Surgery (Radical Prostatectomy)
Surgery is an option for men who have early prostate cancer (T1) or cancer that is localized to the prostate (T2). It may also sometimes be used for men with T3 disease. A Gleason grade of 8 or below is ideally suited for surgery and a PSA level below 20 provided that the cancer is confined to the prostate. However the higher the grade of cancer, (even with a low PSA level), the more chance that microscopic cancer cells may have spread to the capsule of the prostate or beyond meaning that some residual disease may be left behind after surgery. If the PSA level is above 10 then during surgery a surgeon is likely to remove nearby lymph nodes to check for any spread of cancer outside of the prostate (see diagram below).
The human body is covered by a special type of drainage system called the lymphatic system. This system is responsible for transporting excess fluid from the organs and tissues of the body in a fluid called lymph. Lymph fluid will contain various types of cells and substances that are no longer needed. The lymph fluid will be transported through the lymphatic drainage system and pass through small nodules or nodes that act as filtering stations. They are responsible for filtering out the unwanted substances. If one lymph node is not able to filter out the unwanted substances then the lymph fluid will move to the next one. Cancerous cells which break off from the an organ which has cancer and can also travel along this route and become trapped at the lymph nodes where they can then accumulate and infiltrate that area of the body.
Usually men who benefit from surgery are under the age of 70 or in their early 70s and both medically and physically fit. This is because one of the side effects of surgery is some disruption to urinary continence which could reduce the quality of life for older men without extending their life expectancy.
During surgery the whole of the prostate gland as well as the surrounding seminal vesicles are removed. Prostatectomy is considered a major operation although hospital stay will only involve a few days stay.
Surgery to remove the prostate gland and the surrounding seminal vesicles can be performed in several ways. An operation to remove the whole of the prostate is called a prostatectomy. Traditionally surgery has been performed by an “open” operation where a single cut into the abdomen is made. Today laparoscopic (keyhole) surgery is more common and relies on several small incisions being made into the abdomen rather than one cut. A newer procedure called robotic prostatectomy is also available in some hospitals or specialist centres. This is still laparoscopic surgery but instead of manually holding surgical instruments during the operation a urologist will control a computerised machine which will make surgical incisions and remove the prostate gland.
Research has indicated that there is no significant difference in which technique is used to perform a prostatectomy with regard to possible side effects.
Most hospitals that perform prostatectomy will have a special care pathway in place, called an Enhanced Recovery Programme (ERP) to make sure that hospital stay after an operation is as short as possible. Following prostatectomy men should be able to eat and drink straight away and will be given painkillers on a regular basis if they need them.
A small plastic tube called a “drain” may be left in the abdomen for a short time after the operation to collect any excess blood draining from the operation site which could accumulate and delay the healing process.To allow time for the operation site around the prostate to heal a urinary drainage tube called a catheter will be left in place for up to 10-days.
Catheters and Catheter care
A catheter is a plastic tube that drains urine from the bladder. It will be connected to a drainage bag. The catheter is held inside the bladder by a balloon that is inflated with sterile water following insertion. It will therefore not usually come out unless properly removed by deflating the balloon. The balloon of the catheter tends to rest over a sensitive area of nerves in the bladder which may become irritated by its presence. This irritation may make a man feel as if he is bursting to pass urine and sometimes the nerves in the bladder will react to this irritation and force a small amount of urine to be expelled from around the catheter.
- Unless instructed otherwise men can have a shower or bath with the catheter in place.
- Do not use powders or lotions around the catheter or penis entry site.
- If men find the catheter is leaking they should not put non sterile materials around the penis.
- It is very important to drink 2 – 3 litres of fluid daily to flush the urine through and water based drinks tend to prevent bacteria forming in the urine which can lead to infection.
- When emptying or connecting catheter bags men should always wash their hands thoroughly with soap and water before and after the procedure.
- Do not pull or tug at the catheter.
Possible Side effects
Erectile Dysfunction (ED)
The nerves that control a man’s erections are situated adjacent to the prostate gland and during surgery these nerves may be affected. If only a small amount of prostate cancer is present on one or both sides of the prostate than a surgeon may be able to avoid or “save” these nerves, a technique called nerve sparing surgery. In this situation there is a greater chance that a man will regain his erections fully although this may still take a year or more to fully improve. For greater volume disease it is less likely that a surgeon will be able to save these nerves as the priority will be to ensure that no residual cancer is left behind.
