Prostatectomy (Prostate Surgery)
What is a prostatectomy?
A prostatectomy is a major procedure, carried out by a urological surgeon (urologist), in which all or part of the prostate gland is removed. A prostatectomy can be ordered by your doctor to treat prostate cancer and as part of treating some of the other types of cancer that can affect the pelvis.
A prostatectomy can often cure prostate cancer if it has not spread outside the prostate gland. Prostatectomies are also performed in the treatment of non-cancerous conditions affecting the prostate, such as benign prostatic hyperplasia (BPH), when the prostate becomes enlarged and causes urinary problems, and in rarer cases e.g. for prostatitis, an inflammation of the prostate.
There are several different methods of performing a prostatectomy. The method used depends on the reason the procedure is being performed. For example, a radical prostatectomy will be carried out as a treatment for malignant cancer. This type of prostatectomy involves the removal of the entire prostate gland as well as the vas deferens, the duct which conveys sperm from the testicals to the urethra, and the seminal vesicles, the glands which hold the liquid which mixes with sperm to make semen. However, a more benign condition, such as a prostate hyperplasia, would require a simple prostatectomy, in which only part of the prostate is removed.
Prostatectomies generally require general anesthesia, i.e. a kind of anesthesia where the person is asleep during the procedure and does not wake up till the surgery is entirely finished, and a hospital stay of two to three days on average, with a total recovery time of around one to two months. With appropriate aftercare, most people are able to resume physical activities as normal after around six weeks.
When and why is a prostatectomy performed?
A prostatectomy is performed in order to treat a variety of conditions which can affect the prostate gland. The prostate gland is the size of a walnut and is located inside the male body, beneath the bladder and between the bladder and the penis. Women also have a gland which is equivalent to the prostate gland, commonly referred to in medicine as the paraurethral gland or Skene’s gland, but they are much less likely to be affected by problems in this area than men.
In healthy males, the prostate gland produces prostate fluid, one of the main components of semen. The prostate gland also contains muscle fibres. During ejaculation, the prostate functions to push the semen into the urethra, the duct in the penis which conveys urine and semen out of the body.
Prostate problems most commonly develop in later life, predominantly affecting men of over 50 years of age. Problems, which affect the prostate and may be addressed by a prostatectomy, include prostate cancer, prostate enlargement and prostate inflammation (prostatitis).
Prostate cancer is the second most common type of cancer in American males, after skin cancer, affecting around 1 in 7 men in the U.S. at some point during their lifetime. Early-stage prostate cancer is typically asymptomatic and is usually detected during screening tests. When present, symptoms of more advanced prostate cancer may include:
- Loss of appetite and weight loss
- Inability to completely empty the bladder, i.e. urinary retention
- Hematuria: blood in urine, which is visible to the eye or microscopically visible
- Incontinence and erectile dysfunction
Signs of late-stage prostate cancer may include pain in the lower back and/or bones, and lymphedema (localized swelling related to excess lymph-fluid-accumulation, due to blocked lymph drainage paths).
The survival chances for prostate cancer are more favourable than for many other types of cancer. This is because prostate cancer progresses comparatively slowly, so it is often possible to identify and treat the condition before it reaches a critical stage of advancement. In addition to prostate cancer, a prostatectomy may also be carried out to treat or manage other cancers that affect the pelvis, such as bladder cancer and rectal cancer.
Benign prostate hyperplasia (BPH)
Prostate enlargement is unrelated to cancer, and the likelihood of developing prostate cancer is not increased by having this condition. The enlargement of the prostate occurs as men age, and the prostate can grow to the extent that it begins to exert pressure on the urethra. This can cause discomfort and precipitate problems within the urinary system, including:
- Urinary urgency: A strong urge or perceived need to urinate, which may be accompanied by pain and/or fear of urine leakage.
- Urinary frequency: The need to urinate frequently, usually in small quantities, during the night (nocturia) and day.
- Hematuria: Blood may be present in urine. This is due to the fact that the enlargement of the prostate gland, that occurs during BPH, can increase the frequency of breakages in the blood vessels, particularly after physical activity. This often results in recurrent (repeating) episodes of hematuria, until BPH is treated.
