Prostatectomy

Definition
Prostatectomy refers to the surgical removal of part of the prostate gland(transurethral resection, a proce
dure performed to relieve urinary symptomscaused by benign enlargement), or all of the prostate (radical
prostatectomy, thecurative surgery most often used to treat prostate cancer).
Purpose
Benign disease
When men reach their mid-
40s, the prostate gland begins to enlarge. Thiscondition, benign prostatic hyperplasia (BPH) is present in
more than half ofmen in their 60s and as many as 90% of those over 90. Because the prostatesurrounds t
he urethra, the tube leading urine from the bladder out of the body,the enlarging prostate narrows this pas
sage and makes urination difficult. Thebladder does not empty completely each time a man urinates, and,
as a result,he must urinate with greater frequency, night and day. In time, the bladder canoverfill, and uri
ne escapes from the urethra, resulting in incontinence. Anoperation called transurethral resection of the p
rostate (TURP) relievessymptoms of BPH by removing the prostate tissue that is blocking the urethra.No i
ncision is needed. Instead a tube (retroscope) is passed through the penisto the level of the prostate, and
tissue is either removed or destroyed, so thaturine can freely pass from the body.
Malignant disease
Prostate cancer is the single most common form of non-
skin cancer in theUnited States and the most common cancer in men over 50. Half of men over 70and al
most all men over the age of 90 have prostate cancer, and the AmericanCancer Society estimates that 19
8,000 new cases will be diagnosed in 2001.This condition does not always require surgery. In fact, many
elderly men adopta policy of "watchful waiting," especially if their cancer is growing slowly.Younger men o
ften elect to have their prostate gland totally removed along withthe cancer it contains—
an operation called radical prostatectomy. The two maintypes of this surgery, radical retropubic prostatect
omy and radical perinealprostatectomy, are performed only on patients whose cancer is limited to thepros
tate. If cancer has broken out of the capsule surrounding the prostate glandand spread in the area or to di
stant sites, removing the prostate will not preventthe remaining cancer from growing and spreading
throughout the body.

Precautions
Potential complications of TURP include bleeding, infection, and reactions togeneral or local anesthesia.
About one man in five will need to have theoperation again within 10 years.
Open (incisional) prostatectomy for cancer should not be done if the cancer hasspread beyond the prosta
te, as serious side effects may occur without thebenefit of removing all the cancer. If the bladder is retaini
ng urine, it is necessaryto insert a catheter before starting surgery. Patients should be in the bestpossible
general condition before radical prostatectomy. Before surgery, thebladder is inspected using an instrume
nt called a cystoscope to help determinethe best surgical technique to use, and to rule out other local pro
blems.



Description
Turp
This procedure does not require an abdominal incision. With the patient undereither general or spinal ane
sthesia, a cutting instrument or heated wire loop isinserted to remove as much prostate tissue as possible
and seal blood vessels.The excised tissue is washed into the bladder, then flushed out at the end of theo
peration. A catheter is left in the bladder for one to five days to drain urine andblood. Advanced laser tech
nology enables surgeons to safely and effectivelyburn off excess prostate tissue blocking the bladder ope
ning with fewer of theearly and late complications associated with other forms of prostate surgery.This pro
cedure can be performed on an outpatient basis, but urinary symptomsdo not improve until swelling subsi
des several weeks after surgery.
Radical prostatectomy
RADICAL RETROPUBIC PROSTATECTOMY. This is a useful approach if theprostate is very large, or ca
ncer is suspected. With the patient under general orspinal anesthesia or an epidural, a horizontal incision
is made in the center ofthe lower abdomen. Some surgeons begin the operation by removing pelviclymph
nodes to determine whether cancer has invaded them, but recent findingssuggest there is no need to sa
mple them in patients whose likelihood of lymphnode metastases is less than 18%. A doctor who remove
s the lymph nodes forexamination will not continue the operation if they contain cancer cells, becausethe
surgery will not cure the patient. Other surgeons remove the prostate glandbefore examining the lymph n
odes. A tube (catheter) inserted into the penis todrain fluid from the body is left in place for 14-21 days.
