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Adenomectomy of the prostate
Last reviewed: 23.04.2024
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Adenoma refers to a benign neoplasm localized in the prostate gland. This is a fairly common pathology that affects patients over the age of 50 years. The risk of developing the disease in men who suffer from chronic inflammatory diseases of the urinary tract, kidneys, and the bladder is especially high. Also, the risk increases in the presence of infections, violation urodynamics. The disease is manifested by intense pain. In the urine, blood can appear. Often the bladder is not completely emptied, there is a delay in urination. The main method of treatment is adenomectomy.
Most often, surgical methods are resorted to ineffectiveness of other, conservative methods. Also, surgery can not be avoided if there is a pronounced urination disorder. Urgent operation is performed with complete urine retention. Many doctors try to first conduct a catheterization of the urinary tract. But often this method is ineffective and in the end, all the same requires surgical intervention.
Indications for the procedure
If a patient has prostate adenoma, this does not mean that he necessarily needs surgery. Many cases are quite effectively treated in conservative ways. The operation to remove adenoma is carried out only if there is evidence for this. And this is approximately 2-3% of cases.
In most cases, the operation is performed if the adenoma has reached a sufficiently large size, and if it increases very rapidly in size. Usually, the indication for removal is the mass of the adenoma, exceeding 80-100 grams. First of all, they are trying to conduct a transurethral resection of the prostate gland. If for any reason this procedure can not be carried out, an operation is prescribed. This is the main indication.
There are additional indications that indicate the need for an operation. Thus, as an additional indication for adenomectomy, the presence of chronic diseases of the urogenital tract, which occur severely and with frequent relapses, is considered. If a person is blocking the outflow of urine, it is also necessary to urgently carry out the operation. The appearance of blood in the urine, pathological changes in the bladder, pathology and inflammation in the kidney and ureter in different circumstances can also be considered as an indication for the operation.
Preparation
Preparatory activities begin with a urologist. To begin with, a rectal finger examination is performed, after which in most cases there is a need for an analysis for PSA, a prostatic specific antigen. Biological material for the study is the patient's blood. Often it is prescribed for suspected cancer. A negative result allows to exclude prostate cancer. An additional method of research that allows to exclude a cancer tumor is TRUS - a tranuretral ultrasound examination, during which a biological material is collected for further histological examination.
It is also necessary to conduct a comprehensive study of pelvic organs. It is important to submit mandatory clinical tests, a biochemical blood test, and specialist consultations. These are planned measures used in preparation for any operation. Obligatory consultation of a surgeon and an anesthesiologist, an electrocardiogram may be required.
Urofluorometry is used as specific methods of research, as well as measures of residual urine in the bladder. A radiograph of the chest or fluorography is necessary, especially for patients older than 60 years.
Technique of the adenomectomy
After all necessary preparations have been carried out, the patient is anesthetized. Most often, spinal and peridural anesthesia is used, implying intensive regional anesthesia. This allows you to significantly reduce the risk of complications. First of all, such anesthesia allows to overcome pulmonary embolism and prevent the risk of developing deep vein thrombosis. To general anesthesia resort very rarely, mainly in the event that there are contraindications to conducting regional anesthesia.
The adenoma is removed through the incisions. In this case, most often resort to the retropubic or suprapubic access. In some cases, an open, intrusive adenomectomy is used, the essence of which is to penetrate through the incision of the bladder, during which the hyperplastic gland is produced. In this case, the patient's position should be spinal. Before the beginning of manipulations to remove adenoma, a special catheter is introduced into the bladder, which will ensure a reliable outflow of urine from the bladder. After this, a longitudinal incision is made, which provides access to the bladder.
After gaining access to the bladder, they are placed around the edges of special holders that will hold the bladder and allow the surgeon to carry out the necessary manipulations. In order to ensure reliable fixation, a bubble is usually stitched in several places. After the vyluschivanie held, stop bleeding. It often occurs in the area where the adenoma of the prostate has been localized. Then, the bladder is sutured. In it, leave a small tube, which will act as a drainage system and ensure the necessary outflow of substances out. In addition, with the help of this tube, it is possible to wash the prostate. For washing, a solution of furacilin and other means are used to ensure the prevention of bacterial infection. For about a week, the catheter should remain in the bladder. This is necessary so that a new section of the urethra is formed around the catheter (since during the operation a small area is simply removed).
