Common Surgical Edits
The common methods of hyperplastic prostatectomy are as follows: Liu Xiaodong, Department of Urology, Wuhai People’s Hospital
(1) Suprapubic transcatheter prostatectomy;
(2) retropubic prostatectomy;
(3) Trans-perineal prostatectomy;
(4) Transurethral electrodesiccation of the prostate.
The above surgical methods have their own advantages and disadvantages and indications, and should be chosen according to the patient’s condition and the surgeon’s mastery of the procedure.
The open surgery, with the suprapubic transcatheter prostatectomy style being the most used, is the basic surgical method that urologists must master. The procedure is simple, easy to master, and rarely results in postoperative incontinence. For those with other lesions in the bladder, it is more appropriate to choose this surgical approach. However, this procedure requires an incision of the bladder, and if the prostatic envelope is closely adherent to the gland, the envelope may occasionally tear, making it difficult to stop bleeding.
The posterior pubic prostatectomy does not require a bladder incision, and the prostate is removed under direct vision without a suprapubic cystostomy, resulting in a quick recovery. However, the surgery is more complicated, with more bleeding, and improper treatment can cause infection and urinary leakage.
The advantages of transconjunctival prostatectomy are that it is a small operation with little damage, less impact on the whole body and quicker recovery. However, the anatomy of the perineum is complicated, and the poor exposure of the surgical field can easily cause postoperative sexual dysfunction.
Transurethral resection of the prostate (TURP) is less invasive, less painful, faster recovery, and has a wide range of surgical indications. This procedure requires certain equipment and requires a high level of operator skill. At present, TURP has the best results and remains the “gold standard” of BPH treatment.
Indications Edit Transsubpubic prostatectomy
Indications and contraindications
The suprapubic prostatectomy was described by Belfield in 1887 and McGill in 1988, and later by Harris in Australia, who proposed suturing the bladder neck to stop bleeding, making suprapubic prostatectomy more widely performed. Complications are also reduced. The indications for surgery are: (1) prostatic hyperplasia (greater than 60 g) causing obvious symptoms of bladder neck obstruction, residual urine volume greater than 50 ml, recurrent bladder bleeding, infection, etc. (2) Prostatic hyperplasia combined with bladder stones, bladder diverticulum, and upper urinary tract fluid accumulation, etc.
Pre-operative prostate cancer has been clearly diagnosed, and either conservative or radical surgery is not suitable for resection by suprapubic transvesical bladder surgical route. Open suprapubic transsphenoidal prostatectomy is not recommended for patients with severe cardiovascular disease, pulmonary obstructive infectious disease, severe diabetes mellitus, significant abnormalities in liver and kidney function and systemic hemorrhagic disease, etc., until they are well treated and stabilized; or if the patient is estimated to have difficulty tolerating open surgery despite active medical treatment.
Preoperative preparation
1. Patients are mostly elderly, with poor general condition and often accompanied by other diseases (such as hypertension, heart disease and diabetes), so a comprehensive and detailed examination and estimation of the patient’s general condition must be made 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, blood pressure should be measured several times, fundus, electrocardiogram, chest fluoroscopy and liver function should be checked. In cases of renal insufficiency, the bladder should be drained and surgery should be performed after renal function has improved.
2. Preoperative patients are often combined with urinary tract infection. Catheterization can improve the above situation, but long-term retention can cause infection again. In order to reduce postoperative wound infection, antibiotics can be taken several days before surgery, and the bladder can be flushed with an antibacterial solution half an hour before surgery. The commonly used antibacterial solutions are 1:2000 furacilin and 1:5000 potassium permanganate. After the bladder is washed, it is filled with the rinsing solution
3. Cystoscopy can directly observe the condition of the bladder, the type of prostatic hypertrophy and the presence of other comorbidities of the bladder (such as stones, diverticula, etc.), but does not need to be performed routinely before surgery.
4. Before prostatectomy, bilateral vasectomy is usually performed to prevent orchitis.
Surgical points
(1) Incision A median incision is made in the lower abdomen, reaching down to the superior border of the pubic symphysis. The skin, subcutaneous tissue and anterior sheath of the rectus abdominis muscle are incised, and the rectus abdominis muscle is separated to reach the peritoneum.
(2) Incision of the bladder The peritoneum is reflexively folded and pushed cephalad to reveal the bladder. Use two tissue forceps to retract the bladder wall, poke the bladder with curved vascular forceps in between and enlarge the wound, aspirate the urine with suction, retract the bladder with a pulling hook, probe the bladder, pay attention to the size of the prostate, the lateral or middle lobe protruding into the bladder, look for and pay attention to the position of the ureteral orifice, the presence of inter-ureteral ridge hypertrophy, the presence of concurrent diverticula, tumors and stones, etc.
