Prostatectomy - for cancer

The prostate is part of the male reproductive system. It produces some of the fluid that makes up semen, which enriches and protects sperm. Prostate cancer develops when abnormal cells form in the prostate. These cells can keep multiplying and may spread beyond the prostate.

• Cancers that stay within the prostate are called localized prostate cancer.
• Cancer that extends into nearby tissues or the pelvic lymph nodes is called locally advanced prostate cancer.
• Cancer that spreads to other parts of the body, such as distant organs, lymph nodes outside the pelvis or bones, is called advanced or metastatic prostate cancer.

What is prostate cancer surgery?#

Surgery to remove the prostate is called a radical prostatectomy. The aim is to remove the entire prostate and all of the prostate cancer. The operation is carried out by a urologist.

You may be offered surgery if you:

• Have localized or locally advanced prostate cancer that has not spread too far outside the gland
• Are medically fit for surgery and do not have conditions that would put you at significant risk during or after the operation
• Are expected to live for 10 years or longer

The operation usually takes 2 to 4 hours. You will stay in hospital for a few days and then recover over several weeks at home. Most men need some time off work.

Is a prostatectomy right for me?#

There are often several options for treating localized or locally advanced prostate cancer, including surgery, external beam radiation therapy (with or without hormone therapy), brachytherapy, or actively monitoring the cancer. Deciding which treatment is right for you can be challenging.

It is helpful to see both a urologist and a radiation oncologist so you understand the treatment options, possible side effects, benefits and costs. Talk with your doctor, a prostate cancer specialist nurse, or a trusted support service for more information.

Surgery is an effective and potentially curative treatment for prostate cancer. Once the prostate is removed, the pathologist can provide detailed information about the cancer. Some men take comfort in knowing the whole gland, including the cancer within it, has been removed. If a man has urinary difficulties from a narrow or partly blocked urethra, surgery may also improve those symptoms.

It is important to talk to your surgeon about the risks, benefits and limitations of radical prostatectomy before treatment.

Risks of a prostatectomy#

Surgical risks that occur at or soon after surgery may include:

• Infection – this may occur at the wound site, in the urinary tract or chest, or through an intravenous (IV) line. Treatment may include antibiotics.
• Bleeding – this may require a blood transfusion, and in rare cases another operation.
• Deep vein thrombosis (DVT) – this is when blood clots form. A DVT can be life-threatening if the clot dislodges and travels to the lungs (pulmonary embolism). People are given special stockings to wear during the operation and recovery, along with blood-thinning medication to help prevent it. If a DVT does occur, treatment may include more blood-thinning medication.
• Injury to nearby organs – the rectum, bladder and ureters (the slender tubes that drain urine from the kidneys to the bladder) lie close to the prostate and may be accidentally injured. Further surgery to repair the damage may be needed.

Types of prostatectomy#

During a radical prostatectomy, the surgeon removes the prostate gland along with the seminal vesicles and vas deferens. The surgeon cuts the urethra just above and below the prostate, then moves the bladder down and re-joins it to the urethra. Sometimes the surgeon also removes nearby lymph nodes to check whether the cancer has spread.

There are three ways the operation can be done:

• Open radical prostatectomy – the surgeon makes a cut about 8 cm long in the lower abdomen to remove the prostate. The cut may run from below the belly button to the top of the pubic hairline, or across the top of the pubic hairline.
• Laparoscopic radical prostatectomy – keyhole surgery through several small cuts in the lower abdomen. A small camera and surgical instruments are inserted so the surgeon can see and remove the prostate.
• Robotic-assisted radical prostatectomy – keyhole surgery performed with the aid of a robot controlled from a console. This gives the surgeon a clearer view during the operation.

Recovery time and hospital stay may be shorter with laparoscopic or robotic surgery than with open surgery, but all three approaches have similar rates of cancer control and side effects.

Recovering at home#

Planning for your discharge starts within the first day of surgery. The hospital will tell you who to contact if you have problems after you go home. Make sure you understand your follow-up arrangements for removing the catheter and when to see your urologist.

