Urology

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Conventional prostate enlargement surgery

What does this procedure entail?

The surgery is performed through the bladder from a midline incision in the lower abdomen. The surgery should remove the middle part of the prostate or excess tissue inside the prostate (the prostate itself is not removed during this procedure). It is necessary to insert a temporary catheter into the bladder after this procedure.

This type of surgery also allows for the management of other associated problems – removal of cystolithiasis (stones in the bladder) or diverticulum (protrusions of the bladder wall)

What are the alternatives to this procedure?

Follow-up
Drugs
Use of catheter/stent
Endoscopic surgery (e.g. TUR-P, HoLEP)

What should I expect before this procedure?

If you regularly use Anopyrin, Clopidogrel, Warfarin, etc., you must tell your doctor. These medications can be associated with increased risk of bleeding during and after the surgery if they are not stopped in time. In some cases, it is necessary to replace these drugs with injection preparations. It is necessary to consult your general practitioner or cardiologist about this approach.

At the request of the referring physician, you will have to schedule preoperative examinations to assess your overall condition, including laboratory and instrumental tests. If the report does not preclude the indicated procedure, you will be admitted to the hospital. If you don’t undergo a preoperative examination or it is incomplete, you will not be able to have the surgery as scheduled. You will be admitted by a nurse and a member of the medical team will complete your examination and assess your fitness for the surgery.

You will be asked not to eat or drink for at least 6 hours before the surgery!

In the evening before the surgery, you will receive medication from an anaesthesiologist to calm you down so that you sleep well.

Remember to inform your physician about the following possible facts before the surgery:

artificial heart valve
coronary artery stent
pacemaker
artificial joint
artificial vascular graft
neurosurgical bypass
other implanted foreign body
use of the following prescription drugs: Acylpyrin, Anopyrin, Aspirin, Godasal, Clopidogrel, Plavix, Kardegic, Aspegic, Micristin, Ibustrin,Ticlid, Tagren, Ipaton Apo-Tic, Plavix, Persantin, Curantyl, Anturan, Aggrenox, Vessel due F.
drug and other allergies
any abnormalities or eventualities

It is NECESSARY to inform the physician about your use of drugs affecting blood clotting before your admission for the procedure.

What will happen during the surgery?

You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.

The procedure is performed exclusively under general anaesthesia.

Cystoscopy is performed before the procedure itself – examination of the urethra, prostate and bladder using a telescopic instrument. The cut in the middle line in the lower abdomen is then dissected and the previously filled bladder is opened. Eventual bladder stones are removed and all the excess prostate tissue is then removed (then sent for histological analysis). A catheter is inserted into the bladder through the urethra and the bed formed after tissue removal is filled with the filled balloon to reduce bleeding. An additional catheter (epicystostomy) is then inserted through the bladder wall to flush it and prevent the formation of blood clots in the bladder (and clogging of the catheter).

The bladder wall in the area of eventual diverticulum(a) (= protrusions of the bladder wall) is sufficiently released, the protrusion is removed and the opening in the bladder wall is closed with sutures.

After the bladder is closed with sutures, a tubular drain is inserted into the wound, which exits, together with the flushing catheter, through the wound in the lower abdomen.

The whole surgery usually takes 45-60 minutes.

What will happen immediately after the procedure?

You will wake up at the intensive care unit equipped for the continued monitoring of patients immediately after the procedure. The surgeon will inform you about the course of the procedure. You will still have high levels of anaesthetics in your blood at that time, so you may not remember this conversation.

Patients usually have an infusion access point into a vein in their arm; if necessary, a monitoring/infusion port (a tube inserted into the vein to monitor blood pressure or administer drugs and nutrition) will be inserted into a vein (jugular vein) in the superclavicular region (the area between the collarbone and neck).

Nutrition is provided in an intravenous manner shortly after the surgery. You will receive a liquid and mushy diet for the next 2 to 3 days. This procedure is necessary for the proper restoration of gastrointestinal function. Non-compliance of the patient is usually associated with severe abdominal pain, vomiting with the risk of suffocation and may require surgical revision (further surgery in case of complications).

Physical rehabilitation is very important to prevent complications in the postoperative period. You will first exercise on the bed. As soon as your medical condition allows, you will be allowed to sit down and then stand up. After that, you will be able to walk slowly and carefully around the room, initially accompanied by medical staff. Pay close attention to eventual dizziness, uncontrollable weakness, and to gait stability. Otherwise immediately inform medical personnel or anyone in the vicinity.

