OPEN PROSTATECTOMY

Open prostatectomy
Definition : Open prostatectomy is a procedure for removal of an enlarged prostate gland.

Purpose
The primary indication for open prostatectomy is benign prostatic hyperplasia (BPH), a condition whereby benign or noncancerous nodules grow in the prostate gland. The prostate gland is composed of smooth muscle cells, glandular cells, and cells that give the gland structure (stromal cells). A dense fibrous capsule surrounds the prostate gland. The glandular cells produce a milky fluid that mixes with seminal fluid and sperm to make semen. The prostate gland also produces a hormone (dihydrotestosterone) that has a major impact on the gland’s development.

Description
The prostate gland undergoes several changes as a man ages. The pea size gland at birth grows only slightly during puberty, and reaches its normal adult shape and size (similar to a walnut) when a male is in his early twenties. The prostate gland remains stable until the mid-forties. At that time—in most men—the number of cells begins to multiply (cell multiplication), and the gland starts to enlarge. The enlargement—called hyperplasia— is due to an increase in the number of cells.

Cell proliferation in the prostates of older men can cause symptoms (referred to as lower urinary tract symptoms, LUTS), which often include:
• straining when urinating
• hesitation before urine flow starts
• dribbling at the end of urination or leakage afterward
• weak or intermittent urinary strain
• painful urination

Other symptoms (called storage symptoms) sometime appear, and may include:
• urgent need to urinate
• bladder pain when urinating
• increased frequency of urination, especially at night
• bladder irritation during urination

The cause of BPH is not fully understood. Currently, it is thought to be caused by a hormone that the prostate gland synthesizes, called dihydrotestosterone (DHT). This hormone is synthesized from testosterone by a prostatic enzyme called 5-alpha reductase.

Surgery is generally indicated for persons with moderate to severe symptoms, particularly if urinary retention is intractable or if the enlarged prostate (BPH) is related to recurrent urinary tract infections, blood in the urine, bladder stones, or kidney problems.

Open prostatectomy is the treatment of choice for approximately 2–3% of BPH patients who have a very large prostate, a damaged bladder, or another serious related problem. Open prostatectomy is used when the prostate is so large (2.8–3.5 oz [80–100 g]) that transurethral resection of the prostate (TURP, a less strenuous surgical procedure to remove a smaller prostate) cannot be performed.

Additionally, open prostatectomy is indicated for males with:
• recurrent or persistent urinary tract infections
• acute urinary distention
• bladder outlet obstructions
• recurrent gross hematuria (blood in urine) of prostate origin
• pathological changes in the bladder, ureters, or kidneys due to prostate obstruction

Contraindications to open prostatectomy include
previous prostatectomy, prostate cancer, a small fibrous prostate gland, and previous pelvic surgery that may obstruct access to the prostate gland.

Demographics
The cause of BPH is not entirely known; however, the incidence increases with advancing age. Before 40 years of age, approximately 10% of males have BPH. A small amount of hyperplasia is present in 80% of males over 40 years old. Approximately 8–31% of males experience moderate to severe lower urinary tract symptoms (LUTS) in their fifties. By age 80, about 80% of men have LUTS. A risk factor is the presence of normally functioning testicles; research indicates that castration can minimize prostatic enlargement. It appears that the glandular tissues that multiply abnormally use male hormones produced in the testicles differently than the normal tissues do.

Approximately 5.5 million American males have BPH. It is more prevalent in the United States and Europe, and less common among Asians. BPH is more common in men who are married rather than single, and there is a strong genetic correlation. A man’s chance for developing BPH is greater if three of more family members have the condition.