Prostate Surgery: Advice and Comment

Background Information

This article comes from Dr. William Harris, a Doctor of Philosophy who makes no pretense of having studied the Ars Medica professionally, but is slightly qualified to comment on things relative to the Prostate by the experience of having gone through two operations with Holmium and TURP in succession. Trained to observe and comment, he writes this article in third person attitude as a clear way of marking out a difficult road for those who are considering that eye-of-the-needle passage through a constricted prostate gland.

If you are male and after middle age you are finding urination painful, restricted or just slow, you may well have a problem with your prostate. The first thing to do is check with your general physician to have a PSA test done which will show from material leaked into the blood supply if the prostate is healthy. This article describes procedures for a normal prostate, but if cancer is suspected you will have to go another route medically with your doctor's advice.

Just in case you are not sure about the configuration of the urinary system, take a deep breath and look at this picture of a prostate operation in progress. It which shows the bladder as the urine reservoir, sitting on top of the Prostate, which is a walnut sized organ of less than 50 gr, (supplying a special fluid to carry the semen) through which the urethral passage passes connecting through the penis for discharge. This is a very elementary outline of a complex arrangement with sensors in the bladder to maintain a proper pressure for flow, with special constrictor muscles for holding back and then letting urine flow, while the whole system operates in coordination with the kidneys filtering the blood supplied to them by the primary filter which is the liver. (There is a lot of descriptive information on the web which you can find with a google search (s.v. prostate -- TURP -- Holmium ), but much of it is repetitive and lacks critical points of advice.)

But for urinary problems we are concerned mainly with the Prostate, which over time becomes enlarged through the normal action of male hormones. This enlargement will encroach on the width of the passage through the prostate, it can finally stop fluid passage completely and cause an emergency situation, which if untreated will cause death.

The Greeks and Egyptians performed rough perforations of the prostate using bamboo tubes, with a high rate of mortality but in the 16th century Ambroise Par&eacture; was able to remove materials from the urethral passage with a sharpened metal tubular cutter and although his cutting was imprecise and irregular, he was able to save some percentage of the patients with seriously blocked urethral flow. After 1900 a series of experimental procedures worked with surgical, electrical and cauterizing processes to enlarge the passage through the prostate, but until the development some thirty years ago, of the now "gold standard" TURP or "Trans Urethral Resection Procedure", results were uneven and unpredictable.

At the present time as of 2006, there are several pre-surgical options for dealing with a constructed prostate. Your general physical can give you a special alpha blocking drug such a FloMax or Uroxytrol which may shrink the prostate and improve urination. If this works with prescribed dosage, you may be satisfied with the results and not have to consider a surgical approach. There are other drugs like AvoDart which taken over a few months may actually reduce the actual prostate size, and if one of these works and relieves the urination problem, you can defer thoughts of surgery for a while. Some of these drugs may have unexpected side effects which will have to be considered in the efficacy of the whole situation.

The Surgical Options

But if you do have to go further and consider surgery to open up the urethral passage through the prostate gland, you will find three options at the present time. TURP (Trans Urethral Resection Procedure) is considered the most effective and well tried operation. It mechanically nips out bits of tissue from the inside of the prostate passage, flushing them out from the bladder with a continuous flow of water, and in an hour's operation while you are under general or spinal anesthesia, the doctor performs a well practiced surgical procedure. A catheter tube is left in place to drain from bladder through the penis for a day or more, it will be uncomfortable but not painful, and when this is removed you will experience better urine flow. But there will be some blood in the urine, not a lot and perhaps only a half teaspoon full each time before the urine starts to flow. This is distressing but not harmful and is one of the conditions of the TURP operation. The blood may last a few weeks or more, it is a normal part of the process of the healing of the resected urethral passage. You are advised drink a lot of water to flush out the passages and to avoid lifting or heavy exercise for a month or more, after which you can expect the kind of easy urination which you had years ago.

A newer operation with a special Holmium laser works by evaporating tissue as an instrument proceeds through the prostate, cauterizing as it goes while the exploded material is washed out by a continuous flow of water through the bladder and out. A catheter is required but for a shorter time that the TURP operation, and healing is said to be quicker with less blood in the urine. This procedure has been in general trial only for half a dozen years, it seems to have advantages over the TURP but has not been tested for a sufficiently long period. Doctors have not had enough experience with the Holmium laser to determine if it will replace the TURP as shorter in the actual operation and faster in recovery. By 2008 more information on a larger number of cases should give us more information about Holmium. For now it is usable but not preferable to TURP ipso facto.

