What Is a Prostatectomy?

Transurethral resection of the prostate (TURP) is a safer and more effective surgical method to reduce patient pain. It refers to the transurethral resection of the resection of the prostate into the urethra under direct vision. The suprapubic bladder puncture is usually performed before surgery to drain the lavage fluid.

Prostatectomy

Transurethral resection of the prostate (TURP) is a safer and more effective surgical method to reduce patient pain. It refers to the transurethral resection of the resection of the prostate into the urethra under direct vision. The suprapubic bladder puncture is usually performed before surgery to drain the lavage fluid.

Chinese name

Prostatectomy

Foreign name

TURP

Cut off

Prostaglandin protrudes into the urethra

Common technique

Common prostatic hyperplasia methods are as follows:

(1)

Transpubic prostatectomy

Indications and contraindications

The suprapubic prostatectomy was described by Belfield in the United States in 1887 and McGill in the United Kingdom in 1888. Later, Harris in Australia proposed suture the bladder neck to stop bleeding, so that the suprapubic prostatectomy was more widely developed. Pilcher also proposed in 1914 to stop bleeding with capsular compression, which shortened the operation time, reduced intraoperative and postoperative bleeding, and reduced postoperative complications. Its surgical indications are: (1) caused by benign prostatic hyperplasia (greater than 60 grams) Obvious symptoms of bladder neck obstruction, residual urine volume greater than 50 ml, repeated bladder bleeding, infection and so on. (2) Prostatic hyperplasia with bladder stones, bladder diverticulum, and upper urinary effusion.

Prostate cancer has been clearly diagnosed before surgery, no matter it is conservative or radical surgery, it is not suitable for resection on the pubic bone via bladder surgery. For patients with severe cardiovascular disease, infectious diseases of pulmonary obstruction, severe diabetes, significant abnormal liver and kidney function, and systemic bleeding disorders, etc., before the disease is not well treated and stable, or although actively treated by internal medicine, it is estimated that the patient is difficult Those who can tolerate open surgery should not use open suprapubic transcystectomy.

Preoperative preparation

1. Patients are mostly elderly, with poor general condition, and often accompanied by other diseases (such as hypertension, heart disease, and diabetes). Therefore, a comprehensive and detailed examination and estimation of the general condition of the patient must be performed before surgery. In addition to general physical examination, special attention should be paid to the determination of renal function (such as blood non-protein nitrogen, CO2 binding capacity, and phenol red test, etc.). In addition, multiple measurements of blood pressure are needed to check fundus, electrocardiogram, chest fluoroscopy, and liver function. If there is renal insufficiency, the bladder should be drained and surgery should be performed after renal function improves.

2. Preoperative patients often have urinary tract infections. Catheterization can improve the above situation, but long-term indwelling can cause infections. In order to reduce postoperative wound infection, antibiotics can be taken a few days before surgery, and the bladder can be washed with antibacterial solution half an hour before surgery. Commonly used antibacterial solutions are 1: 2000 furacicillin and 1: 5000 potassium permanganate. After the bladder is washed, fill it with a rinse solution

3. Cystoscopy can directly observe the condition of the bladder, the type of prostate enlargement, and whether there are other complications of the bladder (such as stones, diverticulum, etc.), but it does not need to be performed routinely before surgery.

4. Before prostatectomy, in order to prevent orchitis, bilateral vasectomy is usually performed first.

Points of surgery

(1) The incision is made in the midline of the lower abdomen, down to the upper edge of the pubic symphysis, incision of the skin, subcutaneous tissue, and anterior sheath of rectus abdominis.

(2) Cut the bladder and push the peritoneum back to the head side to reveal the bladder. Use two tissue forceps to distract the bladder wall, pierce the bladder and expand the wound with curved forceps, suck the urine with the suction device, pull the bladder with the hook, explore the bladder, pay attention to the size of the prostate, and the lateral or middle lobe protrudes into the bladder Internal conditions, look for and pay attention to the position of the ureteral orifice, whether there is hypertrophy between the ureter, and whether there are concurrent diverticulum, tumors and stones.

(3) If the prostatic hyperplasia is large, the middle lobe protrudes into the bladder cavity. Use a small circular arc to cut the mucosa at the junction of the middle lobe glands and the bladder neck. The urethra presses the forward capsule between the leaves on both sides to rupture the urethral mucosa. From this crack, the leaves are separated along the glands and the "surgical capsule" on both sides, and the entire gland can be scooped out.