Originally, this operation also removed a thin rim of bladder tissue in the area ofthe urethral sphincter—
a muscular structure that keeps urine from escapingfrom the bladder. In addition, the nerves supplying th
e penis often weredamaged, and many men found themselves impotent (unable to achieveerections) afte
r prostatectomy. A newer surgical method called potency-
sparingradical prostatectomy preserves sexual potency in 75% of patients and fewerthan 5% become inc
ontinent following this procedure.
RADICAL PERINEAL PROSTATECTOMY. This procedure is just as curative asradical retropubic prostat
ectomy but is performed less often because it does notallow the surgeon to spare the nerves associated
with erection or, because theincision is made above the rectum and below the scrotum, to remove lymphn
odes. Radical perineal prostatectomy is sometimes used when the cancer islimited to the prostate and th
ere is no need to spare nerves or when the patient'shealth might be compromised by the longer procedur
e. The perineal operation isless invasive than retropubic prostatectomy. Some parts of the prostate can b
eseen better, and blood loss is limited. The absence of an abdominal incisionallows patients to recover m
ore rapidly. Many urologic surgeons have not beentrained to perform this procedure. Radical prostatecto
my procedures last one tofour hours, with radical perineal prostatectomy taking less time than radicalretro
pubic prostatectomy. The patient remains in the hospital three to five daysfollowing surgery and can retur
n to work in three to five weeks. Ongoing researchindicates that laparoscopic radical prostatectomy may
be as effective as opensurgery in treatment of early-stage disease.
Cryosurgery
Also called cryotherapy or cryoablation, this minimally invasive procedure usesvery low temperatures to fr
eeze and destroy cancer cells in and around theprostate gland. A catheter circulates warm fluid through t
he urethra to protect itfrom the cold. When used in connection with ultrasound imaging, cryosurgerypermit
s very precise tissue destruction. Traditionally used only in patientswhose cancer had not responded to ra
diation, but now approved by Medicare asa primary treatment for prostate cancer, cryosurgery can safely
be performed onolder men, on patients who are not in good enough general health to undergoradical pros
tatectomy, or to treat recurrent disease. Recent studies have shownthat total cryosurgery, which destroys
the prostate, is at least as effective asradical prostatectomy without the trauma of major surgery.
Preparation
As with any type of major surgery done under general anesthesia, the patientshould be in optimal conditio
n. Most patients having prostatectomy are in theage range when cardiovascular problems are frequent, m
aking it especiallyimportant to be sure that the heart is beating strongly, and that the patient is notretainin
g too much fluid. Because long-
standing prostate disease may causekidney problems from urine "backing up," it also is necessary to be s
ure that thekidneys are working properly. If not, a period of catheter drainage may benecessary before doi
ng the surgery.
Aftercare
Following TURP, a catheter is placed in the bladder to drain urine and remains inplace for two to three da
ys. A solution is used to irrigate the bladder and urethrauntil the urine is clear of blood, usually within 48 h
ours after surgery. Whetherantibiotics should be routinely given remains an open question. Catheterdrain
age also is used after open prostatectomy. The bladder is irrigated only ifblood
clots block the flow of urine through the catheter. Patients are givenintravenous fluids for the first 24 hours
, to ensure good urine flow. Patientsresting in bed for long periods are prone to blood clots in their legs (w
hich canpass to the lungs and cause serious breathing problems). This can be preventedby elastic stocki
ngs and by periodically exercising the patient's legs. Thepatient remains in the hospital one to two days fo
llowing surgery and can returnto work in one to two weeks.
Risks
The complications and side effects that may occur during and afterprostatectomy include:
 Excessive bleeding, which in rare cases may require blood transfusion.
 Incontinence when, during retropubic prostatectomy, the muscular valve(sphincter) that keeps uri
ne in the bladder is damaged. Less commontoday, when care is taken not to injure the sphincter.
 Impotence, occurring when nerves to the penis are injured during theretropubic operation. Today'
s "nerve-sparing" technique has drasticallycut down on this problem.
 Some patients who receive a large volume of irrigating fluid after TURPdevelop high blood pressu
re, vomiting, trouble with their vision, andmental confusion. This condition is caused by a low salt l
evel in theblood, and is reversed by giving salt solution.
