Prostate surgery basics

🗺️ Anatomy - The Surgical Landscape

• Zonal Anatomy:
  • Peripheral Zone (PZ): ~70% of gland; site of most prostate cancers. Palpable on Digital Rectal Exam (DRE).
  • Transitional Zone (TZ): ~5% of gland; surrounds the urethra. Origin of Benign Prostatic Hyperplasia (BPH).
  • Central Zone (CZ): ~25%; surrounds the ejaculatory ducts.
• Neurovascular Bundles (NVB):
  • Run posterolaterally to the prostate.
  • Contain cavernous nerves (from pelvic plexus) crucial for erectile function.
• Critical Relations:
  • Posterior: Denonvilliers' fascia separates prostate from the rectum.
  • Apex: Near external urethral sphincter (key for continence).

⭐ Injury to the cavernous nerves within the posterolateral neurovascular bundles during radical prostatectomy is the primary cause of post-operative erectile dysfunction.

🔪 Management - The Surgeon's Toolkit

• Transurethral Resection of the Prostate (TURP):

  • Indication: Gold standard for moderate-to-severe BPH.
  • Procedure: Resects tissue from the transitional zone.
  • ⚠️ Complications: Retrograde ejaculation (most common), TURP syndrome.

• Laser Enucleation (HoLEP/ThuLEP):

  • Indication: BPH, especially large glands (>80g).
  • Advantage: ↓ bleeding risk vs. TURP.

• Radical Prostatectomy (RP):

  • Indication: Curative intent for localized prostate cancer.
  • ⚠️ Complications: Erectile dysfunction (cavernous nerve injury), urinary incontinence (sphincter damage).

⭐ TURP Syndrome: Life-threatening dilutional hyponatremia from absorption of hypotonic irrigation fluid (glycine, sorbitol). Presents with nausea, confusion, hypertension, bradycardia, and visual changes.

⚠️ Complications - Navigating the Risks

• Immediate:

  • Bleeding: Most common early issue; monitor for clot retention.
  • TURP Syndrome: Hyponatremia from absorption of hypotonic irrigation fluid (glycine, sorbitol). Presents with confusion, nausea, HTN, bradycardia.
  • Infection: UTI, prostatitis.

• Long-Term:

  • Erectile Dysfunction (ED): Damage to cavernous nerves in posterolateral neurovascular bundles. Nerve-sparing techniques are key.
  • Urinary Incontinence: Stress incontinence from external urethral sphincter injury.
  • Retrograde Ejaculation: Common after TURP; semen enters the bladder.
  • Bladder Neck Contracture / Urethral Stricture: Late fibrotic scarring causing obstruction.

⭐ TURP Syndrome is a medical emergency. The combination of hyponatremia, fluid overload, and potential glycine toxicity can lead to seizures and coma.

📋 Clinical - Post-Op Playbook

• Catheter & Irrigation:
  • Indwelling Foley catheter is standard post-op.
  • Continuous Bladder Irrigation (CBI) post-TURP prevents clot retention. Titrate to keep urine pink.
• Medications:
  • Analgesics for pain.
  • Anticholinergics (e.g., oxybutynin) for bladder spasms.
  • Stool softeners (e.g., docusate) to prevent straining.
• Activity & Monitoring:
  • Avoid heavy lifting (>10 lbs) for 4-6 weeks.
  • ⚠️ Expect initial hematuria; report bright red blood or large clots.
  • Follow-up for catheter removal, pathology review, and PSA monitoring.

⭐ Retrograde ejaculation is the most common long-term complication following TURP.

⚡ High-Yield Points - Biggest Takeaways

• Transurethral Resection of the Prostate (TURP) for BPH risks TURP syndrome (hyponatremia, fluid overload) and retrograde ejaculation.
• Radical Prostatectomy for localized cancer risks erectile dysfunction (cavernous nerve injury) and stress urinary incontinence.
• Nerve-sparing techniques during prostatectomy are critical for preserving post-operative erectile function.
• Post-prostatectomy PSA should become undetectable; a rising PSA signals biochemical recurrence.
• Stress incontinence after surgery is often due to internal urethral sphincter damage.