Prostatectomy corresponds to a minimally invasive or fully invasive procedure for complete or partial removal of the prostate. Micturition disorders may indicate a partial prostatectomy, whereas malignant tumors of the prostate require complete removal. Complete prostatectomies may result in impotence due to nerve injury during surgery.
What is prostatectomy?
The prostate corresponds to an accessory sex gland and is involved in sperm production. In humans, the organ is located below the urinary bladder, where it lines the beginning of the urethra to the pelvic floor. The exocrine gland has excretory ducts into the urethra and contains up to 50 tubuloalveolar individual glands. These glands produce a secretion that is discharged into the urethra and mixes with sperm during ejaculation. The prostatic secretion carries a pH of 6.4 and thus increases the chances of sperm survival in the acidic environment of the vagina. The prostatic secretion also has a motility-inducing effect on sperm. Under certain circumstances, partial or complete removal of the prostate may be necessary. Such an operation is called prostatectomy or prostate enucleation. Partial removal of the prostate is distinguished from radical prostatectomy. Both procedures can correspond to different surgical techniques. In addition to laperoscopic and endoscopic prostatectomies, robotic-assisted procedures exist, for example.
Function, effect, and goals
The most common indication for prostate removal is prostate cancer. This malignant cancer of the prostate gland usually requires a radical prostatectomy. During this procedure, the prostate gland is completely removed. The vesicular glands (vesiculae seminalis) and the prostate capsule (capsula prostatica) are also removed in the invasive procedure. The operation can be minimally invasive and thus correspond to an endoscopy. Such a procedure is known as endoscopic extraperitoneal radical prostatectomy (EERPE). A camera in the pelvic area helps to closely monitor the surgical field during the procedure. However, the surgical procedure is almost exclusively suitable for localized prostate cancer. Laparoscopic prostatectomy also corresponds to a minimally invasive form of prostatectomy. In this procedure, access is gained through five trocars in the lower abdomen. The seminal vesicles and prostate are dissected free during surgery using laparoscopic instruments and then removed. Bleeding can be stopped with bipolar coagulation. Direct suture of the anastomosis between the urethra and bladder stocking is common. If necessary, removal of the iliac lymph node bundles is also performed. Depending on the indication in the individual case, the treating surgeon performs the operation transperitoneally or extraperitoneally without manipulation of the peritoneum. In addition to partially invasive access procedures, open access routes also exist for prostatectomy. One such procedure is retropubic radical prostatectomy (RRP), in which the patient lies spread-eagled on his or her back. The surgeon removes the prostate via a median incision between the belly button and symphysis. He then dissects the prostate free and supplies the vascular plexuses with penetrating sutures. The retropubic approach leaves the organ capsule untouched and is generally used to remove large adenomas. Simultaneous removal of the seminal vesicles and lymph nodes is also conceivable with this open procedure. Worldwide, this type of prostatectomy is the most commonly used. Radical perineal prostatectomy (RPP) is also an open variant of prostatectomy. In this procedure, the surgeon seeks out the prostate through an incision between the anus and scrotum and dissects the gland with metal retractors inserted urethrally. Severely enlarged prostates cannot be operated on with this procedure. Partial removal of the prostate is usually used for benign tumors of the gland if they are accompanied by discomfort during urination. One procedure for partial removal is, for example, transurethral prostatic resection (TURP), in which a surgical instrument is inserted through the urethra. From the transitional zone of the prostate, the surgeon removes certain parts of the gland with a loop-shaped electrode including alternating current RF. The prostate capsule remains intact.Related procedures include transurethral microwave thermotherapy and photoselective vaporization of the prostate (PVP).
Risks, side effects, and hazards
The risks and side effects of prostatectomy depend on the procedure chosen. Radical prostatectomies are relatively difficult operations because of the anatomic conditions, regardless of the method of execution. The prostate is difficult to access in the pelvis. Branches of the cavernous nerve are located only millimeters away. The nerve bundles carry nerve fibers to the erection. If these fibers are accidentally cut or severely stretched, there is a loss of erectile function. A common side effect of radical prostatectomies in the past was urinary incontinence, although this has now fallen far behind impotence. In addition, the penis may shorten during the surgeries because the urethra is joined at the severed ends after excision of individual portions. The penis is pulled a short distance into the body to compensate for the loss of urethra. The foreskin usually retains its conventional shape and is often too long after surgery, which can promote chronic inflammation of the glans. In addition, a common side effect of radical retropubic prostatectomy is inguinal hernia, which requires repeat surgery. In addition to these side effects and risks, there are general anesthesia and surgical risks. These include bleeding and bruising in addition to infection. Pain after the procedure is also common. For people with cardiovascular disease, open procedures with general anesthesia in particular are a severe systemic stress that can be associated with cardiovascular arrest in extreme cases. Allergic reactions to the anesthetic are also among the general surgical risks. The same applies to wound healing disorders or headaches as a reaction to the anesthetic.
