Prostatectomy can be defined as a surgical procedure that involves complete or partial removal of the prostate gland. The prostate is a small gland that forms the part of the male reproductive system and is situated at the base of the urinary bladder. The main function of this gland is to secrete an alkaline fluid that becomes the part of seminal fluid.
Prostatectomy is mainly indicated for treating the following conditions in men that occur at different ages:
- Benign prostatic hyperplasia (BPH): In simple terms, BPH is an enlarged prostate. It is a common, non-cancerous age-related problem of prostate seen in most men later in life. When enlarged, this gland irritates or blocks the urinary bladder causing the following symptoms:
- Slow, interrupted, or weak urine flow
- Increased frequency of urination
- the urgency with leaking or dribbling
- straining to urinate
- In severe cases, complete stoppage of urination.
- Prostate cancer: it is the second most common cancer seen in men beyond the age of 50. It is the third most common cause of death in men. In the case of cancer, there are different methods of performing prostatectomy that are:
- Radical prostatectomy (RP), with either a retropubic or perineal approach: this surgical procedure removes the prostate gland completely. Nerve-sparing surgical removal helps in preserving as much function as possible.
- Transurethral resection of the prostate, or TURP: this procedure removes a part of the prostate gland and is done using an endoscope which is passed through the penis. This procedure does not cure prostate cancer but helps in removing the obstruction until the doctor plans a definitive line of treatment.
- Laparoscopy: it is the surgical removal of the prostate with minimal invasion. It may be used in the following conditions:
- Prostatitis: Inflammation or infection of the prostate gland leads to prostatitis. It is characterized by symptoms of discomfort, pain (prostatalgia), frequent or infrequent urination, and sometimes fever.
- Inability to empty the bladder completely
- Recurrent bleeding from the prostate
- Stones in the urinary bladder with enlargement of the prostate
- Very slow urination
- Urinary retention causing increased back pressure on the ureters and kidneys
Patients must stop all blood thinners, non-steroidal anti-inflammatory drugs (NSAIDs), and platelet inhibitors 10 to 14 days before surgery. Diabetic patients should stop metformin 48 hours before surgery. Patients can take their blood pressure, cardiac, or anti-seizure medications in the morning on the day of surgery except for diuretics, which are not given to prevent fluid and electrolyte loss. A patient must undergo a preoperative evaluation and screening during which a general history is taken along with the physical examination. Routine blood work including complete blood count, chemistry and liver profile, coagulation studies, and an electrocardiogram is done. A day prior to surgery the patient is also given a laxative to clean the bowels and antibiotics to sterilize the colon.
Radical prostatectomy can be performed in following different ways depending on the patient’s requirement:
- Radical prostatectomy with the retropubic (suprapubic) approach: it is a commonly used surgical procedure wherein along with the prostate gland, the lymph nodes around it are also removed. If cancer has spread beyond lymph nodes, additional treatments are needed. This surgery can be done with a small hidden incision for an improved cosmetic effect. It also avoids injury to major muscle groups, making it less painful with a faster recovery.
- Nerve-sparing prostatectomy: often the cancer is tangled with the nerves which must be severed to remove the cancerous tissue. This results in loss of nerve function, and if nerves on both sides are removed, the patient might not be able to have an erection later. The loss of erection is permanent unless any correction surgeries are performed. However, if nerves of only one side are removed, the man may have a less erectile function, and chances of some function being preserved exist.
- Laparoscopic radical prostatectomy: for this surgery many small cuts are made and thin tools are introduced via these cuts. A laparoscope is inserted in one of these cuts which allow the surgeon to see the internal organs during surgery.
- Robotic-assisted laparoscopic prostatectomy is the laparoscopic surgery carried out using a robotic system. During this procedure, the surgeon moves the robotic arm with the help of commands fed to the computer beside the operating table.
- Radical prostatectomy with the perineal approach is used less frequently than the retropubic approach as the nerves can’t be spared easily and the lymph nodes cannot be removed with this surgical technique. This procedure takes lesser time and can be used if the nerve-sparing approach is not needed.
Once the procedure is done, the patient is transferred to the recovery room where he is closely monitored. Patient’s pulse, blood pressure, respiration rate, oxygen saturation, etc. are monitored regularly. Medicines to relieve pain are administered at regular intervals. Once the patient is awake and if his condition is stable, then he is given liquids to drink and then solid foods are gradually started. The drain is usually removed the next day. Slowly, the patient starts walking and as days go, one can walk around for longer periods of time. The urinary catheter remains even after discharge for one to three weeks.
Recovery from surgery usually takes 2 weeks but a complete return to regular activities takes up to 2 months. Avoid lifting heavy objects, or doing strenuous exercises for the first few weeks post-surgery. Light exercises like walking can be taken up once you feel up to it. Ensure you keep having adequate water to wash out any possible infection and clear residual blood in the urine. You can start doing some pelvic floor exercises to improve bladder control after 2-3 weeks. Pain can be taken care of by paracetamol, ibuprofen or any other painkillers that the doctor might have specifically suggested. Avoid sexual activities for up to a month post-surgery. Driving can be taken up a week after surgery.
Following are the complications caused due to this surgery:
- Urinary incontinence: This is uncontrollable, involuntary leaking of urine. This may improve as time passes, but may take even a year. If the surgery is performed after the age of 70, then this symptom may be worse.
- Urinary leakage or dribbling: This symptom is worse immediately after the surgery, but improves over time.
- Erectile dysfunction: Return of complete sexual function post-surgery can take up to two years and may not be complete. Depending on the type of surgery performed, sexual function may get affected.
- Sterility: during complete prostatectomy, the connection between the testicles and the urethra is severed due to which there is no ejaculate on orgasm.
- Lymphedema: Lymphedema occurs due to inflammation, obstruction, or removal of the lymph nodes during surgery causing accumulation of fluid in the legs or genital region over time.
- Penis length: Sometimes surgery may result in reduced penile length.
- Injury to the surrounding organs
Prognosis of prostatectomy depends a lot on the reason for which the surgery is done. It is seen that more than 80% of men who underwent radical prostatectomy for cancer are alive 10 years afterwards, and 60% are still alive at 15 years.
The surgical area should be kept clean and dry. The sutures are removed during a follow-up office visit, if not removed before discharge. Painkillers should be taken for a few days as the incision may be tender for several days post-surgery. Do not drive till the doctor permits and there might be other activity restrictions for a few weeks post-surgery too. Once the catheter is removed, there might be some leaking which improves over time. Contact the physician in case of fever, redness, swelling, or bleeding from the site of incision, severe pain around the site of incision, inability to pass stool or urine once the catheter is removed.