Stages of adenomectomy
Adenomectomy is carried out in several stages. At the first stage, preliminary training is conducted in the operation. It includes consultations with doctors, the delivery of tests, the selection of optimal anesthesia. The preparatory stage ends with the introduction of anesthesia.
The second step is to provide operational access. Various types of cuts can be used, depending on the type and type of operation. At the third stage, necessary manipulations are carried out to remove adenoma. In the fourth stage, the wound is closed and sutures are applied. The postoperative stage includes additional monitoring of the patient, removal of sutures, bandaging, and restorative treatment.
Seizure of adenomectomy
Conducting a posteric adenomectomy implies the need for a cut along the anterior surface of the capsule of the prostate gland. Then further excision of the adenoma with the finger is performed. Before performing the operation, a cytoscopic examination is performed. To perform this procedure, the patient should take a supine position. It is located on the operating table. After this, the patient occupies the position of Tredelenburg, in which the legs are located above the head.
The operating field is then processed. In the bladder, a catheter is inserted, the site is cut from the navel to the pubic bone. After the extraction of the rectus abdominis muscles, a retractor is introduced, which makes it possible to widen the incision. Then, the localization of the venous plexus is determined, the neck of the bladder is secreted. It contains the main artery, which provides blood supply to the prostate gland. After this, the surgical capsule is cut in the area adjacent to the adenoma. Then, finger extraction is performed. After the adenoma has been completely removed, the hemostasis is performed and the wound is sutured along the layers.
This method of adenomectomy has its advantages. In particular, it provides an opportunity to examine the prostate adenoma, the urethra is cut pointwise. As a result, the probability of complications is significantly reduced. You can avoid a delay in urine. In addition, this technique makes it possible to conduct complete hemostasis after the adenoma has been removed, the bladder is not injured.
Disruptive adenomectomy
She carries out another surgical approach. In this case, the lower part of the anterior surface of the bladder is cut. This technique has several advantages over other methods, in particular, you can directly examine the neck of the bladder and its mucosa. In this regard, cumbus adenomectomy is an ideal option for patients who suffer from a complicated form of prostate adenoma that is associated with complications from the bladder.
The procedure is not without certain drawbacks, in particular, it is quite difficult to perform hemostasis. The incision is made along the midline of the abdomen from the navel to the pubic bone. The bladder is opened and further examination is performed. In particular, the mucous membrane is examined. Removal of adenoma and dissection of the capsule of the prostate gland is performed using an electric cautery and special scissors. For the purpose of performing hemostasis, the adenoma bed is sewn after its removal. Then a layered suture of the incision is made through the front surface of the abdominal wall.
[11], [12], [13], [14], [15], [16], [17], [18], [19]
Laparoscopic adenomectomy
One of the main methods to quickly and efficiently remove the adenoma is laparoscopy. This is a universal method, which is used in many fields of medicine. It does not imply the need to make large incisions. Several punctures are made through which special tools are introduced. They provide an opportunity to fully examine the internal organs, to assess the scale of the operation. You can also display the image on the screen. The method makes it possible to accurately, accurately remove the adenoma, practically without damaging neighboring organs and tissues, directly through the incisions.
The recovery period after this operation is quite short. This method is convenient to remove large adenomas. It has a number of advantages, which mainly can be achieved due to the fact that no large, open operating access is being made. In this regard, significantly reduces the risk of infection, risk of bleeding and other complications. After surgery, there are practically no scars, since basically 4 small incisions are made, the diameter of which does not exceed several centimeters. After the operation, these areas are simply sealed with adhesive tape, often there is no need for suturing. The postoperative period ranges from 3 to 5 days, and often even an anesthetic is not used. This is due to the fact that the scale of the damage is insignificant, tissue repair is very quick. Some manage to recover even after 1-2 days. Already on the day of surgery or the next day the patient can get up. Blood loss is insignificant, which is very important for people with coagulation disorders, for the elderly.
In the course of laparoscopy, in most cases resort to such methods of surgical access as the suprapubic and the retropubic method. Contraindications to laparoscopy are the presence of urolisis, diverticulosis of the bladder, inguinal hernia and pathological conditions of the joints, lower limbs.
