Surgical treatment of BPH continues to be very actual problem of modern urology. Despite the fact that experts are struggling to reduce the percentage of surgical interventions, they still need at least one third of patients.
Surgery for BPH is often the only solution that is able not only to deliver man from the tumor and improve his quality of life, as problems with urination, it is often impossible to resolve by any other methods.
The frequency of surgical intervention on the prostate gland is a solid second place in urology. From time to time they lay, struggling with a disease with drugs but conservative treatment gives only a temporary effect, so three out of ten patients are forced to go under the surgeon's knife.
The choice of specific method of surgical treatment depends on tumor size, patient age, presence of comorbidities, the technical capabilities of the clinic and staff. It is no secret that any invasive procedure carries the risk of several complications, and their likelihood is only growing, so the indications and contraindications urologists very carefully.
Indications and contraindications for surgery
Indications for surgical removal of the prostate are:
- A strong narrowing of the urethra with disruption of the bladder, if the latter is delayed a large amount of urine;
- Stones in the bladder;
- Chronic renal failure;
- Acute retention of urine, repeated;
- Infection and inflammatory changes in organs of the urogenital system.
For large tumors when the prostate volume exceeds 80-100 ml, the presence of multiple bladder stones, structural changes of the bladder wall (diverticula) preference will be given to open and the most radical operation – adenomectomy.
If the tumor with the gland do not exceed 80 ml in volume, then you can do a transurethral resection of the adenoma. In the absence of a strong inflammatory process, the stones, the small adenoma of the preferred endoscopic technique using laser, electric current.
Like any kind of surgical treatment, the operation has its contraindications, which include:
- Severe decompensated pathology of the heart and lungs (due to the need for General anesthesia, risk of bleeding);
- Acute renal failure;
- Acute cystitis, pyelonephritis (operate after the elimination of acute inflammatory effects);
- Sharp gra-infectious diseases;
- Aneurysm of the aorta and severe atherosclerosis.
It is clear that many contraindications can move into the category of relative as adenoma, one way or another to remove, so if available, the patient referred to the previous correction of existing violations, which will make future operation safer.
Types of operations for BPH
Depending on the scope of intervention and access are different methods of tumor removal:
- Open adenomectomy;
- Transurethral resection;
- Minimally invasive and endoscopic procedures – laser vaporization, cryosurgery, microwave therapy etc.
Surgical treatment of the prostate using open surgery, some three decades ago, it was almost the only way to remove the tumor. Today invented many other methods of treatment, but this intervention does not lose its relevance. The indications for such surgery include large tumors (more than 80 ml.), related stones and diverticula of the bladder, the possibility of malignant transformation of the adenoma.
Open adenomectomy occurs through the exposed bladder, so it is also called abdominal surgery. This intervention requires General anaesthesia, and its possible contraindications spinal anesthesia.
The operation adenomectomy involves several steps:
- After treatment with antiseptic solution and shaving the hair, made the skin incision and subcutaneous tissue of the abdomen in the longitudinal and transverse directions (not of major importance and is determined by the doctor's preferences and tactics, adopted in a particular clinic);
- After reaching the front wall of the bladder, the latter is dissected, the surgeon inspects the walls and contents on the subject of stones, protrusions, tumours;
- Finger separation and removal of tumor tissue through the bladder.
The most critical stage of this operation is the removal of the tumor, compressing the openings of the urethra, which the surgeon performs with your finger. Manipulation requires skill and experience, because the doctor acts actually blind, focusing only on their tactile sensations.
Upon reaching the index finger of the internal opening of the urethra, the urologist gently tearing the mucous membrane and finger to peel the tumor tissue, which has already pushed itself to the periphery of the gland. To facilitate the selection of the adenoma with a finger of the other hand introduced into the anus, the surgeon can move easy up and down.
If the tumor is selected, it is extracted through the opened bladder, trying to act carefully not to damage other organs and structures. Received the tumor mass is mandatory is sent for histological examination.
In the early postoperative period, a high probability of bleeding, as none of the known methods are not able to eliminate the effect of the intervention. The danger lies not so much in volume of blood loss, as in the formation as a convolution of the blood in the bladder, which may close the outlet and block the urine output.
For the prevention of bleeding and obstruction of the bladder apply a constant irrigation with sterile saline through tubes placed in the lumen of the organ. The tube remains in the bladder for about a week, during which gradually regenerate the damaged tissue and blood vessels, the washing liquid becomes clear, that indicates the completion of bleeding.
The first few days, the patient should empty the bladder at least once an hour to reduce the liquid pressure against the walls of the body and just stitch it. You can then do it less often – time in half to two hours. Full restoration of the pelvic organs can take up to three months.
The undoubted advantage of abdominal adenomectomy is considered its radical, that is, the complete and permanent removal of the tumor and its symptoms. For high efficiency the patient, in turn, "pays" the long period of stay in hospital (up to six weeks in uncomplicated and in case of complications – even longer), the need to "experience" the General anesthesia, risk of complications in the operating wound (abscess, bleeding, fistulae), the presence of postoperative scar on the anterior wall of the abdomen.
