A Suprapubic Prostatectomy (SPP) is an operation performed to remove the enlarged central portion of the prostate (referred to as the transition zone). This is in sharp contrast to the “radical” prostatectomy in which the entire prostate is removed for a diagnosis of cancer, this operations are performed on benign (not cancerous), very large prostates to improve urination.
As men grow older, their prostate gland often enlarges due to an overgrowth of benign tissue (BHP ñ Benign Prostatic Hyperplasia). Consequently, the central portion of the prostate obstructs the flow of urine. Patients with bothersome symptoms may be placed on medications to help open the channel or reduce the prostate size. If medications fail over time, or if a patient does not tolerate the possible side effects of the medicine, then a surgical procedure may be the next step. There are minimally invasive or moderately enlarged glands. The gold-standard operation (often referred to as a “scraping”) is called a TURP (transurethral resection of the prostate). This procedure requires anaesthesia and a brief hospitalisation. This procedure can also be performed using a laser.
In some instances, it may be better to perform an open procedure through an incision in the lower abdomen. The indications to remove the central portion of the prostate via an open operation include:
- When a prostate is so large that one of the other procedures would not work well to remove the obstruction.
- When the prostate is large and complicated by the presence of large or numerous bladder stones which require open entry into the bladder to remove.
Please refer to the detailed instructions provided by the rooms, or download these from the website.
The duration of the operation is different for every patient mostly reflecting difference in each patient’s anatomy, but is usually less than two hours. For the operation, you will be lying supine (flat on your back). General anaesthesia (complete sleep) is often used, but a spinal block is acceptable in some circumstances.
This operation is performed through an incision in the lower abdomen, just above the pubic bones.
The front wall of the bladder is opened and we remove the enlarged center of the prostate through this opening in the bladder. The outer portion of the prostate remains. The bladder is then closed as is the abdominal wall. A catheter is left in the bladder. Lastly, a small drain may be placed just outside the bladder and brought out through the skin. The purpose of the catheters is to create a well-drained bladder (continuous irrigation system) to keep small blood clots from accumulating in the bladder.
Continuous irrigation may be running in through the catheter in your urethra. You may have a sensation of urgency (feeling a need to urinate). This results from the catheter(s) causing bladder spasms. Typically, this feeling disappears over the next few days. If necessary, we can give you medication to help minimize these spasms. In either procedure, the drainage in the bags may be crystal clear or appear bloody for a few days. Both are normal findings.
A typical hospital stay for simple prostatectomy is less than one week. The timing and sequence for removal of the catheters varies according to the clarity of your urine and the presence of the surgeon.
Expectations of Outcome
It is normal to feel a bit tired for a few weeks. We typically tell patients that they will be out of work for two to four weeks (up to six weeks is possible if your job requires heavy lifting or straining) and that it may take several more weeks before you truly feel like yourself.
Most patients are very satisfied after the procedure. Initially, for a few days, some patients may have some difficulty controlling their bladder. However, this improves quickly. Within days to weeks, the following improvements should be expected:
- Stronger force of stream
- Decreased standing around waiting for the urination to commence
- Decreased need to push
- Loss of intermittence (ie. where the flow used to start and stop and start, etc.)
- Loss of the sensation that you are “not really emptying your bladder”
Possible Complications of the Procedure
The vast majority of patients will have no significant problems after the procedure. However, all surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation.
- Blood Loss / Transfusion
The prostate is supplied by a complex network of veins. There is always some blood loss expected. In some instances, blood loss is more severe and necessitates a transfusion.
- Incontinence (Involuntary Loss of Urine)
The type of incontinence most often associated with simple prostatectomy is termed urge-type incontinence (the loss of urine following uncontrolled bladder spasms). Bladders that are obstructed for years over-compensate by squeezing with more force. The bladder is a muscle, and like any other muscle, it thickens and gets stronger with more work. Now that the obstruction is gone, it can take weeks or longer for the bladder to readjust. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel. In extremely rare instances, this may never resolve fully. Total incontinence (the “constant” dripping of urine resulting from damage to the voluntary sphincter) or stress-type incontinence (the loss of urine following coughing, sneezing, lifting a heavy object, swinging a golf club, etc…) are less common following simple prostatectomy.
- Urinary Tract Infection or Urosepsis
Although we may give you antibiotics it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting.
- Wound Infection
As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from the incision site. Usually, these are easily managed with antibiotics and local wound care. In some instances, an area of the superficial (upper layer) incision needs to be opened for adequate drainage.
- Urinary Retention
Sometimes, a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. It is possible, that even with an open channel the bladder is still unable to fully empty or even empty at all. Sometimes it improves over time, and occasionally never. Patients at greater risk are those who presented originally with a severe blockage and huge volumes in the bladder, as well as diabetics in which the bladder may have already lost some ability to contract. Again, in cases that we are suspicious of this outcome, we may have performed a special test on your bladder (urodynamics) to help predict the outcome. If you remain in retention, you may need to live with a catheter or learn to catheterize yourself once to a few times per day.
- Deep Vein Thrombosis (DVT) / Pulmonary Embolus (PE)
In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents two to seven days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to a casualty department and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain.
- Bladder Neck Contracture
Sometimes, the neck of the bladder can scar down (weeks to months later) and restrict proper urine flow. This scar can sometimes be opened up with a small scope (minimally invasive) procedure. Unfortunately, this problem could recur and could eventually jeopardize urinary continence.
Please contact the office within 3 days of discharge. You should make an appointment to see Dr Sved as directed in the hospital. You may see him in his offices at RPA, Bankstown or Strathfield Private Hospital. Do not hesitate to call at any time if you have any concerns.