prostatectomy


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Prostatectomy

 

Definition

Prostatectomy refers to the surgical removal of part of the prostate gland (transurethral resection, a procedure performed to relieve urinary symptoms caused by benign enlargement), or all of the prostate (radical prostatectomy, the curative surgery most often used to treat prostate cancer).

Purpose

Benign disease

When men reach their mid-40s, the prostate gland begins to enlarge. This condition, benign prostatic hyperplasia (BPH) is present in more than half of men in their 60s and as many as 90% of those over 90. Because the prostate surrounds the urethra, the tube leading urine from the bladder out of the body, the enlarging prostate narrows this passage and makes urination difficult. The bladder does not empty completely each time a man urinates, and, as a result, he must urinate with greater frequency, night and day. In time, the bladder can overfill, and urine escapes from the urethra, resulting in incontinence. An operation called transurethral resection of the prostate (TURP) relieves symptoms of BPH by removing the prostate tissue that is blocking the urethra. No incision is needed. Instead a tube (retroscope) is passed through the penis to the level of the prostate, and tissue is either removed or destroyed, so that urine can freely pass from the body.

Malignant disease

Prostate cancer is the single most common form of non-skin cancer in the United States and the most common cancer in men over 50. Half of men over 70 and almost all men over the age of 90 have prostate cancer, and the American Cancer Society estimates that 198,000 new cases will be diagnosed in 2001. This condition does not always require surgery. In fact, many elderly men adopt a policy of "watchful waiting," especially if their cancer is growing slowly. Younger men often elect to have their prostate gland totally removed along with the cancer it contains—an operation called radical prostatectomy. The two main types of this surgery, radical retropubic prostatectomy and radical perineal prostatectomy, are performed only on patients whose cancer is limited to the prostate. If cancer has broken out of the capsule surrounding the prostate gland and spread in the area or to distant sites, removing the prostate will not prevent the remaining cancer from growing and spreading throughout the body.

Precautions

Potential complications of TURP include bleeding, infection, and reactions to general or local anesthesia. About one man in five will need to have the operation again within 10 years.
Open (incisional) prostatectomy for cancer should not be done if the cancer has spread beyond the prostate, as serious side effects may occur without the benefit of removing all the cancer. If the bladder is retaining urine, it is necessary to insert a catheter before starting surgery. Patients should be in the best possible general condition before radical prostatectomy. Before surgery, the bladder is inspected using an instrument called a cystoscope to help determine the best surgical technique to use, and to rule out other local problems.

Description

Turp

This procedure does not require an abdominal incision. With the patient under either general or spinal anesthesia, a cutting instrument or heated wire loop is inserted to remove as much prostate tissue as possible and seal blood vessels. The excised tissue is washed into the bladder, then flushed out at the end of the operation. A catheter is left in the bladder for one to five days to drain urine and blood. Advanced laser technology enables surgeons to safely and effectively burn off excess prostate tissue blocking the bladder opening with fewer of the early and late complications associated with other forms of prostate surgery. This procedure can be performed on an outpatient basis, but urinary symptoms do not improve until swelling subsides several weeks after surgery.

Radical prostatectomy

RADICAL RETROPUBIC PROSTATECTOMY. This is a useful approach if the prostate is very large, or cancer is suspected. With the patient under general or spinal anesthesia or an epidural, a horizontal incision is made in the center of the lower abdomen. Some surgeons begin the operation by removing pelvic lymph nodes to determine whether cancer has invaded them, but recent findings suggest there is no need to sample them in patients whose likelihood of lymph node metastases is less than 18%. A doctor who removes the lymph nodes for examination will not continue the operation if they contain cancer cells, because the surgery will not cure the patient. Other surgeons remove the prostate gland before examining the lymph nodes. A tube (catheter) inserted into the penis to drain fluid from the body is left in place for 14-21 days.
Originally, this operation also removed a thin rim of bladder tissue in the area of the urethral sphincter—a muscular structure that keeps urine from escaping from the bladder. In addition, the nerves supplying the penis often were damaged, and many men found themselves impotent (unable to achieve erections) after prostatectomy. A newer surgical method called potency-sparing radical prostatectomy preserves sexual potency in 75% of patients and fewer than 5% become incontinent following this procedure.
RADICAL PERINEAL PROSTATECTOMY. This procedure is just as curative as radical retropubic prostatectomy but is performed less often because it does not allow the surgeon to spare the nerves associated with erection or, because the incision is made above the rectum and below the scrotum, to remove lymph nodes. Radical perineal prostatectomy is sometimes used when the cancer is limited to the prostate and there is no need to spare nerves or when the patient's health might be compromised by the longer procedure. The perineal operation is less invasive than retropubic prostatectomy. Some parts of the prostate can be seen better, and blood loss is limited. The absence of an abdominal incision allows patients to recover more rapidly. Many urologic surgeons have not been trained to perform this procedure. Radical prostatectomy procedures last one to four hours, with radical perineal prostatectomy taking less time than radical retropubic prostatectomy. The patient remains in the hospital three to five days following surgery and can return to work in three to five weeks. Ongoing research indicates that laparoscopic radical prostatectomy may be as effective as open surgery in treatment of early-stage disease.