Problems associated with BPH can sometimes be managed by taking medication which reduces the size of the prostate and helps to relax the muscles in and around the bladder. In some cases, however, a prostatectomy is necessary in order to relieve the symptoms.
This is a condition in which the prostate gland becomes swollen and inflamed. Prostatitis often occurs as the result of a bacterial infection, caused by bacteria which enter via the bladder or urethra and then infect the prostate. The symptoms of prostatitis include difficulties urinating or starting to urinate, pain which occurs specifically when ejaculating and/or in the perineum (the area between the scrotum and the anus) and generalized pain in the genitals, buttocks and pelvis.
Prostatitis can often be managed or treated using medication to shrink the prostate gland, painkillers and anti-inflammatory medication called alpha-blockers. In chronic cases of prostatitis, where the symptoms cannot be managed or treated by medication, the prostate may be removed by a special type of prostatectomy called a transurethral resection of the prostate (TURP).
Types of prostatectomy
There are several different methods for performing a prostatectomy and several different types of prostatectomy, each appropriate to the treatment or management of different prostate-related conditions.
The main types of prostatectomy are:
- Radical prostatectomy
- Nerve-sparing radical prostatectomy
- Transurethral resection of the prostate (TURP)
Before an individual undergoes the procedure, their urologist will discuss the intended route of surgery, and they will decide together on the best method. It is always important to find out whether or not the prostatectomy is intended to be nerve-sparing, an approach which ideally preserves erections and sexual function.
This type of operation is generally performed on people who are affected by prostate cancer. It involves removing the prostate gland in its entirety. The surgeon may also remove the surrounding tissues, lymph nodes (small pieces of tissue which should filter and clear liquid waste called lymph) and the seminal vesicles.
Nerve-sparing radical prostatectomy
Prostatectomies can compromise a man’s ability to produce or sustain an erection. A nerve-sparing prostatectomy is an innovation on the usual surgical procedure for a radical prostatectomy, in which the surgeon takes special care to spare the two cavernous nerve sheaths. These are clusters of nerves which lie to the sides of the prostate gland. Their function in healthy males is to produce erections.
In nerve-sparing radical prostatectomies, the surgeon will stimulate the nerves electrically and measure erectile functionality using a machine called a penile plethysmograph which measures the blood flow to the penis. This helps the surgeon to perform the surgery without cutting the nerves responsible for erectile function.
It is not always possible to carry out a nerve-sparing prostatectomy successfully. The surgeon’s technical skills and experience will greatly impact the chances of preserving erectile function. Also crucial to the success of this procedure are the age and previous erectile abilities of the male undergoing the procedure.
Transurethral resection of the prostate (TURP)
TURP is predominantly carried out on people who are affected by benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate. By removing parts of the prostate that press on the urethra, TURP may reduce problems related to urination.
This operation is specifically designed to remove the inner part of the prostate which surrounds the urethra. Rather than cutting the skin to perform the operation, the urologist will insert an instrument called a resectoscope into the penis through the tip and extract the relevant tissue by burning it off with an electrical current or vaporizing it.
Unlike BPH, it is not possible to cure prostate cancer using the TURP procedure. However, the operation is sometimes recommended for men who are experiencing the advanced stages of prostate cancer.
Surgical methods for performing a prostatectomy
Traditionally, prostatectomies are carried out by open surgery, in which the surgeon makes a single, long incision in the skin and then removes the prostate and any other required surrounding tissues. However, due to technological advancements, it has become possible to carry out a prostatectomy using less invasive methods such as laparoscopic surgery (keyhole surgery).
An advantage of using the newer, less invasive surgical techniques is that they can often result in shorter postoperative (after surgery) recovery times. In cases, where only part of the prostate is to be removed, it is possible to perform the procedure without cutting into the surrounding skin at all. For example, a transurethral resection of the prostate (TURP) can be performed by inserting a thin tube called a resectoscope into the bladder through the urethra to remove the prostate tissue.
