Prostatectomy
Prostatectomy is complete removal of the prostate and seminal vesicles, whilst trying to preserving the structures that maintain continence and potency.
The procedure can be performed in a traditional open manner or with small robotic instruments through tiny ‘keyhole’ incisions in your lower abdomen.
Erectile dysfunction, some leaking of urine and shortening of the penis may occur.
What and where is my prostate?
Your prostate is a golf ball-sized gland that is situated at the base of your bladder surrounding the urethra tube. Its main function is to add liquid to your ejaculate (semen).
What is a Radical Prostatectomy?
Prostatectomy is surgical removal of the prostate gland, seminal vesicles and in some cases removal of some pelvic lymph nodes. ‘Radical’ means that the whole of your prostate, rather than just a part of it, is removed.
The goal is complete removal of all prostate cancer, preservation of continence, and, if safe to do so, preservation of the erection nerves to your penis. Prostatectomy is an effective curative therapy for many men with prostate cancer including some men with higher risk disease. Most men treated for early prostate cancer will remain alive and healthy for many years to come.
The main advantages of surgery are that the cancer can be removed entirely and a more complete knowledge of prognosis is gained from examination of the removed prostate and lymph nodes and early achievement of an undetectable PSA level (by three months). There is avoidance of side effects from pelvic radiation and androgen deprivation therapy (which is often a component of radiotherapy).
The operation is very safe, however, as with any operation there are small risks of general complications such as bleeding and infection. More serious complications such as blood clots and rectal injury are very rare. You may experience some loss of urinary control which tends to settle within 3-6 months after the surgery but may require you to wear pads. A few men have long term complications with incontinence (less than 5 in 100) which may require other treatments.
Sometimes, after the procedure, it is found on examination of the prostate by the pathologist that the cancer has grown beyond the outer coat of the prostate gland or is at the margin (surface) of the prostate. If this is the case then further additional treatment such as radiotherapy can benefit some men. This will also depend on your PSA level. In the majority of men, the PSA will be close to zero at all times and no further treatment is required.
Alternatives to Surgery
o Active monitoring (watchful waiting) – no active treatment but careful monitoring of your PSA levels, repeated biopsies and further intervention if cancer progresses. This is suitable for some slow growing, small cancers.
o External beam radiotherapy – an intensive 4-7-week course of radiation to your prostate gland. Usually in combination with at least six months of hormonal therapy to suppress your natural testosterone.
o Brachytherapy – implanting permanent radioactive seeds or temporary radioactive rods into your prostate. Seed brachytherapy has been popular in the past however is most appropriate for small slow growing cancers and many of these types of cancers are actively monitored nowadays.
o Hormonal therapy – Drugs given to suppress your natural testosterone level thus slowing, but not eliminating cancer growth.
Surgical Techniques
There are several ways of performing a prostatectomy. These include Open Prostatectomy and Robotic-Assisted Laparoscopic Prostatectomy (RALP).
Both operations involve removal of the entire prostate gland then joining the bladder to the water pipe (urethra) which runs along the penis so that you can pass urine normally. The surgery typically takes two to four hours. A tube (catheter) is left in place for 7-14 days to allow the join to heal.
The open procedure is performed via a single 12cm incision over the bladder.
RALP is keyhole surgery (the DaVinci system) to remove the prostate gland using robotically assisted techniques.
Rod Studd performs both procedures regularly and for most patients either approach will be suitable. You will have a discussion of the pros and cons of each procedure with him. There are certain factors such as previous abdominal surgery, prostate and tumour size which may make the open or the laparoscopic procedure preferable. Compared to open surgery, robotic surgery is more likely to result in less blood loss, less pain after the operation, a shorter hospital stay and smaller scars.
Preparing for Surgery
Rod will discuss optimising your health before the surgery. You will receive the information package from our clinic regarding what to do and what to expect.
For some men who are carrying extra kilos, losing weight ahead of the surgery will be recommended. The prostate gland is located deep within the pelvis so excess abdominal fat can impair access to and visibility in this area. Weight loss in the weeks ahead of surgery can be achieved with the help of Optifast meal replacement. The result and weight loss not only improves surgical visibility but also lead to a faster recovery following surgery.
Blood thinners such as aspirin, clopidogrel, ticagrelor, warfarin, rivaroxaban, and dabigatran will need to be ceased prior to surgery. We will advise you when to stop and re-start these medications. You will have a routine pre-operative blood test and urine sample at your local laboratory. If you are over the age of 65 or have any health issues you will also need an ECG (heart tracing).
The operation is carried out at Wakefield Hospital. You will be admitted on the day of surgery. If you live outside of Wellington then you may prefer to stay in the hospital apartments the night before surgery (currently not available).
The pre-assessment nurse will give you a call about 1 week before the surgery, as a pre-op preparation.
The anaesthetist will speak with you on the telephone the day before and then again immediately prior to surgery. You are encouraged to ask them questions about any concerns you have about the anaesthetic.
