Prostatectomy is surgical removal of a man's prostate gland. It is one possible treatment for prostate cancer and other prostate conditions, such as an enlarged prostate. The operation is performed by a urologist (urologic surgeon) in either open or laparoscopic surgery .
Radical prostatectomy, which includes removal of tissues near the gland, usually cures prostate cancer if the surgery removes all the malignant cells. The incision is usually made through the lower abdomen (retropubic) but also can be made in the groin (perineal). Typically, general anesthesia is used and the patient remains in the hospital for two to four days following surgery. Full recovery may require one month or more.
Partial prostatectomy is generally a treatment for enlargement of the prostate, which is common after age 50. It can also be used to reduce pain and ease urination in men with advanced prostate cancer.
Complications from prostatectomy are those associated with any surgery, including infection and bleeding. Other complications vary depending on the age and health of the man, type of surgery and experience of the surgeon. Two primary concerns men have about radical prostatectomy are the possibilities of impotence and incontinence. Patients can retain sexual function if nerves are not injured during the surgery. Urinary incontinence is usually temporary but bladder problems can continue for years. Radical prostatectomy does cause sterility, but there are procedures that may allow a man to father children, if desired.
What is prostatectomy?
Prostatectomy is surgical removal of the prostate gland . When performed to treat prostate cancer, the procedure usually includes removal of some adjacent tissues and is called a radical prostatectomy. Radical prostatectomy involves open surgery, with the incision made in the lower abdomen (retropubic prostatectomy) or between the scrotum and anus (perineal prostatectomy). A possible alternative to these open prostatectomies is laparoscopic surgery, a minimally invasive procedure that uses several small incisions to remove the prostate.
Partial (or simple) prostatectomy is more often used as a treatment for enlargement of the prostate, which is common after age 50, or to relieve pain and facilitate urination in men with advanced prostate cancer. The surgeon inserts an instrument through the urethra to remove prostate tissue in a transurethral resection of the prostate (TURP). The surgeon also can make cuts in the gland in a transurethral incision of the prostate.
Prostatectomy is not an appropriate treatment for all prostate cancer. Prostate cancer usually grows slowly and may need no initial treatment other than regular monitoring, referred to as "watchful waiting." Surgery usually cannot help advanced cases that have metastasized (spread outside the gland). Radical prostatectomy is generally reserved for patients who :
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Are in good health and under age 70 (older men may also have the surgery).
Have cancer confined to the prostate gland (bone scans or other test results have shown the cancer has not spread to other areas).
The prostate is a walnut-size male reproductive gland located in front of the rectum. It lies below the urinary bladder and surrounds the upper part of the urethra, the tube that at different times carries urine and semen out of the body through the penis. The prostate helps makes seminal fluid, which protects sperm cells in semen. Located behind the prostate are the seminal vesicles, which make most of the seminal fluid. As men age, the prostate tends to enlarge and constrict the urethra, reducing the flow of urine.
Main concerns that many men have about removal of the prostate are related to sexual function and bladder control. Men may avoid impotence if nerve-sparing surgery can be used. Patients usually regain full urinary continence within weeks or months. However, incontinence may last up to 12 months.
According to the American Academy of Family Physicians : -
Patients under age 50 are more likely to retain sexual function.
Patients over 70 are more likely to become impotent.
Impotence is less likely if the tumor is small and nerves do not have to be cut.
Patients rarely have severe incontinence. About one-third may have occasional leaking of urine during laughter, coughing, sneezing or heavy lifting.
Before the prostatectomy procedure
Prostatectomy requires little preparation on the patient's part. Ideally, he is in good physical condition resulting in a faster recovery. It is helpful for a man to prepare emotionally by learning what is involved in the procedure, including the risks and potential complications. In addition, if the man has a wife o partner it can be beneficial for them to participate in the education and the decision process.
Steps to consider before surgery : -
Arranging for time off from work (if necessary) because recovery can take a month or more.
Donating blood weeks in advance for use during the operation.
Using a sperm bank. Radical prostatectomy causes sterility. Men who still want to father children may want to store their semen in advance in a sperm bank.
During the prostatectomy procedure
The steps of a prostatectomy depend on the type of procedure. The most common prostatectomy used to try to cure prostate cancer is radical retropubic prostatectomy. It is performed by a urologic surgeon in a hospital. The surgery, which can last up to four hours, may be done under:
General anesthesia
Spinal anesthesia (injected into the sac of cerebrospinal fluid)
Epidural anesthesia (injected outside the cerebrospinal sac)
Lymph nodes near the prostate may be removed and sent to a pathologist for a detailed examination. The operation may be ended at this point if some of these lymph nodes are found to be cancerous, which indicates metastasis (spread) and a poor prognosis (chance of cure). If there is no lymph node involvement, the surgery proceeds and the prostate is removed, along with surrounding tissue, including the seminal vesicles and sometimes lymph nodes.
