Prostatectomy

Overview

Prostatectomy includes a number of surgical procedures to remove part or all of the prostate gland. The prostate gland is situated in the male pelvis, below the urinary bladder. It surrounds the urethra, which carries urine from the bladder to the penis.

Prostatectomy can be performed in several ways, depending on the condition involved and recommended treatment approach:

Prostate cancer

Radical prostatectomy is surgery to remove the entire prostate gland and surrounding lymph nodes as treatment for men with localized prostate cancer. A surgeon can perform a radical prostatectomy using different techniques, including:

• Robot-assisted radical prostatectomy. The surgeon makes several small incisions in your lower abdomen to remove the prostate. He or she sits at a console, using instruments attached to a computer-assisted mechanical device (robot). The robotic device allows a more precise response to movement of the surgeon's hands.
• Open radical prostatectomy. The surgeon typically makes an incision in your lower abdomen to remove the prostate (retropubic surgery).
• Laparoscopic radical prostatectomy. The surgeon makes several small incisions in your lower abdomen and inserts special tools to remove the prostate.

Enlarged prostate

Simple prostatectomy, on the other hand, is generally recommended for men with severe urinary symptoms and very enlarged prostate glands (rather than prostate cancer), and can be performed open or robotically. This enlargement of the prostate is called benign prostatic hyperplasia, or BPH. Simple prostatectomy doesn't remove the entire prostate, as in a radical prostatectomy, but instead removes just the obstructive part of the prostate that's blocking the flow of urine.

Why it's done

Most often, prostatectomy is done to treat localized prostate cancer. It may be used alone, or in conjunction with radiation, chemotherapy and hormone therapy. Prostatectomy to treat prostate cancer involves removing the entire prostate, seminal vesicles and some surrounding tissue, including lymph nodes.

Prostatectomy options to treat prostate cancer include open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy.

Less often, simple prostatectomy may also be used to treat a blocked urethra caused by BPH. Simple prostatectomy to treat BPH doesn't always involve removing the entire prostate. The surgery eases urinary symptoms and complications resulting from blocked urine flow, including:

• A frequent, urgent need to urinate
• Difficulty starting urination
• Slow (prolonged) urination
• Increased urination frequency at night (nocturia)
• Stopping and starting again while urinating
• The feeling you can't completely empty your bladder
• Urinary tract infections
• Inability to urinate

Simple prostatectomy carries a higher risk of complications and typically results in a longer recovery time than other procedures to treat BPH.

Your surgical team will discuss the advantages and disadvantages of each technique, as well as your preferences, to determine which approach is best for you.

Risks

Radical prostatectomy risks

In addition to the risks associated with any surgery, risks with radical prostatectomy include:

• Bleeding
• Urinary tract infection
• Urinary incontinence
• Erectile dysfunction (impotence)
• Injury to the rectum (rare)
• Narrowing (stricture) of the urethra or bladder neck
• Formation of cysts containing lymph (lymphocele)

Simple prostatectomy risks

Although simple prostatectomy works well at relieving urinary symptoms, it has a higher risk of complications and a longer recovery time than other enlarged prostate procedures such as transurethral resection of the prostate (TURP), laser PVP surgery or holmium laser prostate surgery (HoLEP).

Risks of open simple prostatectomy include:

• Bleeding
• Injury to adjacent structures
• Urinary incontinence
• Dry orgasm
• Erectile dysfunction (impotence)
• Narrowing (stricture) of the urethra or bladder neck

How you prepare

Before surgery, your doctor may want to do a test that uses a visual scope to look inside your urethra and bladder (cystoscopy). Cystoscopy lets your doctor check the size of your prostate and examine your urinary system. Your doctor may also want to perform other tests, such as blood tests or tests to specifically measure your prostate and to measure urine flow.

Follow your doctor's instructions on what to do before your treatment. Here are some issues to discuss with your doctor:

Food and medications

Your medications. Tell your doctor about any prescription or over-the-counter medications or supplements you take. This is especially important if you take blood-thinning medications, such as warfarin (Coumadin) or clopidogrel (Plavix), and nonprescription pain relievers, such as aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others). Your surgeon may ask you to stop taking medications that increase your risk of bleeding several days before the surgery.

Medication allergies or reactions. Also talk to your care team about any allergies or reactions you have had to medications.

Fasting before surgery. Your doctor will likely ask that you not eat or drink anything after midnight. On the morning of your procedure, take only the medications your doctor tells you to with a small sip of water.

Bowel prep before surgery. Your surgeon may ask you to do an enema prior to surgery. You may be given a kit and instructions for giving yourself an enema to clear your bowels the morning of surgery.

