32. Open prostatectomy
Now rarely used.
Indicated in
• Patients with symptomatic bladder outlet
obstruction due to BPH and markedly enlarged
prostate gland,
• Patients with a concomitant bladder condition,
such as a bladder diverticulum or large bladder
calculi
• Patients who cannot be placed in the dorsal
lithotomy position for TURP
36. Nesbit technique for TURP (1943)
• resection from proximal to distal
If large middle lobe, start by it first
1st stage: resect BN (superiorly to inferiorly) 12
to 3 O’clock
2nd stage: resect lat. & median lobes (superiorly
to inferiorly)
3rd stage: resect apical lobes (inferiorly to
superiorly )
37. TURP (Nesbit technique)
1st stage: resect BN (superiorly to inferiorly)
• Resect BN from 12 to 9 o'clock (until see circular fibers of BN)
38. 2nd stage: resect adenoma in quadrants, (superiorly to inferiorly)
(until see fibers of prostatic capsule)
(a): Rt lobe (12 to 9 o’clock)
39. 2nd stage: resect adenoma in quadrants, (superiorly to
inferiorly) (until see fibers of prostatic capsule)
(b): Lt lobe (12 to 3 o’clock)
40. 2nd stage: resect adenoma in quadrants, (superiorly to inferiorly)
(until see fibers of prostatic capsule)
(c): Floor(9 to 6 o’clock)
41. 3rd stage: Apical adenoma removed immediately proximal to EUS,
preserving veru (inferiorly to superiorly)
(a): begin next to the veru → toward the 12 o'clock position
42. 3rd stage: Apical adenoma removed immediately proximal to EUS,
preserving veru (inferiorly to superiorly)
(a): Residual tissue is carefully cleared on the patient's right side
43. 3rd stage: Apical adenoma removed immediately proximal to EUS,
preserving veru (inferiorly to superiorly)
(c): remaining residual tissue is cleared from the patient's left side
44. Another technique
• Resection begins at the proximal portion of the middle lobe at the 6-
o’clock position.
• The resectoscope is placed just proximal to the verumontanum and
the resection performed always controlling the end point of each cut.
• be aware of the position of the verumontanum to avoid extending
below this level or otherwise damage to the sphincter mechanism
may occur.
45. Another technique (cont.):
• Resection in smaller adenomas is now carried directly to the side
lobe.
• It depends on the preference of the surgeon whether to begin on
the left and then to resect the other side or vice versa. .
50. Transurethral radiofrequency needle
ablation of the prostate (TUNA)
• Low-level radiofrequency is
transmitted to the prostate
via a transurethral needle
delivery system
• The resultant heat causes
localized necrosis of the
prostate.
51. Transurethral radiofrequency needle
ablation of the prostate (TUNA)
Side-effects
• bleeding in 1/3 of patients
• Short-term urinary retention in 10-40%.
• UTI in 10% and urethral stricture in 2%.
• Irritative urinary symptoms can last for a
month or more.
• No adverse effects on sexual function
have been reported.
52. Transurethral radiofrequency needle
ablation of the prostate (TUNA)
Efficacy
• TUNA is a successful minimally invasive
treatment option for symptoms associated
with prostatic enlargement.
• However, Concerns remain with regard to
long-term effectiveness.
53. Transurethral microwave
thermotherapy (TUMT)
• Microwave energy is delivered
to the prostate via an
intraurethral catheter which
incorporates a microwave
generator (antenna), a
temperature measurement
system, and a cooling system to
prevent damage to the adjacent
urethra.
54. Transurethral microwave
thermotherapy (TUMT)
• The microwave energy produces prostatic
heating and coagulative necrosis.
• Subsequent shrinkage of the prostate and
thermal damage to adrenergic neurons (i.e.
heat-induced adrenergic nerve block) relieves
obstruction
• Cavities can be demonstrated 3 months post-
treatment by TRUS.
• Low-energy, high-energy, and high-intensity
protocols are available.
55. Transurethral microwave
thermotherapy (TUMT)
Side effects
• Perineal discomfort is common after TUMT, as is
urgency, but these symptoms usually resolve in
a few days.
• Sexual side-effects after TUMT (e.g. impotence,
retrograde ejaculation) are less frequent that
after TURP,
• a catheter may be required for 1-2 week
because of urinary retention in up to 25% of
patients especially with higher-energy protocols.
56. HIFU
• A focused ultrasound beam can
be used to induce a rise in
temperature in the prostate, or
indeed in any other tissue to
which it is applied.
• A transrectal probe is used for
HIFU treatment of the prostate
• There are no randomized trials
comparing its effectiveness
against other treatment
modalities.
57. TUVP
• This technique vaporizes and
dessicates the prostate.
Advantages
• TUVP is as effective as TURP for
symptom control and relief of
bladder outlet obstruction.
• Requirement for blood transfusion
may be slightly less after TUVP
than after TURP.
•
58. TUVP
Side effects
• Retrograde ejaculation occurs 70-100% of
patients and impotence in 0-15%.
• Irritative symptoms seem to be more
troublesome than after TURP and can last
for 4-6 weeks.
• TUVP does not provide tissue for
histological examination, and so prostate
cancers cannot be detected.
60. LASER
• Penetration depends
on wavelength.
• Shorter wavelengths
(600nm-700nm) are
absorbed within a couple
of mm by hemoglobin.
• Longer wavelengths
(1,000nm + ) are
absorbed by fat and
water.
61. Laser Therapy
Mechanism of action of Laser in prostatectomy:
• Ablation (coagulation necrosis).
