Laser TURP (Holmium)

What is a Laser Prostatectomy?

A laser prostatectomy is an operation for men who have problems passing urine because of an enlarged prostate gland. In case the gland is small, the symptoms maybe due to elevated bladder neck in which case a lasertransurethral incision of prostate is performed. The main job of prostate is to produce seminal fluid. It also produces Prostate specific antigen (PSA) which helps keep the urethra clean after seminal fluid ejaculation. The prostate gland sits just below the bladder and surrounds the neck of the bladder and the beginning of the urethra (the tube from which you pass your urine).

Prostate enlargement occurs due to changes in the levels of hormones in the blood in the aging male. When the prostate tissue enlarges inward it squeezes on the urethra causing LUTS – lower urinary tract symptoms like:

Frequency – the need to void often

Urgency – the need to void in a hurry

Nocturia – the need to get up at night to void

Poor stream

Intermittency – the urine starts & stops with no continuous smooth flow

Straining to pass urine – need to apply more effort

Sense of incomplete emptying of the bladder – need to empty the urine more frequently as the bladder keeps significant residual urine during each void.

The aim of the laser prostatectomy is to remove the prostate tissue, which is causing the blockage to relieve the patient of his symptoms.

Why is Laser Prostatectomy Needed?

If your prostate gland becomes enlarged & obstructing your bladder may be unable to empty itself completely. Over a prolonged period, the urine build-up can cause the bladder to thicken & eventually over- stretch the bladder leading to atonia or failure to drain the urine properly. It may also occasionally prevent the kidneys from draining properly. This can lead to kidney damage and chronic kidney diseases. Usually however, the operation is needed because of the unpleasant LUTS – lower urinary tract symptoms start affecting your quality of life (QOL).

 

The Procedure of Laser Prostatectomy

Using anesthetic gel for lubrication a telescopic instrument called a resectoscope is passed up the urethra. The resectoscope has a telescope inside it which is attached to a camera head to view the area of surgery which is displayed on a monitor in a magnified view for surgeon. The thin laser fiber is passed through a working channel in aresectoscope & the laser beam coming from this fiber cuts the obstructing prostatic tissue like a knife back to the level of the prostatic capsule. This removes any tissue causing obstruction of your urine flow.

The pieces of cut prostatic tissue are pushed into the bladder. They are then removed by the ‘morcellator’. The morcellator is a mechanical device, which passes through the morcelloscope into the bladder & cuts the prostate tissue into tiny pieces so that they can be sucked out. Any tissue removed during surgery is collected and routinely sent to our histopathologist to be checked under microscope for the nature of the tissue.

Once all the tissue fragments have been removed, a three way Foleys catheter (drainage tube that passes through the urethra into the bladder) is placed to drain your urine. Gentle irrigation is started as a precautionary measure for 24 hours to prevent formation of clots in the bladder to avoid discomfort to the patient.

Expectations after prostatectomy.

Since the obstructing tissue has been removed there will be an immediate improvement in your urine flow. However as the cavity inside is cut which is non visible to external eye patient may have urgency, frequency & dysuria. As the prostate cavity heals, urinary symptoms improve. In most men the symptoms improve rapidly, but in others the improvement in urgency, frequency and nocturia can take 6-8 weeks.

 

Are There any Untoward Effects after Surgery, Especially on my Sex Life?

After prostate tissue removal, the semen can pass freely back into the bladder, this is called retrograde ejaculation. This is completely harmless and does not affect your health in anyway; however it would be a concern to men wanting to father children in the future as they would have dry ejaculations. This surgery does not affect the orgasmic pleasure.The incidence of retrograde ejaculation after TURP ranges from 50% to 95%; but after TUIP it has been reported as occurring in 0% to 37% of cases. Campbell Walsh Urology , Tenth Edition, 2011.Pg. – 2691.

Wasson and associates (1995) reported on a prospective randomized study in which patients were assigned to either watchful waiting or TURP. Ninety-one percent of the men had no complication during the first 30 days after surgery. Specifically, there was no difference between either group in the incidence of urinary incontinence and impotence. The most frequent complications noted were a need for replacement of urinary catheter (4%), perforation of the prostatic capsule (2%), and hemorrhage requiring transfusion (1%). At the end of 3 years of follow-up, the mortality rate was the same for each group. Campbell Walsh Urology , Tenth Edition, 2011.Pg. – 2687.

