(Prostatectomy, Radical Prostatectomy, Radical Retropubic Prostatectomy, Radical Suprapubic Prostatectomy, Radical Perineal Prostatectomy, Nerve-Sparing Prostatectomy, RP, RPP, RSP)
What is a prostatectomy?
A prostatectomy is a surgical procedure for the partial or complete removal of the prostate. It may be performed to treat prostatic cancer or benign prostatic hyperplasia (BPH).
A common surgical approach to prostatectomy includes making a surgical incision and removing the prostate gland (or part of it). This may be accomplished with either of two methods, the retropubic or suprapubic incision (lower abdomen), or a perineum incision (through the skin between the scrotum and the rectum).
Prior to having a prostatectomy, it is often necessary to have a prostate biopsy. Please see this procedure for additional information.
What is the prostate gland?
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The prostate gland is about the size of a walnut and surrounds the neck of a man's bladder and urethra - the tube that carries urine from the bladder. It is partly muscular and partly glandular, with ducts opening into the prostatic portion of the urethra. It is made up of three lobes, a center lobe with one lobe on each side.
As part of the male reproductive system, the prostate gland's primary function is to secrete a slightly alkaline fluid that forms part of the seminal fluid (semen), a fluid that carries sperm. During male climax (orgasm), the muscular glands of the prostate help to propel the prostate fluid, in addition to sperm that was produced in the testicles, into the urethra. The semen then travels through the tip of the penis during ejaculation.
Researchers do not know all the functions of the prostate gland. However, the prostate gland plays an important role in both sexual and urinary function. It is common for the prostate gland to become enlarged as a man ages, and it is also likely for a man to encounter some type of prostate problem in his lifetime.
Many common problems are associated with the prostate gland. These problems may occur in men of all ages and include:
- benign prostatic hyperplasia (BPH) - an age-related condition of the prostate that is not malignant. BPH is the most common non-cancerous prostate problem, occurring in most men by the time they reach their 60s. Symptoms are slow, interrupted, or weak urinary stream; urgency with leaking or dribbling; and frequent urination, especially at night. Although it is not cancer, BPH symptoms are often similar to those of prostate cancer.
- prostatism - the symptom of decreased urinary force due to obstruction of flow through the prostate gland. The most common cause of prostatism is BPH.
- prostatitis - inflammation or infection of the prostate gland characterized by discomfort, pain, frequent or infrequent urination, and sometimes fever.
- prostatalgia - pain in the prostate gland, also called prostatodynia. It is frequently a symptom of prostatitis.
Cancer of the prostate is a common and serious health concern. According to the American Cancer Society, prostate cancer is the most common form of cancer in men over age 50, and the third leading cause of death from cancer.
There are different ways to achieve the goal of removing the prostate gland. Methods of performing prostatectomy include the following:
- Surgical removal includes a radical prostatectomy (RP), with either a retropubic or perineal approach. Radical prostatectomy is the removal of the entire prostate gland. Nerve-sparing surgical removal is important to preserve as much function as possible.
- Transurethral resection of the prostate, or TURP, which also involves removal of part of the prostate gland, is an approach performed through the penis with an endoscope (small, flexible tube with a light and a lens on the end).
- Cryosurgery is a less invasive procedure than surgical removal of the prostate gland. Treatment is administered using probe-like needles that are inserted in the skin between the scrotum and anus.
- Laparoscopic surgery, done manually or by robot, is another method of removal of the prostate gland.
There are two other types of treatments that can be used for either BPH or prostatectomy. However, there has not yet been enough research done to prove their long-term effects.
- high intensity focused ultrasound (HIFU) - a procedure that uses high-energy sound waves delivered to tissue. The energy that is targeted to tissue causes a heating effect, which then destroys or ablates prostate tissue. This treatment has been used more widely in Europe, and is being studied now in the US. Preliminary outcomes appear to indicate that this treatment is safe and fairly comfortable. However, it is not the best approach for a very large prostate gland and can cause urinary retention.
- laser prostatectomy or laser ablation - a newer procedure, but it can be performed on prostate glands that are larger. A laser works by releasing concentrated light energy in bursts lasting 30 to 60 seconds. It cuts through tissue with a minimum of blood loss. It is also precise enough to dissect away the prostatic lobes (on each side of the prostate gland) from the prostatic capsule. Any dead tissue remaining behind dissolves and eventually passes out through the urine.
