Laparoscopic radical prostatectomy - includes continuing education post-test - Statistical Data Included

AORN Journal,  April, 2002  by Denise Bickert,  Deborah Frickel

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Prostate cancer is the most common type of cancer diagnosed in men, accounting for 11% of cancer deaths. It is the second leading cause of cancer death among men in the United States, after lung cancer. (1) Although there are a variety of treatment modalities available, surgical excision of the prostate gland remains the course of choice for many men with localized disease. Traditionally, a major open abdominal procedure (ie, radical prostatectomy) was the only option, and it required an extended hospital stay and recovery time. Patients often required blood transfusions and were at risk for both incisional infection and secondary infection from the long-term indwelling Foley catheter. Impotence and urinary incontinence were the two most common side effects of the surgery. (2) Surgical techniques have evolved (eg, nerve-sparing surgery in the 1980s), but the development of laparoscopic radical prostatectomy (LRP) has been one of the most significant changes in surgical treatment of this disease. As with any new procedure, training is required for surgeons and perioperative nursing staff members on an ongoing basis as modifications continue to be made. Clinical outcomes need to be monitored continuously, and, to date, the procedure demonstrates good results and higher patient satisfaction than traditional open surgery.

ANATOMY AND PHYSIOLOGY

The prostate gland, which is part of the male reproductive anatomy, is located below the bladder and surrounds the urethra (Figure 1). The front wall of the rectum lies just beneath the prostate. A normal gland is approximately 4 cm in diameter and weighs roughly 20 g, which is comparable to a small walnut. It is made up of fibromuscular tissue that contains alveoli and tubular ducts. (3)

[FIGURE 1 OMITTED]

The prostate is composed of right and left sides and lobes. Conical in shape, the tip farthest from the bladder is called the apex and the wider portion is the base. The base adheres to the bladder and the apex adheres to the fascia and muscle tissue forming the urogenital diaphragm. The prostate gland is enclosed in a prostatic capsule and surrounded by extraperitoneal connective tissue. Denonvilliers' fascia comprises two layers of endopelvic fascia, which separates the prostate from the rectum. (4) If the capsule has been penetrated by disease, there is a greater likelihood that the disease has or will spread. (5)

The gland is divided into three zones (ie, peripheral, central, transition). The largest is the peripheral zone, which makes up two-thirds of the prostate gland. The peripheral zone encompasses the anterior and posterior portions of the prostate, from apex to base. The central zone is the second largest zone. It is cone shaped and incorporates most of the base of the prostate. The transition zone, the smallest zone, is the location where benign prostate hypertrophy (BPH) occurs; therefore, it often is called the BPH zone. (6)

Neurovascular fibers or bundles are located on each side of the prostate. These fibers contain the blood and nerve supply critical to erectile function; therefore, maintaining their integrity during surgery, when possible, is important. (7) The dorsal venous complex is contained in the retroperitoneal connective tissue that covers the prostate. (8) The prostatic pedicles are groupings of connective tissue found on either side of the vas deferens and seminal vesicle. These pedicles help stabilize the prostate.

The bladder is located just above the prostate and posterior to the seminal vesicles, vas deferens, ureters, and rectum. (9) The urethra leads from the bladder through the prostate, past the urinary sphincter, and out the penis. The urinary sphincter is a group of circular muscle fibers located just below the prostate that prevent leakage of urine during physical activity and coughing. A loss of control of this sphincter leads to incontinence. (10)

There are two was deferens in the male anatomy located on the lateral sides of the prostate gland. The vas deferens are tubelike structures that allow sperm to travel from the testicle to the urethra. In the prostate gland, the vas deferens continue as the ejaculatory ducts, which empty sperm into the urethra. The testicles produce the male hormone testosterone and make sperm. (11) During ejaculation, the prostate uses rhythmic contractual movements to secrete prostatic fluid into the urethra. This fluid is an alkaline pH, milky, thin substance that helps protect the sperm as it travels in the acidic female reproductive tract. (12)

Enlargement of the prostate causes a narrowing of the urinary passageway. This narrowing makes it increasingly difficult for the male to maintain a constant flow of urine. Clinical symptoms include

* urinary frequency,

* hesitancy,

* slow urinary stream,

* retention,

* nocturia, and

* dysuria. (13)

PROSTATE CANCER

Adenocarcinoma of the prostate is the most common form of cancer in American males. The American Cancer Society estimated that approximately 198,000 men were newly diagnosed with prostate cancer in 2001. More than 31,000 men were likely to die from the disease in the same year. (14) During their lifetime, one in six men will be diagnosed with prostate cancer, but only one in 30 is likely to die of the disease. The incidence is higher in African American men than in Caucasian or Asian males. (15)