Why is it done?

• For those large benign prostates where a TURP would be too time consuming, and too dangerous.
• Generally, prostates over 200cc
• Not commonly performed in Australia
• This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
• Step-up therapy could have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar and can be used as a first line in these huge prostates as long as the sexual side effects have been discussed.
• Prostate cancer would have been excluded by doing a PSA, and when indicated, with a 3T MRI scan.
• An alternative: A 2 staged-TURP can also be performed to dis-obstruct a huge prostate. Either Bipolar resection or Laser can be utilized
• It provides a quicker solution with more marked side-effects and risks

How is it done?

• Patients will receive a general anesthesia,
• Prophylactic anti-biotic is given.
• An indwelling catheter is placed.
• A lower midline incision is made (or alternatively a horizontal Pfannenstiel-incision), The retropubic space of Retzuis is entered
• A Millen-procedure is done where the prostate capsule and lower part of the bladder is incised in the longitudinal aspect
• The bladder neck mucosa is cut and freed from the prostate away from the ureters as to prevent injury.
• With blunt dissection the apex of the prostate is freed from with the urethra and each lobe is delivered separately.
• Copious bleeding is possible in this phase, and this is where a cell-saver usage is critical to prevent blood transfusions with donor blood.
• Hemostatic sutures are placed over bilateral prostatic vascular pedicles to stop the bleeding.
• Sutures are placed to assist in reducing the cavity left after enucleation
• The bladder neck is pulled down into the cavity to assist with hemostasis.
• Prostate capsule and bladder are closed in 2 layers over a 3-way irrigation catheter
• A drain is left for a couple of days
• You may have continuous Antibiotics over the next few days.

Complications

• Blood loss 400-1200cc, usually less
• Wound infections
• The first 6 weeks are the worst with frequency and urgency as a result
• Stress incontinence may occur and will improve over the next 12 months (12%)
• Complete incontinence at 12 months (2%)
• Erectile dysfunction (bladder neck stenosis 5 % requiring intermittent self-dilatation
• Retrograde ejaculation with Infertility
• Testicular pain similar to vasectomy for up to a week
• Possibility of bowel injury

Post-operative review:

• Review PSA roughly 6 weeks after the surgery to assess post-operative Nadir
• Review in rooms a week later.
• 6 monthly review depending on risk factors.
• If stable with good PSA outcomes, refer back to GP for 6 monthly PSA review

Wes Simple Prostatectomy BPH

Endoscopic vaporization of a benign enlarged prostate, using laser. This allows patients on anti-coagulation therapy to continue their medication with minimal risk of hemorrhage. It also allows a shorter stay in hospital.

Indications:  

• Patients on anticoagulation or anti-platelet therapy
• Smaller prostate
• Where conservative management has failed.
• Patient choice
• This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
• Symptoms include:
  • a weak stream,
  • nightly urination frequency,
  • frequent urination,
  • inability to urinate,
  • kidney failure due to the weak urination (obstruction),
  • bladder stones,
  • recurrent bladder infections.
• Medication such as Flomaxtra, Urorec, Minipress etc. should always be given as a first resort.
• Step-up therapy should have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar
• Prostate cancer first needs to be ruled out by doing a PSA, and when indicated, with a 3T MRI scan of the prostate with an abnormal PSA with a possible prostate biopsy of any suspicious lesions.
• A TUVP can also be performed to dis-obstruct a severe prostate cancer, to allow a normal urination process

How is it done?

• You will receive a general anaesthesia, unless contra-indicated.
• A cystoscopy is performed by placing a camera in the urethra with the help of lignocaine gel
• The inside of the bladder is viewed for pathology. If any suspicious lesions are seen, a biopsy will be taken.
• A vaporization of the prostate is then started and should take 60-120 minutes depending on the size of the prostate.
• Prophylactic antibiotics will be given to prevent any infections.
• Post– operative antibiotics will be continued for 10 days.

No specimen will be obtained due to vaporization, unless PSA was suspicious and an MRI with view to prostate biopsy has excluded a prostate cancer

What can go wrong?

• Any anesthesia has its risks, and the anesthetist will explain this to you.
• No blood loss is expected.
• You will wake up with a catheter in your urethra and bladder. This will remain in the bladder overnight.
• Lower abdominal discomfort for a few days
• NB! Each person is unique and for this reason symptoms vary!

What next?

• You will spend 1 –2 nights in hospital.
• You will a trial without catheter the next day
• You will be discharged as soon as you can completely empty your bladder.
• You may initially suffer from urge incontinence and dysuria (irritable voiding) and will improve within the next 6 weeks.
• Allow for 6 weeks for stabilization of symptoms.
• There may be some blood in your urine. You can remedy this by drinking plenty of fluids until it clears.
• A ward prescription will be issued on your discharge, for your own collection at any pharmacy
• A follow-up appointment will be scheduled for 6 weeks. Remember there is no pathology due to vaporization.
• Don’t hesitate to ask Jo if you have any queries

DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE

Side–effects

• Retrograde ejaculation in more than 90% of patients. Therefore, if you have not completed your family, this procedure is not for you unless absolutely necessary.
• Infertility as a result of the retrograde ejaculation.
• Stress incontinence initially for the first 6 weeks, especially in the elderly and the diabetic patients
• Patients with Multiple Sclerosis, Strokes and Parkinsons have a higher risk of incontinence and risks should be discussed and accepted prior to surgery.
• Urethral stricturing in 2-3% of patients, requiring intermittent self-dilatation.
• Regrowth of prostate lobes within 3-5 years requiring a second procedure.
• NB! Each person is unique and for this reason symptoms vary!

