Prostatectomy

A prostatectomy is a surgery to remove the prostate gland. The prostate gland produces the fluid part of semen and sits underneath the bladder and around the tube that takes urine out of the body (urethra). It’s usually removed to treat prostate cancer or, less commonly, an enlarged prostate (benign prostatic hyperplasia).

There are 2 main types of prostatectomy: a simple prostatectomy that removes the inner part of the prostate gland and a radical prostatectomy that removes the entire prostate gland and surrounding tissues.

This article focuses on radical prostatectomy, which can be performed either as an open prostatectomy or a laparoscopic prostatectomy. A laparoscopic prostatectomy can be performed with the help of robotic technology, where the surgeon uses robotic arms to perform the operation.

Signs of needing a prostatectomy

Prostate cancer

A prostatectomy is most commonly performed to treat prostate cancer to prevent the cancer from spreading to other tissues. Whether a prostatectomy is needed will depend on the type and stage of prostate cancer you have.

Signs of prostate cancer include:

• Blood in your urine and/or semen
• Difficulty urinating or starting to urinate
• Erectile dysfunction ie having difficulty getting and/or maintaining an erection
• Lower back pain or pelvic pain
• Urinating more often and/or having sudden urges to urinate
• Weak urine flow or urine flow that stops and starts

If you notice any of these symptoms, it’s important to see your GP to have them investigated.

Although these symptoms occur in prostate cancer, they can also occur in other conditions, such as benign prostatic hyperplasia (BPH), more commonly known as an enlarged prostate. This can cause problems passing urine.

In severe cases of BPH that do not respond to medications, lifestyle changes or minimally invasive procedures, your doctor may recommend a prostatectomy.

Is a prostatectomy right for you?

In cases of BPH, a prostatectomy can improve your quality of life by resolving problems with urination. However, as every surgery comes with risks, a prostatectomy is not usually recommended to treat BPH unless other treatments have not been successful.

In cases of prostate cancer, which is the most common reason for having a prostatectomy, surgery can help successfully treat the cancer. However, a prostatectomy may not be suitable if the:

• Cancer has spread beyond the prostate — as the goal of a prostatectomy is to prevent the spread of cancer, surgery would not usually help in this case
• Cancer is very slow-growing and low-risk ie unlikely to cause significant problems or reduce life expectancy — close monitoring of the cancer may be recommended instead
• Surgery is considered high-risk due to a patient’s advanced age or other health problems

Alternative treatments to a radical prostatectomy

If you have been diagnosed with a slow-growing, low-risk prostate cancer, your doctor may recommend active surveillance. This is where the cancer is closely monitored, and treatment is only started if the cancer shows signs of growing faster. 

If you have been diagnosed with early-stage prostate cancer that is contained within the inner part of the prostate, a simple prostatectomy may be recommended instead of a radical prostatectomy. This involves removing the inner part of the prostate gland and leaving the outer part (capsule) intact.

If you have been diagnosed with more advanced prostate cancer, which has already spread beyond the prostate gland, your doctor may recommend non-surgical treatments, such as radiotherapy, hormone therapy and chemotherapy.

A radical prostatectomy can be performed as an open surgery or a laparoscopic surgery. A laparoscopic prostatectomy can be performed with the help of robotic technology (known as a robotic prostatectomy or robotic-assisted prostatectomy).

Types of prostatectomy procedures

Open prostatectomy

During an open prostatectomy, a single large cut of around 15–20 cm will be made across your lower abdomen. The prostate is removed through this cut, along with surrounding tissues ie the lymph glands and glands called seminal vesicles.

During this process, the urethra will be cut, disconnecting it from the bladder. After the prostate gland and surrounding tissues are removed, the urethra is reconnected to the bladder. A small rubber tube called a catheter will be inserted into the bladder and pass into the urethra — this helps the newly reconnected urethra heal without narrowing.

A drainage tube may also be inserted and left in place for around 2 days to drain excess fluid from the site of your surgery.

Laparoscopic prostatectomy

During a laparoscopic prostatectomy, several small cuts will be made across your lower abdomen and small plastic tubes will be inserted through them. A thin telescope-like device with a light and a camera on the end (laparoscope) and surgical instruments will be inserted via these cuts.

Another larger cut of around 3–4 cm will be made into your lower abdomen, through which your prostate and surrounding tissues will be removed.

As with an open laparoscopy, the urethra will be cut in order to remove the prostate and will be reattached to the bladder after the prostate is removed. A catheter will be inserted into the bladder and pass into the urethra. A drainage tube may also be inserted to drain excess fluid from the area.

