What is Prostate Surgery?
Urologist, Manipal Dwarka hospital, 9 years of experience
What is Prostate Surgery?
The prostate is a walnut-sized gland in men that is located near the bladder and wraps around the urethra. Cancer of the prostate is one of the most common cancers in men. To be more specific, it is the second most common cancer and the sixth leading cause of cancer death among men worldwide, with 1.1 million cases and 307,000 deaths in 2012. 1,2
Prostate surgery is a procedure that involves the complete or partial surgical removal of the prostate gland. Prostate surgery is also known as prostatectomy. It is performed on patients with prostate cancer, enlarged prostate or benign prostatic hyperplasia (BPH). Prostate cancer can be metastatic which means that it can spread to other parts of the body, such as surrounding bones and lymph nodes. Therefore, surgical removal of the prostate can stop cancer from spreading.
Let us elaborate on prostate surgery in today’s article.
- When is Prostate Surgery done?
- Which medical conditions can be treated by Prostate Surgery?
- In which areas of the prostate do the diseases requiring surgery occur?
- What is the purpose of prostate surgery?
- How is the examination done prior to Prostate Surgery?
- What are the investigations done before Prostate Surgery?
- What is the procedure of Prostate Surgery?
- What happens after Prostate surgery?
- How to take care after Prostate Surgery?
- What are the urinary problems noticed after prostate surgery?
- What are the risks of Prostate Surgery?
- What is the cost of Prostate Surgery in India?
When is Prostate Surgery done?
The most common indications for Prostate Surgery are:
- Prostatism includes frequency of urination, dysuria or painful urination, and the urgency of urination. ( Know more about- Urine Pain )
- Acute retention of urine
- Chronic retention of urine where residual urine is more than 200ml
- Complications like hydroureter which is urine retention in the tube carrying urine from the kidneys to the bladder; hydronephrosis which is a condition in which excessive collection of urine in the kidneys results in the swelling up of the kidneys, stone formation, recurrent infection, blood in the urine
In addition to these, some of the general symptoms include:
- Burning pain during urination ( Know more about- What is Painful and Burning Urination? )
- Difficulty in passing urine
- Blood in urine or semen ( Know more about- What is Blood in Urine? )
- Increased urination at night
- Painful or difficulty in ejaculation. ( Know more about- What is Painful Ejaculation?)
- Pain in pelvis and legs
- Bone pain
Which medical conditions can be treated by Prostate Surgery?
A number of conditions arise from the prostate like prostatic calculi which means stones, acute bacterial prostatitis or inflammation of the prostate due to infection, etc. However, the 3 major conditions that result in prostate surgery are:
- Prostate cancer
- Prostate enlargement
- Benign Prostate Hyperplasia (BPH): Benign or non-cancerous enlargement of prostate seen after 50 years of age. ( Know more about- Prostate Cancer? )
There are many hospitals and oncologists in India who treat prostate cancer with great success, prostate surgery being one of the treatment modalities.
In which areas of the prostate do the diseases requiring surgery occur?
The prostate gland is divided into 3 zones. They are:
- Central zone
- Transitional zone
- Peripheral zone
The central and transitional zone is most commonly affected by benign prostate hyperplasia (BPH) while the peripheral zone is affected by prostate cancer.
What is the purpose of prostate surgery?
The goal of prostate surgery is to:
- cure the disease or condition
- ensure that urinary continence i.e., the ability of the urinary system to function normally is restored. ( Know more about- What is Stress Urinary Incontinence?)
- ensure that ability to have erections is restored
- reduce side effects of the condition like discomfort and displacement of other organs in that region
- reduce the pain even during and after surgery.
How is the examination done prior to Prostate Surgery?
The patient is asked to remove their trousers and underwear for the doctor to examine the prostate. This is called Digital Rectal Examination (DRE).
- In the case of BPH, the prostate is firm and rubbery, the mucosa or membrane surrounding it is mobile
- In the case of prostate cancer, the prostate is hard and mucosa is fixed
What are the investigations done before Prostate Surgery?
The investigations done prior to Prostate Surgery are:
Urine examination: It consists of:
- Routine microscopic examination
- Detection of sugar and blood in the urine
- Urine culture to detect infections
Ultrasound KUB: Ultrasound of Kidney Ureter, Bladder to find out:
- Prostate Volume
- Residual or remaining urine in the bladder
- Hydronephrosis; a condition in which excessive collection of urine in the kidneys results in the swelling up of the kidneys
Serum Prostate-Specific Antigen (PSA): It is a Glycoprotein, the value of which varies with age.
- In the case of a 50-69-year-old patient, which happens to be the most common age group for prostatic abnormalities, the normal value is 0-3mg/ml. This is seen in BPH.
- If the PSA is more than 3mg/ml it can be seen in BPH, prostatitis, or prostate cancer.
- If it is Prostatitis, antibiotics are given and 6 weeks later a PSA Test is done. If the value is normal, the diagnosis was accurate.