While laser prostatectomy appears to be safe and effective, it has some obvious drawbacks. Only trained practitioners are able to perform the procedure appropriately. There is, however, a relatively long post-operative recovery, which lasts several weeks before there is any significant improvement in urinary symptoms. Also, dead tissue cannot be examined for signs of cancer cells once it is destroyed.
Types of radical prostatectomy:
There are two primary methods of radical prostatectomy.
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- radical prostatectomy with retropubic (suprapubic) approach:
This is the most common surgical approach used by urologists (physicians who specialize in diseases and surgery of the urinary tract). If there is reason to believe the cancer has spread to the lymph nodes, the physician will remove lymph nodes from around the prostate gland, in addition to the prostate gland. Cancer has spread beyond the prostate gland if it is found in the lymph nodes. If that is the case, then surgery may be discontinued, since it will not treat the cancer adequately. In this situation, additional treatments may be used.
- nerve-sparing prostatectomy approach:
If the cancer is tangled with the nerves, it may not be possible to maintain the nerve function or structure. Sometimes nerves must be cut in order to remove the cancerous tissue. If both sides of the nerves are cut or removed, the man will be unable to have an erection. This will not improve over time (although there are interventions that may restore erectile function).
If only one side of the bundle of nerves is cut or removed, the man may have less erectile function, but will possibly have some function left. If neither nerve bundle is disturbed during surgery, function may remain normal. However, it sometimes takes months after surgery to know whether a full recovery will occur. This is because the nerves are handled during surgery and may not function properly for a while after the procedure.
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- radical prostatectomy with perineal approach:
Radical perineal prostatectomy is used less frequently than the retropubic approach. This is because the nerves cannot be spared as easily, nor can lymph nodes be removed by using this surgical technique. However, this procedure takes less time and may be an option if the nerve-sparing approach is not needed. This approach is also appropriate if lymph node removal is not required. Perineal prostatectomy may be used if other medical conditions rule out using a retropubic approach.
With the retropubic approach, there is a smaller, hidden incision for an improved cosmetic effect. Also, major muscle groups are avoided. Therefore, there is generally less pain and recovery time.
The goal of radical prostatectomy is to remove all prostate cancer. RP is used when the cancer is believed to be confined to the prostate gland. During the procedure, the prostate gland and some tissue around the gland, including the seminal vesicles, are removed. The seminal vesicles are the two sacs that connect to the vas deferens (a tube running through the testicles), and secrete semen.
Other reasons for radical prostatectomy include, but are not limited to, the following:
- inability to completely empty the bladder
- recurrent bleeding from the prostate
- bladder stones with prostate enlargement
- very slow urination
- increased pressure on the ureters and kidneys from urinary retention (called hydronephrosis)
There may be other reasons for your physician to recommend a prostatectomy.
As with any surgical procedure, certain complications can occur. Some possible complications of both the retropubic and perineal approaches to RP may include, but are not limited to, the following:
- urinary incontinence (uncontrollable, involuntary leaking of urine)
This may improve over time, even up to a year after surgery. This symptom may be worse if you are over age 70 when the surgery is performed.
- urinary leakage or dribbling
This symptom is at its worst immediately after the surgery, and will usually improve over time.
- erectile dysfunction, also known as impotence
Recovery of sexual function may take up to two years after surgery.
RP cuts the connection between the testicles and the urethra. This results in a man being unable to provide sperm for a biological child. A man may be able to have an orgasm, but there will be no ejaculate. In other words, the orgasm is "dry".
Lymphedema is a condition in which fluid accumulates in the soft tissues, resulting in swelling. Lymphedema may be caused by inflammation, obstruction, or removal of the lymph nodes during surgery. Although this complication is rare, if lymph nodes are removed during prostatectomy, fluid may accumulate in the legs or genital region over time. Pain and swelling result. Physical therapy is usually helpful in treating the effects of lymphedema.
- change in penis length
A small percentage of surgeries will result in a decrease in penis length.
Some risks associated with surgery and anesthesia in general include, but are not limited to:
- reactions to medications, such as anesthesia
- difficulty with breathing
One risk associated with the retropubic approach is the potential for rectal injury, causing fecal incontinence or urgency.
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.