A radical prostatectomy can be performed using open surgery. This involves the surgeon making an incision into the lower belly in order to reach the prostate. This is called a retropublic approach. A retropubic radical prostatectomy is the most commonly performed type of prostatectomy.
It is also possible to perform a prostatectomy through an incision made into the perineum (area between the scrotum and the anus). This is called a perineal approach and is associated with a shorter recovery time than the retropubic approach.
Laparoscopic prostatectomy (keyhole surgery)
This surgical technique is also called bandaid surgery or minimally invasive surgery (MIS). It is a modern method of performing operations through small incisions in the body, near the surgery site. One of the instruments will feature a video camera, which facilitates the surgeon seeing inside the body. Laparoscopic prostatectomies can usually be performed through incisions no bigger than 0.5 to 1.5 cm, and surgeons can perform this type of surgery by hand.
Robotic prostatectomies are a type of laparoscopic prostatectomy. Rather than performing the operation by hand, a robotic arm is used to hold the surgical tools. This kind of prostatectomy ideally offers several advantages over the traditional laparoscopic prostatectomies, including:
- Clinically superior results
- Fewer complications
- Faster recovery
- Minimal scarring
Preparing for a prostatectomy
The time between a prostate condition being diagnosed and a prostatectomy being scheduled varies depending on the individual and the advancement of their specific condition. In cases where a prostatectomy is being carried out because of prostate cancer, there is often an interval of six or more weeks between the diagnosis – which involves taking a biopsy – and the scheduling of the operation. This is to allow any inflammation, that has occurred as a result of the biopsy, to heal.
These actions and forward-planning measures are helpful in preparing to undergo a prostatectomy:
Kegel exercises: Schedule an appointment to learn Kegel exercises before the operation. These strengthen the muscles around the bladder (pelvic floor muscles) and will assist the process of regaining normal urinary function after the catheter, which is regularly administered after surgery, is removed. They should be practiced before and after prostate surgery.
Hospital stay: A prostatectomy is an inpatient procedure that will require a hospital stay of two to three days, in general, after which it is possible to return home. Preparing for this, logistically and emotionally, will make this period run as smoothly as possible.
Time off work: Recovery time after a prostatectomy is variable, but it will usually be necessary to book up to several weeks off work. Some people return to non-physical work such as a desk job after only a few days. However, it can take up to six weeks or, in rare cases, even longer to recover sufficiently to return to work after open prostate surgery. The recovery time for returning to work after a laparoscopic prostatectomy is usually shorter, often between two and three weeks.
Avoid non-steroidal anti-inflammatory drugs (NSAIDs): Certain painkillers, such as aspirin and ibuprofen, may affect blood clotting. Using them before surgery can result in excessive bleeding. If needed, acetaminophen (Tylenol or Paracetamol) may be suitable to prevent minor aches and pains. However, no painkiller products should be used in the period before surgery, without first consulting a doctor to check that they are suitable.
These medicines and dietary modifications are helpful preparations for the day before the surgery is due to take place:
Bowel preparation: In order for the surgery to be performed properly, it is vital that the bowel is empty and clean. The doctor will prescribe a bowel preparation to be taken the day before the surgery in order to help remove waste from the area.
Avoid solid food: To prevent the body from creating more feces and compromising the cleanliness of the bowel, it is important to avoid solid food for the day before the surgery and ingest only clear liquids.
Avoid eating or drinking on the day of the surgery: Because general anaesthetic will be used, it is important to avoid ingesting anything before the surgery takes place. People are usually recommended to avoid eating after midnight the night before the surgery takes place, but, in each case, always follow the specific guidelines given by the surgeon or anesthesiologist.
During the procedure
Prostatectomies, depending on the type itself, usually take about one or two, and, in rarer cases, for more complicated open radical prostatectomies, three hours for the urologist to perform, with the whole surgical procedure, including sedation and waking up, usually lasting two to four hours in total.
Immediately after the surgery, a temporary subrapubic catheter (a thin tube) is inserted through the penis or, alternatively, through an incision in the abdomen, in order to streamline the process of urination during recovery. The catheter serves to prevent urine coming into contact with the healing area and often stays in place for about 7 days, but this may also vary greatly, depending on the procedure performed or the patient’s specific recovery progress.
