What is a Prostatectomy, and What Does it Mean for Men Who Have Them?

When a urologist performs a biopsy and diagnoses a patient with clinically significant prostate cancer, the conclusion may be that the disease is localized to the prostate. If the cancer has not spread beyond the prostate, a common next step is a surgical procedure known as a prostatectomy.

A prostatectomy refers to the total or partial removal of the prostate, a walnut-sized gland located in the male pelvis below the bladder and surrounding the urethra that is part of the male reproductive system. There are two types of prostatectomy:

• A simple prostatectomy involves a partial removal of the prostate, leaving the outer portion intact. This is typically done to treat benign prostatic hyperplasia, or BPH — otherwise known as an enlarged prostate, which can cause bladder, kidney or urinary tract problems and commonly occurs as men age. It is not typically done to treat prostate cancer.
• In a radical prostatectomy, the surgeon removes the entire prostate in the hopes of eradicating the cancer from the body, done alone or in concert with radiation, chemotherapy or hormone therapy treatments. This is the type we will focus on for this blog post.

Prostatectomies are common procedures, with about 90,000 conducted each year in the U.S. They’re also safe and effective; more than 75% of men who’ve had the procedure have no recurrence of cancer, according to ZERO, a leading prostate cancer advocacy and educational nonprofit. But the procedure still carries risks, and there is plenty to know about how the surgery is conducted and what it means for patients.

As a reminder, prostate cancer is the most common kind of cancer among men and the second-leading cause of cancer death. However, when caught early, the survival rate is 99%.

How Prostatectomies are Performed

Historically, urologists performed open prostatectomies. These are done by making incisions through either the lower abdomen or the perineum, the skin between the scrotum and rectum, to remove the prostate and surrounding fat and tissues.

The perineal approach is the least common because it cannot extract lymph nodes to test for cancer, and it has a higher risk of erectile dysfunction, but it takes less time to perform. The retropubic approach, done by making an incision from the navel to the pubic bone, avoids major muscle groups, but recovery time and pain can be longer-lasting.

Increasingly, doctors perform the procedure laparoscopically by making several small incisions and inserting a laparoscope, a thin tube with a camera that helps the surgeon see inside during the procedure. Still another version is robotic-assisted laparoscopic prostatectomy, where the surgeon controls a robotic surgical arm while seated before a console and monitor.

After removing the prostate, the surgeon reconnects the bladder to the urethra, the tube that carries urine to the penis and out the body. The surgeon will also connect a catheter to the bladder to help drain urine while the area heals.

Depending on the method used and other factors, the procedure can take up to several hours to complete and involves using anesthesia to put patients to sleep.

A radical prostatectomy is usually an inpatient procedure involving a hospital stay of at least one night, though some patients may be good candidates for outpatient procedures, meaning they can go home a few hours after the procedure is completed.

Risks of Radical Prostatectomies

In any type of radical prostatectomy, the primary risk is avoiding having to cut the nerves surrounding the prostate, known as a nerve-sparing approach, while removing cancerous tumors.

If both sides of nerves must be cut, a man will be unlikely to get an erection and may need special treatments to try and restore erectile functions. If neither nerve bundle is disturbed, erectile function may be unaffected, though it may take months after surgery to accurately gauge recovery. If only one side of the nerve bundles must be cut, some erectile function may remain. The perineal method is riskier because it is more difficult to avoid nerves using this approach.

There are other risks associated with the procedure, including:

• Bleeding
• Urinary tract infection
• Urinary incontinence
• Dry orgasm
• The narrowing or the urethra or bladder neck
• The formation of cysts containing lymph

It’s important to discuss these risks and any concerns you have about them with your doctor.

What to Expect After Surgery

After being sent home following the procedure, patients are typically instructed to avoid any heavy lifting or other strenuous activity and take over-the-counter acetaminophen or ibuprofen. If that’s not enough to manage the pain, the doctor can help find an alternative.

After about a week, the urologist will remove the catheter, and around this time, patients receive their final pathology results, which will tell you whether the procedure was successful in removing all cancerous tissue or if further treatment is needed.

After about a month, most patients are able to resume their normal routines, though some men experience side effects like erectile dysfunction or urinary incontinence or leaking. Recovery time may be significantly longer for men who undergo open prostatectomy.

Time spent with your doctor is invaluable. Use it to your advantage and get the information you need to address any questions or concerns. Don’t be afraid to ask for clarification and take notes — or bring a friend or family member to take notes for you as you assess your best next steps in your care journey.

In our next post, we’ll discuss how prostate cancer treatment affects men’s sexual health.