prostate surgery

The prostate is a fibromuscular gland, elastic, located deep in the pelvis, between the bladder neck and the urogenital ridge, with a pubic symphysis in front and a rectum in the back. There is a posterior urethra passing through it, and the ejaculatory duct passes through the posterior opening of the gland to the side of the posterior urethra. The shape of the prostate is like a topped cone with an upper and lower diameter of about 2.0 cm, a anteroposterior diameter of 3.0 cm, and a left and right diameter of about 4.0 cm. Although in recent years, with the continuous development of endoscopic urology, most patients with benign prostatic hyperplasia have been able to achieve minimally invasive methods such as visible laser prostatectomy (VLAP), prostate electrovaporization (EVP), transurethral resection of the prostate (TURP). Healing, but for the huge prostate, combined with bladder disease that must be treated at the same time, difficult to place the lithotomy position, especially for areas with poor medical conditions, open prostatectomy still has its application value. Prostate surgery includes suprapubic transvesical prostatectomy, retropubic prostatectomy, perineal prostatectomy, and transurethral resection of the prostate. Treatment of diseases: prostate cancer, prostate cancer, preoperative preparation The vast majority of benign prostatic hyperplasia is the elderly. The whole body condition should be closely observed before surgery. Any abnormal conditions should be corrected as much as possible. The operation should be considered after the condition is stable. About one-third of patients with benign prostatic hyperplasia have heart disease, such as abnormal ECG, history of heart failure, angina or coronary artery stenosis. In addition to appropriate medication, a cardiovascular physician should be consulted if necessary. A small number of patients have a history of myocardial infarction, and surgery for such patients should be performed 3 to 6 months after the condition is stable. Other medical diseases, such as pulmonary ventilation obstruction (chronic bronchitis, emphysema, etc.), diabetes, cerebrovascular disease, stroke, etc. should also be treated before surgery. Pay attention to correcting malnutrition and dehydration, electrolyte imbalance, hypoproteinemia, vitamin deficiency and anemia in the elderly. Pay attention to the history of bleeding, previous bleeding or surgery with or without bleeding history, in addition to routine examination of clotting time, platelet count, should also check prothrombin time. Anticoagulation therapy before prostate surgery must be stopped. Part of patients with benign prostatic hyperplasia complicated with chronic urinary retention, often accompanied by impaired renal function. Mild renal dysfunction, surgery is safe, no catheter drainage is required before surgery. Moderate or above renal dysfunction, preoperative bladder drainage, preferably indwelling catheterization (because of the bladder stoma is easy to make the lower abdomen tissue adhesion, scarring, is not conducive to the future open prostate surgery), after the renal function recovery, surgery . In a small number of patients, renal function can not be restored, prostate surgery should not be considered, and urinary dysfunction is feasible. If the catheter is inserted, attention should be paid to aseptic operation and treatment with antibacterial drugs. Residual urine >150ml, urinary frequency is not proportional to residual urine volume or urine flow rate is close to normal, should be used for cystography to understand bladder function. Diabetic patients should also be treated with cystography. In patients with a history of lower extremity muscle spasm, the sphincter EMG should be examined to estimate the factors that cause sphincter obstruction. The prophylactic use of antibiotics is controversial, but antibiotics should be given after urethral device or cystoscopy. Patients with heart valve disease or prosthetic valve replacement should be given ampicillin, gentamicin and so on. Those with a clear urinary tract infection should be treated according to the mid-stage urinary bacterial culture and drug susceptibility test. About 1 in 10 patients with bladder stones can be removed during prostate surgery. Combined renal and ureteral stones should be treated before prostate surgery. Surgical procedure The suprapubic transvesical prostatectomy is the oldest and most easy to expose surgical approach to the prostate. Surgery is relatively simple and easy to master for general surgeons. It is the most popular open surgery. In patients with poor renal function, surgery can be divided into two phases, the first phase of the suprapubic bladder stoma, to restore renal function, and then a second-stage prostatectomy. For patients with bladder stones and bladder diverticulum, it is a good method to treat the above lesions at the same time. This is also a good path for huge prostate resection. This procedure does not enter the posterior pubic space and avoids the risk of infection around the bladder. The biggest drawback of suprapubic transvesical prostatectomy is the difficulty in stopping bleeding. Since the prostate is under the pubic symphysis, it is quite difficult to expose the prostate gland in patients with deep pelvis. The advantage of retropubic prostatectomy is that the prostate operation is performed under direct vision, and the prostate cavity is completely hemostasis. The disadvantage is that entering the posterior pubic space and damaging the prostate venous plexus