Why is laser prostatectomy being recommended?

Photoselective vaporisation of the prostate (PVP) is used to treat bladder obstruction caused by benign (non-cancerous) enlargement of the prostate. 

A high-powered laser is used to core out the prostate by vaporising the centre of the gland, leaving a wide channel and so relieving urinary symptoms. It is hoped that this procedure will offer benefits over the standard operation – the transurethral resection of the prostate gland (TURP).

More information about the TURP can be found later in this leaflet but the anticipated benefits of PVP are:

• shorter hospital stay
• If a catheter is required following surgery it can usually be removed within 24 hours
• The risk of bleeding both during and after the operation is reduced, minimising the need for blood transfusion
• Overall the surgery places less strain on the body.

An appointment will be arranged to provide you with information, to try to answer questions that you may have and check that we have sufficient information about you.

What to expect during your pre operative consultation?
 
A lot of the necessary information and test results will be available and therefore will not require repeating.

You may however be asked to:

• complete a standardised questionnaire to grade your symptoms
• undergo an examination of the prostate. This will entail an internal examination with a gloved finger, possibly with an ultrasound probe to give the best estimate of the prostate size
• repeat a urine flow test
• have a blood test (PSA) to check for prostate cancer. PSA (Prostate Specific Antigen) is a substance made by the prostate gland. Small amounts of PSA pass into the blood stream where its level can be measured. If this has been checked during the previous 12 months it may not need to be repeated. 

You may choose not to undergo the PSA blood test and the ultrasound examination of the prostate and still undergo the PVP procedure so long as you are aware of the reasons why we ask to carry out these tests.

If laser prostatectomy is considered appropriate for you, your name will be placed on the waiting list. If other treatment options are suggested you will be referred back to your original consultant at this stage.

What pre operative preparation is needed?

Before your admission to hospital you will be asked to attend the pre assessment clinic. Pre anaesthetic checks which may be carried out include blood tests, urine tests, heart tracing (ECG) and sometimes a chest x-ray.  A nurse will complete the relevant documentation giving you further opportunity to ask any questions you may have.

At the pre assessment clinic you will be asked about your current medication.  We particularly need the details of medication that may affect bleeding.

You will come into hospital either the day before or on the day of your operation and be seen by the nursing and medical staff on the ward.  You will also be seen by the anaesthetist who will discuss the type of anaesthetic you will have.

On the day of the operation you will be advised to have nothing to eat or drink for several hours before surgery.  You will be asked to change into a hospital gown and be taken to the operating department on your ward bed or on a trolley.

How is the operation carried out? 
 
The duration of the operation itself depends on the prostate size. The total time spent in the operating theatre suite is likely to be several hours.

The first part of the operation is to give you an anaesthetic. You may be completely asleep (general anaesthetic), or just the body from the waist down made numb (spinal anaesthetic), and then a sedative may be given to help the time pass comfortably.

The bladder and prostate gland are accessed via the penis along the urethra (urinary passageway), and the operating instrument, the cystoscope, (sometimes referred to as a ‘telescope’), is passed accompanied by sterile (saline) salt-water. The saline fills the urethra and provides a clear view.  First an inspection is performed. Also the size and shape of the prostate is rechecked by inserting a gloved finger into your anus (bottom). If there are no new or unexpected findings, then the laser fibre is introduced through the cystoscope and the procedure started.  As the laser light is shone onto the prostate surface the prostate tissue can be seen to disappear gradually.

When the surgeon is happy that a clear channel has been created, the need for a catheter (urinary drainage tube) is considered.  Rarely will irrigation (a bag of fluid to continually flush the catheter, as is used after TURP) be required.

What will happen after the operation is completed ?

You will wake up in the recovery area in your bed and when the nurses are happy with your condition a nurse from the ward will come to take you back to the ward.

You will have a drip running into your arm or hand.  This is to prevent dehydration until you are drinking. You will be given a drink when the nurse feels you are ready and able to tolerate it. You should be given a light meal soon after.