During the operation, special equipment is used. It is not in every clinic, so not everyone can afford to carry out the operation in this way. In addition, the operation requires special skills and high qualification of the specialist who conducts the operation. Used trocar, represented by a tube. It contains a channel through which the instruments are inserted. Also at the end of this tool is a special camera that provides a good view. You can also display the image on the monitor. You can even shoot a video. For normal operation, three trocars are sufficient, but to ensure a high quality of surgical intervention, 5 trocars are sometimes used.
The patient is located on the operating table in the position with the legs raised up, being under anesthesia. In this case, the legs are placed on special supports, the head end is lowered than the legs. This situation is called lithotomic. In the bladder, you must always enter a catheter for successful urinary diversion. Trocars are installed in the right areas, the operating field is directly processed, then inflated with a balloon. The incisions are small, in the region of the umbilical canal. At the same time, the usual dissection of the peritoneum is not performed. Control of what is happening is done with the help of video equipment. Through the trocar canal, adenoma is removed. After it has been completely removed, the tools are removed from the cut. The duration of such an operation usually does not exceed two hours.
Additionally, other trocars can be used. They can be brought to the operational access and are used when additional measures are needed. For example, they can be used to introduce electric cauters, dissec- tors and other instruments. Flushing is performed through a catheter inserted into the bladder with a physiological solution.
If necessary, the doctor can leave the catheter in the bladder for about 2-3 days. It provides good drainage. The next day you can get out of bed. And usually after removing the catheter, the patient's discharge is made home. Usually antibiotics are prescribed for the prevention of infections, and also recommend drinking a large amount of liquid. This will provide an opportunity to maintain a good drainage of the wound. Also it is impossible to go in for sports during the postoperative period, to perform heavy physical work. The patient will receive a number of recommendations when discharging, which must be followed in order to recover quickly.
The efficiency of the operation is quite high. It facilitates the patient's condition by 98% (when assessed by the scale of prostatic symptoms). During the operation it is possible to eliminate the entire pathological area. In the subsequent relapse does not arise and the need for re-operation also does not arise.
Simultaneous adenomectomy
Today, an increasing number of specialists resort to a one-stage operation, whereas a two-stage operation goes to the background. It implies the removal of adenoma followed by the imposition of a blind seam on the bladder. Often such an operation is called an ideal adenomectomy.
This method has several advantages. For example, after surgery, there is no need to install suprapubic urinary drainage. This is a high-tech method. A number of specialists are discussing the advantages and disadvantages of this method. However, most specialists agree that this technique is an ideal option for patients with normal secretory and excretory activity of the kidneys. It is also used if it is impossible to conduct a catheterization of the bladder. Also used in the event that conservative methods of treatment are ineffective. It is recommended to hold only if the patient feels well, if the level of residual nitrogen in the blood is normal, and if the person does not have genito-urinary infections.
Contraindicated surgery this method in the event that a person is not able to adequately perceive and assess the situation. Do not spend in the event that a person suffers from severe mental disorders, senile marasmus, severe forms of neuroses. Also, as contraindications, severe cardiac pathologies are considered in the stage of decompensation, when the kidneys and liver are disturbed. Contraindication is the violation of the norm of urea in urine and creatinine in the blood. Various congenital and acquired defects and abnormalities of the urinary tract, tumors, diverticulosis, impaired urine output, sepsis serve as a contraindication to the operation.
A blind seam is superimposed if a person safely underwent surgery. In most cases, surgeons use a midline incision, which is made between the navel and the pubic symphysis. An arcuate incision is used, which allows avoiding urinary fistulas and urine leakage, while innervation is not impaired.
In the course of the operation, a resection of the bladder is necessary. In this case, often associated comorbidities - polyps, cancerous tumors, diverticula. Gradually dilute the edges of the wound. Remove the stones and other possible pathologies, then proceed directly to the adenoma. This is done blindly, so the experience of the surgeon is very important here. Bleeding is stopped in the bed of adenoma. Then, the bladder wall is sutured.
It can be safely asserted that the result of the operation, the prevention of further complications and bleeding depends on how well the operation was performed qualitatively, as well as on the experience and qualification of the surgeon. In general, adenomectomy is not among the complex operations. Recovery after it occurs quickly, complications are rare.
