Content Summary
Laparadoscopic surgery for prostate
The prostate gland has always been one of the most operated organs in men from the fourth decade of life, however, conventional methods such as open surgery brought with them countless unwanted side effects that made many patients go without treatment while diseases progressed.
Among the most frequent side effects of traditional techniques (open prostatectomies) and most feared by patients are erectile and urinary dysfunctions, due to the cutting of penile nerves when extracting the gland.
However, with the passage of time, techniques have evolved and robotic prostate surgery and novel laparoscopic approaches have appeared that produce minimal damage to the tissues and structures neighboring the prostate while significantly improving survival from such aggressive pathologies as cancer. , in which the entire organ must be removed in a procedure known as a prostatectomy.
What is a prostatectomy?
Prostatectomy is a surgical-type medical procedure that is performed as a treatment for pathologies of this important male gland, especially when previous treatments did not work or that pathology is in an advanced state and endangers the patient’s life.
This procedure aims to cut, divide, and remove a part of the prostate (known as a partial prostatectomy) or to remove the entire gland (in a procedure called a total prostatectomy).
The amount of tissue resected (or removed) depends on different factors such as the age of the patient and the degree of prostate involvement. Likewise, prostatectomy also contemplates the removal of lymph nodes adjacent to the gland in case some type of cancer originating in it has been able to invade them.
Although prostatectomy has excellent results and is a surgery of intermediate difficulty, the collateral effects of conventional techniques make it unattractive to patients, many of whom prefer to remain silent if they have symptoms of prostate disease and not seek medical help.
The main negative effect of prostatectomy is directly related to the anatomy of the organ. The prostate is a small organ but it has a complex location: it surrounds the urethra above and behind the base of the corpus cavernosum of the penis, attached to the bladder and surrounded by numerous nerves responsible for limb erection and urinary function.
This greatly hinders the surgical operations of the prostate, and it has been a real challenge to current medical science to find less aggressive methods with the same effectiveness, which fortunately have been achieved, as with surgery by laparoscopic means with excellent results, especially in radical prostatectomies for cancer and prostate tumors.
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When should a radical prostatectomy be performed? And why is laparoscopy the best option to perform it?
Radical prostatectomy consists of the complete removal of the prostate when there is a severe neoplastic (or hyperplastic) process that compromises the organ and the health of the body in general. The pathology that most benefits from this surgical technique is prostate cancer, also known as prostatic carcinoma or malignant prostate tumor.
Traditionally, this medical procedure was performed with the “open technique” where the surgeon operated the gland by first making an incision of no less than 10 centimeters in the anterior abdominal wall, at the level of the pelvis where he separated the prostate and cut it, leaving the path of the urethra free but pulling fine nerves of the penis with it.
Laparoscopic surgery is a new minimally invasive technique performed with high-tech instruments that guarantee not only safety but also effectiveness, with minor side effects and quick recovery that lead to a prompt restart of daily activities.
Radical prostatectomy with laparoscopic methods is indicated in male patients with cancer in the glandular portion of the prostate (or adenocarcinoma) and without metastases, because the latter implies invasion of nearby tissues such as lymph nodes and more difficulty in identifying the affected structures and remove them. In other words, it involves a greater degree of complexity and therefore, not one but several surgery sessions combined with non-surgical treatments such as radiotherapy or chemotherapy.
What is laparoscopic prostate surgery?
Laparoscopic prostatectomy is a minimally invasive surgical procedure that is indicated to remove a prostate invaded by cancer and that differs mainly from open surgery because only five small incisions (less than a centimeter) instead of a single large one.
This reduces trauma to the abdomen and ensures better aesthetic and functional results, with a faster recovery period.
Men subjected to this novel technique have less bleeding, less pain and therefore less postoperative analgesic medication, shorter hospitalization periods, rapid return to daily life, prompt removal of urinary catheters (which are usually uncomfortable) and in general , a faster recovery than with open surgery.