Postoperative care and recovery
The duration of time people stay in hospital after their prostatectomy varies, though it will usually be between two and three days. It is possible, particularly if the procedure was a laparoscopic prostatectomy, to recover sufficiently to return to work after a period of two to three weeks. Nearly everybody who undergoes a prostatectomy recovers sufficiently to return to work after six weeks.
As soon as the operation is complete, and while the person undergoing the procedure is still in the operating room, a temporary suprapubic catheter will be inserted to assist them in urinating during the immediate recovery process. A suprapubic catheter is a hollow, flexible tube which is inserted into the bladder through an incision in the stomach above the navel (tummy button). The catheter is left in place for one or two weeks and helps drain the urine from the bladder whilst the area, which has undergone surgery, is healing. In some cases, instead of the suprapubic catheter, a transurethral catheter leading from the exit of the urethra at the tip of the penis to the bladder may be inserted.
People who have undergone a prostatectomy should expect to see a small amount of postoperative bleeding from the tip of the penis after the catheter has been removed; this is during urination in the days after the surgery and lasts for up to a maximum of 6 weeks after surgery. While the catheter is still in place, some blood and/or blood-like debris are likely to be visible in the urine collection system; this is normal, especially during the first few days after surgery.
In addition to the catheter, a range of devices and techniques are recommended to promote healing during the immediate recovery period:
Donut cushion: Postoperative pain when sitting can be avoided by using a circular cushion with a hole in the middle, and which is called a donut cushion; this allows the wearer to sit down without putting pressure on the surgery site.
Drinking plenty of water: This will help ensure that the urinary system functions as healthily as possible while it is recovering from surgery and will also keep the body hydrated. Staying hydrated is also necessary, because the affected person will be using stool softener in the postoperative period to avoid constipation.
Kegel exercises: These should be practiced before and after the operation to keep the pelvic floor muscles, which control the bladder and urine flow, operational as directed by a doctor. The three areas which are strengthened by Kegel exercises are the bladder which holds the urine, the pubococcygeus muscle which supports the bladder and rectum, and the sphincter urethrae, which helps open and close the urethra. Kegel exercises can help a person to recover from the incontinence caused by undergoing a prostatectomy, which is temporary in most cases.
Limiting other physical activity: Other than the Kegel exercises, it is advisable to limit other physical exercise and heavy lifting during the recovery period. Walking around gently at intervals during the day is recommended, however, to prevent blood clots forming in the groin and legs.
Sexual activity: Urologists advise people who have undergone a prostatectomy to explore the resumption of sexual activity as soon as they feel ready. Even if it is not immediately possible to produce an erection sufficient for performing full sexual intercourse, stimulating the area will help the nerves and muscles involved in producing an erection become used to doing so. Men who have had a successful nerve-sparing prostatectomy tend to recover their erectile abilities quickly.
For men who have had a non-nerve-sparing or unsuccessful nerve-sparing prostatectomy, the process of regaining erectile function can take longer. Medications and/or devices can be prescribed in these cases. In the rare event of a prostatectomy resulting in chronic impotence, surgical procedures such as the insertion of penile implants can help.
Pain medication: Most people will experience some pain in and around the area which has undergone surgery, as well as some pain related to wearing the catheter. The doctor will prescribe suitable painkillers and give advice on how frequently to redose.
Stool softeners: It is normal to be affected by constipation after undergoing surgery. The doctor will prescribe a suitable stool softener to help maintain healthy bowel function.
Urination and incontinence in the postoperative period
People who have undergone a prostatectomy will be taught how to operate the catheter before they leave hospital after the operation. The operation of most catheters is relatively similar and involves collecting the urine in a drainage bag, which can then be emptied into the lavatory. The drainage bag must be changed at appropriate intervals.