 A permanent narrowing of the urethra called a stricture occasionallydevelops when the urethra is
damaged during TURP.
 There is about a 34% chance that the cancer will recur within 10 years ofthe procedure. In additio
n, about 25% of patients experience what isknown as biochemical recurrence, which means that t
he level of prostate-
specific antigen (PSA) in the patient's blood serum begins to rise rapidly.Recurrence of the tumor
or biochemical recurrence can be treated withradiation therapy or androgen deprivation therapy.
Normal results
In patients with BPH who have the TURP operation, urination should becomemuch easier and less freque
nt, and dribbling or incontinence should cease. Inpatients having radical prostatectomy for cancer, a succ
essful operation willremove the tumor and prevent its spread to other areas of the body (metastasis).If ex
amination of lymph nodes shows that cancer already had spread beyond theprostate at the time of surger
y, other measures are available to control thetumor.
Key terms
BPH —
Benign prostatic hypertrophy, a very common noncancerous cause ofprostatic enlargement in older men.
Catheter —
A tube that is placed through the urethra into the bladder in order toprovide free drainage of urine and blo
od following either TURP or openprostatectomy.
Cryosurgery — In prostatectomy, the use of a very low-
temperature probe tofreeze and thereby destroy prostatic tissue.
Impotence — The inability to achieve and sustain penile erections.
Incontinence — The inability to retain urine in the bladder until a person isready to urinate voluntarily.
Prostate gland —
The gland surrounding the male urethra just below the baseof the bladder. It secretes a fluid that constitu
tes a major portion of the semen.
Urethra —
The tube running from the bladder to the tip of the penis that providesa passage for eliminating urine fro
m the body.


























Colostomy
Definition
Ostomy is a surgical procedure used to create an opening for urine and feces to be released from the
body. Colostomy refers to a surgical procedure where a portion of the large intestine is brought through
the abdominal wall to carry stool out of the body.
Purpose
A colostomy is created as a means to treat various disorders of the large intestine, includingcancer,
obstruction, inflammatory bowel disease, ruptured diverticulum, ischemia (compromised blood supply), or
traumatic injury. Temporary colostomies are created to divert stool from injured or diseased portions of
the large intestine, allowing rest and healing. Permanent colostomies are performed when the distal
bowel (bowel at the farthest distance) must be removed or is blocked and inoperable. Although colorectal
cancer is the most common indication for a permanent colostomy, only about 10-15% of patients with this
diagnosis require a colostomy.
Description
Surgery will result in one of three types of colostomies:
 End colostomy. The functioning end of the intestine (the section of bowel that remains
connected to the upper gastrointestinal tract) is brought out onto the surface of the abdomen,
forming the stoma by cuffing the intestine back on itself and suturing the end to the skin. A
stoma is an artificial opening created to the surface of the body. The surface of the stoma is
actually the lining of the intestine, usually appearing moist and pink. The distal portion of
bowel (now connected only to the rectum) may be removed, or sutured closed and left in the
abdomen. An end colostomy is usually a permanent ostomy, resulting from trauma, cancer or
another pathological condition.
 Double-barrel colostomy. This colostomy involves the creation of two separate stomas on the
abdominal wall. The proximal (nearest) stoma is the functional end that is connected to the
upper gastrointestinal tract and will drain stool. The distal stoma, connected to the rectum and
also called a mucous fistula, drains small amounts of mucus material. This is most often a
temporary colostomy performed to rest an area of bowel, and to be later closed.
 Loop colostomy. This colostomy is created by bringing a loop of bowel through an incision in
the abdominal wall. The loop is held in place outside the abdomen by a plastic rod slipped
beneath it. An incision is made in the bowel to allow the passage of stool through the loop
colostomy. The supporting rod is removed approximately 7-10 days after surgery, when
healing has occurred that will prevent the loop of bowel from retracting into the abdomen. A
loop colostomy is most often performed for creation of a temporary stoma to divert stool away
from an area of intestine that has been blocked or ruptured.