Robotic-assisted prostatectomy

A robotic-assisted laparoscopic prostatectomy is performed in the same way as a traditional laparoscopic prostatectomy except the surgeon uses robotic arms to carry out the operation.

Your surgeon will be seated at a console where they can see live video images transmitted by the laparoscope and control the robotic arms to make the necessary cuts and movements.

The robotic arms allow for greater precision and control, with the goal of reducing bleeding and pain after surgery, which helps speed up recovery. At Spire Healthcare, we use the advanced da Vinci® robotic-assisted surgery system to perform robotic-assisted prostatectomy surgeries. This technology is available at selected Spire hospitals nationwide.

How to prepare for a prostatectomy 

Before your surgery is scheduled, you will meet with your consultant surgeon to discuss your prostatectomy, including the risks and benefits, anaesthesia and recovery. You will have the opportunity to raise any concerns and ask any questions that you may have.

You may also need to attend a pre-operative appointment with your care team to review your health and any medications you are taking. If needed, your care team will arrange diagnostic tests before your surgery, such as blood tests or scans.

If you smoke, your care team will advise that you quit smoking before your surgery to help reduce the risk of complications and improve the healing process. They will also let you know how many hours you will need to fast for in the run-up to your surgery — this means not eating or drinking anything other than water and not chewing gum or smoking.

On the day of your surgery, your temperature, blood pressure and pulse will be checked and your urine will be tested for signs of infection. Your ability to urinate may be checked for later comparison during your recovery. You will also be asked to sign an informed consent form.

Before your surgery, you will be asked to change into a hospital gown. If needed, your care team may shave the hair around the site of your surgery — you should not do this yourself.

Who will be involved?

Your prostatectomy will be performed by a highly skilled surgeon called a urologist. Your anaesthesia will be administered by an experienced anaesthetist. You will be cared for by a team of nurses, including a specialised nurse called a theatre nurse who will support the surgeon during your operation.

How long does a prostatectomy take?

A radical prostatectomy, whether it is open, laparoscopic or robotic-assisted, takes around 3–4 hours.

Anaesthesia

A radical prostatectomy is performed under a general anaesthetic. This means you will be asleep during your surgery.

Pain during and after surgery

As a radical prostatectomy is performed under a general anaesthetic, you will not feel any pain during surgery.

Immediately after surgery, you will be given painkillers via an intravenous drip ie a small tube attached to a needle inserted into a vein in your arm. You will have control over how often the painkillers are released into your body — this is called patient-controlled analgesia (PCA).

You will usually have PCA for 1–2 days after surgery. The drip will then be removed and you will be given painkillers in the form of tablets, such as paracetamol and ibuprofen.

What happens immediately after surgery

You will be taken to a recovery room where your pulse, temperature, blood pressure and blood oxygen levels will be closely monitored.

Patient-controlled analgesia will be set up via an intravenous drip to help manage your pain levels.

You may feel groggy, lightheaded, nauseous and/or confused as the general anaesthetic wears off — this can take up to 24 hours. You should not make any major decisions or attempt to drive during this time.

You can drink water 1–2 hours after waking from your surgery and have light meals the next day.

Your hospital stay

If you have a traditional laparoscopic or robot-assisted laparoscopic radical prostatectomy, you will usually stay in hospital for 1–2 days.

If you have an open radical prostatectomy, you will stay in hospital for 3–7 days.

Recovery time

Complete recovery following a prostatectomy can take several months. However, it’s generally faster after a laparoscopic prostatectomy as smaller cuts are made, which means less bleeding and faster healing.

You should continue to walk around and slowly increase your physical activity as you recover. Movement will reduce the risk of blood clots and support your recovery. However, you will not be able to return to strenuous exercise or heavy lifting for 4–6 weeks. You should be able to return to most of your usual activities after 6–8 weeks.

Before you’re discharged from hospital, your care team will make sure that you have been able to drink water, have a meal, go to the toilet and walk around.

Short-term side effects

The area around your wound may feel numb and the scar that develops may feel sore for 6–8 weeks after your surgery.

After your catheter is removed, you may notice some leakage of urine (urinary incontinence). This is usually because the muscles of your pelvic floor have weakened due to surgery. Your care team will instruct you on how to perform pelvic floor exercises to strengthen the muscles. In most cases, after 6 months of regular daily exercises, urine leakage gets better.  

Wound care

Your care team will provide instructions on how to care for your wound. In general, the dressing that will be placed on your wound before you leave hospital should be kept on until you attend your follow-up appointment, where your wound will be examined.

You will need to keep your dressing dry, so it’s recommended that you have showers instead of baths. You can cover the dressing with a plastic sheet secured with medical tape.