What are the advantages of this procedure compared to conventional techniques such as open surgery?
Open surgery for radical or total prostatectomy requires, at a minimum, a 20-centimeter incision in the patient’s abdomen, whereas with laparoscopy, only four to five incision points less than two centimeters are needed. This makes the procedure have a better recovery rate, with minimal complications and leaving an almost imperceptible scar.
- Minimal blood loss (about 150 ml so it is not necessary to receive blood transfusions).
- Hospital stay no longer than two days (on average a day and a half) and the patient can return home, all this depends on the speed of improvement of the patient and how big was his surgery.
- Shorter recovery time.
- Less postoperative pain and risk of infection.
- Less need to take strong pain relievers or non-steroidal anti-inflammatory drugs (NSAIDs). Mild pain can be treated with acetaminophen (or Tylenol®).
- Quick procedure. It does not usually exceed two or three hours in the operating room.
- 90% of patients have a faster return to daily activities (between one and two weeks) and to work (two to three weeks).
Introduction to the Prostate Gland
Prostate anatomy
The prostate is a glandular organ, typical of the male sex, which plays an important role in the human reproduction of men.
Located around the urinary urethra, just below the bladder and in front of the rectum, the normal prostate is about the size of a walnut. This anatomical arrangement increases urinary tract involvement if the gland is enlarged or hypertrophy occurs.
Prostate function
Among the functions that the prostate fulfills are the secretion of seminal fluid (together with the seminal vesicles) and the redirection of semen (conjugated with sperm) at the time of male ejaculation.
The prostate also exerts a valve function that prevents the passage of urine to the testicles (which would trigger a scrotal infection, a urological emergency) and drives the semen when it is sexually stimulated and thus, produce ejaculation.
BPH enlarged prostate 01
The semen that is ejaculated contains a practically perfect mixture of chemicals that are necessary for the sperm to stay alive within the woman’s vaginal canal and carry out the subsequent fertilization of the ovum. These chemicals produced by the prostate and supported by sperm are as follows:
- Fructose, a type of sugar that works as a nutritional support.
- Fibrinogen, which gives consistency to the semen (if it were very watery it would have difficulties to stay in the female cavity).
- Enzymes necessary for the fertilization of the ovum.
- Antibiotic agents.
The secretory functions of the gland are regulated by androgenic hormonal factors, of which testosterone plays the most fundamental role.
Why does the prostate get sick?
The prostate tissues are composed of cells with a high number of receptors for testosterone and that react to the surrounding blood levels of this hormone.
However, over the years and with the set of hormonal changes typical of aging (the levels of testosterone in the blood decline due to a low production of it in the Leydig cells in the testicles), the tissues of the gland become they make the hormone hypersensitive, causing it to become excessively enlarged or hypertrophied.
This is known as benign prostatic hyperplasia (BPH), which is treated with drugs that reduce the number of androgen receptors, and therefore, the sensitivity to these hormones. This male pathology is very common in older men from the fourth decade of life.
BPH enlarged prostate 02
There are more aggressive pathologies that are also highly prevalent, such as prostate cancer, which we will talk about in more detail later.
Prostate cancer
El cáncer de próstata es por mucho, la neoplasia maligna más frecuente en hombres de edades adultas avanzadas. Se trata de la malignización progresiva de los tejidos prostáticos que cursa además, con el agrandamiento de la próstata dificultando la micción y el incremento del riesgo de invasión a tejidos vecinos (o metástasis) si no es tratado oportunamente.
General anatomy of the prostate 01
The success of treatment of prostate cancer is closely related to the stage in which it is detected. Diagnosis of prostate cancer begins with detecting an enlarged prostate through a physical exam known as a digital rectal exam.
Digital rectal examination and analysis of blood levels of prostate antigen (PSA) have been the cornerstone of a suspected prostate enlargement. Cancer diagnosis is made based on a thorough review of the patient’s personal and family history, physical examination, and a biopsy that is now guided by ultrasound images.