In approximately 2-3% patients scarring can occur after surgery at the operation site as the tissues heal leading to bladder neck stenosis or within the urethra called stricture urethra, which may present as obstructive lower urinary tract symptoms. This may need additional surgery called bladder neck incision ( bladder neck stenosis) or optical internal urethrotomy ( for stricture urethra).This can be done as daycare procedure. Some patients may need calibrations in future after such an event if their scar tissue reaction is severe.

Is There a Risk That I Might End Up Incontinent?

Temporary incontinence, or leakage of urine without control occurs occasionally and may last for a few weeks. Usually most patients settle by 6 – 8 weeks.

If you were to have any incontinence after your operation you would be taught exercises to strengthen the pelvic floor muscles, which helps early recovery & maintenance of your continence.

 

Your Consent

You need to sign a consent form for your surgery to proceed. You must understand all the risks, benefits & possible complications of both the surgery & anesthesia before you sign the consent form. All the questions regarding anesthesia, should be addressed to your anesthetist at the time of your PAC (preanesthesia checkup). In case of any queries don’t hesitate o contact Dr Manav Suryavanshi (for surgical clarifications) & your anesthetist in charge regarding anesthesia & premedication queries.

 

Blood Transfusion

It would be rare to require a blood transfusion with this surgery. However, one unit of blood is arranged prior to surgery as a backup. The family is supposed to bring a relative along for replacement donation in case your patient receives a transfusion.

 

About Your Anesthesia

You will not be allowed to eat or drink anything for at least 6 hours before your surgery. You are not supposed to take even water. Nil by mouth means nil by mouth.

There are two main types of anesthesia used for this surgery :

• General Anesthesia: You will be asleep throughout the operation and remember nothing of it.
• Regional spinal Anesthesia

A needle is placed into your back and medicine is injected that will numb your body from the waist down. You will be awake but will not feel the operation.

Feel free to discuss these details with the Anesthetist.

You must not drive any vehicle or operate any machinery for 24 hours after having anesthesia. Someone should drive you home if you go home within 24 hours of your surgery.

Your Operation

On admission you will be informed of your approximate time of surgery and prepared for theatre by your nurse.

You may be given some medicines before theatre. These are charted by your anesthetist and may include tablets for tension, nausea and pain prevention.

You will be escorted to theatre where you will be transferred to the theatre table as per the time your surgery has been slotted for. Once you have been anesthetized your surgery will begin. The operation can take anywhere from 30 minutes to more than two hours depending on the size of your prostate gland.

After surgery the patient is sent to the recovery room & observed for 2 hours prior to being transferred to ward. During this time the family is informed about the culmination of surgery & shown the specimen. However it takes around 1 hour for patients to be stabilized in recovery before a relative is allowed to meet the patient for a short while. It should be remembered it is in the best interest of the patient that the traffic of relatives for meeting is kept under check. Please don’t insist on meeting of more relatives. The patient would anyways be sent to the ward by 2-4 hours as per the availability of beds.

After Surgery

Your nurse will check your blood pressure, pulse and temperature routinely.

The patient has an intravenous fluid on, he also has an irrigation tubing attached to the three ways Foleys catheter from which normal saline irrigation continues for up to 24 hours. This helps prevent formation of clots & hence any blockage of catheter & discomfort to the patient. Liquids are allowed by the time one returns to the ward & soft to normal diets are allowed 4-6 hours after surgery. The urine continues to drain from the bladder into the urine bag. The urine is likely to be blood stained & clears within the first 24 to 48 hours. The catheter is held in place inside the bladder by a balloon so that it doesn’t slip out. Your nurse will monitor your catheter tube and the drainage from it.

Responsibilities for the attendant with the patient

At any moment you or your relative feel that the urobag tube has stopped draining urine, you must inform the staff nurse immediately, so that the block is sorted to prevent any clot formation or distension discomfort to the patient.

As soon as the bottle of irrigation fluid is about to end please keep the nurse informed so that it can be changed in time.

Once you have recovered from your anesthesia your nurse will help you, to get out of bed for the first time. If you have had a spinal anesthesia, you will be asked to lie flat for upto 24 hours after surgery for the anesthesia effect to wear off. Patients are not allowed to keep pillows after spinal anesthesia to prevent post spinal headaches. However you can move gently in time to have dinner & then lie flat again. All these precautions are not required after general anesthesia.

