bulking agents have little role in the management of post-prostatectomy incontinence and there is weak evidence that these agents can offer any improvement.[22][23]Pelvic floor muscle training can speed recovery of urinary incontinence following prostatectomy.[23]
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 ofsildenafil to the recovery regimen.[27]
Remedies to the problem of post-operative sexual dysfunction include:[28]
The use of radical prostatectomy as treatment for prostate cancer increased significantly from 1980 to 1990.[29] As of 2000, the median age of men undergoing radical prostatectomy for localized prostate cancer was 62.[29]
Though a very common procedure, the experience level of the surgeon performing the operation is important in determining the outcomes, rate of complications, and side effects. The more prostatectomies performed by a surgeon, the better the outcomes. This is true for prostatectomies done as open procedures[30] and those done using minimally invasive techniques.[31]
William Belfield, MD is generally credited for performing the first intentional prostatectomy via the suprapubic route in 1885, 1886 or 1887 atCook County Hospital in Chicago.[32][33]Hugh H. Young, MD in collaboration withWilliam Stewart Halsted, MD developed the open, radical and perineal prostatectomies in 1904 at Johns Hopkins Brady Urological Institute, the first version of the procedure that became generally feasible.[34] Irish surgeonTerence Millin, MD developed the radical retropubic prostatectomy in 1945.[35] American urologistPatrick C. Walsh, MD developed the modern nerve-sparing, retropubic prostatectomy with minimal blood loss.[36] The first laparoscopic prostatectomy was performed in 1991 by William Schuessler, MD and colleagues in Texas.[37]
A 2014 survey of prostatectomy fees for uninsured patients at 70 United States hospitals found an average facility fee of $34,720 and average surgeon and anesthesiologist fees of $8,280.[38] These figures primarily reflect costs for radical prostatectomy performed for prostate cancer. The cost of minimally invasive or laser prostate surgery for benign prostatic hyperplasia (such as holmium laser enucleation of the prostate, HoLEP) is typically lower due to shorter hospitalization and fewer resources required.[39]
{{cite journal}}: CS1 maint: multiple names: authors list (link){{cite journal}}: CS1 maint: multiple names: authors list (link)