Definition

Surgical removal of part or all of the prostate gland.

 

Alternative names

prostatectomy; TURP; suprapubic prostatectomy; transurethral resection of the prostate; TUIP

 

Description

The prostate gland is a fibrous organ that surrounds the urinary urethra. An enlarged prostate gland can compress the urethra, thus causing problems with urination. Prostate enlargement may be caused by prostate gland overgrowth (benign prostatic hypertrophy or hyperplasia) or prostate cancer.

Removal of the prostate gland can performed in a number of different ways depending on the size of the prostate, and the cause of the prostate enlargement (such as prostate cancer). The three most common procedures for surgically removing the prostate gland include: transurethral resection of the prostate (TURP), suprapubic prostatectomy, and transurethral incision of the prostate (TUIP).

TURP
Transurethral resection of the prostate (TURP) is the most common surgical procedure for benign prostatic hyperplasia (BPH). TURP is performed using spinal or general anesthesia. A special kind of cystoscope (resectoscope) is inserted into the meatus (opening at the tip of the penis), through the urethra to reach the prostate gland. A special cutting instrument is inserted through the resectoscope to remove the prostate gland. Blood vessels are cauterized (using heat to stop the bleeding) with electric current during the surgery. A foley catheter may be placed to help drain the bladder after surgery. The urine will initially appear very bloody with shreds of tissue. A bladder irrigation solution may be attached to the catheter to continuously flush the catheter thus keeping it from becoming clogged with blood or tissue. The bleeding will gradually decrease, and the catheter will be removed within a few days. You will remain in the hospital for 3 to 5 days.

SUPRAPUBIC PROSTATECTOMY 
Although the transurethral approach is commonly used, other surgical approaches to removal of the prostate gland, such as the transvesical, retropubic and suprapubic approaches may be required. The primary advantage of the transurethral approach is that it does not create an external incision, which may be a potential site for introducing infection.

To perform a suprapubic prostatectomy (often called an open prostatectomy), an incision is made in the lower abdomen through which the prostate gland is removed. This is a much more involved procedure that requires an extensive hospitalization and recovery period. Open prostatectomy is often performed along with a lymph node dissection (removal) in treatment of prostate cancer.

Suprapubic prostatectomy is performed using general or spinal anesthesia. You will return from surgery with a foley catheter in place and a suprapubic catheter inserted in the abdominal wall to help drain the bladder. A drainage tube is also placed in the abdominal cavity to drain excess blood and fluids from the area.

Your urine may initially appear very bloody, but this should resolve in a few days. The foley catheter and suprapubic catheters will remain in place for about three weeks to allow the incisions to heal.

You will return from surgery with several IV lines in place to provide you with fluids and nourishment. A nasogastric tube (NG tube) will be inserted during surgery to decompress your stomach until normal bowel function returns. Your anesthesiologist may discuss with you various options for pain relief after surgery. A combination of epidural narcotics and/or IV patient-controlled analgesia (PCA) may be used to manage post surgery pain.

You will also return from surgery wearing anti-embolism stockings or an inflatable anti-embolism devices. These devices are used to reduce your risk of developing blood clots, which are more common after large abdominal surgeries. Additionally, you will be encouraged to start moving and walking early after surgery. You may be instructed on how to use an incentive spirometry device (a plastic device that indicates how much air is breathed in at one time) to gradually increase the depth of your respirations, as well as performing deep breathing and coughing maneuvers in order to prevent pneumonia.

TUIP 
Transurethral incision of the prostate (TUIP) is similar to TURP, but is usually performed in people who have a relatively small prostate. This procedure is performed on an outpatient basis and does not require a hospital stay. A small incision is made in the prostatic tissue to enlarge the lumen (opening) of the urethra and bladder outlet, thus improving the urine flow rate and reducing the symptoms of BPH. A foley catheter may be placed to help drain the bladder after surgery. The catheter will remain in place for a few days after surgery. You may be instructed on how to remove the catheter at home.

Transurethral laser incision of the prostate (TULIP) and visual laser ablation (VLAP) are two newer procedures that use lasers to cut out or destroy the prostate tissue. These procedures are similar to the transurethral incision of the prostate (TUIP). Laser is being evaluated for use in removal of prostatic tissue because of the ability to easily control bleeding and decrease the amount of time required for healing.

Other treatments being investigated for treating the symptoms of prostate enlargement include balloon dilation of the prostatic urethra and placement of prostate stents that stretch open the narrowed urethral passage through the prostate gland.

Symptoms of prostate enlargement and blockage (obstruction) include:

• frequent urination with small amounts of urine

• recent need to urinate at night (nocturia)

• difficulty starting a stream of urine

• slow stream of urine

• urine dripping out of urethra after urination (dribbling)

• feeling that bladder is never empty

Indications

Prostate removal may be recommended for:

• inability to completely empty the bladder (urinary retention)

• recurrent bleeding from the prostate

• bladder stones (calculi) with prostate enlargement

• extremely slow urination

• stage A and B prostate cancer

• increased pressure on the ureters and kidneys (hydronephrosis) from urinary retention

Prostate surgery is not recommended for men who have:

• blood clotting disorders

• bladder disease (neurogenic bladder)

Expectations after surgery

TURP is typically successful at removing the symptoms of an enlarged prostate, although some sources report that within 10 years, about 20% of the people will require another surgery to remove additional prostate tissue.

TUIP has been shown to successfully relieve the symptoms of benign prostatic hyperplasia (BPH) in people with a relatively small prostate gland.

Suprapubic prostatectomy is usually successful in relieving the symptoms of benign prostatic hyperplasia.

 

Convalescence

Hospital stay for open prostatectomy is about 7 to 10 days. Complete recovery from surgery can take 3 weeks. Drink plenty of fluids to help flush fluids through the bladder. Avoid coffee, cola drinks, and alcoholic beverages as these can cause irritation of the bladder and urethra.

 

Risks

Risks for any anesthesia are:

• reactions to medications

• problems breathing

Risks for any surgery are:

• bleeding

• infection

Additional risks include:

• problems with urine control (incontinence)

• difficulty achieving and maintaining an erection (impotence)

• loss of sperm fertility (infertility)

• passing the semen into the bladder instead of out through the urethra (retrograde ejaculation)

• urethral stricture (tightening of the urinary outlet)

Cost

The costs of any surgery varies significantly between surgeons, medical facilities, and regions of the country. Patients who are younger, sicker, or need more extensive surgery will require more intensive and expensive treatment.

Surgery charges can be separated into five parts:
1. Surgeon's fee: variable
2. Anesthesiologist's fee: averages $350 to $400 per hour
3. Hospital charges: basic rate averages $1,500 to $1,800 per day (more for the intensive care unit (ICU) or private rooms)
4. Medication charges:
5. Additional charges: assisting surgeon, treatment of complications, diagnostic procedures (such as blood or X-ray exams), medical supplies, or equipment use.

Insurance coverage for surgery expenses depends on many factors and should be explored for each individual instance.