After surgery you may or may not experience some of the following symptoms:

• A burning sensation and the desire to go to the toilet. These symptoms are easily treated with mild pain relievers and medications, which change the acidity of the urine. The desire to go to toilet is because both the rectum & bladder have common nerve supply & is induced by balloon of the catheter irritating the trigone.

• A stinging or burning sensation at the tip of the penis where the catheter enters. This can be due to the instruments used during the operation and is easily relieved by applying an anesthetic gel.

• Feeling of bladder fullness may be caused by blockage of the catheter by a blood clot or accidental kinking of the tube. The nurse easily clears these blockages once informed by you.

• Bladder spasms (short, sharp, grabbing pains). This is due to the bladder trying to expel the catheter because of irritation. These may be controlled by medications. Our aim is to keep you as comfortable as possible, it is important that the nurse knows when the pain or discomfort starts so your symptoms can be treated and relieved as quickly and easily as possible. At all times, your nurse is there to help you, please ring your bell if you need assistance and your nurse is not nearby. 
You will be asked to drink extra fluids after your surgery and for the next few days after your discharge. This helps dilute the blood in the urine, washes away debris and helps prevent infection. Water is best, but any fluid is fine. There is no need to drink excessive amounts of fluid; once the urine is free of blood you should drink just enough to keep your urine a pale yellow to clear color.

• A catheter is removed 24 to 48 hours after surgery in the ward, if the urine is clear. If it is decided to keep the catheter for 4-5 days you would be shown how to empty the catheter bag and care for it before going home. Catheter is removed on an OPD basis in this case & the patient voids comfortably a couple of times before he is sent home. The catheter is removed by deflating the balloon. The catheter slides out easily once the balloon is deflated, causing little discomfort.

Once the catheter comes out you may at first have a burning sensation when passing urine. This settles in 2-3 days time. One should drink more water for next 7-10 days (> 3 litres/day). If these symptoms continue for longer and are associated with frequency going to the toilet and cloudy, offensive smelling urine &/or fever with chills you should contact us on Urology Helpline (+91-9560398928) as soon as possible as these are signs of a urine infection.

There is 4% chance of patients not being able to void after catheter removal. This happens if the edema & inflammation in the raw prostatic fossa is not settled. This settles by recatheterising such patients for 4-5 days & removing the catheter.

 

Going Home

Before leaving the ward, you will be given a discharge information letter that contains documentation of the procedure performed & medicines that need to be taken.

You will be given an outpatient appointment at Urofort (+91-9910103545) or at our hospital with Dr Manav by Urology Coordinator (+91-9560398967) as per your convenience 5-7 days after surgery. By this time the histopathology report of the prostatic tissue is also available & is discussed with you.

If you are prescribed antibiotics to take, it is very important that you complete the whole course of tablets, even if you feel better and don’t think they need to be finished.

 

Once Home

It takes time for the raw surface inside the prostate cavity to heal. Until it does you may have some discomfort passing urine, and experience some urgency, frequency, and nocturia. These symptoms subside as healing progresses and can be relieved with the help of mild pain relievers and other medications, which will be prescribed in Discharge slip.

Passage of some blood in urine may be normal & may continue upto 10-14 days. The bleeding may be intermittent. This is the normal process of healing and you need only be concerned if you have fresh (cherry red color) heavy bleeding that does not stop or if your are unable to pass your urine at all which may be due to a blood clot blocking the urethra. If either of these unlikely events should occur you should contact your own doctor immediately or go to your nearest emergency department.

Continue to drink plenty of fluid if bleeding persists otherwise drink enough to keep your urine a pale yellow to clear color.

You can do most things after your operation except for any heavy lifting, straining or strenuous activity which should be avoided for 4-6 weeks after surgery. Apart from avoiding strenuous activities you will be able to continue with your normal daily routines.

In the hospital the nursing and medical staff are always available to help with whatever needs you have. If you are worried about anything before or after your surgery, or if you have any further questions or would like more information, please do not hesitate to ask.

For More Information

Meet us at

Medanta Kidney & Urology Institute

Medanta – The Medicity

Sector 38, Gurgaon, Haryana – 122001, India

For appointment Call+91-9910103545

Email – info@urofort.com

Web address – www.manavsuryavanshi.com