Once you are fully conscious, you should:

ask if the planned outcome was achieved
inform the medical staff about any problems
ask what you can and cannot do
ask all the questions you have for the healthcare professionals and members of the medical team.
remember (and understand) why the surgery was performed, how it turned out, and what will follow

After the surgery, there is always bleeding from the prostate area. Blood in the urine usually disappears within 48-72 hours. If blood loss is more significant, you will be given a blood transfusion. Revision (surgical control) may be considered in case of massive or persistent bleeding. The filling of the catheter balloon is gradually decreased until the catheter is removed on day 5 after the surgery. Afterwards, you will urinate spontaneously. If urination is free and no residual urine remains in the bladder, the epicystostomy will be removed. Initially, urination may be painful and may be more frequent than usual. The initial issues can be alleviated by medication. These problems usually disappear within a few days to weeks. You may have blood in the urine again during the first 24-48 hours after the removal of the catheter. Exceptionally, the patient may not be unable to urinate spontaneously at all after this surgery. In this case, the catheter is inserted again so that the tissue may heal. The catheter is permanently removed days to weeks later.

The drain from the wound is removed about 3-5 days after the surgery; sutures are removed from the wound before discharge from the hospital.

The average hospitalisation is 10 days.

What are the postoperative risks or complications?

Common (10% of procedures of this type)

Temporary mild burning, bleeding and frequent urination after the procedure
About 75% of patients do not have semen ejaculation during orgasm (backflow into the bladder)
Treatment may not relieve all the symptoms associated with the condition before the prostate surgery
Weak erection (impotence in approximately 14% of patients)
Bladder, testicular or kidney infections requiring antibiotic treatment
Bleeding requiring further surgery and/or blood transfusion (5%)
Possible need to repeat treatment due to repeated obstruction – inability to urinate (approximately 10% of patients)

Occasional (2-10% of procedures of this type)

Urinary tract scarring
An accidental cancer finding in the removed tissue, which may require further treatment
Incomplete bladder emptying may require self-catheterisation. This happens when the bladder is weak.
Inability to urinate after the surgery with the need for a new catheter
Loss of control of the bladder (incontinence), which may be temporary or permanent (2-4%).

Rare (2% of procedures of this type)

Very rarely, injuries to the bladder or surrounding organs (more often when the diverticulum is removed) requiring a longer catheter or open surgical correction.
Urinary fistula in the wound requiring prolonged catheter insertion or surgical correction

Hospital infections

MRSA colonisation (0.9% – 1 of 110)
Intestinal infection by clostridium difficile (0.01% – 1 of 10,000)
MRSA blood infection (0.02% – 1 of 5,000)
Hospital infection rates may be higher in high-risk patients, such as in cases requiring long-term drainage, after a previous infection, after prolonged hospitalisation or after multiple hospitalisations.

What should I expect when I return home?

When you are discharged from the hospital, you should:

get recommendations on recovery at home
ask when you can return to normal activities such as work, exercise, driving, cycling, housework
get a contact number for further questions after returning home or in case of trouble
ask about the date of the following check-ups and the place where you should come (hospital or your attending physician)
make sure you are aware of the reason, course and outcome of the surgery, the results of examinations or the removal of tissues or organs.

At your departure from the hospital (sometimes several days later), you will receive a hospitalisation report. The document contains important information about your hospital stay, your surgery and recommended follow-up. If you need to call your attending physician or visit the hospital for any reason, take this document with you so that the physician knows the details of your treatment. This is especially important if you need to consult another doctor or longer after discharge.

What else should I watch out for?

If you experience more frequent problems, burning or difficulty urinating, or have unusual bleeding, consult your attending physician.

About 1 in 5 men suffer from bleeding within 10-14 days of hospital discharge; it is caused by the separation of the healing tissue in the prostate bed. Increasing fluid intake should help reduce this bleeding and it should gradually stop. If there is no improvement, you should see your doctor. In the event of severe bleeding, large amounts of clots or obstruction of the urethra, you should see your doctor immediately. They will probably refer you back to the hospital.

Any important information?

Removing excess prostate tissue should not adversely affect your sex life, provided you had a normal erection before surgery. You can resume sexual activities as soon as you feel well, usually after 3-4 weeks.

It is advisable to do pelvic floor exercises after the surgery. They will improve your bladder control when you return home. Symptoms of urgent and irritating urination can last up to 3 months. Flow rate will improve immediately.

The results of the histological analysis of the collected tissue will be discussed at the postoperative check-up. This surgery does not fully eliminate the risk of prostate cancer in the future.

Most patients need 2-4 weeks of rest at home before they are able to handle a full workload. Before returning to work, we recommend a 3-4-week-long rest period; if you have a physically strenuous occupation, it should be up to 12 weeks. You should avoid lifting heavy loads at this time. It is also advised against cycling for 6, or better up to 12 weeks.