• Resection.
• Vaporization.
These mechanisms are employed through
1) Visual laser ablation of the prostate.
2) Laser vaporization of the prostate.
3) Laser resection of the prostate.
4) Laser enucleation of the prostate (with tissue morcellation).
5) Laser incision of the prostate.
6) Interstitial laser coagulation of the prostate.
63. Laser Therapy
There are four types of laser for the prostate:
1) Neodymium: Yttrium-Aluminum-Garnet (Nd:YAG)
laser: utilizes wavelengths of 1064 nm causing
coagulative necrosis of the prostate.
2) Potassium Titanyl Phosphate (KTP) laser:
Doubling the frequency of pulsed (Nd:YAG) laser energy with a KTP
crystal has led to the creation of a 532 nm wavelength selectively
absorbed by Hb.
The 60-W KTP laser has proved that a higher-power laser beam could
speed up vaporization.
So, the 80-W KTP laser was introduced (Green light photoselective
vaporization laser system).
64. Laser Therapy
3) Holmium: Yttrium-Aluminum-Garnet (Ho:YAG) laser:
• The Ho:YAG utilises wavelength of 2140 nm.
• It causes vaporization rather than coagulation.
• can be used for resection (HoLRP) or enucleation
(HoLEP).
4) Diode laser:
has 3 components:
1. portable diode laser unit,
2. specialized fiber optic delivery system that allows optical
monitoring of tissue temperatures,
3. laser.
65. Visual laser ablation of the
prostate
It is based on the principle of laser coagulation.
Surgical technique:
The laser energy is delivered to the prostate gland with a side-firing,
noncontact, free-beam laser.
The most widely used laser energy is the Nd:YAG.
The obstructive tissue then starts to slough during the next 4 to 8
postoperative weeks, leading to a patent prostatic urethra.
Adverse effects:
Prolonged irritative voiding
symptoms which may last for
weeks and sometimes months.
66. Laser vaporization of the prostate
The Green Light company improved the power of the 532
nm laser up to 80 W KTP and 120 W high-performance
system (HPS) with lithium triborate (LBO).
Photoselective vaporization of the prostate (PVP) is
considered an easy technique creating prostatic fossa
resembling TURP.
Indications of PVP:
1) Prostates larger than 80 ml can be done.
2) Patients with a high risk.
3) Elderly aged 80 years or more.
4) Anticoagulant users .
67. Laser vaporization of the
prostate
Surgical technique:
Vaporization is started at the 6 o'clock position or at one
of the two lateral lobes of the prostate.
Effective lasing makes many air bubbles.
A Foley catheter is placed for less than 24 hours before a
voiding trial is done.
Advantages
No significant blood loss or fluid absorption was noted
during or immediately after PVP.
Side effects transient hematuria (8.6%), dysuria (9.3%)
and urinary retention (5%).
68. Laser resection of the prostate
It is based on the principle of laser vaporization.
Holmium: YAG is the most widely used laser for this
technique.
Surgical technique
the laser fiber cuts the prostatic lobes into pieces small
enough to be evacuated through the resectoscope
sheath to create a TUR-like cavity.
69. Laser enucleation of the prostate
(with tissue morcellation)
Indication:
Alternative to open prostatectomy in large prostates.
Surgical technique
Bilateral bladder neck incisions from orifices to veru.
The median lobe is enucleated then the lateral lobes.
Prostate tissues in the bladder are fragmented and
aspirated with the morcellator.
Adverse effects:
Recatheterization (2.9%), UTI (2.3%), urethral stricture or
bladder-neck contracture (3.2%) and reoperation (2.8%).
70. Laser incision of the prostate
• based on the principle of tissue vaporization
• a contact-tip laser fiber is used to deliver high
energy along the prostatic urethra, causing a linear
tract of tissue vaporization.
• It is performed on relatively small glands (< 30 g).
71. INTERSTITIAL LASER COAGULATION
A standard cystoscope is used to insert
the laser fiber transurethrally into the
prostate gland.
The intraprostatic temperature reaches
100°C within a few seconds and is
maintained for150 seconds resulting in
tissue coagulation.
Adverse Effects
Retreatment rate in 16% and UTI in 20%
of patients.
72. Plasmakinetic vaporesection of the
prostate (PKVP)
A new technique based on creating a
plasma arc, vaporizing tissue and achieving
hemostasis to a predictable depth.
73. Plasmakinetic vaporesection of the
prostate (PKVP)
• current is passed through the active electrode of the
device that approaches boiling point and a plasma
corona is formed, creating very high resistance between
the active and return electrodes.
• Tissue entering the corona (lower resistance) is
vaporized and adjacent tissue is sealed up to 0.5 mm.
74. Plasmakinetic vaporesection of the
prostate (PKVP)
Advantages of PKVP
1) The bipolar current and the use of saline irrigation
eliminates the risk of TUR syndrome.
2) Hemostasis is achieved to a predictable depth.
3) The working element is the return electrode , thus,
eliminating the risk of skin burns and obturator jerk.
4) Safe to be used in patients with cardiac pacemakers.
5) used in high risk patients, patients with bleeding disorder
and patients receiving anticoagulative therapy.
Disadvantages of PKVP
It does not provide histopathological specimens which
may miss incidental cancers.
75. Trans-urethral resection in saline
(TURis)
• Using a bipolar electrode this technique
allows working with saline medium.
• The technique offers familial technique
with minimal bleeding and use in high risk
patients with cardiac pacemakers and
arrhythmias.