All men normally experience some level of incontinence (leakage of urine) after the catheter has been removed, particularly after involuntary bodily actions such as sneezing or laughing. It is also common to experience sudden impulses to urinate while the catheter is in place. This is called a bladder spasm. Bladder spasms should ideally not be particularly painful or occur very often. Therefore, it is wise to consult the doctor if they occur frequently enough to be bothersome or are accompanied by acute pain.
For most men, urinary problems are temporary and are effectively resolved by practicing pelvic floor and Kegel exercises regularly, as recommended by the doctor. Pads should be worn whilst urinary leakage is occurring and changed throughout the day as needed.
Very rarely, men who have undergone a prostatectomy develop a permanent kind of urinary incontinence called chronic urinary incontinence. If urinary incontinence remains a problem after the catheter has been removed, further surgical procedures will be considered to treat the incontinence. For example, the insertion of an artificial urinary sphincter, a device which regulates the release of urine from the bladder, may need to be considered as an option.
Penile rehabilitation (regaining erectile function)
All prostate surgery procedures disrupt the nerves and blood vessels that control the way erections form. For this reason, all prostatectomies will compromise erectile function, at least initially. Up to 50 percent of men who have had a successful nerve-sparing procedure, i.e. the nerves were left untouched as planned during the procedure, regain their pre-prostatectomy (before surgery) erectile functionality within one year. For men, who have not had nerve-sparing procedures, it is still possible to recover most or the entire extent of their pre-treatment erectile capability.
Prostate surgery can alter the sensation of the male orgasm. In some men, the orgasm ceases to be as intensely pleasurable or ceases to be pleasurable at all. This change in sensation is principally caused by the fact that, in radical prostatectomies, both the glands which make seminal fluid and the vas deferens (the sperm ducts) are no longer operational, so the male orgasm must occur without the ejaculation of semen. Sometimes, especially common after TURP surgery, the semen may still be ejected, will not, however, leave the body, but be transported into the bladder; this is called retrograde ejaculation.
Occasionally, men who have undergone a prostatectomy report experiencing pain when orgasming after they have recovered. It is possible for the pain – which usually affects the perineum and pelvis – to occur either occasionally, at regular intervals or every time the affected person engages in sexual intercourse. The incomplete removal of the seminal vesicles during the prostatectomy procedure is thought to be a principal cause of postoperative pain on orgasming.
Factors, which affect the chances of regaining one’s erectile functionality after the procedure, include:
- The skill of the urologist: The greater their experience and success rate at preserving sexual function, the more likely a given procedure is to conclude with this outcome.
- Age: Younger men are more likely than older men to keep or regain their erectile abilities.
- Previous sexual profile: The greater a man’s virility and ability to produce erections before the procedure, the more likely he is to keep or regain it after the procedure.
Doctors will usually encourage postoperative patients to resume sexual activity as soon as the catheter is removed in order to preserve their penile function. The sooner after surgery a man begins exploring his erectile abilities, the more likely he is to regain most or all of his normal sexual functionality. This process is called penile rehabilitation.
The success of penile rehabilitation depends foremost on whether or not a man has undergone a nerve-sparing prostatectomy. Non nerve-sparing prostatectomies and unsuccessful nerve-sparing prostatectomies damage the two bundles of nerves associated with producing erections.
If both bundles of nerves are sufficiently damaged, it may no longer be possible for a man to have spontaneous erections without the aid of devices or medications that assist the bodily process in cases when it can no longer happen naturally. However, in cases where spontaneous erections are no longer possible, there are several possible treatment options which may help with overcoming erectile dysfunction after a prostatectomy.
Treatment options for erectile dysfunction after prostatectomy include:
The best medication for assisting erectile function is Alprostadil, a man-made version of prostaglandin E1, a substance naturally made in the body to help produce erections. Five to ten minutes before sexual activity takes place, this medication can be applied by injection (brand name Caverject) into a certain part of the penis, as a suppository into the tip of the penis (brand name MUSE), or applied as a cream.
Alprostadil has significantly fewer and less severe side effects than most oral medications which can be used to treat erectile dysfunction. It works by widening the blood vessels and increasing the blood flow to the penis, causing an erection. If side effects occur, these are usually non-serious and are limited to prolonged erections, pain and dizziness. Another advantage of Alprostadil is that the dosage can be adjusted to to determine the duration of an erection.