The area around your wound will be swollen and may also appear purplish due to bruising. Both the swelling and bruising will get better in 2–3 weeks.

You will develop a scar. Initially the scar will be red and thick but as it heals it will become thinner and pale in colour.

Passing urine after surgery

Your care team will make sure that you pass urine within 24 hours of your surgery. Your catheter will remain in place for up to 2 weeks and will be removed by a nurse at an outpatient appointment.

Before you leave hospital, your care team will give you instructions on how to look after your catheter, including how to properly secure the catheter bag to your leg and how to clean the area where your catheter enters your urethra.

They will also advise you on what to expect when using your catheter eg sensations, the appearance of your urine and discharge or leakage around the catheter.

To ensure urine drains well out of your catheter and to reduce the risk of a urinary infection, you will be advised to drink at least 2 litres of water every day.

Opening your bowels after surgery

You may not be able to open your bowels for a few days after your prostatectomy. If you have not opened your bowels after 2–3 days and are feeling uncomfortable, your doctor may prescribe a laxative.

It’s important to follow a high-fibre diet after your surgery to help reduce the risk of constipation and subsequent straining when opening your bowels as this can slow your recovery.

Sexual activity

You can usually resume sexual activity after 6 weeks if you feel comfortable. However, it’s normal to experience erectile dysfunction after a radical prostatectomy. You may, therefore, want to speak to your doctor about treatment for erectile dysfunction at your follow-up appointment.

Pain relief

While you’re in hospital you will either have painkillers administered via an intravenous drip or regular painkiller tablets.

When you’re discharged, you’ll be given a prescription for 2 weeks of painkillers, such as paracetamol and ibuprofen, to take as instructed by your care team.

Smoking

Smoking can slow down the healing process. It’s advised that you don’t smoke for at least 6 weeks while you recover from surgery.

Driving

Your doctor will advise you about when you can return to driving. In general, you should not return to driving until you can comfortably make an emergency stop and turn your body to reverse your vehicle without experiencing any pain from your wound.

Time off work

Whether you have an open prostatectomy or a laparoscopic prostatectomy, you will likely need at least 6 weeks off work. If your work is physically strenuous, you may need more time off before you can return.

Every surgery comes with risks, such as excessive bleeding, excessive scarring, tissue damage, nerve damage and infection.

The risk of infection of the wound site is reduced by giving antibiotics before and after the surgery. However, the risk cannot be completely removed. If you notice the below signs of infection, contact your care team as soon as possible:

• Increased pain
• Increased redness
• Increased swelling
• The area around the wound site feeling warm to touch
• Unusual discharge from the wound site ie yellow- or green-tinged discharge

General anaesthesia also comes with risks, including nausea, vomiting, dizziness, confusion and headaches as the anaesthetic wears off. There’s also a very low risk of developing an allergic reaction to the anaesthetic.

Risks and complications specific to a radical prostatectomy include:

• Damage to the rectum —  this occurs in a few individuals in every 100 and may need an additional surgical procedure to be performed during your prostatectomy
• Erectile dysfunction — this affects almost all individuals after a radical prostatectomy
• Hernia — damage to the abdominal muscles during surgery increases the risk of a hernia in a few individuals in every 100
• Penis appearing shorter — removal of the prostate gland can make the penis appear shorter; this affects a few individuals in every 10 and can be treated with exercises to lengthen the penis
• Poor urine flow — scarring where the urethra is reattached to the bladder can cause poor urine flow for a few individuals in every 100
• Urinary incontinence — around 1 in 10 individuals will develop urinary incontinence on straining (eg coughing, laughing or sneezing) that persists for years after surgery

A radical prostatectomy cuts the connection between the testicles and the tube through which sperm leaves the body during ejaculation (urethra). You will, therefore, continue to make sperm in your testicles, but this sperm will not be ejaculated during sexual intercourse. This means you will not be able to conceive a child naturally.

However, you can choose to save some of your sperm in a sperm bank before your prostatectomy. This will give you the option of trying to conceive a child through fertility treatments, such as intrauterine insemination (IUI) or in vitro fertilisation (IVF). It’s important to have this discussion with your consultant before you make a decision about having a prostatectomy.

Can a prostatectomy affect your sex life?

In most cases, a radical prostatectomy leads to erectile dysfunction ie the inability to get and/or maintain an erection. This is caused by damage to the nerves when the prostate gland is removed. In some cases, nerve-sparing surgery can be performed to reduce damage to the nerves.

If nerve-sparing surgery is not possible, there are treatments for erectile dysfunction that will allow you to get and maintain an erection. These include injections, vacuum pumps and penile implants.