Cryosurgery

Also called cryotherapy or cryoablation, this minimally invasive procedure uses very low temperatures to freeze and destroy cancer cells in and around the prostate gland. A catheter circulates warm fluid through the urethra to protect it from the cold. When used in connection with ultrasound imaging, cryosurgery permits very precise tissue destruction. Traditionally used only in patients whose cancer had not responded to radiation, but now approved by Medicare as a primary treatment for prostate cancer, cryosurgery can safely be performed on older men, on patients who are not in good enough general health to undergo radical prostatectomy, or to treat recurrent disease. Recent studies have shown that total cryosurgery, which destroys the prostate, is at least as effective as radical prostatectomy without the trauma of major surgery.

Preparation

As with any type of major surgery done under general anesthesia, the patient should be in optimal condition. Most patients having prostatectomy are in the age range when cardiovascular problems are frequent, making it especially important to be sure that the heart is beating strongly, and that the patient is not retaining too much fluid. Because long-standing prostate disease may cause kidney problems from urine "backing up," it also is necessary to be sure that the kidneys are working properly. If not, a period of catheter drainage may be necessary before doing the surgery.

Aftercare

Following TURP, a catheter is placed in the bladder to drain urine and remains in place for two to three days. A solution is used to irrigate the bladder and urethra until the urine is clear of blood, usually within 48 hours after surgery. Whether antibiotics should be routinely given remains an open question. Catheter drainage also is used after open prostatectomy. The bladder is irrigated only if blood clots block the flow of urine through the catheter. Patients are given intravenous fluids for the first 24 hours, to ensure good urine flow. Patients resting in bed for long periods are prone to blood clots in their legs (which can pass to the lungs and cause serious breathing problems). This can be prevented by elastic stockings and by periodically exercising the patient's legs. The patient remains in the hospital one to two days following surgery and can return to work in one to two weeks.

Risks

The complications and side effects that may occur during and after prostatectomy include:
  • Excessive bleeding, which in rare cases may require blood transfusion.
  • Incontinence when, during retropubic prostatectomy, the muscular valve (sphincter) that keeps urine in the bladder is damaged. Less common today, when care is taken not to injure the sphincter.
  • Impotence, occurring when nerves to the penis are injured during the retropubic operation. Today's "nerve-sparing" technique has drastically cut down on this problem.
  • Some patients who receive a large volume of irrigating fluid after TURP develop high blood pressure, vomiting, trouble with their vision, and mental confusion. This condition is caused by a low salt level in the blood, and is reversed by giving salt solution.
  • A permanent narrowing of the urethra called a stricture occasionally develops when the urethra is damaged during TURP.
  • There is about a 34% chance that the cancer will recur within 10 years of the procedure. In addition, about 25% of patients experience what is known as biochemical recurrence, which means that the level of prostate-specific antigen (PSA) in the patient's blood serum begins to rise rapidly. Recurrence of the tumor or biochemical recurrence can be treated with radiation therapy or androgen deprivation therapy.

Normal results

In patients with BPH who have the TURP operation, urination should become much easier and less frequent, and dribbling or incontinence should cease. In patients having radical prostatectomy for cancer, a successful operation will remove the tumor and prevent its spread to other areas of the body (metastasis). If examination of lymph nodes shows that cancer already had spread beyond the prostate at the time of surgery, other measures are available to control the tumor.