- If the values don’t come back to normal in the PSA Test after 6 weeks, it could be BPH or cancer
- Thus, to differentiate between BPH and cancer a Biopsy is done which is called a TRUS (TransRectal USG) Guided Tru-cut Biopsy. Minimum of 12 biopsies are taken. But here the risk of sepsis is higher.
- Now, a Transperineal Template biopsy for the prostate is done. It is better for anterior lobe biopsy.
What is the Procedure of Prostate Surgery?
After detailed Digital Rectal Examination (DRE) and investigations have been done, surgical procedures can be undertaken.
- In the case of Prostate cancer, the types of surgeries considered are:
Radical prostatectomy: This involves removal of the entire prostate, including the seminal vesicles and vas deferens which happen to be parts of the testes.
The steps of Radical prostatectomy are as follows:
- The patient would have to remove any kind of jewelry from the body
- The bladder has to be emptied before the procedure
- An intravenous (IV) line will start
- Excessive hair at the surgical site is removed
- Cleaning of the skin is done with an antiseptic solution
- The heart rate, blood pressure, breathing, and blood oxygen level are monitored during the surgery
- Once the patient has been sedated, a tube for breathing is inserted through the throat into the lungs
- Anesthesia is given to numb the region
- A catheter is inserted into the bladder
The types of Radical Prostatectomy done are:
- Retropubic
- Suprapubic
- Perineal
In case of retropubic or suprapubic:
- The patient is asked to lie on the back
- An incision is made from below the belly button to the pubic region
- Lymph nodes are dissection first
- From the prostate gland; the nerve bundles will be released carefully
- The urethra which is a thin tube through which urine passes out of the body is identified
- The seminal vesicles which are glands that are part of the reproductive system may also be removed
- The prostate gland is removed
- In the right lower area of the incision, a drain is inserted
In case of perineal:
- The patient is made to lie on the back. The hips and knees are bent and the legs spread apart
- An inverted U-shaped incision will be made
- The doctor tries to avoid any kind of trauma to the nerve bundles in that area
- The prostate gland along with any tissue that is affected in that area is removed
- The seminal vesicles may be removed in case of abnormality
At the end of both procedures:
- Suturing is done at the site of the incision
- The incision area is dressed with a bandage
The advantage of retropubic prostatectomy is that in this type of surgery the surgeon has access to lymph nodes and tissues around that region that may have gotten infected, while the advantages of perineal prostatectomy are quicker recovery and less severe pain in comparison to retropubic surgery.
- Laparoscopic approach to radical prostatectomy: This procedure is not as invasive as radical prostatectomy and is done by making several small incisions to remove the prostate with the help of specialized instruments.
- Laparoscopic radical prostatectomy: For this process, several small surgical instruments with small tubes are inserted, with a camera at one end, through small cuts to remove the prostate.
- Robotic-assisted laparoscopic radical prostatectomy: A camera is attached to the robotic interface. Thus, the robotic instruments can be controlled while sitting in an operating room.
- In case of urinary outlet obstruction due to BPH.
Surgical and minimally invasive treatment is chosen, if the following criteria are met:
- The patient has been diagnosed with lower urinary tract symptoms due to BPH that results in a hindrance to daily activities
- The urine flow rate of the patient is below normal
- The patient has not been able to satisfactorily void urine with medication individual has failed a trial of satisfactory voiding with medication
Firstly, just like other procedures, the patient has to be under general anesthesia which means unconscious throughout the procedure. If general anesthesia cannot be given, a spinal anesthetic is given which allows the patient to be awake but blocks all sensation from below the waist. An antibiotic is injected to reduce the chances of infection.
The types of surgeries and the steps after anesthesia, in this case, are as follows:
Transurethral resection of the prostate (TURP):
- A cystoscope which is a narrow tube that consists of a light and camera at the end is used to visualize the prostatic region
- Fluid like glycine is continuously sprayed in that region
- The enlarged prostate is located by the surgeon
- It is then cut out by manually navigating a loop through it
- The central, transitional, and majority of the peripheral zone is removed in this process but some part of the peripheral zone is left behind and this results in the recurrence of cancer because cancer is most common in the peripheral zone
- This is done using a high-frequency diathermy current, which is a surgical technique in which heat is produced and applied to a part of the body by the high-frequency current
- This results in the destruction of unhealthy tissue and clotting of blood vessels
Holmium laser enucleation of the prostate (HoLEP):
- For HoLEP, the patient is asked to lie on his back with his legs raised
- A resectoscope is a surgical instrument that is inserted through the urethra which is the tube that carries urine from the bladder to be released
- The resectoscope has a camera through which a surgeon can see the internal structure of the prostate gland
- The laser is then inserted into the resectoscope and can be used to free up the enlarged prostate tissue from the outer shell that surrounds it, called the capsule. It is also used to seal up any blood vessels
- The laser is removed from the resectoscope and a morcellator is inserted. The tissue left behind in the bladder can be suctioned out using a morcellator
- The resectoscope is removed once the tissue has been suctioned out
- A urinary catheter is inserted
Transurethral laser incision of Prostate (TULIP):
- A resectoscope is inserted through the tip of your penis into the urethra which is the channel that carries urine from the bladder
- In the area where the prostate and the bladder are connected, the doctor cuts small groves
- This helps to open out the channel. Thus, urine is allowed to pass easily
- TULIP is less invasive and thus preferred to treat BPH
Open (Simple) Prostatectomy: This involves the removal of the prostatic adenoma or tumor. The complete removal of the prostatic adenoma under direct visualization in the suprapubic and retropubic approaches is one of the advantages of open (simple) prostatectomy over TURP.
