Prostatectomy

Overview

A prostatectomy involves the surgical removal of either the entire or a portion of the prostate by a surgeon. The prostate is a small gland within the male reproductive system, encompassing the urethra—the tube for the passage of semen and urine from the body. The prostate adds additional fluid to the ejaculate. During ejaculation, the fluid (semen) produced by the prostate travels into the urethra, and the surrounding muscles contract to expel semen from the urethra upon orgasm.

Types of prostatectomy

There are two main categories of prostatectomy.

Simple prostatectomy

The prostate gland consists of two components: an inner portion that enlarges with age and an outer part that forms a capsule, resembling the pulp and peel of an orange, respectively.

In a simple prostatectomy, a surgeon makes a vertical incision in the lower abdomen. Through this incision, they extract the inner part of the prostate while leaving the outer portion untouched, akin to the way one might consume the pulp of an orange while preserving the peel.

Alternatively, the procedure can be done laparoscopically, which is a less invasive approach than traditional open surgery. The surgeon makes two to four small incisions (each half an inch or less) in the abdomen. A slender rod with a camera at the end (laparoscope) is inserted into one incision to provide visual access inside the body. Surgical tools are then introduced through the other incisions to remove the inner portion of the prostate.

Radical prostatectomy

In a radical prostatectomy, the entire prostate gland is removed by a surgeon, typically along with surrounding fat and tissues, including seminal vesicles (which contribute to ejaculate) and lymph nodes. The procedure involves reattaching the urethra to the bladder using stitches and cutting the vas deferens, the tube transporting semen from the testicles to the urethra.

Radical prostatectomy can be performed as open surgery or laparoscopically. In an open radical prostatectomy, a vertical incision is made between the belly button and pubic bone to access and remove the prostate. In a laparoscopic radical prostatectomy, several small incisions are made for the insertion of a laparoscope and surgical tools, providing a less invasive alternative.

For some individuals, a robotic laparoscopic radical prostatectomy may be an option, where a surgeon controls a robot’s arms to navigate intricate areas inside the body. This method is less invasive than open surgery and allows for more precise movements.

A single port radical prostatectomy, a newer technique, involves robot-assisted surgery with instruments entering through a single small incision in the lower abdomen. It is less invasive, promotes faster recovery, and results in minimal scarring compared to traditional laparoscopic and robotic radical prostatectomy, though its availability may be limited in certain hospitals due to its novelty.

Reasons for undergoing the procedure

Doctors typically suggest a radical prostatectomy as a primary treatment for prostate cancer limited to the prostate in men and individuals Assigned Male at Birth (AMAB).

Alternatively, if there is a condition causing urethral blockage and impacting urination, such as Benign Prostatic Hyperplasia (BPH), a doctor may recommend a simple prostatectomy.

Risks

Every surgical intervention carries inherent risks. Some potential risks associated with a prostatectomy encompass:

• Blood clots
• Infection
• Problem with healing
• Anesthesia side effects
• Potential requirement for a blood transfusion
• Accumulation of fluid at the surgical site, known as seroma

Additional potential risks associated with a prostatectomy comprise:

• Erectile dysfunction
• Incontinence
• Minimal or absent ejaculation following orgasm (dry orgasm)
• Reduction in penile size (attributed to diminished erectile function)
• Depression

Before the procedure

Prior to a prostatectomy, you will have a consultation with a doctor who will discuss the most suitable type of prostatectomy procedure for your situation, which may involve a simple or radical approach.

During this meeting, the doctor will assess your overall health, taking your vital signs such as temperature, pulse, and blood pressure. It is crucial to inform them about all medications you are currently taking, including prescription, Over-The-Counter (OTC), and herbal supplements. Certain medications like aspirin, anti-inflammatory drugs, specific herbal supplements, and blood thinners can elevate the risk of bleeding, and you may need to temporarily discontinue them before the surgery. Always consult with your doctor before discontinuing any medications.

Provide comprehensive information about any allergies you have, including medications, skin cleansers (like iodine or isopropyl alcohol), latex, and foods.

The doctor will also provide specific guidelines regarding dietary restrictions before the prostatectomy. Typically, you should refrain from eating or drinking anything after midnight on the night before the surgery. If there are essential medications, they can be taken with a small sip of water, following the guidance provided by your doctor.

During the procedure

A group of healthcare professionals will carry out a prostatectomy. This team usually comprises a urologist, an anesthesiologist, and nurses.

The anesthesiologist will administer general anesthesia to induce sedation, rendering you unconscious and pain-free throughout the procedure. Once you are under anesthesia, a doctor will insert a urinary catheter—a small, flexible tube that facilitates the drainage of urine from your bladder into a collection bag.

The specific steps of the procedure differ based on whether you undergo an open prostatectomy or a robotic prostatectomy.

Open prostatectomy

In the course of an open prostatectomy, the urologist will employ a sharp, sterile knife (scalpel) to meticulously create a vertical incision, typically positioned between your belly button and pubic bone (suprapubic). In certain instances, an alternative location, such as the skin between the anus and scrotum (perineum), might be chosen by the urologist, although this approach is less common.

The incision size typically ranges from 6 to 12 inches, providing the urologist with a clear view of the prostate and the surrounding tissues. Closure of the incision is achieved using stitches (sutures) or small metal staples. Additionally, a small silicone tube (surgical drain) may be affixed to eliminate blood or fluid from within your body. These drains are usually in place for a few days immediately post-surgery before a doctor removes them. The removal of a surgical drain is typically painless and does not necessitate additional pain medications or anesthesia.