Medications to improve a man’s erections can be used after surgery as well as a manual vacuum device to promote blood flow to the penis. A man will also not be able to father children following prostatectomy .For more information on treatment for ED please see here.
Normal urinary continence is maintained by two valves (sphincters) situated around the bladder, the internal urinary sphincter and the external urinary sphincter. During prostatectomy the internal urinary sphincter will be removed. This will mean that following surgery men may suffer from a type of urinary incontinence called stress incontinence where they may not be able to control their ability to pass urine. This may mean that they may leak some urine and may need to wear protective pads for a short time after surgery. Special exercises called pelvic floor exercises are recommended for all men who are undergoing prostatectomy. These are designed to strengthen the pelvic floor muscles which also contribute to urinary continence. Men who are going to have surgery should start practising these as soon as possible (see below).
How to Perform Pelvic Floor Exercises
The pelvic floor supports the bladder and the bowel and is made up of layers of muscle that stretch from the tailbone at the back to the pubic bone in front. Research has shown that men who practice these may notice an improvement in their erections. They are especially important to perform after surgery to remove the prostate gland (prostatectomy).
How to find the pelvic floor muscles
To find your pelvic floor muscles, men should sit or lie comfortably with the muscles of your thighs, bottom and stomach relaxed.
Muscles around the anus
Men should then tighten the ring of muscle around the anus without squeezing your bottom as if they are stopping diarrhoea or wind. They should not hold their breath.
Muscles around the urethra
To feel these muscles imagine men should imagine that they are trying to stop their flow of urine mid-stream, and then restart it. If performed correctly they should feel the base of your penis move up slightly towards their abdomen.
Tighten and draw in the muscles around the anus and urethra, lifting the muscles up inside. Count to five, then release and relax. Men should have a ‘definite feeling of letting go’. Repeat this up to maximum of 8 to 10 squeezes, resting for 10 seconds after each tightening of the muscles. Men should follow this by 5 to 10 short, strong squeezes in quick succession.
Repeat the slow and quick squeezes around three to four times a day.
If men are not sure whether they are performing the exercises correctly they can ask their GP or hospital team to refer them to a physiotherapist or continence specialist who will be able to make sure that they are performing them correctly.
Urinary symptoms should improve quickly after surgery and may normalise within 2-3 months but a small percentage of men may find that after a year they still suffer some minor stress incontinence when they laugh, cough, sneeze or perform sudden movements, however this does not tend to interfere with their day to day lifestyle.
I have had a prostatectomy and my surgeon has told me that I had a positive margin; what does this mean?
Once the prostate gland has been removed it is carefully examined by tissue specialists (histo-pathologists) under a microscope to identify the full extent of the cancer. Even if the cancer was confined to the prostate gland it may sometimes be found to be extending to the surgical resection margin (cut). This may mean that there is more chance that microscopic cancer cells may have escaped and may become active again in the future. The prostate secretes PSA and therefore once it has been removed PSA levels in the blood should be undetectable (less than 0.1). If the PSA rises above this level there is more chance that further treatment usually with radiotherapy may be needed. However it is not clear when to receive radiotherapy in this situation and men who have a positive margin may be asked to consider taking part in a clinical trial called RADICALS which is trying to evaluate the best time to use radiotherapy in this situation.
Bladder Neck Stenosis and Urethral Stricture
During surgery there will be a natural anatomical gap between the urethra and bladder where the prostate was situated. This is surgically repaired by re-joining the urethra to the bladder with stitches. Sometimes surgery may cause “scar tissue” to at the operation site and narrow the urethra which may in turn cause men difficulty in passing urine. This is termed a urethral stricture. In this situation a minor surgical procedure can be performed to widen the urethra.
Once the prostate has been removed no PSA level should be detectable. Men will usually be asked to have a PSA blood test at around 4-weeks after surgery and will be reviewed in clinic with the results of their operation at around 6-weeks. The whole of the prostate tissue will be have been analysed and the results discussed at an MDT meeting to decide if any other treatment may be beneficial. If there is any obvious evidence that residual prostate cancer may still be present or it was found that the cancer had spread further than first thought then treatment with radiotherapy to the area where the prostate used to be (prostatic bed) may be recommended. In this situation men will be referred to an oncologist (cancer specialist) to discuss possible radiotherapy treatment. Otherwise they will be reviewed in the outpatient clinic usually every 3-months with a PSA blood test. This will gradually increase to 6- monthly and then yearly.
For more information on prostatectomy from the British Association of Urology Surgeons please see the links below.
Last reviewed 04/06/2018. Next review 04/12/2018.
References available on request.