(If the middle lobe is large and protrudes into the bladder cavity, use a small circular knife to cut open the mucosa at the junction of the middle lobe gland and the bladder neck; if the prostate is only enlarged on both sides of the lobe, directly reach into the posterior urethra with the right index finger, press forward the peritoneum between the two sides of the lobe, so that the urethral mucosa is split, and from this split to both sides of the lobe along the gland and the “surgical peritoneum The entire gland can be removed by separating it from the “surgical envelope”.
(4) Hemostasis After removing the gland, use a pull hook to pull open the bladder, quickly fill the prostate fossa with hot saline gauze and compress to stop the bleeding for about 5 minutes. Re-sterilize the external urethral orifice and select an 18-22F two-lumen Foley catheter. Apply lubricant to insert into the urethra. Two tissue forceps are used to clamp the prostatic artery bleeding at 5 and 7 points on the bladder neck trauma edge, and a thick circular needle and intestinal thread are used to make a figure-of-eight suture at 5 and 7 points, and the suture should pass through the deep muscle layer and the “surgical envelope” to stop the bleeding. Intermittently suture the bladder neck at 12 points with 3 to 4 stitches, adjust the catheter, inject 15 to 20 ml of saline to fill the balloon, and tract the catheter outward so that the balloon compresses the bladder neck and prostate fossa to stop bleeding. If the inter-ureteral crest is hypertrophic, wedge resection should be done at the same time. A cystostomy is made at the anterior wall near the top of the bladder, the bladder is flushed and closed, and after placing a silicone drainage tube in the posterior pubic space angle, the abdominal wall incision is closed layer by layer with silk sutures.
Trans-pubic retropubic prostatectomy
Indications and contraindications
In 1945, Ferrance Miller standardized the procedure by changing the incision to a transverse one and pre-ligating the blood vessels to stop bleeding. The advantage of this procedure is that it is performed under direct vision and allows careful treatment of bleeding points in the glandular fossa. Its surgical indications are (1) Larger prostate, weighing more than 80 to 100 grams. (2) Prostatic hyperplasia combined with one or more bladder diverticula. (3) Prostatic hyperplasia with large bladder stones that are difficult to treat with lithotripsy. (4) Fibrosis of the bladder neck, requiring wedge resection. (5) Cases of prostatic hyperplasia with ankylosis of the hip joint that cannot be placed in the osteotomy position for transurethral or transepithelial surgery.
The contraindications are basically the same as for suprapubic prostatectomy. When there is an acute lower urinary tract infection, this route must be used only after the infection has been controlled, and if the posterior pubic space is poorly drained, it is easy to cause infection or even complication of osteitis pubis. In addition, combined systemic bleeding disorders and coagulation mechanism disorders, such as hemophilia, leukemia, fibrinogen deficiency and severe liver disease, etc., should not use this pathway, because once intraoperative bleeding is often not easy to control. If intravesical lesions (e.g., stones, tumors, etc.) are also present and require intravesical exploration, it is best to use the Dettmar method to make a combined longitudinal incision in the prostate envelope and bladder neck.
Surgical points
(1) Incision A straight incision is made from the superior border of the pubic symphysis to the umbilicus in the lower abdomen. The rectus abdominis muscle is incised and the rectus abdominis muscle is separated from the conus muscle on both sides to reveal the anterior bladder wall.
(2) Exposure of prostate The peritoneal reflex is pushed upward, and the posterior pubic space is gently and bluntly peeled away with the fingers to reveal the bladder neck and the front of the prostate, and an automatic abdominal incision retractor is placed to gently retract the incision to fully expose the surgical field.
(3) Incision of the prostatic envelope The prostatic vein plexus is ligated transversely with short thick sutures at the prostatic envelope near the bladder neck in the pubic symphysis. The length of the incision on the pericardium depends on the size of the prostate, generally the incision is about 3-4 cm long and the prostatic pericardium is cut transversely between the two rows of ligatures. After the pericardium is cut, the grayish-white hyperplastic gland can be seen, and there is often a clear line of demarcation between the pericardium and the gland.
(4) Removal of the prostate gland The gland is separated from the envelope with curved scissors under the envelope to make the gap between the two clearer, and then the prostate is peeled off with fingers along the gap between the gland and the envelope, and at the tip of the prostate, the urethra is cut with curved scissors close to the tip. After removing the hyperplastic prostate gland, immediately fill the prostate fossa with hot saline gauze to stop the bleeding by compression.
(5) Stopping the bleeding After a few minutes, remove the gauze filling the fossa and then carefully examine the prostate fossa. Use a small pull hook to pull open the prostate envelope incision and reveal the posterior lip of the bladder neck. There is often active arterial bleeding at two points, 5 and 7, and the bleeding should be stopped with intestinal sutures in a figure of eight pattern, and other bleeding points in the bladder neck should be stopped with sutures.
