Prostatectomy

What is a Prostatectomy?

A prostatectomy is the surgical removal of the prostate. Most often this refers to the removal of the entire prostate for prostate cancer (Radical Prostatectomy) see below. There are times when parts of the prostate may be removed for benign conditions such as benign prostate hyperplasia (BPH). This type of open prostatectomy is now commonly avoided by doing an endoscopic resection of the obstructing portion of the prostate gland (TURP).

Radical prostatectomy refers to the removal of the entire prostate gland, seminal vesicles, and soft tissue near the gland to allow good surgical margins. The part of the urethra traveling through the prostate gland is also removed. The remaining urethra near the sphincter muscle is then reattached surgically to the bladder neck. This area of attachment is called the anastomosis.

What is the purpose of a Radical Prostatectomy?

Radical prostatectomy is done with the intention to remove prostate cancer before it can spread to outside the prostate gland. It is best suited for healthier men under age 70 with cancer confined to the prostate gland.

Types of Prostate Surgery

There are three types of Radical Prostatectomy: retropubic, perineal, and laparoscopic/robotic. They are classified according to the incision site. All three can accommodate a “nerve-sparing” procedure which includes carefully dissecting the erectile nerves away from the prostate during removal.

• Retropubic: The retropubic incision is made in the center of the lower abdomen and is often called open prostate surgery. The vertical incision is between 8 and 10 centimeters, extending from the pubic bone toward the umbilicus (naval). Through this incision, the lymph nodes can be checked for cancer and the prostate can be removed while sparing the nerves. It avoids the larger body cavity called the peritoneum where the intestines reside. It is sometimes preferred when patients have had extensive prior abdominal (peritoneal) surgery, which makes the robotic procedure difficult.
• Perineal: The 4 centimeter perineal incision is made in the perineum (the flat area between the scrotum and anal sphincter). Surgeons cannot perform the PLND during this procedure but are considered acceptable because PSA testing, DRE findings, and Gleason scoring may predict the likelihood of lymph node metastasis.
• Laparoscopic and Robotic: The laparoscope is a slender, tube-like instrument which allows the surgeon to see inside the abdominal cavity and excise the prostate through a series of small incisions rather than a long single one. The addition of the surgical robot to laparoscopic prostate surgery has made the procedure easier to learn for many surgeons. Robotic-Assisted Laparoscopic surgery (RALP) uses the same incisions and tools as laparoscopic prostatectomy but uses robotic arms controlled by the surgeon while sitting at a console in the operating room. RALP has nearly replaced pure laparoscopic prostate removal.

What are common symptoms following my prostatectomy?

After prostatectomy patients generally spend 1-3 nights in the Hospital. After discharge, you should be independent in activity and with good pain control with the help of pain medication. A small amount of bleeding or bloodstain on the surgical gauze dressing is expected. There may be some swelling, bruising, and firmness at the site of the incisions.

Radical prostatectomy will cause at least temporary erectile dysfunction (ED) Depending on the patient’s age and the degree of nerve-sparing that was possible, erections may return to some degree over 6 months to 2 years time. The nerve-sparing procedure is best for patients who have low volume and low-grade cancer that is away from the neurovascular nerve bundles.

Urinary incontinence (leakage of urine) is very common immediately after surgery but generally improves with pelvic muscle exercises and time. Men often need to use protective pads for urinary leakage until they rehabilitate the urinary sphincter muscle. Some patients recover their urinary control quickly but it may take 6 to 18 months for others to gain full improvement. A small number of patients may have lasting urinary leakage, which requires a second procedure to correct it.