(4) Hemostasis After removing the glands, pull the bladder with a hook, quickly fill the prostate socket with hot saline gauze, and compress the hemostasis for about 5 minutes. Re-sterilize the outer urethral orifice and use a 18 ~ 22F two-cavity Foley catheter. Apply lubricant to the urethra. Use two tissue forceps to clamp the bladder neck wound edges at 5 and 7 points of the prostate artery bleeding, and use a thick round needle and bowel line to make a figure 8 suture at 5 and 7 points. The suture should pass through the deep muscle layer and "surgical "Envelope" can stop bleeding. The bladder neck was sutured intermittently at 12: 3, 4 needles, the catheter was adjusted, 15-20 ml of normal saline was injected to fill the balloon, and the catheter was pulled outward, so that the balloon pressed the bladder neck and prostate socket to stop bleeding. If the ureter is enlarged, wedge resection should be performed at the same time. A bladder fistula was made at the anterior wall near the top of the bladder, and the bladder was flushed and closed. A silicone drainage tube was placed at the posterior pubic space, and the abdominal wall incision was sutured with silk threads layer by layer.

Retropubic prostatectomy

Indications and contraindications

In 1909, Vanstockum first performed a retrobladder retropubic prostatectomy. In 1945, FerrariMiller changed the incision to a horizontal shape, pre-ligated blood vessels to stop bleeding, and standardized the operation, which is generally called Miller operation. The advantage of this surgery is that it can be performed under direct vision, and the bleeding points in the glandular fossa can be carefully treated. Its surgical indication is (1) a larger prostate, weighing more than 80-100 grams. (2) Prostatic hyperplasia with one or more bladder diverticula. (3) Prostatic hyperplasia is accompanied by large bladder stones that are difficult to treat with lithotripsy. (4) Wedge resection is required for fibrosis of the bladder neck. (5) In cases of benign prostatic hyperplasia of hip joint, lithotomy position cannot be placed for transurethral or perineal surgery.

Its contraindications are basically the same as those of suprapubic prostatectomy. When there is an acute lower urinary tract infection, this route must be used after infection control. If the drainage of the posterior pubic space is not smooth, it may easily cause infection or even pubic inflammation. In addition, combined with systemic hemorrhagic diseases and coagulation mechanism disorders, such as hemophilia, leukemia, fibrinogen deficiency, and severe liver disease, this approach should not be used, because bleeding during surgery is often difficult to control. If there are intravesical lesions (such as stones, tumors, etc.) at the same time, and intravesical exploration is needed, it is best to use the Dettmar method for a combined prostate incision and a longitudinal incision of the bladder neck.

Points of surgery

(1) The incision is made from the upper edge of the pubic symphysis to the umbilicus. A straight midline incision is made in the lower abdomen. The rectus abdominis is cut, and the rectus abdominis and the conic muscle are separated to the sides to expose the anterior wall of the bladder.

(2) Expose the prostate and push the peritoneal reflex upward, and gently bluntly peel the posterior pubic space with your fingers to expose the bladder neck and the front of the prostate. Place an automatic abdominal incision retractor and gently retract the incision to allow the surgical field of vision Fully revealed.

(3) Incision of the prostate capsule with a short thick suture at the prostate capsule of the pubic symphysis near the bladder neck, the prostate vein plexus was sutured transversely. The length of the incision on the capsule is determined by the size of the prostate. Generally, the length of the incision is about 3 to 4 cm. The prostate capsule is cut transversely between two rows of ligation lines. After incision of the capsule, gray-white proliferative glands can be seen, and there is often a more obvious dividing line between the capsule and the glands.

(4) To remove the prostate, use a curved scissors to slightly separate the gland and the capsule along the subcapsular to make the gap between the two more clear. Then use your fingers to peel the prostate along the gap between the gland and the capsule. At the tip of the prostate, use Cut the urethra with a curved shear close to its tip. Immediately after excision of the prostatic hyperplasia gland, the prostate fossa was packed with hot saline gauze to compress the hemostasis.

(5) Remove the glandular stuffing gauze a few minutes after hemostasis, and then check the prostate fossa carefully. Pull the prostate capsule incision with a small hook to reveal the posterior lip of the bladder neck. Active arterial bleeding often occurs at 5 and 7 o'clock. Use bowel suture to stop bleeding. Other bleeding points in the bladder neck should be sutured. Hemostasis.