Preparation
As with any surgical procedure, the patient will be required to sign a consent form after the procedure is
explained thoroughly. Blood and urine studies, along with various x rays and an electrocardiograph
(EKG), may be ordered as the doctor deems necessary. If possible, the patient should visit an
enterostomal therapist, who will mark an appropriate place on the abdomen for the stoma, and offer pre-
operative education on ostomy management.
In order to empty and cleanse the bowel, the patient may be placed on a low residue diet for several days
prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing by mouth
after midnight. A series of enemas and/or oral preparations (GoLytely or Colyte) may be ordered to empty
the bowel of stool. Oral anti-infectives (neomycin, erythromycin, or kanamycin sulfate) may be ordered to
decrease bacteria in the intestine and help prevent post-operative infection. A nasogastric tube is inserted
from the nose to the stomach on the day of surgery or during surgery to remove gastric secretions and
preventnausea and vomiting. A urinary catheter (a thin plastic tube) may also be inserted to keep the
bladder empty during surgery, giving more space in the surgical field and decreasing chances of
accidental injury.
Aftercare
Post-operative care for the patient with a new colostomy, as with those who have had any major surgery,
involves monitoring of blood pressure, pulse, respirations, and temperature. Breathing tends to be
shallow because of the effect of anesthesia and the patient's reluctance to breathe deeply and
experience pain that is caused by the abdominal incision. The patient is instructed how to support the
operative site during deep breathing and coughing, and given pain medication as necessary. Fluid intake
and output is measured, and the operative site is observed for color and amount of wound drainage. The
nasogastric tube will remain in place, attached to low intermittent suction until bowel activity resumes. For
the first 24-48 hours after surgery, the colostomy will drain bloody mucus. Fluids and electrolytes are
infused intravenously until the patient's diet is can gradually be resumed, beginning with liquids. Usually
within 72 hours, passage of gas and stool through the stoma begins. Initially the stool is liquid, gradually
thickening as the patient begins to take solid foods. The patient is usually out of bed in 8-24 hours after
surgery and discharged in 2-4 days.
A colostomy pouch will generally have been placed on the patient's abdomen, around the stoma during
surgery. During the hospital stay, the patient and his or her caregivers will be educated on how to care for
the colostomy. Determination of appropriate pouching supplies and a schedule of how often to change
the pouch should be established. Regular assessment and meticulous care of the skin surrounding the
stoma is important to maintain an adequate surface on which to apply the pouch. Some patients with
colostomies are able to routinely irrigate the stoma, resulting in regulation of bowel function; rather than
needing to wear a pouch, these patients may need only a dressing or cap over their stoma. Often, an
enterostomal therapist will visit the patient at home after discharge to help with the patient's resumption of
normal daily activities.
Risks
Potential complications of colostomy surgery include:
 excessive bleeding
 surgical wound infection
 thrombophlebitis (inflammation and blood clot to veins in the legs)
 pneumonia
 pulmonary embolism (blood clot or air bubble in the lungs' blood supply)
Normal results
Complete healing is expected without complications. The period of time required for recoveryfrom the sur
gery may vary depending of the patient's overall health prior to surgery. Thecolostomy patient without oth
er medical complications should be able to resume all dailyactivities once recovered from the surgery.
Abnormal results
The doctor should be made aware of any of the following problems after surgery:
 increased pain, swelling, redness, drainage, or bleeding in the surgical area.
 headache, muscle aches, dizziness, or fever.
 increased abdominal pain or swelling, constipation, nausea or vomiting or black, tarrystools
Stomal complications to be monitored include:
 Death (necrosis) of stomal tissue. Caused by inadequate blood supply, this complicationis usu
ally visible 12-24 hours after the operation and may require additional surgery.
 Retraction (stoma is flush with the abdomen surface or has moved below it). Caused byinsuffi
cient stomal length, this complication may be managed by use of special pouchingsupplies.
Elective revision of the stoma is also an option.
 Prolapse (stoma increases length above the surface of the abdomen). Most often resultsfrom
an overly large opening in the abdominal wall or inadequate fixation of the bowel tothe abdomi
nal wall. Surgical correction is required when blood supply is compromised.