Key terms

BPH — Benign prostatic hypertrophy, a very common noncancerous cause of prostatic enlargement in older men.
Catheter — A tube that is placed through the urethra into the bladder in order to provide free drainage of urine and blood following either TURP or open prostatectomy.
Cryosurgery — In prostatectomy, the use of a very low-temperature probe to freeze and thereby destroy prostatic tissue.
Impotence — The inability to achieve and sustain penile erections.
Incontinence — The inability to retain urine in the bladder until a person is ready to urinate voluntarily.
Prostate gland — The gland surrounding the male urethra just below the base of the bladder. It secretes a fluid that constitutes a major portion of the semen.
Urethra — The tube running from the bladder to the tip of the penis that provides a passage for eliminating urine from the body.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Prostate Cancer." Section 17, Chapter 233 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
Marks, Sheldon. Prostate Cancer: A Family Guide to Diagnosis, Treatment and Survival. Cambridge, MA: Fisher Books, 2000.
Wainrib, Barbara, et al. Men, Women, and Prostate Cancer: A Medical and Psychological Guide for Women and the Men they Love. Oakland, CA: New Harbinger Publications, 2000.

Periodicals

Augustin, H., and P. G. Hammerer. "Disease Recurrence After Radical Prostatectomy. Contemporary Diagnostic and Therapeutical Strategies." Minerva Urologica e Nefrologica 55 (December 2003): 251-261.
Gomella, L. G., I. Zeltser, and R. K. Valicenti. "Use of Neoadjuvant and Adjuvant Therapy to Prevent or Delay Recurrence of Prostate Cancer in Patients Undergoing Surgical Treatment for Prostate Cancer." Urology 62, Supplement 1 (December 29, 2003): 46-54.
Nelson, J. B., and H. Lepor. "Prostate Cancer: Radical Prostatectomy." Urologic Clinics of North America 30 (November 2003): 703-723.
Zimmerman, R. A., and D. G. Culkin. "Clinical Strategies in the Management of Biochemical Recurrence after Radical Prostatectomy." Clinical Prostate Cancer 2 (December 2003): 160-166.

Organizations

Cancer Research Institute. 681 Fifth Ave., New York, NY 10022. (800) 99CANCER. http://www.cancerresearch.org.
National Prostate Cancer Coalition. 1156 15th St., NW, Washington, DC 20005. (202) 463-9455. http://www.4npcc.org.
Prostate Health Council. American Foundation for Urologic Disease. 1128 N. Charles St., Baltimore, MD 21201-5559. (800) 828-7866. http://www.afud.org.

prostatectomy

 [pros″tah-tek´to-me]
surgical removal of the prostate.
radical prostatectomy removal of the prostate with its capsule, seminal vesicles, ductus deferens, some pelvic fasciae, and sometimes pelvic lymph nodes; performed via either the retropubic or the perineal route.

pros·ta·tec·to·my

(pros'tă-tek'tŏ-mē),
Removal of a part or all of the prostate.
[prostat- + G. ektomē, excision]

prostatectomy

/pros·ta·tec·to·my/ (pros″tah-tek´tah-me) excision of all or part of the prostate.
radical prostatectomy  removal of the prostate with its capsule, seminal vesicles, ductus deferens, some pelvic fasciae, and sometimes pelvic lymph nodes; performed via either the retropubic or the perineal route.
radical retropubic prostatectomy  radical prostatectomy through the retropubic space via a suprapubic incision.
suprapubic transvesical prostatectomy  removal of the prostate through a suprapubic incision and an incision in the urinary bladder.

prostatectomy

(prŏs′tə-tĕk′tə-mē)
n. pl. prostatecto·mies
Surgical removal of all or part of the prostate gland.

