Prostate Surgery
By prostate Doc at 29 September, 2008, 5:44 pm
Prostatectomy for Cure
Selection of candidates suitable for surgery is based on the natural history of prostate cancer, its Gleason score, the life expectancy of the candidate, and consideration of morbidity from the operation. The best candidates for total prostatectomy are those likely to benefit from it, and therefore, they should be young enough to enjoy the benefit from cure.
Candidates ideally are those less than 75 years old in clinical stage T1B, T2A, or T2B, and some T2C. Some candidates with PSA can- cers, that is T1C may also benefit if they have medium to high-grade Gleason scores. Prostatectomy for cure in prostate cancer has been referred to as radical prostatectomy based on historic operation of removal of pelvic lymph nodes and wide exci- sion of the prostate. More modern terminology would describe the operation as a total prostatectomy removing the prostate and seminal vesicles in a controlled fash- ion preserving the neural vascular bundles when possible, which lie next to the pros- tate, and preservation of the anatomical urinary sphincter. Excision of the pelvic lymph nodes can be omitted with low levels of PSA testing and well-differentiated tumors that have less than a 10% chance of lymph node involvement. Removal of the prostate is most often done by the retroperitoneal approach (Fig. 1.2), with an incision in the midline from the umbilicus to the pubis, palpation of the pelvic lymph nodes, and removal of the prostate by incising the endopelvic fascia on both sides of the prostate, taking down the puboprostatic ligaments, and dividing the urethra at the apex of the prostate and retrograde removal of the fascia along side of the prostate, taking care to avoid the neural vascular bundles respon- sible for erection. The prostate is circumferentially removed from the bladder neck, taking the seminal vesicles with the specimen . The bladder neck is recon- stituted with anastomosis to the urethra giving urinary continuity and ideally pre- ser ving urinary continency and potency. Total prostatectomy may also be achieved by the perineal route, making an inci- sion across the space between the scrotum and the anus, giving immediate access to the prostate. With careful dissection, the neural vascular bundles can also be spared, and the prostate removed in a similar fashion to the retroperitoneal approach. Lymph node dissection is not possible by this method unless done separately by open inci- sion or laparoscopic means. The perineal approach has been favored by some sur- geons as giving better continuity of the urethra to the bladder. Complications of total prostatectomy include total incontinence in 3-5% of patients, stress inconti- nence in 9%, and erectile impotence from 30-50%. Walsh’s modifications of prostatectomy include the nerve-sparing prostatectomy, which has allowed preser- vation of potency in 50-70% of men in the younger age groups.
Cryoablation of the prostate which involves freezing of the prostate, has been reintroduced as a form of treatment for prostate cancer, which is localized. There are no long-term studies to show how well this works, but in the early experience many men have a positive biopsy following the treatment and a high incidence of compli- cations secondary to rectal injury and fistula. It remains to be determined whether this form of treatment will be as effective as external beam radiation or total pros- tatectomy in curing prostate cancer. Cryosurgery has also been used following fail- ure of radiation therapy to the prostate. Transurethral resection of the prostate, removing the inner core of the prostate, but leaving the capsule intact, remains an option for some men who have bulky obstruction, which may be tumor or mixture of BPH and tumor. Older men who need relief of obstructive symptoms and not necessarily cure, may undergo transure- thral resection of the prostate, which may be combined by hormone ablation by medi- cation or orchiectomy. Treatment of complications from prostatectomy is usually successful. Urinary incontinence of a mild nature can be improved by anticholinergic medication such as oxybutynin or tolterodine tartrate to relax the bladder, strengthening of the urinary sphincter with muscle exercises, and occasionally with injection of the vesicle neck transurethrally with collagen bulking agents. Ultimately, total incon- tinence can be cured with implantation of the artificial urinary sphincter. Treatment for erectile impotence may be quite successful with penile injection of vasodilators such as prostaglandin or a triple mixture of papaverine, prostaglan- din, and phentolamine. The vacuum ErecAid device, an external vacuum pump with compression band, is also useful, and sildenifil (Viagra) 50-100 mg tablets has also been used successfully following prostatectomy. Ultimately, insertion of a semi-rigid or inflatable penile prosthesis can be used for complete rehabilitation, as patients remain capable of achieving orgasm following surgery.
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