Robotic prostatectomy

In the course of a robotic prostatectomy, the urologist utilizes a scalpel to create either a single small incision (single port prostatectomy) or multiple tiny incisions (multi-port prostatectomy), with each incision being no larger than approximately 3/4 of an inch. Through these small openings, the urologist introduces a laparoscope and robotic surgical equipment.

Subsequently, the urologist extracts the prostate gland and seminal vesicles from the surrounding tissues. They proceed to reconnect your urethra to your bladder using small sutures. Additionally, the urologist may conduct the removal of lymph nodes and examine them for signs of cancer.

Upon completion of the procedure, a doctor employs stitches and/or staples to close the incisions, with sutures being the method of choice for robotic surgery. Furthermore, a surgical drain may be secured at one of the incision sites.

Typically, a prostatectomy requires approximately two to four hours for completion.

After the procedure

Following a prostatectomy, your incision sites will be covered with bandages or skin glue.

The administration of anesthesia will be discontinued by the anesthesiologist, and you will gradually regain consciousness within a few minutes, though you may still feel groggy.

Transitioning to a recovery room, doctors will monitor your awakening and overall health. Once awake, pain management will be addressed. While a robotic prostatectomy is generally less painful than an open procedure, you will still require pain medication and management strategies during the recovery period. Short-term nausea is a common side effect of anesthesia after surgery, and if experienced, doctors will provide medication to alleviate it.

A liquid diet will be recommended for one to two days post-surgery to aid in recovery, with a gradual reintroduction to solid foods as healing progresses.

On the day after surgery, providers will encourage you to get out of bed and walk. This promotes healing, enhances blood flow, and restores function to affected areas while also preventing complications such as blood clots and pneumonia.

A urinary catheter is typically used after a prostatectomy. The duration depends on the type of surgery and your surgeon’s assessment of your bladder healing time—ranging from two to three days for a simple prostatectomy to as long as 10 to 14 days for a radical prostatectomy.

Once deemed healthy and no longer in need of monitoring, you will be discharged. The timing varies, with some individuals going home on the same day, while others may stay in the hospital for one to two days. A companion is necessary to drive you home, and having assistance for a few days post-procedure is advisable. Fatigue may persist for several weeks, and refraining from heavy lifting or strenuous exercise is crucial for proper incision site healing.

Before your discharge, the doctor will prescribe medications, which may include pain relievers, stool softeners, antibiotics, and blood-thinning medications.

A standard hospital stay after a robotic prostatectomy ranges from one to two days, with the possibility of some individuals being discharged on the same day as the procedure. In contrast, the usual hospital stay for an open prostatectomy is three to four days.

Outcome

Temporary urinary incontinence is common for many individuals following a prostatectomy, with higher rates observed after a radical prostatectomy compared to a simple prostatectomy. Various types of incontinence may manifest, including:

• Urge incontinence: This involves a sudden, uncontrollable urge to urinate.
• Stress incontinence: This refers to involuntary urination during physical activities like exercising, coughing, or sneezing.
• Orgasmic incontinence (climacturia): This occurs when urine leaks during sexual arousal, and there may also be the release of urine during orgasm.

After the removal of their catheter, numerous individuals regain excellent control of their urine stream, although some may experience varying degrees of leakage for several weeks. Generally, good urinary control is achieved by most individuals within six to 12 weeks post-procedure.

For those who have undergone a prostatectomy, resuming sexual activity is often possible once they have fully healed, a process that typically takes four to six weeks.

Erection after the procedure

Erectile difficulties are less prevalent following a simple prostatectomy for Benign Prostatic Hyperplasia (BPH), but nearly all individuals encounter erectile dysfunction after undergoing a radical prostatectomy for prostate cancer. The underlying cause of this dysfunction lies in the procedure’s impact on the nerves responsible for erections, which are in close proximity to the prostate gland. In some cases, doctors may need to remove part or all of a nerve as a part of prostate cancer treatment.

Even if a doctor manages to preserve all nerves, most individuals may not experience erections for several months post-prostatectomy. Improvement in erection function is expected to occur gradually around six months after the surgery. However, achieving the same level of erection hardness and sexual function as before may take up to two years.

Despite potential difficulties in obtaining erections post-surgery, individuals can still experience orgasm and maintain normal sensation. It’s noteworthy that there might be little to no ejaculate present. Commencing sexual activity after regaining control of the urine stream is crucial to ensure continued blood flow to the penis, helping prevent the development of fibrosis—thick scar tissue that may complicate the attainment of firmer erections.

Following an open prostatectomy, most individuals can typically return to regular activities approximately eight weeks post-surgery. Recovery tends to be swifter after a robotic prostatectomy, with many people resuming normal activities within four to six weeks.

Nevertheless, the pace of your recovery is contingent on factors such as the specific type of prostatectomy, your health history, and any concurrent conditions. Your doctor is the most qualified individual to provide personalized guidance on your recovery timeline.

The duration of your return to work post-prostatectomy is influenced, in part, by the nature of your job. For jobs with less physical demand, resuming work is typically feasible within two to three weeks. Conversely, individuals engaged in more physically demanding occupations might require a longer recuperation period, ranging from four to six weeks before returning to work.