The cream version of alprostadil ‒ marketed as Vitaros ‒ is the newest form of this medication. It comes in a single-use container with a plunger, barrel and protective cap, containing either 200 or 300 micrograms of alprostadil in 100 mg of cream. The appropriate dose strength for each person is decided in consultation with their doctor.
Storage and application guidelines for Vitaros include:
- Vitaros should be stored in the fridge, but can be taken out before use in order to reach room temperature, for ease of application. If it is taken directly out of the fridge, it may need to be warmed up for use by massaging the tube in one’s hands.
- It is best to urinate before applying Vitaros. Urination after application will result in cream being expelled from the urethra, lessening its erectile effects.
- Each tube of Vitaros contains the right amount of medication for a single dose, which should be applied, with clean hands and in full to the penis, by injecting it into the urethra, using the single-use applicator pump provided. The penis should then be kept upright for 30 seconds so that the cream can be absorbed. Any leftover cream can be rubbed in around the tip of the penis. Hands should be washed after application.
- Vitaros will usually take effect in 5-30 minutes after application. It is not an aphrodisiac, and sexual stimulation will therefore be necessary to achieve an erection. For most people, the effects last between one and two hours. A full, warm sensation in the penis is not a cause for concern, and may remain for several hours after use.
Vitaros should not be used more than once within any 24 hour period. A person should not exceed three doses in a week.
If only one set of the nerve bundles that control erections has been damaged, it is possible to stimulate erections using pharmaceuticals such as sildenafil, commonly known as Viagra, vardenafil and tadalafil. These medications are taken orally, and they work by counteracting Phosphodiesterase-5 (PDE5), a chemical naturally occurring in the body, thereby increasing blood flow to the penis during sexual stimulation.
PDE5 inhibitors are associated with several side effects including headaches, a runny nose, hot flushes, an upset stomach and light sensitivity. In some cases, they can cause more severe and permanent vision problems, such as blindness.
These medications are known to react with nitrate-containing drugs used to treat heart disease, so it is important to discuss possible interactions with the doctor in cases where PDE5 inhibitors may be taken in combination with other medications, especially heart medications.
These are mechanical pumps which cause an erection by drawing blood into the penis when the air is sucked out of the pump, after it has been placed over the penis. Erections created with the use of a vacuum device require a band to be applied to the base of the penis to trap the blood for the duration of the intercouse. The band can then be removed afterwards.
For people for whom no other treatments for post-prostatectomy erectile dysfunction are effective, implants may help. These can be surgically inserted into the penis, which requires an operation.
Risks and side-effects
As with any major surgical procedure, a prostatectomy carries certain risks and possible side effects. These include problems that can occur immediately after the surgery, such as an allergic reaction to substances in the anaesthetic medication, as well as problems which can occur later on. For instance, the formation of blood clots or infections developing near the surgery site.
Complications which can arise from the procedure can include:
All prostatectomies disrupt the normal flow of urine from the bladder and out of the penis through the urethra. For this reason, everybody who undergoes a prostatectomy will experience a period when they have difficulties controlling the speed and flow of their urination in the immediate aftermath of the procedure.
Most men regain their bladder control after several weeks or months after the catheter is removed, particularly in cases when there are no other complications and Kegel exercises are practiced as recommended. Some people do not recover their bladder control, this is called continuous incontinence, which may be treated with further surgery and/or by using devices to regulate the flow of urine and control the bladder, such as an artificial sphincter.
Bleeding after the surgery
Because all prostatectomies involve cutting internal tissue, and, in most cases, also external tissue, there is the potential for problematic bleeding to occur after the procedure has been performed. It is important to consult the doctor as soon as possible if bleeding, especially fresh blood occurs beyond the initial recovery period (see passage above) or if the bleeding is very strong in the initial period. Either circumstance may indicate a hemorrhage, and should therefore should be investigated.
If bleeding does continue after the catheter is removed, then it might be a sign of internal bleeding after surgery, and medical attention should be sought immediately.