- Your physician will explain the procedure to you and offer you the opportunity to ask any questions you might have about the procedure.
- You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
- In addition to a complete medical history, your physician may perform a physical examination to ensure you are in good health before you undergo the procedure. You may also undergo blood tests and other diagnostic tests.
- You will be asked to fast for eight hours before the procedure, generally after midnight.
- Notify your physician if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).
- Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
- Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
- If you smoke, you should stop smoking as soon as possible prior to the procedure, in order to improve your chances for a successful recovery from surgery and to improve your overall health status.
- You may receive a sedative prior to the procedure to help you relax.
- The areas around the surgical site may be shaved.
- Based upon your medical condition, your physician may request other specific preparation.
Radical prostatectomy requires a stay in the hospital. Procedures may vary depending on your condition and your physician's practices.
Generally, a radical prostatectomy (retropubic or perineal approach) follows this process:
- You will be asked to remove any jewelry or other objects that may interfere with the procedure.
- You will be asked to remove your clothing and will be given a gown to wear.
- You will be asked to empty your bladder prior to the procedure.
- An intravenous (IV) line will be started in your arm or hand.
- The skin over the surgical site will be cleansed with an antiseptic solution.
- The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
- Once you are sedated, a breathing tube may be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery.
- The physician may choose regional anesthesia instead of general anesthesia. Regional anesthesia is medication delivered through an epidural (in the back) to numb the area to be operated on. You will receive medication to help you relax and analgesic medication for pain relief. The physician will determine which type of anesthesia is appropriate for your situation.
- A catheter will be inserted into your bladder to drain urine.
Radical prostatectomy - retropubic or suprapubic approach:
- You will be positioned on the operating table, lying on your back.
- An incision will be made from below the navel (belly button) to the pubic region.
- The physician will usually perform a lymph node dissection first. The nerve bundles will be released carefully from the prostate gland and the urethra (narrow channel through which urine passes from the bladder out of the body) will be identified. The seminal vesicles may also be removed if necessary.
- The prostate gland will be removed.
- A drain will be inserted, usually in the right lower area of the incision.
Radical prostatectomy - Perineal approach:
- You will be placed in a supine (lying on your back) position in which the hips and knees will be fully bent with the legs spread apart and elevated with the feet resting on straps. Stirrups will be placed under your legs for support.
- An upside-down U-shaped incision will be made in the perineal area (between the scrotum and the anus.)
- The physician will try to minimize any trauma to the nerve bundles in the prostate area.
- The prostate gland and any abnormal-looking tissue in the surrounding area will be removed.
- The seminal vesicles (a pair of pouch-like glands located on each side of the male urinary bladder that secrete seminal fluid and promote the movement of sperm through the urethra) may be removed if there concern about abnormal tissue in the vesicles.
Procedure completion, both methods:
- The incisions will be sutured back together.
- A sterile bandage/dressing will be applied.
- You will be transferred from the operating table to a bed, then taken to the post-anesthesia care unit (PACU).
After the procedure, you may be taken to the recovery room to be closely monitored. You will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level.
You may receive pain medication as needed, either by a nurse, or by administering it yourself through a device connected to your intravenous line.
Once you are awake and your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as you are able to tolerate them.
The drain will generally be removed the day after surgery.
Your activity will be gradually increased as you get out of bed and walk around for longer periods of time.
The urinary catheter will stay in place upon discharge and for about one to three weeks after surgery. You will be given instructions on how to care for your catheter at home.
Arrangements will be made for a follow-up visit with your physician.
Once you are home, it will be important to keep the surgical area clean and dry. Your physician will give you specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, in the event they were not removed before leaving the hospital.
The surgical incision may be tender or sore for several days after a prostatectomy. Take a pain reliever for soreness as recommended by your physician.
You should not drive until your physician tells you to. Other activity restrictions may apply.
Once your catheter is removed, you will probably have some leaking of urine. The length of time this occurs can vary.
Your physician will give you suggestions for improving your bladder control. Over the next few months, you and your physician will be assessing any side effects and working to improve problems with erectile dysfunction.
Notify your physician to report any of the following:
- fever and/or chills
- redness, swelling, or bleeding or other drainage from the incision site
- increase in pain around the incision site
- inability to have a bowel movement
- inability to urinate once catheter is removed
Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.