The operation to remove the prostate is called a radical prostatectomy. The aim is to remove the prostate, and so all the cancer inside it, and stop the cancer from spreading to other parts of the body. It is not a suitable option for all men who have prostate cancer.
Why might a radical prostatectomy be suggested?
• As a primary/main treatment for prostate cancer when the cancer is localised and contained within the prostate;
• When the cancer has not spread (metastasised) to other parts of the body;
• After a period of active surveillance if there are signs of the cancer growing;
• When the cancer is thought to require treatment rather than surveillance;
• For men who are expected to live for at least 10 years;
• For men who are otherwise healthy and are fit enough to have a general anaesthetic;
• If there has been previous treatment for prostate cancer, such as radiotherapy, and the cancer has not spread out-with the prostate but the cancer has recurred.
Preparing for a radical prostatectomy.
As pelvic floor exercises are important to help regain continence after the operation, information might be given on when to start and how to do pelvic floor exercises A referral may also be made to a physiotherapist who specialises in continence. For further information about pelvic floor exercises there is a booklet available in the Resources section: Pelvic Floor Exercises for men
Surgery to remove the prostate
This is a fairly major operation and there are a few ways that a radical prostatectomy can be done. Laparoscopic (keyhole) and robotic assisted are becoming the most common way of removing the prostate.
Laparoscopic radical prostatectomy (keyhole surgery).
With laparoscopic radical prostatectomy, you will have five small cuts across your lower tummy. Each of these cuts will be around 1cm long and has a special, small plastic tube (called ports) are placed inside. Each cut serves a different purpose during the operation; one is used for a camera that magnifies the prostate and surrounding area magnify inside, 3 others are used for the instruments to undertake the operation.
The final cut is made slightly longer, about 3-4 cms to allow the urologist to insert the special instruments needed so that the prostate and seminal vesicles can be taken out.
For further information about this procedure see page 45 of the booklet Early prostate cancer explained and also the booklet Minimal access radical prostatectomy for prostate cancer
Robotic assisted laparoscopic radical prostatectomy (keyhole surgery)
This is similar to the operation described above. However, the operation is carried by a surgeon with the assistance of a robot. In the operating theatre, a side cart with the robot is placed next to the operating table. Four robotic arms are attached to the robot on the side cart. The instruments the surgeon needs to carry out the surgery are then attached to these arms. There are a variety of very small (about 7mm in width) instruments that can be attached to the robot arms. The advantages of these are that they have a much greater range of movement than the surgeon’s hands, and, because the instruments are so small, they allow the surgeon to carry out the operation in a very small space.
One of the arms has a 3D, high magnification camera attached which sends images from inside your tummy to the screen where the surgeon is sitting. The 3D image combined with high magnification gives the surgeon an all-round, very clear view of the prostate and means that he/she can carry out a very precise operation.
The instruments and camera attached to the arms are inserted into your body through special small plastic tubes called ports so that the operation can be carried out. The surgeon uses and controls these instruments on the robotic arms, instead of using instruments held in his/her hands. The surgeon is in the same room as the man but sits away from him at a console or control panel. The surgeon controls and precisely directs the instruments to carry out the operation. The robot does not and cannot carry out the operation on its own.
Open radical prostatectomy (called retropubic radical prostatectomy)
This may be the operation recommended to some patients by some surgeons in Scotland. It differs from the above as there is only one quite large incision (cut) in the lower part of the tummy, usually from the tummy button to the pubic bone. This will often be about 7-10cms (about 4 inches) long. However the greater distance between your tummy and pubic bone then the longer the cut is likely to be. The prostate will be taken out through this larger incision. Although this was the operation of choice for many years, it is not as common now with most urologists favouring the two procedures mentioned above.
Radical perineal prostatectomy
This means that an incision (cut) is made in the area between the scrotum and the back passage and the prostate is taken out through this cut. Although this approach is very rarely recommended in Scotland, it may be the operation of choice for certain men.
What happens during the operation?
The surgeon may have already discussed removing lymph nodes if the cancer is intermediate or high-risk. Lymph node dissection (if necessary) will be done at the same time as the prostatectomy.
Am I likely to have a catheter?
A catheter is a long, thin, flexible, soft hollow tube that is used to drain urine out of the bladder into a drainage bag outside the body. During the operation a catheter will be put into the bladder to help urine flow and to maintain a watertight join between your water-pipe and the neck of your bladder whilst the initial swelling settles after your operation. There is a possibility that the catheter may leak in the first days after the operation.
The catheter will usually stay in place for about 1-2 weeks so it’s likely that the man will go home with the catheter in place, but this can vary in different hospitals. It’s important to look after the catheter carefully to help prevent the risk of infection. If urine seems cloudy and has a strong unpleasant smell, if the man feels hot and feverish with a high temperature, shivery, sick, has a headache or low back pain then this could be a sign of infection and it’s important to make an appointment with the GP who will most likely give a short course of antibiotics.