Procedure and technique: What is laparoscopic prostate surgery?
Previous preparation
Before surgery, the surgeon performs a series of consultations to examine the patient (physical examination) and order imaging studies such as MRIs and ultrasound of the pelvic region. This is used to assess the condition of the prostate and anticipate what the surgery will be like. Some blood tests are also indicated to determine blood chemistry through a complete blood count.
Depending on the patient and their previous pathologies (such as coronary syndrome, valve pathologies, arterial hypertension or angina pectoris), the doctor may also order an electrocardiogram or a pulmonary function test to assess the patient’s health status.
In addition to this, it is also recommended that the patient modify some habits and lifestyles such as:
- Stop taking anticoagulant drugs such as aspirin or warfarin (or any other similar).
- Stop consuming pain relievers and non-steroidal anti-inflammatory drugs.
- Maintain a liquid or semi-liquid diet in the 24 hours prior to surgery to prepare the intestines and prevent diarrhea due to the effect of local anesthesia.
- After midnight the day before surgery, it is recommended to drink very little fluids. A few small sips of water will be enough to quench your thirst should it appear.
- Abstinence from alcohol, tobacco and any type of narcotic is probably also indicated. Quitting smoking is key to helping the body and the tissues manipulated in the surgery perceive better blood flow and oxygen supply to accelerate the recovery process.
How is anesthesia for surgery?
The anesthesia required in this type of surgical intervention is general anesthesia given the anatomy of the abdomen and pelvis, which contain abundant important nerve tracts. This ensures that the procedure is completely painless.
Before the intervention, the patient must meet with the anesthesiology specialist, and perform some tests to determine the type of anesthesia appropriate to the patient, in terms of type of drug and dose.
This pre-anesthetic evaluation also serves to rule out any hypersensitivity to it.
During surgery: step by step
The team of surgeons makes some incisions in the abdomen, usually between four and five incisions of approximately two centimeters. The surgical instruments necessary for the total resection of the gland and a video camera will be inserted through these holes, which will serve to show the execution of the procedure on a TV monitor.
Once the holes have been made into the pelvic cavity, the urological surgeon proceeds to:
- Through one of the holes made (located near the navel) a very thin cannula responsible for injecting carbon dioxide into the abdominal cavity will be introduced in order to lift the wall of the abdomen and thus widen the field of vision of the surgeon.
- The cannula containing the video camera is inserted into one of the small holes made in the abdominal wall to assess the state of the prostate gland and nearby anatomical structures (if there are signs of abdominal infection or any other pathology of Importance, surgical intervention should be discontinued).
- If nothing abnormal or pathological is seen, the surgeon accesses with his specialized instruments to the place of the anatomical position of the prostate, below the urinary bladder. If necessary, layers of deep tissue are cut to access the lymph nodes that drain lymph from the prostate because they may be invaded by cancer cells.
- The prostate is carefully separated from neighboring tissues, especially the supporting connective tissues that are attached to it and the nerves leading to the penis.
- The blood vessels and nerves to the gland are cut.
- Cut the pedicle attaching to the urinary bladder and urethra (the prostatic portion of the urethra is completely excised).
- The prostate and seminal vesicles are removed.
- The upper end of the urethra is reconnected with the lower portion of the bladder.
- Holes are sutured entry of laparoscopic instruments.
Some lymph nodes will also be removed for studies and biopsies.
Laparoscopic prostate surgery
Care after laparoscopic prostate surgery
After the surgery the doctors will keep the patient for two or three days in the hospital to monitor the progress of the surgery and anticipate any complications that may develop.
During this period of hospitalization, it is recommended that the patient take short and slow walks to improve blood circulation in the lower part of the body and promote tissue repair.
- In addition, the patient's diet will be liquid or semi-liquid. Progressively more solid foods will be incorporated until the patient's usual diet is completely reestablished as directed by the treating physician.
- It is completely normal that after a surgical procedure of this type patients feel nausea and vomiting because the intestines are temporarily stopped by the anesthesia used. This is benign and goes away on its own within 24 hours.