Gentle activities are recommended while the catheter is still in place. When it is removed, you can slowly return to activities that do not involve straining, and it is important to re-start your pelvic floor exercises at this point. It is normal to feel tired after surgery, so rest when you need to. Your healthcare team will advise when you can return to driving and exercise.

See your surgeon immediately if you notice signs of infection such as fever, discharge, redness, swelling or problems with urination. If you cannot see your surgeon, visit a doctor or go to your nearest emergency department.

Possible side effects of surgery#

All prostate cancer treatments, including surgery, can have side effects. The types can generally be predicted, but how severe they are differs from person to person. The more you learn about your treatment and its possible effects beforehand, the better prepared you will be.

Urinary side effects#

Most men have some degree of urinary leakage (incontinence) after the catheter is removed. This can be managed by wearing pads. For most men, incontinence improves within 2 to 12 weeks, but for some it takes longer (3 to 12 months). Occasionally it becomes a long-term problem, and further surgery may be done to improve continence. Continence generally returns faster in younger men and in those who did pelvic floor exercises before surgery.

In a small number of men, scar tissue can develop where the urethra was re-joined to the bladder (the anastomosis). The urine stream may become weaker, harder to start, or the bladder may be difficult to empty. If this happens, a telescope is passed into the bladder (cystoscopy) to look at the anastomosis, and occasionally further surgery is needed.

Lymph gland side effects#

Men who have lymph glands removed during surgery may develop a collection of fluid (lymphocoele) at the site. This may need draining or may settle on its own. Minor swelling in the legs (lymphoedema) can also occur. Although rare, seeing a physiotherapist can help manage any swelling. Talk to your healthcare team about any symptoms so they can provide the right treatment and support.

Sexual side effects#

• Erection problems (erectile dysfunction) are a common side effect. This is when you cannot achieve or maintain an erection firm enough for sexual activity. It may be temporary or permanent, and it is common to lose erections in the short term. Erections can take 18 to 24 months to recover, and there are many treatment options to discuss with your specialist or healthcare team.
• Dry orgasm occurs in all men after a radical prostatectomy. Because the prostate and seminal vesicles make most of the fluid in semen, removing them means there is no longer any ejaculation when you orgasm. Men report different experiences: some describe a more intense orgasm, others find it less pleasurable.
• Infertility results from the loss of ejaculation. If you plan to have children after treatment, discuss this with your partner and healthcare team beforehand.
• Climacturia is leaking urine during orgasm. Emptying your bladder before sex can help, and you can use a condom if this is a concern for you or your partner. Speak with your doctor.
• Change in penis size – some men notice shortening of the penis after surgery, on average about 1.2 cm. This may be due to scar tissue or reduced nerve or blood supply.

Ongoing care#

Follow-up appointments will be offered to check that you are recovering. You may see your urologist within the first 6 to 8 weeks after surgery and have your first PSA blood test around that time. After surgery, the prostate and surrounding tissue are examined by a pathologist to determine the grade and stage of the cancer, whether it spread through the gland walls, and whether it was completely removed. Your urologist uses this information and your 6-to-8-week PSA result as a baseline for your continuing care. Ask your healthcare team about your ongoing follow-up.

Managing your wellbeing#

If you have prostate cancer, it is normal to feel a wide range of emotions such as shock, deep sadness, anxiety, anger, fear and frustration. Some days will be worse than others. You may also notice physical effects of stress, like nausea, stomach upsets, feeling irritable or on edge, and trouble sleeping.

It can help to talk through your worries with a partner or close friend, gather information and advice from trusted sources, and focus on keeping well. If you are very distressed and it is affecting your life, talk to your doctor or a member of your healthcare team, or contact a trusted support service for further help.

Key points#

• Deciding which treatment is right for you can be challenging
• Surgery is an effective and potentially curative treatment for prostate cancer
• If a man has urinary difficulties from a narrow or partly blocked urethra, surgery may improve those symptoms
• Infections may be treated with antibiotics
• Blood-thinning medication is given to help prevent clots after surgery

Where to get help#