Prostatectomy: Indications and Risks

Prostate is a gland located before the base of the urinary bladder in males. Prostatectomy is a procedure for partial or complete removal of the gland. About 90,000 prostatectomies are performed annually in USA.

Types of Prostatectomy

There are two types of prostatectomy like:

• Radical prostatectomy: used for men with localized prostate cancer this procedure removes the complete prostate gland and the adjacent lymph nodes. This can be accomplished in different ways: Open surgery, Laproscopic surgery, Robot-assisted
• Simple prostatectomy: used for men with non-cancerous enlargement of the prostate where some part of the prostate is removed to alleviate the urinary complains.

Prostatectomy Procedure

Prostatectomy is performed either under general anesthesia or general anaesthesia accompanied by intrathecal injection. Depending upon the procedure your doctor makes the incisions to operate.

Radical prostatectomy

• Open surgery: your surgeon makes an incision from your navel to your pubic bone and after careful dissection removes the gland, seminal vesicles and the surrounding lymph nodes. The incision is closed with the help of sutures. This surgery carries a lower risk of nerve damage compared to other surgeries.
• Laproscopic surgery: after making small incisions in your lower abdomen, your surgeon introduces special ports to remove the gland and the surrounding tissue including the seminal vesicles and lymph nodes.
• Robot-assisted: your surgeon does the surgery by controlling a robot from a console. The screen shows a magnified image of the surgical field, and the surgeon controls the robot which helps in making fine movements

Simple prostatectomy

• After the effect of anaesthesia kicks in your surgeon will insert a thin tube called a catheter into your bladder which will drain the bladder. The surgeon will then make an incision from below your navel to your pubic bone. Depending upon the technique used the incision may or may not run through the urinary bladder. On reaching the prostate, the part obstructing the flow of urine will be removed. The incision is then closed with the help of sutures.

Indications for Prostatectomy

Radical prostatectomy is indicated for males for the treatment of localized prostate cancer in addition to chemotherapy and radiation therapy.

Simple prostatectomy is used to help treat the symptoms of enlargement of prostate which include:

• Difficulty in beginning urination
• Weak stream of urine
• Dribbling at the end of urination
• Increased frequency of urination, especially at night
• Difficulty in completely emptying the bladder
• Urinary tract infection

Preparation for Prostatectomy

Before the surgery your doctor would like to run a few tests to measure the size of your prostate and evaluate your urine flow. To visualize your urethra and bladder your doctor might perform a cystoscopy. A set of routine blood tests might be ordered to check for your fitness for the surgery.

Your doctor would like to know about the medications that you’ve been taking and might ask you to stop taking some of them like blood thinners and over-the-counter pain relief medications. You are also requested to inform your doctor about any clotting disorder that you might have or have a family history of. The doctor would also like to know about allergy to any medications that you’ve experienced so far. About 12 hours before the surgery your doctor will ask you to stop ingesting solid meals and restrict yourself to a liquid diet. From the night before the surgery you will be advised to not ingest fluids too. Your surgeon may also prescribe a laxative or give you an enema kit to ensure that you have a clean bowel on the day of the surgery.

Risks of Prostatectomy

Complications associated with radical prostatectomy are:

• Urinary tract infection
• Urinary incontinence
• Erectile dysfunction
• Bleeding
• Injury to rectum during the surgery
• Narrowing of the urethra due to formation of a stricture

Complications associated with simple prostatectomy are:

• Bleeding
• Urinary incontinence
• Damage to adjacent structures
• Dry orgasms
• Narrowing of urethra
• Erectile dysfunction

The risks of complications in simple open prostatectomy are more than those seen in the newer methods like Trans Urethral Resection of Prostate (TURP) or Holmium Laser Prostate Surgery (HoLEP).

Recovery after Prostatectomy

After the surgery, you will be taken to the recovery room where your vitals will be monitored as the effect of the anesthesia wears off. You will also be administered pain medications via an intravenous. After the effect of anesthesia is over you will be encouraged to walk to prevent the formation of blood clots after the surgery. A catheter will be in place when you go home. Most men need the catheter for about 8-10 days. You are advised to arrange for someone to drive you home from the hospital as it is not advised to drive with the catheter in place. At home, you are advised to gradually resume your day to day activities. You will be able to return to the normal activity level in about four to six weeks. You are advised not to engage in strenuous activity until you doctor says it is okay to do so.

Resources:

• https://www.onclive.com/publications/obtn/2011/march-2011/robotic-assisted-laparoscopic-radical-prostatectomy-has-steep-learning-curve

• American Urological Association

• https://www.nice.org.uk/guidance/ipg193