(6) Insert the urinary catheter. Insert the F-22Foley three-lumen urinary catheter from the urethra and place the tip of the urinary catheter into the bladder through the prostate capsule incision. The incision of the prostate capsule was sutured continuously with the intestine line, and the outer layer was sutured intermittently, and then 20-30 ml of physiological saline was injected into the urinary balloon.

Transperineal prostatectomy

Indications and contraindications Transperineal prostatectomy is an operation developed on the basis of perineal bladder stone removal. Until 1903, Young adopted the perineal inverted "Y" incision for the first time to design and improve transperineal exposure. Prostate retractors and other devices for the prostate make this operation under direct vision and strongly advocated. Its indications are:

(1) Prostatic hyperplasia causes long-term symptoms of lower urinary tract obstruction, residual urine volume in the bladder is greater than 60 ml, or renal function is impaired.

(2) Patients with early stage prostate cancer are suspected. During the perineal open prostate biopsy, such as frozen section microscopy, which is considered to be cancer, can be immediately converted to prostate cancer radical surgery.

(3) The prostate body is filled with stones, and those who have symptoms need prostatectomy.

(4) For obese patients, it is difficult to remove the prostate from the pubic bone or after the pubic bone.

(5) For patients with chronic bronchitis, emphysema, and cardiovascular disease, who are at higher risk for elderly and infirm patients.

Its contraindications are relatively young and require sexual function maintenance, hip joint or spinal rigidity; perineal surgery or infection, scar tissue is severe; or severe eczema, dermatitis and other diseases.

Points of surgery

(1) The incision is an inverted U-shaped incision in the perineum. The midpoint of the incision is about 2 cm from the edge of the anus. The ends of the incision are bent toward the anal plane and terminate at the inside of the ischial tuberosity.

(2) After cutting the central tendon and incision of the subcutaneous tissue, the sciatic rectal fossa is bluntly separated on both sides of the central tendon, and the superficial perineal and deep transverse muscles should not be separated before the separation to avoid incision of the urogenital septum and damage to the urethral sphincter.

(3) After the central capsule of the prostate capsule is severed, it is separated upward along the front of the rectum, and the rectal urethral muscle is exposed and severed. The retractor was used to retract the posterior levator ani muscle to expose the Dirichlet fascia. The posterior layer of the fascia was incised and continued to separate along the plane of the anterior and posterior layers of the fascia. The front of the rectum was opened to reveal the prostate capsule.

(4) The prostate is excised, the prostate capsule is removed, the glands are divested under the capsule, the urethra is cut across the apex of the prostate, a straight Lowsley prostate retractor is inserted from the prostate urethra into the bladder, and the two leaves of the retractor are opened. The prostate is pulled downwards, the glands and capsules are free, and the prostate glands are removed.

(5) Hemostasis Immediately fill the glandular fossa with hot saline gauze to compress the hemostasis. If there is bleeding, use gut suture to stop bleeding.

(6) Suture the prostate capsule and insert the F-22 three-lumen urethral catheter into the bladder from the outer mouth of the urethra. Use the intestine to surround the catheter to make an intermittent suture between the bladder neck and the urethral end of the membrane. Then use the intestine to suture the prostate capsule incision. . Introduce 20-30 ml of normal saline into the urinary balloon.

(7) Place drainage. Rinse the wound, repair the central tendon with silk suture, place drainage tubes in the gap on both sides of the incision, and suture the subcutaneous tissue and skin layer by layer.

Transurethral prostate surgery

Indications and contraindications

Transurethral prostatectomy is less disruptive, less painful, and quicker recovery than patients with open prostatectomy. Its surgical indications are:

(1) There are symptoms and signs caused by benign prostatic hyperplasia. Such as dysuria, increased residual urine and urinary retention.

(2) Surgery should be completed within 60 minutes, and adenomas smaller than 60 grams are removed.

The contraindications are:

(1) Cardio-cerebrovascular diseases: severe hypertension, acute myocardial infarction, uncontrolled heart failure, and recent hemiplegia due to cerebrovascular accidents.

(2) Respiratory diseases: severe bronchial asthma, emphysema combined with lung infection, and significantly reduced lung function.

(3) Severe liver and kidney dysfunction.

(4) Systemic bleeding disorders.

(5) Severe diabetes.

(6) Patients with pacemakers are generally not recommended for TURP.

(7) Adenomas are too large, exceeding 60 grams.

(8) Acute urogenital infection.

Points of surgery

(1) Clean the urethra and urinary bladder. Inject 1% Xinjieer solution to clean the urethra and bladder.