can cause uncontrolled bleeding. The basic point of retropubic prostatectomy is to close the pubis prostate ligament close to the prostate capsule, so it can directly enter the prostate tip and prostatic urethral space, free prostate, can be pulled up into the incision above the pubic symphysis, under direct treatment of the prostate and The urethra reduces the risk of bladder neck damage. When the suprapubic and retropubic incision is used, it is convenient for extra large prostate resection. Post-pubic prostatectomy is difficult to operate in obese patients. Postoperative pubic osteomyelitis is not common, but more common than the suprapubic approach. The greatest advantage of perineal prostatectomy is that the surgical injury is small and the postoperative recovery is fast. This procedure is particularly suitable for those with hyperplastic glands mainly located in the urethra. Hemostasis is more thorough, no large venous plexus is encountered, and there is little risk of major bleeding. It can be used for posterior prostate biopsy and for drainage of prostate abscess. The disadvantage of this route is that patients need to take excessive bladder lithotomy position, which is not suitable for patients with cardiopulmonary disease and advanced arthritis; the incidence of postoperative urinary incontinence is relatively high; the chance of rectal injury is more; the loss of postoperative sexual function is also higher. universal. Transurethral resection of the prostate is a surgical procedure for prostate resection at home and abroad. According to statistics, 80% to 90% of benign prostatic hyperplasia units use this procedure. This method does not require an incision, and there is no complication of open surgery. The patient has little pain and recovers quickly after surgery. Old and frail patients who cannot tolerate open surgery can also be treated with this method. Especially suitable for patients with small prostatic hyperplasia (about 30 ~ 40g), prostate fibrosis and bladder neck sclerosis. However, transurethral resection of the prostate requires special equipment. The operation of the electric resection technique is more difficult than the open surgery. Major complications such as major bleeding, perforation of the bladder and prostate capsule, and hyponatremia (transurethral resection syndrome) can occur during surgery. . Postoperative complications such as urinary incontinence and urethral stricture. In recent years, some hospitals in China have undergone transurethral microwave radiation plus electric cut to treat benign prostatic hyperplasia. This operation uses microwave thermal coagulation to first coagulate prostate tissue protein and occlude blood vessels, and then cut or reduce bleeding and reduce transurethral resection. The risk of cut syndrome. Because there is no bleeding during the electric cutting, the visual field is clear, which is conducive to the mastery and promotion of the electric cutting technique, and the complications after the electric cutting are greatly reduced. The patient does not need blood transfusion during and after surgery, saving a lot of blood. There is no need to flush the bladder after surgery, and the patient has less pain after surgery and recovery is faster. complication (1) bleeding Early postoperative bleeding, bright red urine, blood clots, treatment by hemostatic drugs, blood transfusion and other measures, it is necessary to stop bleeding again. Secondary postoperative hemorrhage usually occurs within 1 to 3 weeks after surgery, and is often caused by detachment of the absorbable line of hemostasis in the bladder neck or prostatic fossa or the loss of infected necrotic tissue. The balloon can be inserted into the bladder to compress the bladder neck, and the blood clot in the bladder is washed away. 100% of the 1% compound potassium aluminum sulfate solution is injected into the bladder, and left for 20 minutes, and can be given 3 to 4 times per day depending on the situation. And intravenous infusion, given antibacterial drugs and hemostatic drugs. Most of the above treatments will work. If the blood clot is filled in the bladder, use a flusher to aspirate. If it fails, re-cut the bladder to clear the blood clot. (2) catheter detachment For suprapubic or retropubic prostate surgery, a suture can be placed at the head end of the catheter, through the abdominal wall, and fixed on the gauze pad covering the abdominal wall to prevent the catheter from slipping off. After perineal prostatectomy, the catheter can be removed first. If you can urinate on your own, you do not need to re-insert the catheter. If the bladder can not be urinated, the bladder can be inflated obviously. The catheter can be re-inserted by an experienced doctor. The catheter can be lined with a metal guide. The left hand is inserted into the anus to guide the tip of the catheter into the bladder, avoiding insertion into the bladder neck or Below the triangle. After the catheter is inserted, there is not much urine, and a small amount of contrast agent (not more than 5 ml) can be injected, and the X-ray film of the bladder area is taken to determine whether the position of the catheter is correct. If the catheter fails to be inserted, it is feasible to puncture the stoma, until the patient can urinate, and then remove the stoma. (3) extravasation of urine Urinary extravasation after retropubic prostatectomy is associated with improper suture of the prostate capsule or infection of the wound. In this case, as long as the catheter is circulated smoothly, it can self-heal