The surgeon will attempt to spare the nerve fibers that flank the prostate unless they are cancerous. The primary goal of the surgery is to remove all of the cancer possible. For this reason, one or both nerves may need to be cut or completely removed. These nerves control erections and the patient becomes impotent if nerves are removed or severed. Sparing the nerves does not guarantee that a man will avoid impotency.
Following the removal of the gland and necessary surrounding tissues, the incision is then closed with sutures. While the patient is still under anesthesia, a catheter is threaded through the tube-like urethra of the penis into the bladder to allow urination during healing.
The procedure differs slightly in another type of open prostatectomy called perineal prostatectomy. The surgeon makes an incision in the perineum, the area between the scrotum and the anus. This procedure may last as little as an hour and a half and involve less pain during recovery. It is used less often than retropubic, however, because it cannot remove lymph nodes and surgeons cannot easily avoid cutting the nerves that control erections.
In addition to these open prostatectomies, some major medical centers offer laparoscopic radical prostatectomy (LRP). The surgeon makes several shorter incisions and uses a camera and specialized tubular instruments to remove the prostate and surrounding tissues. Laparoscopic surgery is less invasive and usually results in a shorter recovery period.
Some medical facilities are using robotic-assisted laparoscopy to perform prostatectomies. The procedure is similar to LRP but he surgeon directs the robot rather than directly handling the instruments. Both of these procedures require surgeons with specialized training.
In late-stage cases where radical prostatectomy cannot cure prostate cancer, partial prostatectomy may be used to relieve pain and ease urination. Types of partial prostatectomy:
Transurethral resection of the prostate (TURP) : - The surgeon inserts a wire-like instrument called a resectoscope through the urethra and uses electricity to cut out layers of prostate tissue. Spinal or general anesthesia is used, and the surgery takes about an hour. Blood in the urine is common after surgery. A temporary catheter is placed through the urethra to drain urine from the bladder during healing.
Transurethral incision of the prostate (TUIP) : - The surgeon inserts an instrument through the urethra and makes a few small cuts in the prostate to reduce the gland's constriction of the urethra and improve the flow of urine. This procedure is newer and performed less often than TURP. Advantages of TUIP include less loss of blood and less risk of retrograde ejaculation, where sterility results because the semen flows backward into the bladder. Anesthesia is used, but TUIP sometimes does not require an overnight hospital stay.
After the prostatectomy procedure
Recovery time following prostatectomy will vary depending on the type of surgery performed : -
Radical prostatectomy (retropubic or perineal) : - This surgery may require the patient to stay hospitalized for two or three days and miss work for three to five weeks. The catheter may remain for one to three weeks. When the patient urinates, the fluid flows through the plastic tube and collects in a bag for disposal.
Laparoscopic prostatectomy : - Long-term experience with laparoscopic prostatectomy is not yet available. This surgery may require a hospital stay of only one day. Some physicians and patients report that it involves fewer complications, less pain and faster recovery than open surgery.
Partial (simple) prostatectomy (transurethral resection of the prostate [TURP] or transurethral incision of the prostate [TUIP]) : - Generally, a patient is discharged from the hospital after a day or two and can return to work in a week or two. A catheter placed through the urethra is used for a few days to drain urine from the bladder. TUIP does not always require a hospital stay.
If the surgery was performed for cancer, the surgeon and oncologists will review the pathology reports. Some patients may need to receive additional treatments, such as radiation therapy or hormone therapy. Recent studies have suggested that removal of the prostate and surrounding lymph nodes may be adequate treatment for advance prostate cancer. Although adding radiation therapy may reduce the risk of the cancer returning, it did not seem to improve overall survival. However, the use of radiation therapy following prostatectomy to destroy any remaining cancer cells continues to be an area of debate.
For other men, the follow-up plan will include regular visits to a physician and tests including a blood test for a substance called prostate-specific antigen (PSA). Additional blood tests , scans and x-rays may also be performed. If the tests indicate recurrent cancer, possible treatments include radiation therapy, cryotherapy, hormone therapy or chemotherapy .