If a catheter was inserted, it will be removed a few hours after surgery or the following day. The timing of the catheter removal will depend upon several factors, including the type of anaesthetic you have had, how well you recover from the anaesthetic and how much blood there is in the urine.  You may go home once you are passing urine and emptying your bladder satisfactorily.

What problems can occur?

Before your planned surgery it is important that you understand what the surgery entails and the possible side effects. On rare occasions, as with the standard TURP operation, there will be patients who are unsuccessful in passing urine following the laser operation.  This may require the re insertion of a catheter for a period of time and a further or alternative operation may need to be considered at a later date.

Urinary control

Some men experience discomfort in the penis or urethra immediately after the operation (typically in recovery). This usually lasts a few hours, easing when urine is passed. Painkillers can be given which will help.

If passing urine frequently and with ‘urgency’ (difficulty holding on), was a problem beforehand, this may continue after the operation and may be temporarily worse.
 
Some men may develop ‘cystitis’ symptoms up to two weeks after the operation, passing urine frequently with a burning sensation.  Infection should be ruled out initially and sometimes a course of medication is required.

5% of men may have difficulty passing urine after the operation, often men who have been shown to have an ‘underactive’ or poorly emptying bladder beforehand. This may result in a catheter being required. Some of these men may then go home with e catheter in place and return as an outpatient to have the catheter removed.

Bleeding

Some patients have noted bleeding after the operation, (sometimes not appearing until approximately two weeks later), probably due to the separation of scabs internally.  Again, infection should be ruled out but rarely does this require further treatment.

Effects on your sex life

Approximately 25% of men may experience retrograde ejaculation (semen going into the bladder) resulting in a ‘dry orgasm’. If this occurs it may affect your ability to father children but you cannot rely on this as a method of contraception. Some men report change in sensation of orgasm.

Impaired erection

There have been no reported cases in med undergoing this procedure to date, however there cannot be a complete guarantee that this will never occur.

As with any operation, other surgical complications can occur. These include infections, heart problems or deep vein thrombosis (blood clots in the legs). The risks of these will be discuss in the pre admission clinic and where necessary specific preventative measures will be taken.

Are there any alternatives to this surgery ?

At the present time the standard operation performed for relieving symptoms cause by enlargement of the prostate gland is called transurethral resection of the prostate gland (TURP), when the enlarged prostate tissue is shaved away from the inside surface, again using cystoscopic instruments.  Please refer to the leaflet ‘Having a Prostatectomy’ available in the department.

As the PVP procedure is relatively new it is not possible to predict the long term outcome of this operation.  However, based on the currently available information it appears favourable and equivalent to TURP. Caution about the long term is a point stressed by NICE (www.nice.org.uk the independent body that assesses treatments offered by the NHS).

What can I do when I get home?

Strenuous activity (e.g. digging, carrying heavy items) should be avoided for two weeks following your operation. Driving can be resumed after one week (some car insurance is not valid during the recovery period after an operation. Check with your insurance company). Sports such as golf or cycling may be resumed after two weeks.

Avoid becoming constipated as straining may lead to bleeding from your prostate cavity. If necessary you can be given a mild laxative to take home after your procedure.

Sexual activity may be resumed as soon as you feel ready. If you do ejaculate there may be some discolouration of the semen for some weeks. This is normal and soon settles.

Bearing in mind the type of activity and responsibility involved, you may return to work when you feel fit which is usually between 2-7 days.

Follow up

You will be sent home with a letter for your General Practitioner and with any medication you need.

A follow up appointment will be made for you about three months after your operation.  At this appointment you will be asked to provide a urinary flow rate test, so come with a full bladder if possible.  You will also be asked to repeat the symptom score that you had completed before your surgery.

Contact points

If you have any problems following your discharge from hospital you may contact the ward you were on for advice.  Alternatively you may contact your GP.  If the matter is urgent and you are unable to contact the hospital please contact the emergency medical services in the usual way.

More comprehensive information leaflets are also available from the department and information is available on the internet. The equipment manufacturer provides some information at Laserscope

Please feel free to bring any formation with you that you may have obtained from any source and we will try to any questions you may have.

Finally

In addition to the information that we ask for please do not hesitate to feed back any comments directly to the team involved.