Prostate gland removal

Also known as: Prostatectomy

Anatomy or system affected: Endocrine system, glands

Definition: A surgical procedure to remove all or part of an abnormal prostate gland

Indications and Procedures

The removal of the prostate gland, or prostatectomy, may be performed when enlargement of the gland blocks or reduces the outflow of urine. Removal may also be indicated in prostate cancer or inflammation of the prostate (prostatitis).

Enlargement of the prostate gland, also known as benign prostatic hyperplasia (BPH), may affect men over the age of fifty. Because the prostate gland is situated so that it surrounds the urethra, when it enlarges, it can compress the urethra and reduce the flow of urine. Symptoms usually include a gradual reduction in the ability to urinate effectively. Since the flow of urine out of the urethra is obstructed by the enlarged gland, the patient experiences difficulty starting urination and a weak stream.

In the early stages, the urinary bladder muscle becomes heavier and stronger to compensate for the increased resistance in the urethra. Eventually, however, the bladder is unable to expel all the urine and becomes distended. This urinary retention can cause abdominal swelling and a perceived urgency to urinate. In fact, the bladder may contract frequently and cause a need for frequent urination. This is one sign of bladder muscle failure and the need for medical attention. In some patients, there may be incontinence as a result of the leakage of small volumes of urine.

Prostate cancer is a malignant growth of the prostate gland. Most patients with prostate cancer are in their seventies; this condition also occurs in middle-aged men. The symptoms that develop are similar to those of BPH. Diagnosis is usually made by a digital rectal examination, ultrasonography, prostate biopsy, and a blood test for prostatic-specific antigens.

The treatment for both BPH and prostatic cancer involves medical management and surgical removal of all or part of the gland. In BPH, finasteride (Proscar) can be used to reduce the size of the gland and diminish symptoms. Prostate cancer can sometimes be managed using drugs that block or reduce the production of testosterone. Such agents include flutamide (Eulexin) and leuprolide. If medical management is not effective, surgical removal of the gland is usually indicated.

The most common surgical procedure for the removal of part of the prostate gland is transurethral resection of the prostate (TURP), which is performed using an instrument called a resectoscope. The patient is first anesthetized using spinal or general anesthesia. Then the resectoscope is inserted into the urethra at the tip of the penis and directed up toward the prostate gland. The resectoscope allows the surgeon to view the urinary bladder and prostate and insert a cutting instrument or heated wire into the area of the prostate to be removed. As the gland is cut away, it is removed from the urethra by suction. Any bleeding that may occur is stopped by a cauterizing electrode, which seals the vessels. After the prostate gland has been removed, the surgeon withdraws the resectoscope and inserts a catheter into the bladder to drain urine and any remaining blood or tissue.

If a more radical procedure than transurethral resection is needed, as in cases of prostate cancer, then retropubic prostatectomy is performed. This operation requires that the patient be anesthetized. The surgeon makes a horizontal incision just above the pubic hairline into the abdominal cavity and exposes the urinary bladder and prostate gland. A cut into the capsule that encases the gland is made, and the surgeon begins to remove the prostate gland. To drain excess fluid from the pelvic cavity, the surgeon places a temporary, flexible tube near where the prostate was excised. Bleeding vessels are cauterized, and the abdominal wall is sutured. A urethral catheter is inserted and left in place to aid in draining the bladder of blood and urine. An alternative to retropubic prostatectomy is perineal prostatectomy, in which the prostate is accessed through an incision in the perineum, the area between the scrotum and anus; this procedure is less common because it carries a higher risk of nerve damage. Another option is laparoscopic prostatectomy, in which four or five very small incisions are made in the abdomen, through which computer-guided instruments and a camera are inserted to perform the procedure.

Uses and Complications

After the removal of the urethral catheter, the patient is encouraged to drink large amounts of fluids and pass urine. Occasionally, the patient may experience frequent and painful urination but should still consume adequate amounts of liquids to help clear the urinary tract of blood and other postoperative debris. A few patients will continue to have incontinence for several weeks.

More severe complications include intra-abdominal bleeding from surgery, infections, and blood clots that obstruct urine outflow from the bladder. Bleeding within the pelvic and abdominal cavities is usually detected and corrected during surgery. If it occurs after prostatectomy, a second operation may be required to find and stop the bleeding. Most infections of the urinary tract can be adequately treated with appropriate antibiotic therapy. Urinary obstruction resulting from a blood clot can be washed out with a catheter in the urethra.

A large percent of men undergoing retropubic prostatectomy experience impotence following the surgery and can range between 40 and 60 percent in the eighteen months following surgery. Rates depend on the type of surgery performed and individual factors such as age. While many receive relief naturally, some patients may experience permanent erectile dysfunction. This complication is more common in older patients and can often be treated with drugs such as Viagra.

For most men, the hospital stay is about two days for transurethral resection of the prostate, two to three days for open surgery, and overnight for a laparoscopic procedure. Several weeks after the surgery, the patient can resume all activities, including intercourse. Most men are sterile, however, immediately after either procedure because most of the sperm and seminal fluid are expelled backward into the urinary bladder (retrograde ejaculation). The ejaculate is then excreted with the urine during the next urination.

In the United States, doctors perform approximately 90,000 prostatectomies each year, and new advances in surgical procedures were made regularly. In the 2020s, laparoscopic prostatectomy procedure was often performed using robotic-assisted methods.

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