(6) Insertion of catheter The F-22Foley three-lumen catheter is inserted from the urethra and the tip of the catheter is placed into the bladder under direct vision through the prostatic envelope incision. The prostatic envelope incision is closed with continuous sutures using intestinal sutures, and the outer layer is closed with several interrupted sutures, and then 20-30 ml of saline is injected into the catheter balloon.
Trans-perineal prostatectomy
The procedure was developed on the basis of perineal removal of bladder stones until 1903 when Young first adopted an inverted “Y” shaped incision in the perineum and designed and improved the prostatic retractor to expose the prostate through the perineum. The following are the indications for this procedure
(1) Prostate enlargement causing long-term lower urinary tract obstruction symptoms, bladder residual urine volume greater than 60 ml, or causing impaired renal function.
(2) Patients suspected of having early prostate cancer, intraoperative open prostate biopsy via perineum, which can be immediately changed to radical prostate cancer surgery if the frozen section microscopy identifies it as cancer.
(3) Patients whose prostate body is filled with stones and have symptoms requiring prostatectomy.
(4) For patients with excessive obesity, it is difficult to perform suprapubic or retropubic resection of the prostate gland.
(5) For patients with combined chronic bronchitis, emphysema and cardiovascular disorders, the risk is greater in the elderly and frail patients.
The contraindications are relatively young age, the requirement to maintain sexual function, hip or spinal ankylosis; previous surgery or infection in the perineum, serious scar tissue; or serious eczema, dermatitis and other disorders.
Key points of surgery
(1) Incision An inverted U-shaped incision is made in the perineum, with the midpoint of the incision about 2 cm from the anal margin and the ends of the incision curved toward the anal plane and terminating at the medial aspect of the sciatic tuberosity.
(2) Cut the central tendon After cutting the subcutaneous tissue, bluntly separate the sciatic rectal fossa on both sides of the central tendon, and do not separate the front beyond the superficial and deep transverse perineal muscles to avoid cutting the urogenital septum and damaging the external urethral sphincter.
(3) Reveal the prostatic envelope After cutting the central tendon, separate upward along the front of the rectum to reveal and cut the recto-urethral muscle. The posterior anal levator is retracted with a retractor to reveal the Diaphragm, the posterior layer of this fascia is cut, and the separation continues along the plane of the gap between the anterior and posterior layers of this fascia, and the anterior rectum is pushed away to reveal the prostatic pericardium.
(4) Resection of the prostate gland The prostatic envelope is cut open, the gland is stripped subconsciously under the envelope, the urethra is cut transversely at the tip of the prostate, the straight Lowsley prostatic retractor is inserted into the bladder through the prostatic urethra, the two lobes of the retractor are opened, the prostate is retracted downward, the gland is freed from the envelope, and the prostatic gland is removed.
(5) Stop bleeding Immediately fill the glandular fossa with hot saline gauze to stop the bleeding, if bleeding, use intestinal sutures to stop the bleeding.
(6) Suture the prostatic envelope Insert the F-22 three-lumen catheter from the external urethra into the bladder and use intestinal sutures around the catheter to make interrupted sutures between the bladder neck and the broken end of the membranous urethra, then close the prostatic envelope incision with intestinal sutures. Inject 20 to 30 ml of saline into the catheter balloon.
(7) Placement of drainage. Rinse the wound, repair the central tendon with silk sutures, place drainage tubes in the gap on both sides of the incision, and suture the subcutaneous tissue layer by layer, skin by skin.
Transurethral prostate surgery
Indications and Contraindications
Transurethral resection of the prostate is less painful and quicker to recover than open prostatectomy, and its indications are (1) signs and symptoms caused by prostate enlargement and obstruction. The procedure can be carried out in the presence of a large number of people who have difficulty urinating, increased residual urine and urinary retention.
(2) The surgery should be completed within 60 minutes, and adenomas less than 60 grams should be removed.
The contraindications are (1) cardiovascular and cerebrovascular disorders: severe hypertension, acute myocardial infarction, uncontrolled heart failure, and recent hemiplegia due to cerebrovascular accidents. (2) Respiratory diseases: severe bronchial asthma, emphysema combined with pulmonary infection, and significantly reduced lung function. (3) Severe hepatic and renal insufficiency. (4) Systemic bleeding disorders. (5) Severe diabetes mellitus. (6) Patients with pacemakers are generally not suitable for TURP. (7) Adenoma too large, exceeding 60 grams. (8) Acute genitourinary system infection.
Key points of surgery
(1) Clean the urethral bladder The urethra is injected with 1% Neosporin solution to clean the urethra and bladder.