Open adenomectomy
An open adenomectomy is also called an overdose. It is used in the event that it is impossible to remove the adenoma in other ways. It is indicated in the event that the adenoma has reached a sufficiently large size, and also if it can not be removed by transurethral resection. There are no contraindications to this operation. Do not perform an operation only if the person is in serious condition, if he has serious concomitant diseases that can interfere with any operation. Postpone the operation will have to in the event that a person is sick with an infectious or inflammatory disease. In this case, you must first cure the disease that prevents the operation, then - go directly to the operation.
During an open surgery, anesthesia is used. Usually, general anesthesia is used in combination with regional anesthesia. The decision as to which method of anesthesia is more appropriate to choose in each particular case is made by the anesthetist. It is based on the results of analyzes, conclusions of other specialists, as well as on their own data of objective and subjective research of the patient.
The operation requires preliminary preparation. The more qualitatively the training will be conducted, the more likely the successful operation will be. In a few weeks, you need to comply with the optimal diet, take the necessary tests, pass a survey of the main specialists. Immediately before the operation, hair removal from the pubic area is performed. Usually the patient does it on his own, but in case of impossibility to carry out these manipulations independently, these actions are performed by medical personnel. Approximately 8 hours before the operation, you can not eat and drink water.
An open surgery carries a lot of risks for young men, because the risk of a potency violation is great. Therefore, young people are very rarely used for this type of surgery, only if drug therapy does not give a positive result, and if other methods are ineffective.
The operation is performed in several stages. So, first cut the bladder. In this case, the doctor has access to the affected part of the prostate. Immediately before the procedure, you need to install a catheter. It will allow excess fluid to flow out of the operated cavity.
The incision is localized in the suprapubic region. After there is open access to the bladder, with the help of special tools, produce a cut. Using a surgical forceps, the bladder is lifted. During the course of the catheter, the location of the neck of the bladder is determined. Then another incision is made around the inner orifice of the urethra.
The previous manipulations give an open access to the prostate gland, which allows the doctor to make the tumor out. Immediately after removal of the adenoma, the doctor removes the remains of damaged tissue, stops bleeding, provides aseptic conditions and sutures the bladder. The doctor leaves a small tube in the bladder, which will provide good drainage in the postoperative period. With the help of this catheter, you can rinse the operating cavity, relieve it of blood clots and excess exudate. This significantly reduces inflammation, promotes accelerated healing of damaged tissues. Also in most cases, another incision is made along the inner opening of the urethra and its circumference.
After surgery, the need for a catheter is maintained for a week. This is an important condition for rapid and successful rehabilitation. The catheter acts as a foreign body through which exudate is exhaled. Also, this will quickly form a new site around the urethra. Such areas are formed at the site of the removed part of the bladder. At the same time, such education is extremely important due to the fact that during the operation, a complete removal of part of the bladder. It is this intervention that is the reason for the violation of potency in most men.
When performing an adenomectomy by an experienced physician, complications are extremely rare. Only in exceptional cases, open bleeding develops, which is caused by damage to the blood vessel. An allergic reaction may also occur if the patient has a tendency to allergies.
Especially dangerous is a possible anaphylactic shock, but this happens very rarely, because this is the extreme stage of the development of an allergic reaction and appears with a high level of sensitization and allergization of the body. Usually this condition is clearly visible from the results of the tests, therefore, an experienced doctor will always insure himself and take the necessary measures to prevent such complications. Also the patient is obliged to observe precautions, and it is necessary to warn the doctor about the propensity to allergic reactions. In the postoperative period, complications can occur in about 20% of cases.
Transurethral adenomectomy
Under transurethral adenomectomy means a special technique for performing an operation for resection of the prostate adenoma, during which endoscopic technique is applied. When the operation is performed through the urethra, a special tube is introduced through the urethra, through which it is possible to observe the internal state of the operated cavity.
It is possible to display the image on the monitor screen. This allows the doctor to monitor the accuracy of the operation and monitor all necessary manipulations. This makes it possible to remove the adenoma of the prostate as accurately and accurately as possible, with minimal damage to surrounding tissues. The risk of postoperative complications, bleeding, and infections is also significantly reduced. Recovery and healing proceeds quickly enough, soreness is minimized.