Clothing and personal items

Your treatment team may recommend that you bring several items to the hospital including:

• A list of your medications
• Eyeglasses, hearing aids or dentures
• Personal care items, such as a brush, comb, shaving equipment and toothbrush
• Loosefitting, comfortable clothing
• A copy of your advance directive
• Items that may help you relax, such as portable music players or books

Plan ahead to avoid wearing these items into surgery:

• Jewelry
• Eyeglasses
• Contact lenses
• Dentures

Arrangements after surgery. Ask your doctor how long to expect you'll be in the hospital. You'll want to arrange in advance for a ride home, because you won't be able to drive immediately following surgery.

Activity restrictions. You may not be able to work or do strenuous activity for several weeks after surgery. Ask your doctor how much recovery time you may need.

What you can expect

Before the procedure

Before surgery, your doctor will give you a general anesthetic, which means you'll be unconscious during the procedure. Or you may receive a spinal anesthetic, which means you'll be conscious during surgery but won't feel any pain, although spinal anesthetic is rarely used anymore. In some instances, intrathecal injections are also provided in addition to general anesthetic.

Your doctor may also give you an antibiotic right before surgery to help prevent infection.

During the procedure

Robot-assisted radical prostatectomy. Your surgeon sits at a remote control console a short distance from you and the operating table and precisely controls the motion of the surgical instruments using two hand-and-finger control devices. The console displays a magnified, 3-D view of the surgical area that enables the surgeon to visualize the procedure in much greater detail than in traditional laparoscopic surgery. The robotic system allows smaller and more-precise incisions, which for some men promotes faster recovery than traditional open surgery does. Just as with open retropubic surgery, the robotic approach enables nerve-sparing techniques that may preserve both sexual potency and continence in the appropriately selected person.

You usually can return to normal activity, with minor restrictions, two to four weeks after surgery.

Standard retropubic radical prostatectomy. Your surgeon makes an incision in your lower abdomen, from below your navel to just above your pubic bone. After carefully dissecting the prostate gland from surrounding nerves and blood vessels, the surgeon removes the prostate along with nearby tissue. The incision is then closed with sutures. Compared with other types of prostate surgery, retropubic prostate surgery may carry a lower risk of nerve damage, which can lead to problems with bladder control and erections.

Simple prostatectomy. Once the anesthetic is working, your doctor may perform a cystoscopy. A long, flexible viewing scope (cystoscope) is inserted through the tip of your penis to see inside the urethra, bladder and prostate area.

Your doctor will then insert a tube (Foley catheter) into the tip of your penis that extends into your bladder. The tube drains urine during the procedure. Your doctor will make a cut (incision) below your navel. Depending on what technique your doctor uses, he or she may need to make an incision through the bladder to reach the prostate.

If you also have a hernia or bladder problem, your doctor may use the surgery as an opportunity to repair it.

Once your doctor has removed the part of your prostate causing symptoms, one to two temporary drain tubes may be inserted through punctures in your skin near the surgery site. One tube goes directly into your bladder (suprapubic tube), and the other tube goes into the area where the prostate was removed (pelvic drain).

After the procedure

After surgery you should expect that:

• You'll be given intravenous (IV) pain medications. Your doctor may give you prescription pain pills to take after the IV is removed.
• Your doctor will have you walk the day of or the day after surgery. You'll also do exercises to move your feet while you're in bed.
• You'll likely go home the day after surgery. When your doctor thinks it's safe for you to go home, the pelvic drain is taken out. You may need to return to the doctor in one or two weeks to have staples taken out.
• You'll return home with a catheter in place. Most men need a urinary catheter for five to 10 days after surgery.

Make sure you understand the post-surgery steps you need to take, and any restrictions.

• You'll need to resume your activity level gradually. You should be back to your normal routine in about four to six weeks.
• You won't be able to drive for at least a few days after going home. Don't drive until your catheter is removed, you are no longer taking prescription pain medications and your doctor says it's OK.
• You'll need to see your doctor a few times to make sure everything is OK. Most men see their doctors after about six weeks and then again after a few months. If you have problems, you may need to see your doctor sooner or more often, although it's unlikely.
• You'll probably be able to resume sexual activity after recuperating from surgery. After simple prostatectomy, you can still have an orgasm during sex, but you'll ejaculate very little or no semen.

Results

Robot-assisted prostatectomy can result in reduced pain and blood loss, reduced tissue trauma, a shorter hospital stay, and a quicker recovery period than a traditional prostatectomy. You usually can return to normal activity, with minor restrictions, two to four weeks after surgery.

Open simple prostatectomy provides long-term relief of urinary symptoms due to an enlarged prostate. Although it's the most invasive procedure to treat an enlarged prostate, serious complications are rare. Most men who have the procedure generally don't need any follow-up treatment for their BPH.