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Prostatectomy

Prostatectomy has been practiced for more than 100 years as a treatment for prostate cancer. However, it has been refined greatly in recent years such that results and patient-experience are much better than they were only a decade or two ago. Currently, the great majority of prostate removal surgeries are performed in a “minimally invasive” way. In other words, the surgery is performed via several small punctures rather than a large incision.

Our doctors have extensive experience with all of the major techniques for prostate removal and currently are employing robotic assist laparoscopic prostatectomy (DaVinci prostatectomy), including “nerve sparing” for the great majority of men who opt for prostate removal as treatment.

Men who are good candidates for this type of treatment have prostate cancer that is likely confined to the prostate. These men should also have adequate health and fitness such that surgery and anesthesia do not pose a major risk. Prostatectomy tends to be the most popular choice for men who are younger at the age of diagnosis.

What exactly is the prostate and what does it do?

The prostate is a walnut-sized gland located between the bladder and the penis that helps to make semen.

What is a PSA?

PSA stands for prostate-specific antigen, which is a substance made by cells in the prostate gland (both normal cells and cancer cells). PSA is mostly found in semen, but a small amount is also found in the blood. Most healthy men have levels under 4 nanograms per milliliter (ng/mL) of blood. The chance of having prostate cancer goes up as the PSA level goes up.

When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not guarantee that a man doesn’t have cancer – about 15 percent of men with a PSA below 4 will have prostate cancer on a biopsy. Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50 percent.

The American Cancer Society recommends that men make an informed decision with their doctor about whether to be tested for prostate cancer. Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment. The American Cancer Society believes that men should not be tested without learning about what we know and don’t know about the risks and possible benefits of testing and treatment.

Starting at age 50, men should talk to a doctor about the pros and cons of testing so they can decide if testing is the right choice for them. If they are African American or have a father or brother who had prostate cancer before age 65, men should have this talk with a doctor starting at age 45. If men decide to be tested, they should have the PSA blood test with or without a rectal exam. How often they are tested will depend on their PSA level.

What is a prostatectomy?

It is the removal of the entire prostate, the seminal vesicles (small sac-like organs attached to the back side of the prostate) and some surrounding tissue. In some cases, some lymph nodes are removed at the time of surgery as well.

Why is prostatectomy still popular when there are non-surgical and less-invasive treatments available?

Some of this has to do with physician and patient preference, but the major factor is probably the prostatectomy's long history of effectiveness. Cure rates in the 90+ percent range are expected when the tumor proves to be confined to the prostate.

Although there is certainly some debate in this area, long-term (15-year) survival rates are generally believed to be somewhat better than with the other treatment options. PSA is expected to be undetectable after prostatectomy, and this makes follow-up fairly simple and worry-free. Prostatectomy does not carry any of the long-term risks associated with radiation therapy such as secondary malignancy or bleeding problems that can occur in a small percentage of patients many years after radiation.

What happens during a typical hospitalization for a prostatectomy?

You are admitted to the hospital on the same day as the surgery, having taken laxatives at home in the days prior to arrival. The surgery itself is performed under general anesthesia and typically takes about two hours. Following surgery, you spend several hours in the recovery room and are then transferred to a regular hospital room for the remainder of their stay. The typical stay in the hospital is one to two days if there are no complications.

You have a catheter draining your bladder, which stays in for approximately 10 days. You are taught how to care for this. Very quickly after surgery, you are encouraged to do deep breathing exercises, to get out of bed and to begin walking. The diet is slowly advanced, first to clear liquids and then usually to full liquids (things like pudding) before discharge. IV lines and drains are removed prior to discharge.

What is follow-up care like?

An office appointment at about 10 days after surgery is necessary to remove any skin staples and the catheter. After this, you are instructed to get PSA blood tests at regular intervals, usually every three to four months for the first two years and then less frequently thereafter. You are taught exercises that aid in recovery of urinary control and given the option of medicine or injections for the purpose of sexual rehabilitation. This is highly recommended to begin soon after surgery for patients who wish to resume having sexual intercourse in the future.

How long does full recovery take?

This varies widely from patient to patient, but there are some general rules of thumb. You should not drive a car for 10 days after surgery and should not lift anything over 10 pounds for three weeks. After the catheter is removed, there is a period of incontinence (involuntary urinary leakage) lasting from a few days to several months, depending on the individual. You may feel tired and require extra rest for about a month after surgery. If you have a non-strenuous job and desire to return to work quickly, you can usually go back to work part-time after the catheter is removed. Patients who do heavy manual labor typically need to be off work for six to eight weeks.

What are some of the drawbacks of prostatectomy?

Even though prostatectomy has been refined and considerably improved during the past two decades, it is still a major operation and has significant risks (see below). An additional drawback is that despite our best testing and effort before the surgery, we will discover in about 20 percent of the cases after the prostate is removed that the tumor goes beyond the capsule of the prostate. For these men, the long-term cure rate is lower than the 90+ percent cure rate when the cancer is contained.

What risks and complications are associated with prostatectomy?

Certainly most patients do just fine, but some of the most important and most frequent risks are:

  • Bleeding: This surgery always involves some blood loss. Our experience with robotic prostatectomy has shown dramatically lower blood loss than with open prostatectomy. We no longer recommend self-donation of blood or directed donation from a family member. Only about 2 percent of patients will bleed enough that they will need a transfusion.
  • Infection: Wound infections or urinary infections are unusual. The medical literature shows that the risk of infection with robotic surgery is lower than it is with open surgery.
  • Impotence: Even with modern “nerve-sparing” techniques, loss of potency is experienced in about 30 percent of patients who were potent before surgery. The younger the patient and the better his potency before surgery, the more likely he is to get good recovery of erectile function after surgery. We recommend a specific erectile rehabilitation program after the surgery to encourage return of function. It is important to remember that recovery is occurring for at least 18 months after surgery.
  • Incontinence: All patients have some leakage immediately after the catheter comes out. About 2 percent of patients will still have enough leakage that they require a pad for more than a year after surgery. About 20 percent of patients will have a slight or very infrequent amount of leakage not requiring pads. We recommend a specific exercise program after surgery to hasten return of urinary control. At least half of patients will not require pads by their six-week post-operative office visit.
  • Damage to adjacent organs: Less than 1 percent of the time, structures such as the rectum or ureters can be damaged during the operation. Usually these injuries can be repaired at the same time as the initial surgery.
  • Death: Less than 1 percent of the time, a patient can have a catastrophic problem such as a heart attack or embolus (blood clot to the lungs) during or after surgery that can lead to the patient's death.

How will my lifestyle be changed by having my prostate removed?

Your life should change very little. After the initial post-op period, you should feel well. You should urinate normally and carry on all activities as you did before. You will no longer be fertile and may need assistance to be potent. There will also be no semen produced when you ejaculate. Other than these changes, you will likely be back to “normal.”