Surgery of the Prostate Gland

Chapter 85 Surgery of the Prostate Gland



Harry W. Boothe


Surgical procedures of the prostate gland include biopsy, drainage procedures (including ultrasound-guided percutaneous needle drainage, drain tube placement, omentalization, and marsupialization), and resection procedures (partial or complete resection of prostatic cysts and partial or complete prostatectomy). Perform orchidectomy of the patient with prostatic disease either before or at the time of prostatic surgery (see Chapter 87 for castration technique). Prostatic disorders that may require surgery include hyperplasia, trauma, infection (abscess), cyst formation, and neoplasia. A thorough understanding of prostatic anatomy is necessary before performing surgery. Information in this chapter refers only to the dog because prostatic disease is extremely rare in cats. See Chapter 84 for additional information on prostatic diseases.



ANATOMY



• The prostate gland completely encompasses the proximal portion of the male urethra at the neck of the bladder.

• The position of the prostate is age dependent; the prostate is confined to the pelvic cavity until about 4 years of age and is essentially totally within the abdomen by 10 years of age.

• The dorsal prostatic surface is flattened and has a mid-dorsal sulcus. The gland has a relatively thick capsule and is divided into right and left lobes by a prominent median septum.

• The two deferent ducts enter the craniodorsal surface of the prostate.

• The blood supply is closely allied to the nerve supply, with both being located in the lateral pedicles and entering the prostate dorsolaterally. The prostatic artery gives off branches to the ductus deferens, urethra, urinary bladder, ureters, and rectum. Damage to branches of the prostatic artery may result in devascularization of surrounding structures.

• The hypogastric (sympathetic) and pelvic (parasympathetic) nerves follow the vasculature.



Key Point


The hypogastric and pelvic nerves are required for micturition and continence. Avoid iatrogenic trauma to these structures.



• The prostatic lymph vessels empty into the median iliac lymph nodes.


BIOPSY



Preoperative Considerations



• Accurate preoperative assessment of prostatic size, consistency, and location is important. Palpation (both rectal and abdominal), radiography (including contrast radiography), and ultrasonography are helpful in gaining this information. Ultrasound can also be used to assist in obtaining fine needle aspirates of the prostate (see Chapter 84).

• Adequate immobilization of the prostate gland during biopsy is indicated, particularly when using needle biopsy techniques.



Key Point


Perform aspiration of the prostate before needle biopsy to exclude abscessation.



Procedure for Percutaneous Needle (Punch) Biopsy



Objectives



• Obtain a representative sample of the prostate gland for histologic and microbiologic evaluation.

• Avoid entering the prostatic urethra.

• Minimize blood loss and potential dissemination of infection.


Equipment



• Tru-Cut or similar type of biopsy needle (one-handed model) or Franklin-Silverman needle

• Scalpel blade and handle


Technique



1. Place the dog in sternal recumbency with the tail positioned over the back.

2. Prepare the perineal region from the base of the tail to ventral to the level of the ischial tuberosities.

3. Direct an assistant to exert gentle pressure on the caudal abdomen to move the prostate gland into the pelvic inlet.

4. Perform rectal examination to define the position of the prostate gland.

5. Incise the perineal skin (5 mm long) just off the midline midway between the anus and the ischial tuberosity.

6. Insert the biopsy needle in the closed position through the prostatic capsule under digital control within the rectum by the other hand.

7. Fully insert the inner cannula into the prostate gland and, while holding the inner cannula stationary in its extended position, sharply advance the outer cannula over the inner rod.

8. Remove the biopsy needle in a closed position.

9. Verify that an adequate biopsy has been obtained by seeing prostatic tissue in the specimen notch.

10. Place the biopsy sample in the appropriate containers for histologic and microbiologic testing.


Surgical Procedure: Wedge Biopsy



Equipment



• Standard general surgical pack and suture

• Laparotomy sponges

• Balfour retractors


Technique



1. Place the dog in dorsal recumbency on a level surgery table.

2. Aseptically prepare the ventral abdominal region from the xiphoid process to caudal to the pubic brim.

3. Incise the skin and ventral abdominal wall from the umbilicus to the pubis while avoiding the prepuce. Use a midline abdominal approach. Alternately, a paramedian approach to the caudal abdomen can be used.

4. Gently retract the urinary bladder cranially using a stay suture. Isolate the prostate gland with moistened laparotomy sponges.

5. Excise a representative wedge of prostatic tissue, while avoiding the urethra on the midline and the dorsolateral aspect of the prostate gland, using a scalpel blade.

6. Close the prostatic defect (simple interrupted or continuous pattern, absorbable suture).

7. Routinely close the ventral abdominal incision in three layers.


Postoperative Care and Complications



Short Term



• Closely monitor for hemorrhage, including hematuria, infection, and urine leakage.

• Monitor for postoperative orchitis and scrotal edema.


Prognosis



• The prognosis depends on the disease process(es) present.

• Prostatic biopsy is usually associated with minimal patient morbidity.


DRAINAGE PROCEDURES



Preoperative Considerations



• Perform ultrasonography to determine the degree and location of cavitation within the prostatic parenchyma.

• Distinguish between infectious and non-infectious causes of fluid retention within or near the prostate gland.

• Perform microbiologic testing of prostatic fluid to assist in selection of an antimicrobial agent.

• When prostatic abscessation is present, drainage, omentalization, or resection of diseased parenchyma is indicated.

• Perform orchidectomy before or at the time of a prostatic drainage procedure.



Key Point


Always biopsy and obtain culture samples from the prostate as part of the drainage procedure.



• Choice of drainage procedure (i.e., ultrasound-guided percutaneous needle drainage, placement of drain tubes, omentalization, or marsupialization) depends on the size and location of prostatic cavitation. Large cystic lesions may be more amenable to partial resection and omentalization.


Objectives



• Thoroughly evacuate cavitary lesion(s).

• Create a common cavity to provide ventral drainage (surgical drainage).

• Thoroughly lavage the cavity at the time of drainage (surgical drainage).

• Avoid entering the prostatic urethra if possible.

• Minimize blood loss and dissemination of infection.


Procedure for Ultrasound-Guided Percutaneous Drainage



Equipment



• Ultrasound unit with a 7.5- or 8.5-MHz transducer (see Chapter 4)

• 22-gauge spinal needle, extension set, and syringe


Technique



1. Place the dog in dorsal or lateral recumbency (use sedation or anesthesia).

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Aug 27, 2016 | Posted by in SMALL ANIMAL | Comments Off on Surgery of the Prostate Gland

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