There is a third option for in-office treatment with an Indigo laser, usually reserved for patients whose health precludes a general anesthesia operation. This can be used as a first experiment to see if it helps in certain cases, but it is not sufficiently aggressive to open up a really constricted urethral tube.

Before you go further, your doctor will want to do a sonogram test to see how much urine is being retained in the bladder when you think you have emptied it dry. A reader is placed on your greased belly and the nurse plots a few points and comes up with a figure. If you are retaining something like 240 ml. or 8 ounces, that means there is a constriction which the bladder muscles cannot overpower; in other words you have signs of a prostate problem. The doctor can then order a test for the amount of flow you produce, which will give a low figure if the flow is insufficient, against a range where 15 ml/sec is a good flow for a healthy prostate.

But if you want to find out more about your flow, which you have been estimating in the restaurant mens' room by the time you take standing while others are already out the door, you can do this in a semi-scientific way which is what doctors did it a generation ago. Place a clock with second hand in view, hold a pail down to urinate into (curious that men say 'piss", women usually 'pee') and check the total seconds for the urine in full flow. Now pour it out into your wife's kitchen measuring cup (?!) and see how many ounces you got. Multiply oz. by 30 (actually 31) to convert ounces to milli-liters or ml. and divide by the number of seconds. As an example, if you got four ounces, which converts to 120 ml. and then divide that by the twenty second it took, you get 4 oz. 120 ml./20 which produces a milli-liter per second figure of 6ml/s. This would an unsatisfactory dribbling figure, far below the optimal average of a healthy 15 ml/sec. Then you can approach you doctor with a suspicion that you are going to need help and it is good to know this ahead of time. Of course your doctor can do all this more accurately with hospital instrumentation, but some of us prefer a 'hands-on' approach, even if you splash a little in the process.

Personal Considerations

If you have tried the pre-surgery drugs and found they didn't work to your satisfaction, and you are preparing to think about surgery, the first step will be to find the right doctor. It is important to have a doctor who will take time to explain what his procedures are and what you can expect in terms of recovery and improvement. If your first interview with a doctor doesn't seem good, if he doesn't want to take time to explain what he does, what the options are and what the rates of improvement in his practice have been, don't go further with examinations and find another doctor. Some surgeons are experts in their work but not good explainers, some consider their work what they do in the operating room, some are simply not verbal people and not comfortable explaining their work. If you want to know the details beforehand, you need the right doctor for this, and most of us will face surgery best if we know what is actually involved. You want to be comfortable with your doctor, especially in this operation which has overtones which touch a man's sexual identity. Resumption of sexual habits after surgery is something that deserves discussion since some specific changes may occur.

At the present time the surgeon doing this operation gets a limited authorized Medicare payment, is it no longer the $2000-3000 of ten years ago and may be as low as $700-1000 now, including three postoperative visits. Urologists are not like heart surgeons, they do not get rich on their work, and not many young doctors go into this field. But there is another side to this: Getting experience with the TURP operation takes time, there may be fifty operations before the surgeon is fully in charge of the procedure. Young doctors in Urology may not have this experience, so it is wise to inquire how many operations a doctor has performed with what rate of success. If such a question isn't answered, best go on to another man. A doctor in his mid fifties who has twenty five years of surgical TURP experience with the prostate is a better bet for this operation than a recent intern .

For the Holmium procedure, there will not be a long history of experience. One doctor told me he had done ten operations and was still evaluating the value of Holmium. He further remarked to a patient after a Holmium operation that TURP was the better operation! Another doctor I asked about the value of Holmium said to ask him again in a year, when evaluations would be more complete. In the meantime a new method which injects ethanol directly into the prostate is being developed and may turn our to be better than previous methods, but this will not be available for use for a few years more. In other words, think ahead with careful examination of the options, and if you can wait before surgery, you may get a better operation at a later date. But the well proved TURP will still be the gold standard of Urology for your foreseeable future unless you plan to be a centenarian.

The Operation and some Details

Say you have decided to have an operation on your prostate. The first thing you have to decide is whether you and you doctor decide on general anesthesia or a spinal injection. Some who have tolerated anesthesia before with no difficulty or secondary effects may prefer this from past experience, but many anesthesiologists will note that the spinal has less danger overall. You can discuss this with your doctor at the hospital but best prepare through reading on the web ahead of time. The spinal can be adjusted so you are partly aware or not at all aware of the operation, so a desire to be "absent" while the work is being done can go with either option.