(2) Inserting the resectoscope When inserting the resectoscope, it should be placed slowly along the direction of the urethra.

(3) Check the bladder and posterior urethra. Note the presence of diverticulum, tumors, and stones in the bladder. Observe the relationship between the triangular area and the left and right ureteric orifices and the increase of adenomas. Marginal relationship with sperm and external sphincter.

(4) After the pubic bladder is inserted into the drainage cannula after the bladder is filled, the pubic bone is inserted into the drainage cannula with a bladder puncture to drain the lavage fluid during drainage.

(5) The resection sequence varies from one surgical method to another, and is generally divided into three areas: bladder neck area, middle prostate area, and apical area.

A small adenoma resection: Cut out the lavage canal at 6 o'clock, remove the left and right lobes, remove the ventral tissue at 12 o'clock, and remove the apical tissue.

Resection of B adenoma: mid-lobectomy at 6 o'clock, cutting of the sulcus at 1 or 11 o'clock, resection of lateral lobe, removal of ventral tissue at 12 o'clock, and excision of apical tissue.

Precautions

After the transurethral prostatectomy, the patient was returned to the ward. Do not eat infusions on the same day. The patient can eat a liquid diet the next day after surgery, and the drainage urine will be cleared. Generally, the catheterization can be removed within 24 to 72 hours. tube. In the future, except for some individuals who are unable to urinate, weak urination, excessive residual urine, or abnormalities such as bleeding, it is generally not necessary to reinsert the catheter. If the operation goes well, the patient can be discharged 4 to 5 days after the operation.

During the first month of discharge, patients should be cautious in their lives, taking care to avoid lifting heavy objects, not drinking, not having sex, and preventing constipation. Due to the possibility of delayed bleeding and infection after this operation, patients should always pay attention to any abnormal conditions such as hematuria, urgency, dysuria, nocturia, the thickness of the urinary line, and the presence of gray and white tissue in the urine. If the above situation occurs, you should return to the operating hospital at any time for follow-up.

Complications after transurethral prostatectomy can be divided into two major categories of early complications and late complications.

Early complications include transurethral resection syndrome, also known as hyponatremia, urinary tract infection, shock, diffuse intravascular coagulation, etc., which occur rarely and will be treated during hospitalization, which will not be described in detail. However, transurethral resection of the prostate is unique to this operation, so it will be explained a little. Transurethral resection of the prostate is not performed under direct vision. In order to keep the surgical field clear and punch out the cut tissue, it must be continuously irrigated during the electrocutting, and the irrigation solution will be continuously absorbed into the blood. If too much water is absorbed into the tissue cells, it will cause hyponatremia and water poisoning, that is, brain edema, pulmonary edema and heart failure may occur in the body. Therefore, the operation must strictly control the operation time and the amount of irrigation fluid to prevent the occurrence of syndrome.

Late postoperative complications occur after the patient is discharged from the hospital, so patients need to pay attention to observation and discovery.

(1) Poor urination or even urinary retention after surgery. The reasons are as follows: one is the incomplete resection of the proliferative glands during surgery, and the solution is re-cut; the other is that the patient had a neurological defect at the same time, making it difficult to urinate. Examine and treat, and explain clearly to the patient the dual causes.

(2) Hematuria under the microscope is sometimes seen after abnormal urination, and pyuria persists for several months. There are two reasons for this: one is that the necrotic tissue gradually comes off due to the wound healing process, and the other is that there may be kidney disease. Therefore, a detailed inspection should be done to find out the cause and deal with it.

(3) Due to the application of prophylactic antibiotics before and after surgery, the postoperative incidence of epididymitis has been greatly reduced, but there are still a few cases. If postoperative scrotal swelling and pain occur, you should seek medical treatment in time.

(4) Urinary incontinence may be related to surgery, or it may be caused by inflammation, tumors, stones or neurological factors, so you should check accordingly to find out the cause.

(5) The urethral stricture should be carefully identified, urethral dilatation should be given, or resection should be performed again.

(6) Impotence occurred in about 1.4% of patients after sexual dysfunction. Many patients complain of unsatisfactory sexual intercourse, the reason may be related to mental factors, and psychological counseling should be given. After the resection, the internal urethral sphincter may be incompletely closed, leading to retrograde ejaculation, that is, semen does not exit the body and enters the bladder. Those without fertility problems do not need treatment, and those with fertility requirements can try ephedrine treatment, which is sometimes effective.