Our practice nurse will see you remove the catheter within 1-2 weeks’ time and 8 weeks’ time again as a follow-up.
What happens during my operation?
A general anaesthetic will be used – you will be asleep throughout the procedure. During surgery, you will be given antibiotics by injection.
Robotic-Assisted Laparoscopic Prostatectomy (RALP)
Robotic surgery is performed via keyhole incisions and uses sophisticated mini-instruments which are under the control of the surgeon. The robot mimics and assists the surgeon’s movements; it does not do the operation. The technique is now widely used because of its high degree of surgical accuracy, and because your recovery is faster than it is for open surgery.
Six small incisions are made into the abdomen through which the robotic instruments are inserted. The robot is placed beside you in the operating theatre. The robot has four arms - three for instruments and one for a high magnification 3-D camera to allow the surgeon to see inside your abdomen. The robotic instruments are small – approximately 7mm in width. The surgeon sits in the same rooms but away from the patient and with the robotic technology is able to carry out more controlled and precise movements in a small space within the body.
The muscle fibres and nerves that control continence are preserved.
The erection nerves lie very close to the prostate, forming a cobweb of delicate strands over the surface. If your erections were normal before the procedure, it is normally possible to preserve them (nerve-sparing prostatectomy). It can be very successful in maintaining erections after the procedure although they may take some time to recover. The nerves can only be preserved if cancer has not reached the layer where they lie.
The skin is closed with absorbable sutures which are located under the skin and are not visible and the outside is sealed with skin glue.
Blood loss is usually less than 200mL and the risk of a blood transfusion is <2%.
Rarely, the surgeon may convert from a robotic procedure to an open procedure. This would happen if there was difficulty such as excessive bleeding or difficult dissection during the surgery and the surgeon felt that continuing the operation as an open procedure would be safer for you.
Open Prostatectomy
Open surgery is performed via a 12cm incision located in the lower abdomen over your bladder. Instead of using robotic assistance, the surgery is performed directly with instruments held by the surgeon. Magnification is employed during the surgery and precise preservation of the important structures involved in incontinence and potency can still be achieved. The skin is closed with absorbable sutures which are located under the skin and are not visible and the outside is sealed with skin glue. Two thin rectus sheath catheters are left in the wound for regular administration of a local anaesthetic to assist with reduction in pain.
Blood loss is usually around 500mL. The risk of a blood transfusion in my hands is <2%.
For some men with very large prostates or large cancers or a history of previous abdominal surgery, an open procedure may be preferable.
What happens immediately after surgery?
Once your surgery has finished, you are taken to the recovery room where you will wake up.
There will be a catheter in your bladder and sometimes a small wound drain.
You will often feel a sense of needing to empty your bladder. This is normal and is due to the irritation and spasm of the bladder caused by the catheter. This sensation slowly resolves and medication can be given to help relax the bladder. The catheter is held in place with a 3cm inflatable balloon on the catheter tip so cannot fall out with normal activity. Your catheter will remain in for approximately ten days to allow the new join (anastomosis) between your bladder and urethra to heal.
Typically, after one hour in the recovery room, you are taken back to the ward. You will be able to sit up in bed and eat dinner on the evening of surgery and walk about the ward that day or the following morning. Blood thinners and calf compressors are used to reduce the risk of blood clots forming within the veins. Post-operative pain is well controlled through the use of regular pain medication. Once you are comfortable and confident in caring for the catheter you can head home. Hospital stay is typically 1-2 nights for robotic surgery and 2-3 nights for open surgery.
What should I expect when I get home?
When you are discharged from the ward you will need some baggy trousers or track pants as you may find that your abdomen is uncomfortable and the catheter is easier to manage if your clothing is loose.
There will be some blood, urine, and mucus which passes alongside or through the catheter and is particularly noticeable after passing a bowel motion– this is normal. You should wash the area with soap and water to remove this discharge to reduce any irritation. Keeping a high oral fluid intake reduces the risk of catheter blockage.
You may notice some swelling and bruising around the wounds, the penis, and the scrotum which takes several weeks to resolve. You may also notice small firm lumps below the wound – these are normal and are simply the knots in the suture material used to close the wound. The suture slowly dissolves and will disappear within 3 months. Most men feel quite tired after surgery and this takes several weeks to resolve.
Following surgery, you will be given a prescription for regular pain medication as well as some laxative medication to keep your bowels regular and thus avoid any straining.
Light walking is encouraged straight after the surgery. After four to six weeks you may resume heavy lifting.
Showering, bathing, and getting the wounds wet is fine – the skin has been sealed with glue.
Driving is safe once you are comfortable to do so and feel able to make an emergency stop. This would normally be around 3 weeks following surgery.
Removal of the Catheter
Your catheter will be removed by the clinic nurse at Urology Care Wellington 7-14 days after surgery. This is straightforward. You will be given an antibiotic tablet at the time of catheter removal. Afterward, you will be monitored by the nurse to make sure that you are able to pass urine. She will check your wounds are healing and will discuss the use of pads and pelvic floor exercises.