prostatectomy

[pros′tətek′təmē]
Etymology: Gk, prostates + ektomē, excision
surgical removal of a part of the prostate gland, such as that performed for benign prostatic hypertrophy, or the total excision of the gland, as performed for malignancy. Type and crossmatching of blood are done to prepare for possible transfusion. In the transurethral approach, the most common approach, a resectoscope is inserted into the urethra, and through it shavings of prostatic tissue are cut off at the bladder opening. The perineal approach is used for biopsy when early cancer is suspected or for the removal of calculi. In the suprapubic approach a large catheter is positioned into the bladder through the abdomen. Wound drains are placed in both the perineal and the suprapubic approaches. After surgery hematuria is expected for several days. Bleeding may be controlled by increasing the pressure at the balloon end of the urethral catheter. If arterial the bleeding is bright red with clots and increased viscosity and may lead to hemorrhagic shock, requiring transfusion and surgical intervention. The bladder catheter is connected to a closed system of irrigation with drainage. Meticulous aseptic technique is required to prevent infection when tending catheters, tubings, and collection bags, as well as when changing the dressing. Catheter patency is ensured, as well as care to prevent blockage or kinking of the drainage tubes. Accidental removal or dislodging of catheters is prevented. Bladder spasm may occur if a catheter becomes blocked or result from the irritation of the balloon of the catheter in the bladder. Antispasmodic drugs may prevent spasm but are not given in severe cardiac disease or if glaucoma is present. The nurse also assesses the patient's ability to void in adequate amounts when the urethral catheter is removed. Complications of prostatectomy include urethral stricture, especially with the transurethral approach; urinary incontinence; and impotence, especially with the perineal approach.
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Prostatectomy

prostatectomy

 Urology The surgical removal of part or the entire–radical/total prostate and some surrounding tissue. See Microwave prostatectomy, Nerve-sparing prostatectomy, Perineal prostatectomy, Radical prostatectomy.

pros·ta·tec·to·my

(pros'tă-tek'tŏ-mē)
Removal of part or all of the prostate.
[prostat- + G. ektomē, excision]

prostatectomy

An operation to remove an enlarged PROSTATE GLAND or to remove enough of it to relieve urinary obstruction. Prostatectomy is usually performed via the urine tube (urethra) using an instrument called a resectoscope which incorporates a heated wire used to cut away unwanted tissue. This is called transurethral prostatectomy (TURP). Total prostatectomy is performed to treat cancer of the prostate.

prostatectomy

surgical removal of the prostate.

Patient discussion about prostatectomy

Q. 4 years post prostatectomy with psa=0 the psa went up to 0.3. how come? what does it mean?

A. It probably means you still have some prostate tissue in your body despite the surgical removal. This tissue can grow and produce PSA. You should be followed up by a urologist to keep track of your PSA. If it keeps rising perhaps there will be a need of another ultrasound examination to see exactly what is left.

More discussions about prostatectomy
References in periodicals archive ?
A non-cutting trocar was then used to gain direct access to the abdominal cavity, with the remaining ports placed under direct vision in the standard radical prostatectomy configuration with two 8-mm ports on the patient's left and an 8-mm and 12-mm assistant port on the patient's right.
Vorstman continued, "The intentional withholding of information, deceptions, and distortions regarding the radical prostatectomy being perpetrated now by robotics advocates know no bounds.
Surgical approaches should be deferred for at least 12 months following prostatectomy (15) and include male slings for mild intrinsic sphincter deficiency (ISD) or artificial urinary sphincters--the gold-standard treatment and last resort--for severe ISD.
These trends are concerning because both IMRT and robotic prostatectomy are considerably more expensive than the less aggressive approaches they are displacing, the researchers added.
Current treatment practice for patients following prostatectomy is to only monitor those patients until biochemical recurrence has occurred.
A recent Health Technology Assessment performed on behalf of the National Institute for Health Research has suggested that robotic prostatectomy may lower operative complication rates further and improve cancer control, however, we have to remember that the report also concludes there remains some uncertainty about the level of improvements as there is a lack of quality data from randomised trials.
Comparisons between prostatectomy and radiotherapy were adjusted extensively in an attempt to compare similar men who simply had different treatments.
Thus the practice of treating low-risk disease with radical prostatectomy is at odds with the best available evidence from PIVOT that surgery for low-risk cancer isn't effective.
In a previously announced retrospective study of stored leftover serum of 85 post-prostatectomy patients, NADiA(TM) ProsVue(TM) detected levels of PSA after radical prostatectomy that were undetectable using conventional ultra sensitive assays.
Such diagnosis on final radical prostatectomy was proved wrong most of the time.
New research suggests that robot-assisted laparoscopic prostatectomy (RALP) provides comparable oncologic control as retropubic radical prostatectomy but is associated with better functional outcomes.
Robot-assisted anatomic prostatectomy is an emerging technique for management of prostate cancer.

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