in 1 to 2 weeks. In severe cases of extravasation of urine, in addition to keeping the catheter open, the wound is placed in a double cannula to accelerate wound healing. Early urinary extravasation after perineal prostatectomy, as long as the drainage strip is fluent, can stop itself. If urinary extravasation occurs after the catheter is removed, a rubber band should be placed in the deep part of the wound until the extravasation stops. If the extravasation of urine continues for 5 days or more, a fine catheter should be inserted into the catheter to indwell. (4) Acute epididymitis Acute epididymitis may occur several days to several weeks after various prostate operations. Ligation of bilateral vas deferens during surgery can significantly reduce the incidence of epididymitis. If epididymitis occurs, antibiotic treatment should be strengthened. The patient rested in bed, the scrotum was raised, the early local cold compress, and the late hot compress. Topical treatment relieves symptoms and speeds recovery. If an abscess has formed, the drainage should be cut open. (5) acute cystitis and pyelonephritis After the prostate surgery, due to the indwelling catheter, there is more bacteriuria. If an acute urinary tract infection is complicated, the antibacterial drug should be adjusted according to the urinary bacterial culture and drug sensitivity test. If the inflammation persists or recurrent, check for obstructive factors and measure residual urine. If there is more residual urine, the catheter should be indwelled to drain the urine, and the urine is mixed with mucus purulent secretion. The bladder can be washed regularly with 1% neomycin solution. (6) urinary incontinence Urinary incontinence after prostate surgery is mostly temporary, and it disappears for several days to several weeks. A small number of patients last longer, and patients are encouraged to practice an anal fistula. There is still hope for recovery within half a year to one year. Individual patients may experience permanent urinary incontinence due to heavier bladder neck and external urinary sphincter injury or innervation of the external sphincter. Other treatments should be taken. (7) rectal injury and feces There are many opportunities for rectal injury after perineal prostatectomy, and it is important to prevent it from happening. Familiar with anatomical landmarks and levels, meticulous operation, familiar with the location and characteristics of the Denonvillier fascia, avoiding violent blind separation. The anterior layer of the fascia is in close contact with the posterior wall of the prostate capsule, while the posterior layer covers the front of the rectum. There is a potential gap between the anterior and posterior layers. The separation between the anterior and posterior layers not only reduces bleeding but also damages the rectum. The urethral rectal muscle is cut off in time, and the finger is inserted into the anus to help determine the relationship between the intestinal wall and the prostate, and the chance of rectal injury can be reduced. If a rectal injury occurs accidentally during surgery, it should be repaired immediately to avoid delay and form fecal fistula. The injury involves only the rectal muscle layer, while the intact mucosa only needs to suture the damaged muscle layer. If the injury causes the intestinal mucosa to rupture and perforate, the rectal wall should be fully dissociated, and the mucosal layer and the muscular layer should be sutured intermittently without tension. After the rectal injury is repaired, the anus should be enlarged to about 10cm for 5 minutes, and the anal sphincter can be paralyzed for several days after surgery. Fasting for 2 to 3 days reduces the chance of bowel movements. Postoperative anal cannula, about 15cm deep, if the anal canal is blocked, should be replaced, should not be washed. The anal canal was removed 1 week after surgery. Oral neomycin 3d. Indwell the catheter until the feces are healed. In patients with severe rectal injury, a temporary sigmoid costomy is required. (8) difficulty urinating Urethral stricture and bladder neck stenosis can occur after prostate surgery. The main clinical manifestations are dysuria, fine urinary lines, and even dripping. In severe urinary incontinence can occur in severe patients. The urethral catheter is helpful for diagnosis. If the urethral catheter is difficult to be inserted due to stenosis, bladder urethral manometry can be considered when the cause is difficult to diagnose. There is less chance of urethral and bladder neck stenosis in the suprapubic and retropubic prostatectomy, about 1% to 2%. The bladder neck stenosis can reach 3% to 12% after radical prostatectomy. The latter is mostly due to surgery. Failure to properly match the bladder mucosa and urethral mucosa or excessive suture of the bladder neck. The prevention of bladder neck stenosis is to perform a wedge-shaped resection of the bladder neck triangle during operation, correctly aligning the bladder mucosa and urethral mucosa, and avoiding excessive suture of the bladder neck to stop bleeding. The prevention of postoperative urethral stricture is that the time of indwelling the urethra should not be too long, the urinary catheter should not be too thick, and the silicone catheter with less irritation should be used. If urethral or bladder neck stenosis has occurred, it is usually done 1 or 2 times of urethral dilatation, and a few cases of ineffective expansion should be treated with internal incision.

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