- Medications are also indicated to relieve postoperative pain and antibiotics to prevent possible infections.
- The patient must remain two or three weeks of physical rest at home, taking care not to do strenuous physical exercise or lift heavy loads. It is recommended that the patient walk a little more each day to increase blood risk until they return to normal activities.
The idea of all this time of careful recovery is that the patient can progressively return to their daily life without overloading the body with great physical efforts that could, among other things, damage the intervened tissues and complicate the prognosis.
Radical prostatectomy by robotic laparoscopy: What is the difference with traditional laparoscopy?
Traditional laparoscopy and robotic laparoscopy are based on the same technique: a set of surgical devices inserted into a cavity and a video camera that helps to observe the procedure. The difference between these two variants lies in the instrumentalist.
In traditional laparoscopic surgery, surgeons perform the techniques and procedures on site, manipulating the instruments themselves. Between two and three surgeons are required in the operating room to carry out the intervention in a coordinated manner.
With robotic (or robot-assisted) laparoscopy, the surgeon sits in front of a control panel and with the help of a TV monitor moves the instruments within the patient’s body. The system has robotic arms and they move in accordance with the physician’s movements.
In this last technique, the surgeon is required to have specific skills for this technique, which offers even better results than traditional laparoscopy.
What are the results?
It is estimated that 97 percent of patients with localized prostate carcinoma achieve positive results after laparoscopic radical prostatectomy. Obviously these results can vary from patient to patient with the amount of prostate tissue excised. In some cases, tissues adjacent to the prostate such as fatty tissue, seminal vesicles and some of the urethra or urinary bladder are removed.
How long does laparoscopic prostatectomy surgery take?
The time required to perform a laparoscopic radical prostatectomy can vary from between 2 hours 30 minutes and 3 hours 30 minutes depending on the anatomy of each individual, the size of the prostate and if it is required to remove other surrounding tissues.
Most patients can go home the day after the intervention, so the hospital stay is minimal, although rest at home is required. Two or three weeks are enough to return to daily activities completely. The treating physician will be in charge of indicating how much time is necessary based on the postoperative check-ups.
Another important factor is the placement of a catheter to urinate without straining the urethra after surgery.
With conventional techniques (open surgery) the catheter must remain inside the patient’s penile urethra for about two or three weeks since the degree of trauma to the tissues was greater.
However, with laparoscopic prostate surgery it is possible to remove the bladder catheter (better known as a Foley catheter) on the third day after the intervention.
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Frequently asked questions about prostate surgery
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Since minimally invasive laparoscopic methods are used, the risks and probability of post-intervention complications are very small. However, among the complications that may occur are:
• Blood in the urine (hematuria).
• Infections, especially urinary tract (UTI).
• Post-surgical pain, what e is treated with pain relievers.
• Hematomas at the sites near the laparoscopy holes.
According to the European Association of Urology, it is estimated that almost 9 percent of men who undergo this procedure develop urinary incontinence because some nerve bundles that control the bladder sphincter muscle are likely to be cut during the removal of the prostate. , which relaxes during urination. It is difficult to predict how likely you are to cause urinary incontinence before surgery.
Men who undergo laparoscopic prostatectomies again enjoy a completely normal and voluntary urinary function, without discomfort or signs of obstruction, about three months after surgery.
It must be taken into account the significant percentage of patients who, due to prostate disorders (such as benign prostatic hyperplasia or malignant gland tumors) lost the ability to urinate calmly, so three months is longer than positive to regain this function.
After the surgery, the doctor will give specific instructions on the care of the operation site to speed up the healing and recovery process. More specifically, of the incisions that were made in the skin and, for this, the care is as follows:
• Place sterile adhesive, especially for these cases, on the incision site for about 10 days to two weeks after the intervention. This will help each incision stay as dry, clean, and protected as possible from clothing rubbing.
