1 ) Minimally Invasive Techniques :
a) SPAD – super selective intra- prostatic androgen deprivation : In this procedure, a radiopaque dye is injected into the vein of the leg after which an X-ray of the venous network is carried out (venography). Then a medicine that shrinks the blood vessels is injected into the vein (sclerotherapy) resulting in reduction of prostate volume. This provides relief in cases of nocturia, improves bladder emptying and increases urine outflow. There are minimum sideeffects as compared to traditional surgery.
b) Transurethral microwave thermotherapy (TUMT) :
• It is a very effective treatment in case of BPH and provides relief from lower urinary tract symptoms after a single procedure.
• It is a minimally invasive technique performed under local anesthesia.
• A special microwave urinary catheter is inserted through the urethra into the enlarged prostate. The microwave antennae are then heated up to at least 111 degree Fahrenheit which destroys the surrounding tissues.
• The procedure takes around 30 minutes to 1 hour after which there is slight swelling and irritation in the prostate. A Foley’s catheter is placed in the bladder to allow bladder emptying without increasing the prostatic irritation and is removed within 3-5 days.
• There may be a few risks like pain after the procedure, urinary retention and infection but the incidence is very less.
• The problem of urinary retention resolves within a week’s time, but some patients replace the Foley’s catheter with a temporary prostatic stent to allow volitional emptying of bladder. This improves their quality of life.
c) Transurethral needle ablation (TUNA) :
• In this procedure low energy frequency radio energy is delivered through two needles placed inside the prostate by passing through the urethra, creating a high temperature in a small zone, which destroys the excessive prostatic tissue without damaging the urethra.
• The procedure is performed under local anesthesia on an outpatient basis. It is a single session treatment procedure with the number of needles varying with size of the prostate.
• It is fairly safe and effective and has minimal side-effects.
2 ) Surgical Procedures :
a) Trans urethral resection of prostate (TURP) :
• It is the most popular method among patients and doctors for resolving prostate related problems and is considered after medical intervention fails.
• It involves removing whole or a portion of the prostate gland through the urethra.
• The procedure is performed under spinal or general anesthesia and involves visualizing the gland using a endoscope.
• A Resectoscope (which contains an electrical loop to cut the bulging prostate tissue and seal the supplying blood vessels) is introduced inside the penis.
• The surgery lasts for around 1 and half hours, and cut tissue is carried by fluid into the bladder from where it is washed out.
• The patient can go home after 3-5 days. Patient is advised to drink lots of fluids and avoid any strenuous activity for a few days (maximum 6 weeks) till the scar heals.
• He is cured of the symptoms occurring due to urinary pathway obstruction like urinary incontinence, dribbling, nocturia etc.
• This procedure has very few side effects and a faster recovery period. But sometimes it can cause backward ejaculation of semen (into bladder instead of urethra) during intercourse. This can be managed by certain drugs that keep the mouth of the bladder narrow to reduce backward flow of semen into it.
b) Radical Prostatectomy :
• It is the traditional open surgery method used when TURP cannot be performed due to reasons like highly enlarged prostate or bladder injury etc.
• It is mainly indicated in prostate cancer but can also be done in cases of BPH.
• The surgery is performed under general anesthesia and an incision is made in the lower abdomen just above the pubic bone (Retropubic approach). At times the incision can be made between the scrotum and the anus depending on the enlargement of the gland or spread of the tumor (Perineal approach). The incision of perineal approach is smaller and has lesser blood loss as compared to retropubic approach and hence has a faster recovery period.
• On reaching the prostate gland, the gland and extra tissue is scooped out and in case of any injury to surrounding organ like the bladder; a tissue repair is carried out. The urethra is reattached to the bladder and a catheter is left in the bladder to drain out urine.
• In case prostate cancer is suspected, then surrounding lymph nodes are also removed and sent for biopsy.
• The patient stays in the hospital for a week and is discharged with the urine catheter in place that has to be kept for 1-3 weeks’ time.
c) Laser Prostatectomy : is the latest trend in BPH and prostate cancer surgeries because they have lesser blood loss and quicker recovery period. But long term effects of this surgery are yet to be determined.
There are four Types of Laser Surgeries:
1. Green Light PVP Laser : This procedure uses green light to vaporize the prostate and useful for majority of patients with enlarged prostate. A tube with light and lens called the cystoscope is inserted into the penis. The laser beam is introduced through the cystoscope and directed towards the prostate. It creates high energy which vaporizes the excess tissue and relieves the urethral blockage. The procedure is done in a short time and the patient can go home the same day and resume daily non strenuous activities within a couple of days.
2. Holmium Laser : This is the most commonly used technique and is performed under general anaesthesia. The laser of 2140nm wavelength and 0.4mm penetration is introduced through the cystoscope that is inserted into the penis at the start of the procedure. The laser cuts and vaporises the enlarged prostate tissue and relieves urinary blockage. Some tissue pieces are directed to the bladder from where they are flushed out. The procedure is done in a short time and the patient can go home the same day or the next day and resume daily non strenuous activities within a couple of days. The procedure is relatively bloodless.
3. VLAP : This procedure has many disadvantages and has become virtually obsolete with the coming of Holmium Laser. The technique uses neodymium:yttrium-aluminum-garnet (Nd:YAG) laser which has a wavelength of 1064nm. The laser beam is directed towards the prostate gland via the cystscope. The beam generates a lot of heat which coagulates the gland tissue. The surgery is performed under regional or general anaesthesia. The technique was not popular among patients as the coagulated portion caused irritation. Also the urine catheter had to be kept for long. Soon this was replaced by Holmium Laser.
4. ILC : Interstitial Laser coagulation therapy was used to coagulate tumours which could not be cut and removed especially in the brain, neck, liver, pancreas etc. in this procedure the laser probe is in direct contact with the prostatic tissue and generates temperature of 60 degrees Celsius which destroys the cell protein. The destroyed cells are absorbed in due course of time and a shrunken prostate gland remains. The urethra is not affected. The procedure is performed under general or regional anaesthesia. The rigid laser probe is inserted through the cystoscope and pushed till it enters the prostate after which it is activated to produce the heat. The effect is localised to the prostate tissue only.
d) Robotic Prostatectomy : This procedure is carried out using the computer and is an advanced form of minimally invasive surgery. In this technique, small incisions are made in the lower part of the abdomen and the entire surgery is carried out using Tele-manipulator. The surgeon performs actions, which moves the Tele-manipulator which in turn is connected to the robot’s arms which replicate the surgeons hand movements and perform the surgery. The surgery is controlled remotely but involves great precision because of which it is soon becoming very popular. The procedure has resulted in favourable outcome as there is less blood loss, faster recovery and shorter hospital stay.
Surgeons also perform laparoscopic robot assisted surgeries using the Da Vinci system which uses miniature surgical tools to carry out the surgery through the keyhole incisions. This method is gradually gaining popularity in treatment of prostatic cancers as there is great precision involved while removing the prostate gland without affecting the other tissues.
No comments:
Post a Comment