Just like Radical prostatectomy, open (simple) prostatectomy has 3 different approaches: retropubic, suprapubic, and perineal. The main difference is that in open prostatectomy only the prostatic tumor is removed while in radical prostatectomy, the prostate along with the seminal vesicles and vas deferens may be removed. One other difference is that open prostatectomy is not done in the case of prostate cancer.
What happens after Prostate surgery?
- After prostate surgery, the patients remain admitted to the hospital for a few days, until recovered
- The patient is required to stay in the hospital for a couple of days, but in some cases, he is allowed to go home after 24 hours
- After surgery, the bladder is irrigated by normal saline using a catheter
- Antibiotics are given to the patient
- The catheter that was placed through the penis of the patient right up to the urinary bladder to drain the urine is retained there for 72 hours
- The doctor or the nurse advises the patient on how the catheter should be maintained in that region
- The doctor also gives instructions to the patient about the care he has to take off the surgical site.
How to take care after Prostate Surgery?
- Adherence to examinations and tests by a doctor are also be necessary to ensure that the patient is recovering and that cancer has not recurred
- The patient should not do any kind of physical activity after surgery unless the doctor gives permission
- Care of the surgical site should be taken to prevent any sort of pressure or trauma to that region
What are the urinary problems noticed after prostate surgery?
Irrespective of the kind of surgery done, the place where the incision is taken will always be slightly sore for a few days. In addition to that area, the urinary system is temporarily affected. The patient might experience:
- blood in the urine
- urinary itching or irritation
- burning sensation while urinating.
- difficulty holding urine which results in experiencing sudden urgency to urinate
What are the risks of Prostate Surgery?
Complications associated with prostate surgery can be similar to any other major surgical procedure. They consist of the general complications seen in any surgery like excessive blood loss, reaction to anesthesia, etc. along with complications specific to the organs surrounding the site of the surgery like the urinary bladder, urethra, which is the tube-like structure that carries the urine out from the urinary bladder. In short, the common complications are:
- Bleeding
- Blood clot formation in the legs
- Formation of blood clots in the pelvic region which is the area between the abdomen and thighs
- Pulmonary embolism which are blood clots that travel to the lung from the legs. (Know more about- What is Pulmonary Embolism? )
- Infection at the site of surgery
- Urinary incontinence which means the inability to control urine
- Erectile dysfunction or impotence (ED)
- Urinary tract infection
- Narrowing which is called stricture formation of the urethra
- Narrowing of the neck of the bladder
In addition to the complications mentioned, some of the more specific ones related to TURP are:
- Water intoxication is an increase in water content in the body that leads to fluid overload resulting in Congestive Cardiac Failure. This is called TURP Syndrome
- Hyponatremia or a decrease in the sodium content of the body
- Perforation of the bladder or injury to the bladder
- Stricture of the urethra which is narrowing of the tube due to scarring
- Retrograde ejaculation is the flow of ejaculate or semen in the opposite direction i.e., into the bladder
What is the cost of Prostate Surgery in India?
The total cost of prostate surgery in India can range from around INR 3,00,000 to INR 4,00,000. However, there are many large hospitals and experienced doctors in India who specialize in prostate surgery. But the cost varies from hospital to hospital. Hence, it is important to consult a Urologist.
If you are coming from abroad, in addition to the cost of prostate surgery, there will be a cost of staying in a hotel, the cost of living, and the cost of local travel. Apart from this, after the surgery, the patient stays in the hospital for 3 days and in the hotel for 14 days for recovery. So, the total cost of prostate surgery comes around INR 4,50,000 – INR 5,00,000.
We hope your question, what is prostate surgery, has been answered through this article.
If you want more information and treatment of Prostate Surgery, you can contact a Urologist.
We only aim to give you information through the article. We do not recommend medication, or treatment in any way. Only a doctor can give you the best advice.
References:
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- Cancer of Ro. GLOBOCAN 2012: estimated cancer incidence, mortality, and prevalence worldwide in 2012. 2012.
- Facchini G, Perri F, Misso G, D Aniello C, Scarpati G, Rossetti S, Pepa CD, Pisconti S, Unteregger G, Cossu A, Caraglia M, Berretta M, Cavaliere C. Optimal management of prostate cancer based on its natural clinical history. Curr Cancer Drug Targets 2017; 28: 1-16.