Benefits and risks of prostatectomy
Radical prostatectomy can offer great hope to a man with prostate cancer. The procedure can cure the cancer if the surgery removes all malignant cells. One recent study found that death from prostate cancer remains minimal among patients with early prostate cancer who underwent a radical prostatectomy. This study included some of the most long-term data for this select group of patients. Other studies have supported high survival rates in men with localized prostate cancer treated with prostatectomy.
However, potential risks with prostatectomy include : -
Impotence : - This will occur if some or all of the nerves that flank the prostate are injured. Even if nerve-sparing surgery is used, temporary impotence for up to a year is common with radical prostatectomy. The rate of impotence can be as low as 25 percent in patients under age 60, but as high as 80 percent in men over 70 even if the nerves remain intact, according to the American Cancer Society .
Sterility : - Radical prostatectomy and partial prostatectomy can cause infertility.
Urinary incontinence : - Severe inability to control urination is uncommon after prostatectomy. However, some men have occasional difficulty with leakage or dribbling.
Fecal incontinence : - Loss of bowel control is possible but uncommon after prostatectomy.
Lymphedema : - Accumulation of fluids near the genitals or in the legs. This is a rare complication if lymph nodes are removed during prostatectomy.
According to a study, men with localized prostate cancer who undergo a radical prostatectomy are more likely to experience urinary and sexual dysfunction than those who receive external beam radiation therapy. However, bowel problems are more common in men receiving radiation therapy.
In addition, prostatectomy involves the usual risks of surgery, such as : -
Heavy loss of blood
Allergic reaction to or overdose of anesthesia
Blood clots, stroke, heart attack and other cardiac complications
Infection at the incision
Death
Some research has found that men who are obese have a greater chance of cancer recurrence or death following prostatectomy. However, recent studies have suggested that while obese men are more likely to have relatively aggressive tumors, their risk of death or recurrence in the 10 years following surgery is no greater than men of normal weight.
Lifestyle considerations with prostatectomy
Prostatectomy can have a profound effect on a man's life. The primary issues are impotence, incontinence and sterility but there are many ways to deal with these side effects and have a satisfying life.
Impotence (also called erectile dysfunction ) is the inability to produce an erection capable of sexual penetration.
Most physicians believe that regaining potency is helped by attempting to achieve an erection as soon as the body has recovered from surgery. Generally this is about six weeks after the prostatectomy.
Methods of coping with impotence include : -
Medications : - A class of pills called phosphodiesterase inhibitors, commonly known as erectile dysfunction (ED) drugs under many brand names, can promote erections if prostatectomy has not cut or damaged both nerve bundles. These drugs can interact dangerously with some heart medications and their use should be discussed with a physician.
Prostaglandin E1 : - This fatty acid produced in the body can cause erections if injected into the penis before intercourse. Injection is said to be nearly painless. It can also be supplied as a tiny suppository inserted into the opening of the urethra at the end of the penis. Prostaglandin E1 may not work if there is severe nerve damage .
Vacuum pump : - A medically approved plastic tube is briefly placed over the penis before intercourse. Air is pumped out of the tube to stimulate an erection. A vacuum pump may work if there is nerve damage.
Penile implant : - There are several types of implants available. A typical type features inflatable plastic cylinders surgically placed in the spongy tissue of the penis. A tube connects the cylinders to a pump placed into the scrotum. A reservoir of liquid used to fill the cylinders is placed in the lower abdomen. The man can achieve an erection by pressing the pump to fill the cylinders. The liquid later drains back into the reservoir. A urologist or other physician can give more details about available implants and their usage.
Few men have permanent severe incontinence after prostatectomy. Normal bladder function usually returns within several weeks or months. Men may have occasional stress incontinence (leakage of urine when laughing, coughing, sneezing or exercising).
If urinary incontinence is a problem, possible treatments include : -
Medications that affect the muscles of the bladder or its sphincter
Performing Kegel exercises to tighten the pelvic and bladder muscles
Use of pads, absorbent undergarments and other incontinence products
Self-catheterization. Inserting a tube into the urethra to drain urine.
Surgery in case of severe long-term incontinence, including collagen implants and implantation of an artificial sphincter.
Radical prostatectomies and many partial prostatectomies cause sterility because they result in retrograde ejaculation, where the semen is discharged back into the bladder rather than out of the penis through the urethra. In some cases, it may be possible to retrieve semen from the bladder and use it for artificial insemination. Semen also may be stored in a sperm bank before undergoing prostatectomy. Sterility is not an issue for most patients because prostatectomy is usually performed in older men, but for some it is a concern.
A physician can offer more information about treatment options for incontinence, impotence and sterility. Prostate cancer survivor groups and other men's support groups can also help men prepare for and deal with the aftermath of the surgery.
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