GreenLight PVP Operation information

(Photoselective Vaporisation of the Prostate)

pre and post op views

 

 
 
 
 
 
 
 

 

 

 

 

 

 

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 Mr Muir was one of the earliest international users of the GreenLight laser, and the first European user of the new HPS system. He is a founder member of the International GreenLight Users’ Group, a multinational collaboration dedicated to improving results and training in surgery for benign prostate disease. He has published many papers on laser prostatectomy as well as having lectured in and taught doctors from every continent. 

This section describes the procedure involved in having a prostate operation.

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You will have discussed the reasons behind having the surgery, which are to relieve the obstruction to the flow of urine through the prostate by removing the central part of the prostate.

PVP is done usually for benign swelling of the prostate although it may be used to relieve the obstruction of a prostate cancer. However it does not remove the whole prostate and is not a "cancer operation." .

 How is the operation carried out?

The operation is carried out under light general (asleep) anaesthetic or a spinal (awake but numb from the waist down). We usually favour the lght general anaesthetic with local anaesthesia placed around the prostate, since this may reduce the risk of needing a catheter after the operation

Under anaesthetic a telescope is passed into the bladder. The laser is then applied to the prostate to vaporise the obstructing prostatic lobes.  

When the prostate shows a nice wide open cavity the operation is complete. A cut in the bladder neck muscles may be carried out. A catheter (soft plastic drainage tube) may then placed in the bladder to drain the urine for a day or two. However most men do not need a catheter  at all, and even men in retention can sometimes go home catheter free!

After passing water you can usually leave hospital; if a catheter is left in place this is removed the following morning unless there has been a previous problem with retention of urine in which case I may recommend leaving it for a few more days.

Some men may fail to pass water after the operation: this is much more common if the surgery is being done where the bladder has been stretched or is emptying poorly and this would be discussed with you in detail.

In men with good bladder emptying there is still a possibility of around 5% of some difficulty passing urine after the catheter is removed: this may require a short period with a small soft catheter to rest the bladder but has no long term ill effects and does not require prolonged hospitalisation. No special preparation for the surgery (i.e. shaving or diet) is required. You will usually come in on the day of the operation and should starve for at least six hours prior to the scheduled operating time.

 You may not need to not stop aspirin or other anti-platelet drugs prior to the operation but if you are taking warfarin or heparin then it is imperative we are able to monitor the effects of the drug

Following the operation it is unusual to have more than minimal discomfort. The majority of men will need only simple painkillers, but as in any surgery there may rarely be more discomfort requiring strong painkillers or drugs to calm bladder spasm.

Most patients will be able to pass urine on waking up and will be able to go home once they have done this a a second time. For some men a night in hospital for monitoring may be needed due to general health problems. It is very  unusual to need to stay in hospital due to the operation itself. If a catheter is left in this is usually removed the following morning and can be done either at hospital or at home by the patient.

 

 What are the side effects?

Despite the absence of a cut in the skin, this is still classified as a major operation. The risk of major bleeding is very small - well under one percent, and there is little or no absorption of flui during surgery.  Advances in anaesthetic techniques reduce the risk of serious chest infection.

While most men now leave hospital without a catheter, some may initially fail to pass water after the operation: this is much more common if the surgery is being done where the bladder has been stretched or is emptying poorly and this would be discussed with you in detail. In men with good bladder emptying there is still a possibility of around on in twenty of some difficulty passing urine min the first few days : this may require a short period with a small soft catheter to rest the bladder but has no long term ill effects and does not require prolonged hospitalisation.

The major side effect is of dry orgasm, which is when the semen falls back into the bladder or is blocked in the prostate ducts instead of coming out through the penis. It occurs in about 30% - 60% of men after PVP (the risk depends on prostate size and technique.) Some men may feel the orgasm to be somewhat less intense if this happens, but usually learn to appreciate the sensations again. Retrograde ejaculation may cause sterility but cannot be relied upon as a form of contraception since some sperms may still be expelled.

Impotence has not been reported after this operation, although any operation on the prostate carries a theoretical risk. Several men in my series have noted a reduction in erectile strength, but the majority who have noticed a difference in this area have found their erectile capacity to be improved, presumably due to general quality of life benefits.

If urgency and getting up at night are major problems prior to the operation, or of there is any history of incontinence, I usually recommend a urodynamic examination to confirm that obstruction is present. Despite this about one man in six with these symptoms may find they persist post operatively, due we presume to a primary overactivity of the bladder. If this does happen there are medical treatments which will usually help.

Since not the entire prostate is removed, regrowth can occur. The figures suggest that one man in five will need revision surgery over a ten-year period due to prostate regrowth for the TURP operation this has replaced, and we expect similar figures for PVP.

Lastly, stress incontinence may rarely occur. The incidence is less than one per cent (at the time of writing one in nearly six hundred patients). Pelvic floor exercises, which I may recommend in the recovery period, may strengthen the muscles around the prostate and speed a return to full continence.

 How long does recovery take?

We have observed most patients to have a halving or more of their symptoms within six weeks of surgery. However, the bladder may be overactive for a few weeks after the operation, giving a sense of things getting worse before getting better. It is thus sensible to avoid any long journeys after the procedure for a few weeks. Bladder function can keep improving for up to four months after the procedure.

If urgency and getting up at night are major problems prior to the operation, or of there is any history of incontinence, I will usually have recommended a urodynamic examination to confirm that obstruction is present. Despite this about one man in six with these symptoms may find they persist post operatively, due we presume to a primary overactivity of the bladder. If this does happen there are medical treatments which will usually help.

Severe bleeding is uncommon after PVP, but  you will probably pass a little blood in the first few weeks, particularly at the start of the urine stream. If bleeding is a major problem then it is important to drink well and to have a urine sample checked to rule out urinary infection.

After any surgery you may feel tired and a bit emotional for a number of weeks. This is quite normal, but if you feel depressed it is important to let someone know.We have observed most patients to have a halving or more of their symptoms within six weeks of surgery. However, the bladder may be overactive for a few weeks after the operation, giving a sense of things getting worse before getting better. It is thus sensible to avoid any long journeys after the procedure for a few weeks. Bladder function can keep

It is sensible to avoid heavy lifting for three weeks after the operation since any sudden increase in abdominal pressure can cause bleeding to occur, but there is no need to stay off driving.

You can return to work when you feel fit and depending on your job: most men are able to retun to work within a few  days., but it may be necessary to avoid travelling if the bladder is overactive in the first week.

What follow up is required?

We will ask you to get in touch for a telephone check within the first few days, and if there are problems a review appointment will be made. Otherwise follow-up at three months with a measurement of the flow rate and bladder emptying, possibly with a blood test review, will be arranged. For larger prostates or for patients who have been in retention a final check at one year may be recommended.

Thereafter it will usually be possible for your family doctor to keep an eye on things although we may ask you to have some tests repeated (on a voluntary basis) to help with our research into this technique: if we did this there would be no extra cost to you.

 

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