Most patients have some incontinence when the catheter is taken out and most are pad-free three months after surgery. Over nine out of ten are pad-free after a year. We recommend that you start the pelvic floor exercises as soon as your catheter is removed and repeat them every day.
To be prepared for your catheter removal and any temporary urine leakage, you should ensure that you have your own supply of pads at home prior to attending for catheter removal. Bring two pads to your appointment for catheter removal.
Return to Work
Most men are able to return to a sedentary job after 2-4 weeks.
Recovery of Urinary Control
During prostatectomy, the sphincter muscle surrounding the urethra which controls continence is carefully separated from the prostate gland before being reattached to the bladder. This causes temporary sphincter muscle weakness.
Consequently, after catheter removal, there will often be involuntary urine leakage requiring the use of pads. Recovery of continence is variable, but most men are pad-free with good control within 3 months.
Recovery of continence is faster in younger, fit men and slower in older, overweight men, men with very large prostates or pre-existing urinary symptoms, and those who have had a wider resection of the gland in order to remove cancer that has penetrated the capsule of the gland.
Continence may continue to improve out to 12 months post-prostatectomy.
Focused pelvic floor physiotherapy may be recommended and if required I will direct you to a specialist physiotherapist for this. Ultimately, over 95% of men recover normal continence.
If there is persistent leakage beyond 12 months post-operatively then consideration needs to be given to surgically correcting this. Most men suffering from this will have a permanent resolution of incontinence with the placement of a sub-urethral sling. For rare cases of more severe leakage then implantation of an artificial urinary sphincter may be required.
Recovery of Sexual Function
Surgery to remove the prostate gland interferes with sexual and reproductive function. Principally the ability to get and maintain an erection and always the permanent loss of ejaculation fluid. There may be a penile shortening of 1cm or more, this is likely if nerves have been intentionally resected.
During surgery, we aim to preserve the fine nerves controlling penile erection. These run over the surface of the prostate gland as they pass to the blood vessels within the penis. These nerves are easily damaged during surgical removal.
The likelihood of recovery of satisfactory sexual function depends upon several factors: pre-operative sexual function, age, a necessity for resection of the nerves, and surgical expertise. Other factors which make erectile dysfunction more likely include high blood pressure, diabetes, obesity, and smoking.
Younger men with a normal sexual function who are suitable for nerve preservation and who have surgery by a surgeon experienced in nerve preservation are more likely to recover reasonable erectile function.
You may begin sexual activity again two weeks after your operation, as long as you feel comfortable.
There may be a 12-month period of relatively poor function before recovery occurs. I recommend early “penile rehabilitation” for men motivated to resume penetrative sexual activity. This comprises regular induction of or enhancement of erections via vacuum pump usage and oral or injectable medications. Our clinic nurse will be able to instruct you in these techniques.
What are other possible risks?
General problems that can occur while you are in hospital recovering are similar to those for any major operation. These include:
o Bleeding requiring the need for a blood transfusion or re-operation
o Injury to nerves
o A chest infection
o Blood clots in your lower leg, which could pass to your lungs
- This includes leg swelling, leg pain, chest pain, or shortness of breath. Blood clots after surgery are rare but dangerous and need urgent treatment.
If you experience any of these symptoms then you need urgent medical review.
o Wound infection
Specific Risks for a prostatectomy
Common:
o Temporary difficulties with bladder control
o Impairment of erections due to nerve damage
o Inability to ejaculate or father children because the structures which produce seminal fluid have been removed
Occasional :
o Scarring at the bladder exit resulting in weakening of the urinary stream and requiring further surgery (2-5%)
o Long term incontinence requiring pads or further surgery (<5%)
o Further treatment at a later date, including radiotherapy or hormone treatment
o Lymph collection in the pelvis if lymph node sampling is performed
o Apparent shortening of the penis
o Development of a hernia in the groin area or at a port site
Rare :
o Bowel injury requiring a temporary colostomy
What else should I look out for?
If you develop a fever, increased redness, throbbing or drainage at the site of your operation, pain or swelling of one leg, shortness of breath, or chest pain please contact our office during the week or contact Mr. Studd mobile after hours.
Follow up
Approximately two to three weeks following surgery, Mr. Studd will contact you by telephone once the surgical pathology report is issued.
The report gives us information about cancer prognosis and if there are adverse pathologic features then we may discuss the possible benefit of further treatment such as radiotherapy. You will have a PSA level checked three months following surgery and then we will meet for a review.
From this point, the requirement for ongoing review depends upon your recovery or need for further therapies. For men who have made a smooth recovery follow up from three months on is with their GP only. PSA tests are continued six-monthly for three years then annually thereafter. The PSA level should remain ‘undetectable’ – which means that the laboratory cannot detect any PSA in your blood. The laboratory expresses this on the report in this way: PSA <0.03ng/mL. If the PSA becomes ‘detectable’ (>0.03ng/mL) then this indicates residual prostate cancer and we will need to meet again to plan further imaging and management.