 Stenosis (narrowing at the opening of the stoma). Often associated with infection aroundthe s
toma or scarring. Mild stenosis can be removed under local anesthesia. Severestenosis may r
equire surgery for reshaping the stoma.
 Parastomal hernia (bowel causing bulge in the abdominal wall next to the stoma). This is
due to placement of the stoma where the abdominal wall is weak or creation of an overlylarge
opening in the abdominal wall. The use of an ostomy support belt and specialpouching supplie
s may be adequate. If severe, the defect in the abdominal wall should berepaired and the
stoma moved to another location.

















Colectomy
consists of the surgical resection of any extent of the large intestine (colon). It is also an occasional
term used to describe removing the entire large intestine along with the rectum, but the appropriate
term is proctocolectomy, where the whole large intestine and rectum are removed.
Indications
Some of the most common indications for colectomy are:
 Colon cancer.
 Diverticulitis and diverticular disease of the large intestine.
 Trauma.
 Inflammatory bowel disease such as ulcerative colitis or Crohn's disease. Colectomy neither
cures nor eliminates Crohn's disease, instead only removing part of the entire diseased large
intestine. A colectomy is considered a cure for ulcerative colitis because the disease attacks
only the large intestine and therefore will not be able to flare up again if the entire large intestine
(cecum, ascending colon, transverse colon, descending colon and sigmoid colon) and rectum
are removed. However, it does not take away extra-intestinal symptoms.
 Prophylactic colectomy can be indicated in some forms of polyposis, Lynch syndrome and
certain cases of inflammatory bowel disease because of high risk for development of colorectal
cancer.
 Bowel infarction
 Typhlitis
Traditionally, colectomy is performed via an abdominal incision (laparotomy), though minimally
invasive colectomy, by means of laparoscopy, is growing both in scope of indications and popularity,
and is a well-established procedure as of 2006 in many medical centers. Recent experience has
shown the feasibility of single port access colectomy,
[1]

Resection of any part of the colon entails mobilization and ligation of the corresponding blood
vessels. Lymphadenectomy is usually performed through excision of the fatty tissue adjacent to
these vessels (mesocolon), in operations for colon cancer.
When the resection is complete, the surgeon has the option of immediately restoring the bowel, by
stitching or stapling together both the cut ends (primary anastomosis), or creating a colostomy.
Several factors are taken into account, including:
 Circumstances of the operation (elective vs emergency);
 Disease being treated; (i.e, no colectomy surgery can cure Crohn's disease, because the
disease usually recurs at the site where the healthy sections of the large intestine were joined
together. For example, if a patient with Crohn's disease has a transverse colectomy, their
Crohn's will usually reappear at the resection site of the ascending and descending colons.)
 Acute physiological state of the patient;
 Impact of living with a colostomy, albeit temporarily;
 Use of a specific preoperative regimen of low residue diet and laxatives (so-called "bowel prep").
An anastomosis carries the risk of dehiscence (breakdown of the stitches), which can lead to
contamination of the peritoneal cavity, peritonitis, sepsis and death. Colostomy is always safer, but
places a societal, psychological and physical burden on the patient. The choice is by no means an
easy one and is rife with controversy, being a frequent topic of heated debate among surgeons all
over the world.
Types
 Right hemicolectomy and left hemicolectomy refer to the resection of the ascending
colon (right) and thedescending colon (left), respectively. When part of the transverse colon is
also resected, it may be referred to as anextended hemicolectomy
 Transverse colectomy is also possible, though uncommon.
 Sigmoidectomy is a resection of the sigmoid colon, sometimes including part or all of the
rectum (proctosigmoidectomy). When a sigmoidectomy is followed by terminal colostomy and
closure of the rectal stump, it is called a Hartmann operation; this is usually done out of
impossibility to perform a "double-barrel" or Mikulicz colostomy, which is preferred because it
makes "takedown" (reoperation to restore normal intestinal continuity by means of
ananastomosis) considerably easier.
 When the entire colon is removed, this is called a total colectomy, also known as Lane's
Operation. If the rectum is also removed, it is a total proctocolectomy.
 Subtotal colectomy is resection of part of the colon or a resection of all of the colon without
complete resection of the rectum.