(2) Placement of electrospectroscope The electrospectroscope should be inserted slowly in the direction of the urethra.
(3) Examination of the bladder and posterior urethra Pay attention to the presence of diverticula, tumors and stones in the bladder, observe the position of the triangle and the left and right ureteral orifices in relation to the enlarged adenoma, the morphology of the internal urethra, the length of the prostatic urethra, the seminal frenulum, the relationship between the distal margin of the lateral lobe and the seminal frenulum and the external sphincter.
(4) Suprapubic cystocentesis to place drainage cannula After filling of the bladder, the bladder is cystocentesis one transverse finger above the pubic symphysis to place a drainage cannula to drain the intraoperative irrigation fluid.
(5) Sequence of resection The surgical approach varies from family to family, but overall there are three zones of resection: bladder neck zone, mid prostate zone, and acinar zone.
A resection of small adenomas: excision of the irrigation tract at 6 o’clock, excision of the left and right lobes, excision of the ventral tissue at 12 o’clock, and excision of the apical tissue.
B resection of large adenoma: middle lobe resection at 6 o’clock, excision of marker tract at 1 or 11 o’clock, excision of lateral lobes, excision of ventral tissue at 12 o’clock, and excision of apical tissue.
Precautions
After the transurethral resection of the prostate, the patient will be sent back to the ward and given fluids without food on the same day, and the patient will be able to eat a liquid diet on the second day after the operation, and the drained urine will turn clear. In the future, except for individuals who cannot urinate, have weak urination, and have excessive residual urine, or bleeding and other abnormalities, it is generally not necessary to insert the catheter again. If the procedure goes smoothly, patients can be discharged from the hospital 4 to 5 days after surgery.
During the first month of discharge, patients should be careful to avoid heavy lifting, alcohol and sexual intercourse, and to prevent constipation. Since there is a possibility of delayed bleeding and infection after this procedure, patients should always pay attention to detect any abnormalities such as blood in urine, urgency, painful urination, nocturia, how thick or thin the urine line is, and whether there are small pieces of grayish-white tissue in the urine, etc. If any of these conditions occur, they should always return to the operating hospital for follow-up.
The postoperative complications of transurethral resection of the prostate can be divided into two categories: early complications and late complications.
The early complications include transurethral resection syndrome, also known as hyponatremia, urinary tract infection, shock, and diffuse intravascular coagulation, which are rare and are treated during hospitalization, so we won’t go into detail. It is only the transurethral resection of the prostate syndrome that is unique to this procedure, so I will explain it a little. Transurethral resection of the prostate is not performed under direct vision. In order to keep the surgical field clear and to flush out the cut tissue, constant flushing must be performed during the electrical resection, and the flushing fluid is constantly absorbed into the blood. If too much water is absorbed into the tissue cells, it can cause hyponatremia and water toxicity, i.e., the body may experience cerebral edema, pulmonary edema and heart failure. Therefore, the procedure must be strictly controlled in terms of operative time and amount of flushing fluid to prevent the syndrome.
Late postoperative complications occur after the patient is discharged from the hospital and therefore need to be observed and detected by the patient himself.
(1)Poor urination or even urinary retention even after surgery The reasons for this are: firstly, incomplete excision of the hyperplastic gland during the surgery, and the solution is to electrically excise it again; secondly, the patient originally had both neurological defects making urination difficult, and the patient should be given the appropriate examination and treatment, and the dual reasons should be explained clearly to the patient.
(2) Abnormal urination Microscopic hematuria is sometimes seen after surgery, and pusuria lasts for several months. There are also two reasons for this: one is caused by the gradual shedding of necrotic tissue despite the trauma healing process, and the other is that there may be renal lesions. Therefore, detailed examination should be done to clarify the cause and give treatment.
(3) Epididymitis The postoperative incidence of epididymitis has been greatly reduced due to the application of prophylactic antibiotics before and after surgery, but there are still a few occurrences, and prompt consultation should be made if intra-scrotal swelling and pain occur after surgery.
(4) Urinary incontinence It may be related to surgery, or it may be caused by inflammation, tumor, stone or neurological factors, therefore, corresponding examination should be done to find out the cause.
(5) Urethral stricture The site of stricture should be carefully identified and urethral dilatation should be given or treated with electrodes again.
(6) Sexual dysfunction Impotence occurs in about 1.4% of patients after surgery. There are also many patients complaining of unsatisfactory sexual intercourse, the reasons for which may be related to psychological factors and should be given psychological guidance. Because of the incomplete closure of the internal urethral sphincter after electrodesiccation, it may cause retrograde ejaculation, i.e. semen does not go out of the body but into the bladder. Those without fertility problems do not need to be treated, and those with fertility requirements may try ephedrine treatment, which is sometimes effective.