Prostate removal

Prostate removal is surgery to remove or destroy part or all of the prostate gland -- an organ at the base of the bladder in men.

See also: Benign prostatic hypertrophy

An enlarged prostate can cause problems urinating and urinary tract infections. Removing all or part of the prostate gland can often relieve these symptoms. Prostate removal can be performed in a number of different ways, depending on the size of the prostate and the cause of the prostate enlargement.

The three most common procedures for removing the prostate when there is no cancer are:

• Transurethral resection of the prostate (TURP)
• Laser prostatectomy (or less-invasive heat-based procedures)
• Open prostatectomy

The decision regarding the type of prostatectomy depends on the size of your prostate gland. For glands bigger than 30 grams and less than 80 grams (this number depends on the experience of the surgeon), TURP is performed. If the prostate is bigger than 90 grams, open prostatectomy is recommended.

TURP

Transurethral resection of the prostate is the most common, and most proven surgical procedure for benign prostatic hyperplasia (BPH). TURP is performed using spinal or general anesthesia.

A tube-like instrument called a cystoscope is inserted into the penis through the urethra and up to the prostate gland. A special cutting instrument is inserted through the cystoscope to remove the prostate gland piece by piece. An electric current is used to stop the bleeding during surgery. This is called cauterization.

After surgery, a Foley catheter is placed in the body to help remove urine. The urine will first look bloody, but will clear with time.

A liquid solution may be attached to the catheter to flush the area and keep the tube from becoming clogged with blood or tissue. The bleeding will gradually decrease, and the catheter will be removed within 1 - 3 days. You will stay in the hospital for 1 - 3 days.

LASER PROSTATECTOMY

Laser prostatectomy uses beams of light to destroy prostate tissue. This procedure is usually performed on an outpatient basis and does not require a hospital stay.

The laser beam destroys any prostate tissue that is blocking the opening of the urethra and bladder. This improves the urine flow rate and reduces the symptoms of BPH. A Foley catheter may be placed to help drain the bladder after surgery. The catheter will usually stay in place for a few days after surgery.

LESS INVASIVE PROCEDURES

Less invasive procedures may be a choice for certain patients who are unable to have a more invasive procedure, or who choose to have a less invasive procedure. However, none of the less-invasive procedures have been proven to be better than TURP. Your doctor can discuss the pros and cons of each procedure with you.

These procedures use different forms of heat to destroy prostate tissue:

• Transurethral needle ablation (TUNA) uses high-frequency sound waves (ultrasound).
• Transurethral microwave thermotherapy (TUMT) uses a microwave antenna fed through a catheter.
• Transurethral electrovaporization (TUVP) is similar to TURP, except it uses a roller ball to heat the prostate tissue.
• Water-induced thermotherapy (WIT) uses a heated water catheter.
• Interstitial laser coagulation (ILC) and holmium laser enucleation of the prostate (HoLEP) use lasers.

OPEN PROSTATECTOMY

Open prostatectomy is open surgery to remove all or part of the prostate gland. Types of open prostatectomy include:

• Transurethral approach (most common)
• Transvesical approach
• Retropubic approach
• Suprapubic approach

The main advantage of the transurethral approach is that it does not create an outside surgical cut. However, it is difficult to remove a large prostate using this approach.

To perform an open prostatectomy (sometimes called suprapubic or retropubic prostatectomy), a surgical cut is made in the lower abdomen between the belly button and the penis. The prostate gland is removed through this cut.

Only the inner part of the prostate gland is removed. The outer portion is left behind (similar to scooping out the inside of an orange). This procedure usually requires a longer hospital stay and recovery period.

Open prostatectomy is performed using general or spinal anesthesia. You will return from surgery with a Foley catheter in place. Occasionally, a suprapubic catheter will be inserted to help drain the bladder.

A solution may be attached to the catheter to prevent it from becoming clogged with blood. A drainage tube may also be placed in the abdomen to drain blood and fluids from the area.

Urine may look bloody at first, but it should start to look normal in a few days. The Foley catheter and suprapubic catheters will remain in place for 5 days to a few weeks until the bladder has healed enough.

TRANSURETHRAL INCISION OF THE PROSTATE (TUIP)

TUIP is similar to TURP, but is usually performed in men with a smaller prostate. An instrument is used to remove the prostate tissue that is blocking urine flow. This procedure usually does not require a hospital stay.

Prostate removal may be recommended for:

• Bladder stones with prostate enlargement
• Bleeding from the prostate
• Inability to completely empty the bladder (urinary retention)
• Increased pressure on the ureters and kidneys (hydronephrosis) from urinary retention
• Stage A and B prostate cancer
• Very slow urination

Prostate surgery is not recommended for men who have:

• Bladder disease (neurogenic bladder)
• Blood clotting disorders

Risks for any anesthesia are:

• Reactions to medications
• Problems breathing

• Bleeding
• Infection

Other risks include:

• Difficulty getting and keeping an erection (impotence)
• Infertility
• Passing the semen into the bladder instead of out through the urethra (retrograde ejaculation)
• Problems with urine control (incontinence)
• Urethral stricture

Complications depend on the type of surgery you have.

Most men who have prostate surgery have improved symptoms and urine flow rates.

TURP usually can relieve the symptoms of an enlarged prostate. However, reports find that within 10 years, about 20% of men will need another surgery to remove more prostate tissue.

Patients who have less-invasive procedures such as TUMT or TUNA are more likely to need surgery again in 5-10 years.

Patients recovering from surgery for an enlarged prostate may have:

• Blood in the urine
• Burning with urination
• Frequent or urgent urination

The hospital stay after open prostatectomy is 4 - 7 days. Complete recovery from surgery can take 3 weeks.

To help you recover:

• Drink plenty of fluids to help flush liquids through the bladder.
• Avoid coffee, cola drinks, and alcoholic beverages because these can irritate the bladder and urethra.
• Do not do any lifting for 3 - 4 weeks.
• Use a stool softener to help prevent constipation, which can delay the healing process.

Kirby R, Lepor H. Evaluation and Nonsurgical Management of Benign Prostatic Hyperplasia. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007; chap 87.

Roehrborn CG, McConnell JD. Benign Prostatic Hyperplasia: Etiology, Pathophysiology, Epidemiology, and Natural History. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007; chap 86.

Fitzpatrick JM. Minimally Invasive and Endoscopic Management of Benign Prostatic Hyperplasia. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007; chap 88.

Mattiasson A, Wagrell L, Schelin S, Nordling J, Richthoff J, Magnusson B, et al. Five-year follow-up of feedback microwave thermotherapy versus TURP for critical BPH, a prospective randomized multicenter study. Urology. 2007;69:91-96.