Wes TURIS

This is a radiation therapy option for the management of a localized prostate cancer.

Criteria include:

• PSA less than 10
• Gleason 3,4 adenocarcinoma prostate,
• Higher grades may have extra-prostatic extension requiring combined External Beam Radiation
• Staging negative, (bone scan negative, CT negative)
• Not younger than 65

• It is the localized radiation of the prostate, by means of trans-perineal placement of Radio-active I-125 seeds.
• This is a nerve sparing procedure and patients have a good opportunity to maintain this.
• The procedure takes 2-3hours excluding the anesthetic time.
• This is an alternative to a Radical Retropubic Prostatectomy for low-intermediate risk prostate cancer. Prostates are generally smaller than 50cc.
• Could be ideal for those patients with excessive BMI and fitting the cancer specific criteria.

How is it done?

• Under a General Anaesthetic
• Presence of Radiation Oncologist and Physicist
• Lithotomy position
• Trans-rectal placement of an ultrasound probe
• Real-time accumulation of digital images to allow real-time placement of Radioactive Iodine seeds according to an intra-operative plan

PSA failure:

• PSA not dropping to a nadir value, preferably 0,2ng/ml.
• 3 consecutive PSA rises following RRP.

Complications

• Perineal hematoma
• Wound infections
• Urgency frequency and weak stream
• Limited Erectile Dysfunction, which may only surface after 18 months after treatment.
• Lower ejaculate volume.
• Testicular pain similar to vasectomy for 2-3 days

Post operative care:

• A post-procedure CT scan to account all the seeds and exclude migration of seeds.
• Normal diet
• A salt water or Betadine Douche is required after every stool for the first week
• A 3-month course of Flomaxtra to ease Lower Urinary Tract Symptoms
• Wounds generally heal in 7-10 days

Catheter care

• Your catheter will remain until you are awake.
• Post-operative review:
• Radio-Oncology will review a few weeks later.
• You will review with me at 6 weeks post-procedure to check if you are doing fine.
• Review PSA roughly 3 months after the procedure to assess PSA track
• You should reach your Nadir (lowest PSA) at 6– 9 months after the procedure. The lower the better.
• 6 monthly PSAs thereafter.
• Expect a PSA Bump at approximately 9-12 months after the procedure, The PSA should drop thereafter
• If stable with good PSA outcomes, refer back to GP for 6 monthly PSA review

Download Information Sheet

Wes Low Dose Brachytherapy

Not covered by Medicare / Health Fund yet, possibly early 2026

What is IRE

• Irreversible Electroporation Therapy—breaking up of cell membranes using electric current by means of creating holes in the cell walls (Nano-pores)
• Non-thermal ablation

Why is it done?

• Treatment for localized prostate cancer
• Single focus disease
• Prostate preserving
• Ejaculate sparing
• Continence preserving

How is it done?

• Focal therapy of prostate cancer, usually a single lesion
• Preferably Gleason 3,4 or more aggressive
• Preserving prostate supporting tissue and erectile function and continence

You would have had a 3T MRI study possibly a PET PSMA as well prior to confirming your prostate cancer. Usually, whole gland biopsies are taken of the prostate via the perineum to prove unifocal cancer.

• This procedure is done under general anesthesia as a day procedure and takes approximately 60-90min (incl anesthetic time)
• It is performed with the patient lying in lithotomy (legs in stirrups) position
• Prophylactic antibiotics are essential and a script with details is provided on the day of signing consent.
• A trans-rectal ultrasound is placed
• 4-5 NanoKnife electrodes are paced approximately 2cm apart surrounding the focal cancer.
• An electrical current of 3A is run at 800-1331mcs pulse causing a non-thermal ablative technique
• Total treatment as soon as electrodes are placed is < 5 minutes

Complications

Side–effects

• Hematuria (blood in urine) 2-3days
• Hematospermia (blood in ejaculate) will become less the more often you ejaculate.
• Bacteremia (infection) with low-grade fever and feeling unwell
• Perineal hematoma
• Perineal pain and penis tip pain
• Prostate swelling causing bladder outlet obstruction requiring a catheter for up to 5 days

ANY FEVER REQUIRES URGENT ATTENTION

What next?

• You will be discharged with an indwelling catheter for 3-5 days depending on the size of your prostate and the lesion treated
• You may have necrotic tissue developing requiring a resection (treatment involving the urethra).
• Difficulty in urination up to 6 weeks after the procedure
• It could feel like you are sitting on a golf ball for a week

Should there be any signs of fever or cold shivers, you are to return to the hospital or Emergency Department without hesitation

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Wes Nanoknife

Copyright 2019 Dr Jo Schoeman