• Avoid taking aspirin to treat pain, in that case, it is possible to take over-the-counter pain relievers such as acetaminophen.
• It is normal for the skin near the incision sites to change color and become a little bluish or dark. This is completely normal and will go away on its own after a couple of days.
• When to drive a car again is a frequent question among men undergoing this surgery and the truth is that there is no set time, but in most patients they can do it again in about 10 to 14 days. All this depends on the doctor’s instructions.
Erectile dysfunction (ED) represents the most important and most prevalent risk that is run when performing a radical prostatectomy, regardless of its surgical modality. Obviously, doctors are very careful when removing the prostate and leaving the bundle of nerves that supply the penis and genital structures intact. However, the anatomy indicates that there is a close relationship between the gland and these nerves, so when removing it, it also takes some nerves with it, reducing the sensitivity of the area and the erectile response of the corpora cavernosa. However, all is not lost. If male sexual impotence, erectile dysfunction or weak erections occur, other therapeutic methods can be used to maintain the active sexual life of patients.
These therapeutic methods include:
• Phosphodiesterase 5 inhibitor drugs, better known as retardants of the sildenafil, taladafil or vardenafil type. Generally orally, in tablets.
• Intracavernous injections of vasodilator drugs, with excellent results in the short and medium term.
• Suction or vacuum pumps.
• Penile implants.
The European Association of Urology speaks of a 40.9 percent risk of developing ED after a radical prostatectomy intervention.
No, because the prostate that will eventually be removed does not have the function of producing sperm (this occurs in the testicles, inside the scrotum).
After surgery, ejaculations will be slightly less abundant (because the prostate produces some semen) but the ability to fertilize remains intact unless there are problems with the testicles.
If you are in the recovery period and notice the following symptoms, it is important to call your doctor or go for a consultation:
• Fever over 40 ° C.
• If the pain is very strong or does not go away with the indicated painkillers.
• Difficulty urinating or blood in the urine.
• Dizziness and vertigo.
Yes, it is necessary to use a catheter or bladder catheter for some time after (a couple of days) laparoscopic radical prostatectomy surgery because it is necessary to give the urethral tissues an opportunity to reconnect and heal.
Any male patient diagnosed with localized prostate cancer without metastasis may be a candidate for laparoscopic radical prostatectomy.
However, each case must be treated and evaluated individually since in rare cases, a tumor not so well located within the prostate glandular tissue can be approached by laparoscopic methods.
Doctors recommend absolute sexual abstinence for one month after such an intervention. This withdrawal includes penetrative sex, masturbation, and ejaculation (ejaculation may be painful or bloody).
Developing minor erectile problems after a potentially life-threatening organ has been removed is somewhat minor. In fact, it is rare with this technique and men continue to enjoy active and fulfilling sex lives.
In many other cases, erectile dysfunction was already an underlying problem. That is, it was already present before surgery (especially in obese, diabetic, hypertensive or very old patients).
Among the alternatives to treat erectile dysfunction are:
• Phosphodiesterase 5 inhibitor drugs such as sildenafil, taladafil or vardenafil that favor the relaxation of the blood vessels that go to the penis and therefore, the erection mechanisms are enhanced.
• Intracavernous injections of alprostadil, a drug with a vasodilator effect that infiltrates the base of the corpora cavernosa of the penis and has a long-lasting effect.
• Vacuum pumps, suction devices into which the penis is inserted in a flaccid state to induce an erection.
• Penile implant surgery, a definitive and surgical solution to the problem.
Medical references and bibliography
- LAPAROSCOPIC SURGERY FOR PROSTATE: ADVANTAGES AND ELEGIBILITY WEB MD
- LAPAROSCOPIC RADICAL PROSTATECTOMY NCBI – USA
- LAPAROSCOPIC PROSTATECTOMY: WHERE DO WE STAND? NCBI – USA
- SURGERY FOR PROSTATE CANCER AMERICAN CANCER SOCIETY
- UAE GUIDE TO PROSTATE CANCER Scielo
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