After the operation the nurse will give you under doctor's orders pain relievers, which can be shots of small amounts of morphine for immediate relief of pain, or later an anodyne like PercoSet (oxycodone). Asked how much pain you feel on a scale of one to ten, you will possibly say middling as a precaution, and you may get more medicine than you need for suppressing pain. Try to get as little as you need, since oxycodone damps intestinal peristalsis and can result in severe constipation. This is especially bad in the days after the operation when muscular efforts to defecate will press directly on the recently operated prostate, and will cause increased bleeding. Look at one of the pictures and you will see the rectum is right behind the prostate!

This is something which should be taken care of beforehand by starting a regimen on stool softeners and/or a Metamucil type powder in abundant water the day before the operation, but not in the forbidden hours just before you go to the operating room. The nurse may give you a stool softening pill with you dinner in the hospital before you are sent home, but this is too little and too late as well. It will do no harm to have a loose stool when you come home, even a light diarrhea will be more suitable than hard stools which impinge on the bleeding prostate gland. Less oxycodone and more attention to stool softening will make a big difference in comfort and recovery.

The attending nurse will tell you when you are back in your room with that uncomfortable catheter dangling from your penis, that you should wash around it carefully when you get home. But she may not tell you why! After the operation there may be a sticky mucus around the gland end of the penis which can stick the head together with the prepuce in a very painful way. But there is a simple way to avoid this: First clean with soap and water, then smear a fingerful of clean Vaseline around the area and the problem is avoided. Keeping the area lubricated for a few days will be important.

Bleeding is always somewhat frightening, especially when it comes as a surprise out of your penis. The TURP operation is noted as causing bleeding for some time, which may be two weeks or up to a month as the incisions inside the prostate start to heal. But generally the amount of blood coming out is small, it may be a quarter teaspoon- full after the first few days, but it looks like a lot in the toilet bowl, and you may think it is all coming from you bladder, which would be serious. So try to let the blood flow onto the toilet porcelain on the front and note if is a splash, or a series of a dozen drops, or just a few spots after a week or two. Then flow the rest of the urine into the center of the bowl and it should be clear light yellow if you have been drinking the glass of water each waking hours as you were told. If the major flow continues quite red, you should call you doctor and report this, if light yellow then the bladder is clear and the blood flow is just from the resected areas in the prostate.

In urination after the operation you will feel some lumps or clots coming out with the urine; these are a tissue like the scab on a dry wound or cut, but flat and slippery since not exposed to the air. These are normal and although they might feel odd and surprising, they are usual in the postoperative stage. If there are large clots which impede flow, or more than a few flat ones in each urination, you should call you doctor, and remember to keep drinking water which is necessary for the flushing out of residues from the operation.

Cautions on the sheet from the hospital may say to avoid walking at all, even up a stairs slowly; going out to the mailbox or sitting in a driven car; drinking coffee or alcohol. Best to be careful but ask you doctor about these cautions and which he wants you to observe for a week, for two weeks or for more. The recovery period is usually stated as four to six weeks, with the cessation of bleeding as a sign or healing of the resection of the prostate. But remember where the prostate is! You virtually sit on it, you strain the pelvic base muscles around it when you evacuate, when you walk or run, when you cough or choke. For a month or two have a certain degree of respect for your Prostate, the organ you were formerly hardly away of as part of your uro-genital system.

I wrote the following above, but the same information applies with different figures postoperatively:
<      As you recover you may want to find out in a few weeks how effective the operation was, and you can do this in a semi-scientific way which is the way doctors did it a generation ago. Place a clock with second hand in view, hold a pail down to urinate into (curious that men say 'piss", women usually 'pee') and check the total seconds for the urine in full flow. Now pour it out into your wife's kitchen measuring cup (?!) and see how many ounces you got. Multiply oz. by 30 (actually 31) to convert ounces to milli-liters or ml. and divide by the number of seconds. As an example, if you got eight ounces, which converts to 240 ml. and then divide that by the twenty second it took, you get 8 oz= 240 ml./20 which produces a milli-liter per second figure of 12 ml/s. This is a very satisfactory figure, a bit below the optimal average of 15, not as high as a firehose 20 ml/s and far better than your previous dribbling 4 ml/s before the surgery. Congratulations, you operation was a success! Of course you doctor can do with hospital instrumentation far more accurately, but some of prefer a hands-on approach even if you splash a little in the process.

William Harris
Prof. Em. Middlebury College