Contraindications to the procedure
Adenomectomy may have certain contraindications. So, the operation is not performed if there is a history of cancer or fibrotic proliferation of the prostate, even if the dimensions of these tumors are extremely small. It is also not carried out if access to the prostate gland is difficult if previously performed operations on the pelvic organs.
A complete resection of the adenoma is contraindicated in the event that there is an infection or inflammatory disease in the body, and even more so. Usually, in this case, the operation is postponed until the inflammatory or infectious process is completely eliminated. This is confirmed by laboratory and instrumental studies.
The operation can be contraindicated in case of decompensation of diabetes mellitus, the presence of cardiac pathology, especially if it is in the decompensated stage. Also, contraindication to the operation is acute myocardial infarction, thromboembolism, as well as other acute conditions.
Consequences after the procedure
In the event that the operation is performed correctly, and there are no other aggravating factors, or concomitant diseases, complications do not arise. However, complications such as bleeding that can result from natural fragility, increased vascular permeability, or a tendency to bleed may occur.
An allergic reaction also often occurs with a tendency to allergies. Especially often, an allergy occurs when exposed to anesthesia. As a consequence of surgery, mechanical damage to the urethra, or damage to surrounding tissues, is also considered.
Complications after the procedure
Today, the risk of complications is minimized, as the technique of adenomectomy is improved. The risk of blood loss is minimized due to improved cutting techniques and special operational access.
In addition, modern laboratory methods allow you to monitor the level of allergic organism and respond in a timely manner to the changes that occur. With the help of various monitors and instrumental methods, it is possible to monitor cardiac and circulatory parameters, thereby reducing the risk of developing blood circulation and cardiac pathology.
A few hours after surgery, the risk of developing blood loss is preserved, so the patient remains in the intensive care unit for further monitoring and control of the condition. Nevertheless, modern methods make it possible to reduce the risk of bleeding to a minimum. Also, within a few days after the operation, the patient may be bothered by urge to urinate, sometimes a tendency to urinary incontinence, inflammatory processes in the bladder.
The degree of severity of complications arising depends on the state of the bladder before the operation, on the severity of the pathological process. Potency, erection can be violated. So-called erectile dysfunction occurs in 3-5% of cases. Quite often there is retrograde ejaculation, in which sperm enters the bladder during ejaculation. This phenomenon occurs in 50-80% of cases.
The operation is accompanied by neurologic complications, which most often affect the circulatory system, bronchopulmonary system. Also, myocardial infarction, a heart attack, deep vein thrombosis can develop. In many cases, circulatory disorders develop. Violation of cerebral circulation is considered especially dangerous. Most often it develops as a type of blood pressure rise, ends with a stroke. The frequency of such potentially life-threatening complications is less than 1%.
Reviews
If you analyze the reviews, it can be noted that patients try to avoid surgery to remove prostatic adenoma if possible. In the event that medication does not help or there are no other treatment options, patients are treated for surgery. Many men doubt, they first ask for advice from a doctor, collect reviews from other men who have had to endure such an operation.
In general, the reviews are positive. The operation allows men to noticeably improve the condition, normalize urination, eliminate pain and feel like a man again. The operation is fast enough, after surgery, pain does not happen. If they arise, they quickly enough stop with the help of pain medications. The main advantage of such an operation is that men feel the disappearance of pain when urinating, disappearing false urge to urinate.
Many men admit that they tried in every possible way to avoid surgery. At the same time, the medicines prescribed by the doctor were applied, resorted to phytotherapy and traditional medicine. But the effect, as a rule, left much to be desired, so in the end all the same you had to apply operational methods. At the same time, as most patients note, preparation is simple and practically no different from preparing for any other operations. Usually, surgery is resorted to when the natural outflow of urine is completely blocked. Therefore, it is necessary to do the operation in an emergency order, as a result of which the duration of the preparatory period is minimized.
Immediately after the surgery, patients experience pain for a while, but they quickly pass. A man in a few days begins to walk, feels good. In the first 3-4 days, blood in the urine may persist. In most cases, inpatient treatment lasts approximately 5-7 days, after which the patient is discharged home. Still some time it is necessary to supervise a status of kidneys, a liver, a bladder, and also to estimate a condition of seams. In general, we can say that patients are satisfied. It should be noted that adenomectomy does not require a long recovery.