Blood clots that develop after prostate surgery tend to form in the legs or less commonly the groin area. Loose blood clots can then cause pulmonary embolism, a life-threatening condition in which the blood clot travels to the lungs and causes a blockage in the pulmonary artery, the blood vessel which carries the blood from the heart to the lungs. Walking around and consistently practicing pelvic floor exercises in the initial recovery period is an effective way to prevent clots from forming.
Damage to nearby organs
This can occur in the event of a surgical error. Urologists are careful to perform the procedure as precisely as possible so as to minimise the risk of causing damage to the surrounding area. However, in rare cases, injury to the surrounding tissue and organs can still be sustained.
Adverse reactions to the anesthesia
If a person has a history of swelling of the face or generalised itching, it is important to inform the anaesthetist before the procedure because, although allergic reactions to anaesthesia can be mild, involving only wheezing or some skin irritation, it is also possible to experience an anaphylactic response which can be life-threatening.
Somebody suffering from an allergic reaction to an anaesthetic may display signs like breathing difficulties, low blood pressure, rashes, hives and swollen skin around the eyes or mouth and throat. It is possible to perform tests prior to the surgery to identify which chemicals trigger an allergic reaction and if necessary an appropriate alternative anaesthetic solution can then be chosen.
Other adverse reactions, such a muscle soreness, a sore throat from the breathing tube or nausea and vomiting after the surgery are a lot more common than allergic reactions. Around 10 percent of people will experience some kind of adverse reaction to anaesthetic drugs, and anaesthetists are trained to recognise and treat reactions as and when they occur during or after surgery.
Infections at the surgery site
The parts of the body which are most likely to be infected after surgery are located in the abdomen (the belly). Infections after prostate surgery are usually due to the intestine being injured during surgery, which is more common in cases where the prostatectomy has been carried out by keyhole surgery than when an open approach has been used.
This is a rare complication of removing the lymph nodes around the prostate during prostate surgery. Removing any of the body’s lymph nodes can affect the lymphatic system. Functioning normally, the lymph nodes act as a drain for lymph fluid which circulates around the body. When this protein-rich fluid cannot drain out through the lymph nodes, it can build up and stagnate in the area of the body where the lymph nodes were removed, and infection-causing bacteria can develop.
- Heaviness and achiness in the genital area or legs
- Reddening of the skin in the genital area or legs
- Changes in the size and shape of the legs
- Swollen skin
- Reduced flexibility
Always consult a doctor if lymphedema is suspected. If lymphedema is left untreated, the growing pool of undrained lymph can spread to surrounding areas of the body, such as the back and legs. Treatment for lymphedema focuses on redistributing this buildup of lymph within the body, so that it can be drained by other, functioning, lymph nodes. This may involve:
- Applying a compression system, such as a special bandage, to the affected area
- Manual lymph drainage, a specific type of massage performed by a doctor or occupational therapist
- Stretching exercises
- Deep breathing exercises
- A manual pump to use at home
Pelvic lymphocele is a possible complication of prostate surgery, most commonly associated with undergoing a radical prostatectomy. A lymphocele occurs when the local lymphatic system is compromised due to surgery as a result of which, a buildup of lymph drains into a nearby cavity, rather than being drained from the area where the lymph nodes were removed.
When lymphocele occurs after prostate surgery, the buildup of lymph is usually found in the retroperitoneal space, i.e. behind the membrane that lines the abdominal cavity and covers the abdominal organs. Lymphocele can be symptomless, and can resolve spontaneously, without the need for treatment.
When symptoms of lymphocele do occur, they may include:
- Abdominal pain
- A sensation of fullness
- Reddened or swollen skin
- Urinary urgency or the need to urinate frequently
- Edema (swelling) of the genitals and/or legs
Seek prompt medical attention if symptoms of lymphocele are present. The presence of symptoms indicates that the lymphocele has grown to a size, at which treatment will be required in order to remove it. Left untreated, lymphocele can cause other problems to develop, including obstruction of the urinary tract, obstruction of the blood flow to the surgery site and/or compression of nearby blood vessels, which will slow down the post-surgical healing process.