Transurethral resection of the
Transurethral resection (TUR) is considered the "gold standard" in the treatment of benign prostatic hyperplasia. This operation is performed most frequently, and, however, it is very complex and requires impeccable skills and jewelry techniques surgeon. TOUR indicated in patients with adenoma, in which the volume of the breast does not exceed 80 ml, and when the planned duration of intervention less than an hour. For large tumors or risk of malignant transformation in the tumor with a preference for open adenomectomy.
The benefits of the TOUR are the lack of stitches and scars, short recovery period and quick improvement in the health of the patient. Among the disadvantages is the impossibility of removing large adenomas, and also the need for the clinic complex and expensive equipment, which is able to use a trained and experienced surgeon.
The essence of TRANS-urethral removal of the adenoma is the excision of the tumor through the urethra. Surgeon using endoscopic tools (resectoscope) penetrates the urethra into the bladder, inspects it, finds the location of the tumor and remove it with a loop.
The duration of the operation confined within hours. This is due to the posture of the patient he's lying on his back, legs raised and divorced, as well as long stays in the urethra is fairly large diameter tool, which can cause pain after and bleeding.
Adenoma cut in pieces, in the form of shavings, until, as will appear in the field of view of the parenchyma of the gland. In the bladder by this time accumulated a significant amount of fluid floating in her "chips" tumors that are removed with a special tool.
After excision of the tumor and irrigating the cavity of the bladder, the surgeon once again confirms the absence of bleeding vessels that can be coagulated by electric current. If everything is in order, the resectoscope is removed outside, and into the bladder catheter Foley.
After removing the catheter, the men reported significant relief, the urine moves freely and a good jet, but when you first pass urine it can be painted in red. Do not be afraid, this is normal and must never happen again. In the postoperative period it is often recommended to urinate, to prevent stretching of the bladder walls, allowing it to regenerate mucosa.
Among the gentle methods of treatment of BPH include laparoscopic removal. It is carried out using equipment that is inserted into the pelvic cavity through a puncture of the abdominal wall. Technically these complex operations that require penetration into the body, so the preference is given to the TOUR.
Minimally invasive prostate surgery
Minimally invasive methods of treatment successfully developed and implemented in various fields of surgery, including and urology. These include:
- Microwave thermo therapy;
- Vaporization via electric current;
- Electrocoagulation of the tumor;
- Laser ablationem.
Advantages of minimally invasive treatment are the relative safety, fewer complications compared to open surgery, a short rehabilitation period, no need for General anesthesia and the possibility of its application in men, which operation is contraindicated, in principle, on a number of comorbidities (severe heart failure and lung pathology of blood clotting, diabetes, hypertension).
In General these methods can be considered access through the urethra without incision of the skin and the possibility of local anesthesia. The only difference is the physical energy that destroys the tumor, laser, ultrasound, electricity, etc.
Microwave thermotherapy is exposed to the tissue of tumors with high-frequency microwaves, which heat up and destroy. The method can be applied to both transurethral and with the introduction of recto-osprey in the rectum, the mucosa where the procedure is not damaged.
Vaporization leads to heating of the tissue, vaporizing fluid from the cells and their destruction. This effect can be achieved by acting with electric current, laser, ultrasound. The procedure is safe and effective.
During cryoablation, on the contrary, the adenoma is destroyed by the action of cold. The standard method is liquid nitrogen. The wall of the urethra during the procedure, warmed, to prevent its damage.
Treatment of BPH by laser is a very effective and one of the most modern ways of getting rid of the tumor. Its meaning lies in the action on the tumor tissue to laser radiation and simultaneous coagulation. Advantages of laser treatment – a secure, fast, heavy and elderly patients. The efficiency of laser removal of the prostate comparable to that during the TOUR, the probability of complications is significantly lower.
Laser vaporization is, as they say, "the last peep" in the field of minimally invasive treatment of BPH. The exposure is carried out with a laser emitting green rays, which leads to boiling of water in the cells of the tumor, its evaporation and destruction of the parenchyma of prostate. Complications of such treatment practically does not happen, and patients have noticed dramatic improvement of health immediately after surgery.
Possible effects of surgery for BPH and rehabilitation
No matter how hard the surgeons to completely eliminate the probable complications of radical treatment impossible. Particularly high risk for abdominal surgery, it is when you TOUR, and in the case of endoscopic removal is minimal.
The most frequent complications in the early postoperative period can be considered:
- Infectious-inflammatory changes;
- Thrombosis of leg veins, pulmonary artery and its branches.
More long-term effects are developing within the organs of small pelvis. This stricture (narrowing) of the urethra against the background of the proliferation of connective tissue, sclerosis of the bladder wall in the place of origin of the urethra, sexual dysfunction, urinary incontinence.
To prevent complications it is important to follow the doctor's recommendations regarding behaviour immediately after the intervention and at a later date, until such time as the tissue will recover completely. In the postoperative period should:
- Limited physical activity no less than a month;
- To exclude sexual activity for a month at least;
- To ensure a good drinking regime and timely emptying of the bladder (preferably more often);
- To abandon spicy, spicy, salty foods, alcohol, coffee;
- To perform daily exercises to enhance blood flow and improve overall tone.
Treatment of adenoma can be free in a public hospital, but many patients choose paid surgery. Their price really varies depending on the level of the clinic, equipment and settlement.