Potential side-effects of a radical prostatectomy:
Urinary incontinence (not able to control when you pass urine)
This means that you may not be able to hold urine inside your bladder after the catheter is taken out and will leak some urine when you cough, sneeze, laugh or move about. Almost all men have some incontinence so it’s nothing to feel embarrassed about. It’s usually managed effectively using incontinence pads and will improve as the healing process takes place. How long and how much this will be troublesome is affected by several factors and varies from individual to individual. Although incontinence is a common side-effect, it’s usually temporary with the majority of men regaining full continence (ability to control passing urine) over time. Up to 2-3% of men will not recover their continence fully and may require a second operation to make them dry again.
Doing pelvic floor exercises prior to the radical prostatectomy and on a regular basis afterwards helps the man regain continence.
Erectile dysfunction (ED)
When a man has trouble getting or keeping an erection firm enough to have intercourse it is called erectile dysfunction or sometimes impotence. Not being able to have an erection can affect men at different ages and stages in their life and for different reasons.
You don’t need a prostate to have an erection. However, the prostate lies close to nerve bundles and blood vessels that are needed for a man to have a normal, natural erection and can be stretched or damaged during a radical prostatectomy. After a radical prostatectomy, it’s usual for men to be unable to have an erection as the body needs time to heal. In fact, it’s common not to have an erection in the first 6 to 9 months after surgery and it may take 18 to 24 months to return to normal erection function.
One of the things that may affect your erection is whether the surgeon was able to save the nerves (called nerve sparing surgery) that lie very close to the prostate which are responsible for erections and potential recovery of erectile function.
For some men, to make sure that all the cancer is removed during their radical prostatectomy, it isn’t possible to save these nerves and blood vessels. In this case, it is no longer possible to have a natural erection. For other men, it is possible to save the nerves, and around 50% to 80% of men will get back the normal erection function they had before surgery – but it may take up to 2 years to fully recover.
Retrograde ejaculation or ‘dry orgasm’
After radical prostatectomy many men find that the sensation of orgasm may be changed or different. Retrograde ejaculation means that at the end of sexual intercourse nothing comes out of the penis because the semen has passed backwards into the bladder rather than down the penis. Some men may notice that they leak a small amount of urine at the time of climax; this is nothing to worry about as urine is sterile and harmless. Retrograde ejaculation is usually permanent when it occurs.
What can be done to help?
Many doctors now think that after surgery the sooner you start having stimulation or trying to have intercourse may actually improve the chances of having the same kind of erection as you did before your operation. Touching, caressing, holding and massage can all help.
If erectile dysfunction is a difficulty, it’s important to let the CNS or urologist know, even though it may be a bit embarrassing, as they are used to hearing about difficulties like this. There are a few options for trying to make the quality of erections better:
Medication to be taken by mouth
Pills that can help include Sildenafil (brand name Viagra®), Vardenafil (brand name Levitra®), Tadalafil (brand name Cialis®). These work by increasing the blood flow to the penis to help you have an erection and work best if the nerves are still intact.
Medication that is injected
A treatment that is injected into the penis is very successful for some men, and can be effective even if the nerves are not intact. If this treatment is recommended, you will be taught how to do the injection. The medicine makes the blood vessels in the penis swell and allows it to fill with blood and so become erect.
MUSE – medication by an applicator
MUSE stands for medicated urethral system for erections. The medicine is given by a small applicator that has a thin tube inside it. This tube holds a small pellet of medicine, which is the same as that used in the injection discussed above.
This is a cream that is applied into the opening and around the tip of the penis.
If injections or tablets haven’t helped, or if another option is preferred, then a vacuum pump can be tried. This works by suction drawing blood into the penis.
For further information see the booklet Prostate conditions and erectile dysfunction
Constipation, and your bowels being sluggish, is a temporary but common side-effect after radical prostatectomy and it may take time to get back to what was normal for you. That said, some men find constipation troublesome while others do not. Being constipated can be painful, make you feel very uncomfortable and may affect your wounds and healing if you strain or push too hard to pass a bowel movement. It’s best not to let this go on for too long before asking for advice from your CNS, consultant, GP, pharmacy or NHS 24 as there are medicines that can help make constipation better. Before buying any over-the-counter medicines for constipation, check with your CNS, GP, pharmacy or NHS 24 what would be best in this instance.
You can help by having enough fluid each day by drinking around two litres (about eight glasses of water), including more fibre in your diet by switching to wholemeal bread, bran type cereals and eating at least five portions of fruit and vegetables each day.
Follow up appointments
Most likely an appointment will be arranged to attend the urology outpatient department in about 6 to 8 weeks’ time (depending on availability). You will most likely be asked to have a PSA test done at your GP practice prior to your clinic appointment so the clinician or CNS has an up-to-date PSA level. At your clinic appointment, you will be asked how you are, hear about your results and have your wound examined.
How do I know if the treatment has worked?
The urologist or CNS will want to see how you are with regular check-ups. Your PSA level will be measured. After a radical prostatectomy, your PSA should drop quickly and should be practically undetectable*. If it does not drop this low or starts to rise then this suggests there may be cancer cells elsewhere in your body.
* In this case undetectable will mean at its’ lowest limit and will vary depending on the type of test used. The CNS or urologist will chat over with you what undetectable means.
For further information about radical prostatectomy see pages 44 to 67 of the booklet Early prostate cancer explained, as well as the booklets Early prostate cancer explained: deciding on treatment and Minimal access radical prostatectomy for prostate cancer