In addition to a physical examination, an ultrasound or CT scan may be carried out in order to diagnose lymphocele. Treatment for symptomatic lymphocele may involve:
Marsupialization: This is a surgical technique which involves cutting a slit into the area occupied by the lymphocele and suturing it into an open position, creating a pouch shape and thereby allowing the buildup of lymph to drain freely out of the previously enclosed space. It is usually carried out as an outpatient procedure. Laparoscopic marsupialization has recently become the first line treatment for pelvic lymphocele, although it is also possible to perform marsupialization via open surgery. In laparoscopic marsupialization, a very small incision is made in the skin near the lymphocele; marsupialization can then be carried out robotically, using image guidance.
Percutaneous drainage: This procedure is carried out under local anesthetic and takes around one hour to perform. A small incision will be made in the skin near the site of the lymphocele. Doctors will use image guidance to insert a needle attached to a catheter into the lymphocele, and the fluid will then be drained out of the body, via the catheter, into a drainage bag.
Performing surgery other than TURP on the prostate weakens the layers of pelvic tissue and muscle tissue of the lower belly where the incision was made. This can cause internal parts of the body, such as parts of the intestine, to gravitate from their normal location, causing pain and a distinctive bulge to form in the groin area. Men are ten times more likely to experience an inguinal hernia than women, and their chances of developing the condition later on are significantly increased by having undergone an open surgery prostatectomy.
Good to know: An additional, less common, complication of prostate surgery is Peyronie's disease. This condition causes a shortening and curvature of the penis and primarily affects men in their fifth or sixth decade of life. Peyronie’s disease shares this characteristic with most prostate-related conditions that require a prostatectomy, but there is little evidence to support or refute the idea that they are necessarily linked.
However, the shortening of the urethra, that can occur as a result of a prostatectomy, can cause the penis to shorten and curve in a manner that is hard to distinguish or is even indistinguishable from the curvature caused by Peyronie’s disease.
Q: Can a prostatectomy cause a change in penis length?
A: Yes. It is very common for the penis length to decrease after prostate surgery, due to the fact that a portion of the urethra is often removed with the prostate. Radical prostatectomies generally cause the greatest decrease in penis length. In most cases, the length of the penis is most diminished immediately after the procedure and the difference between its postoperative length and original length decreases as the person recovers.
Q: Can a prostatectomy cause loss of fertility?
A: Radical prostatectomies are the type most commonly associated with a loss of fertility. This is because they involve cutting and/or removing the vas deferens, meaning that the sperm no longer have a conduit to travel from the testicles and out of the body in seminal fluid. A man, who has had a radical prostatectomy, can no longer father a child naturally, but can choose to save (bank) his sperm for future use before the operation. It is important to talk to the doctor before the procedure is carried out and make arrangements if this is needed.
Q: Is it possible to drive a car during the recovery period from a prostatectomy?
A: One should avoid driving completely whilst the catheter is in place. After the catheter is removed, it is nevertheless advisable to avoid certain activities such as driving for two to four weeks after the operation and to confirm with one’s doctor that one is fit to resume them on a follow-up visit.
Q: What precautions should I take to keep clean and promote healing while the temporary catheter is in place and after its removal?
A: The subrapubic or transurethral cathether is a thin, flexible tube; a temporary device which is inserted after prostate surgery in order to streamline urination during recovery. It is usually worn for around one or two weeks, during which time a person should keep the surrounding area as clean and dry as possible. This can be achieved by washing the rest of the body with a sponge or flannel, rather than bathing or showering fully. Drinking plenty of water is advised in order to keep the urinary system functioning normally.
It is not unusual to experience some pain and/or irritation in the urethral area due to the presence of a transurethral catheter or some discomfort in the lower belly area if a suprapubic catheter is used. Suitable painkillers to take during the recovery process will be recommended by one’s doctor, and any irritation should clear up on its own once the catheter is removed. Some people may experience temporary urinary incontinence after the removal of the catheter. If this occurs, urinary pads should be worn until normal urinary function is restored.
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