Prostatectomy

ALSO KNOWN AS: Radical prostatectomy, transurethral resection of the prostate (TURP)

DEFINITION: Prostatectomy is the surgical removal of part or all of the prostate gland. A radical prostatectomy refers to prostate gland removal and removal of surrounding tissue. A transurethral resection (TURP) refers to the removal of only part of the prostate.

Cancers treated:Prostate cancer

Why performed: A radical prostatectomy is performed to remove cancer that is confined to the prostate gland and surrounding area. This procedure is not usually done when cancer has spread beyond the prostate gland to distant tissues or organs.

A TURP is commonly done to relieve symptoms associated with benign prostatic hyperplasia (BPH). With BPH, the prostate gland is enlarged and squeezes the urethra, creating problems with urination. Removal of part of the prostate gland can usually alleviate those symptoms.

Patient preparation: Generally, no food or drink is consumed after midnight on the day before undergoing general anesthesia. The evening before a radical prostatectomy, a bowel preparation is usually taken to cleanse the colon.

Steps of the procedure: For a radical prostatectomy, the procedure varies depending on which method the surgeon uses: open, laparoscopic, or laparoscopically assisted prostatectomy. Typically, general anesthesia is used with all these procedures.

Open surgery involves an incision in the lower abdomen if the retropubic approach is done, or in the groin between the anus and the penis for the perineal approach. The retropubic approach is most common and allows the surgeon to remove the prostate gland and the lymph nodes, if necessary, to be checked for cancer spread beyond the prostate. This approach allows the surgeon to attempt to preserve the nerves that help control bladder and sexual function. Lymph node removal can be done with the perineal approach, but a separate incision must be made, and preservation of sexual function is not possible. The open procedure can take from two to four hours to complete.

With laparoscopy and the laparoscopically assisted approach, several small incisions are made in the lower abdomen. The laparoscope allows the surgeon to see inside the abdominal cavity and remove the prostate and surrounding tissue. With the robot-assisted procedure, the surgeon performs the procedure remotely with a robot. Occasionally, a laparoscopic procedure may need to be converted to an open procedure if difficulty is encountered.

No abdominal incision is needed for a TURP. A cutting instrument or a heated wire loop is inserted through the penis to the prostate gland to remove or destroy prostate tissue. The bladder is then flushed with sterile solution to remove the destroyed tissue from the body. Further, doctors have begun to use aquablation, a non-thermal technology that also resects the prostate tissue but may be more accurate and safer than traditional TURP methods.

With all these procedures, a small flexible tube called a urinary catheter is inserted into the bladder and left in place to drain urine during the healing process.

After the procedure: An open prostatectomy is considered major abdominal surgery. Patients typically remain in the hospital for two to four days. Recovery time can be as long as twelve weeks. A laparoscopic procedure is less invasive. The hospital stay is usually two to three days, and recovery time ranges from two to six weeks. The urinary catheter is typically removed one to three weeks after the procedure.

With a TURP, the hospital stay is generally one to two days. The urinary catheter is generally left in place for one to three days after the procedure.

Risks: General complications from undergoing a major surgical procedure may include bleeding, blood clots, heart problems, infection, allergic reaction to anesthesia, and, in rare cases, death.

Short-term complications from a radical prostatectomy may include urinary incontinence, which is the inability to control the bladder. This condition generally improves, and full bladder control is regained over time.

The risks from a TURP may include excessive bleeding, a urinary tract infection, or pain with urination. Some men temporarily develop problems due to the large amounts of irrigating fluid used to flush out the bladder. A more permanent condition that can develop is a stricture, a permanent narrowing of the urethra that can occur if the urethra is damaged during the procedure.

Results: When prostate cancer is confined to the prostate gland, the cure rate is very high. Five-year survival approaches 100 percent. Overall, prostatectomy success rates are highest for men with low-risk disease and vary depending on the surgeon’s technique and experience with the procedure. One long-term study following men who underwent radical prostatectomy found that between five and twenty years following the procedure, 3 percent had died of prostate cancer, 5 percent had cancer spread to other organs, and 6 percent had a localized reoccurrence of cancer. 

Erectile dysfunction is a common side effect. The nerves that control erections are located on both sides of the prostate gland and are easily damaged or may be removed during the procedure. Age and erectile function before surgery can affect the likelihood of problems after the procedure.

Urinary incontinence is another common problem with this procedure and includes occasional urine leakage to complete inability to control urine flow. In some cases, additional surgery may be necessary to correct the problem. In the 2020s, doctors developed the Retzius-sparing approach to prostatectomy which allowed doctors to better preserve anatomical structures, reducing the rate of post-surgical incontinence.

With a TURP, urination problems generally stop after the swelling has subsided.

After the surgical procedure, it is important for the patient to discuss monitoring his condition with additional testing to ensure that the problems have not returned.

Bibliography

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