Radical Prostatectomy: A Patient's Perspective

What is the Prostate Gland?

The prostate is a small almond-shaped gland located at the base of the bladder. It has an important role in sexual life. It contributes significant fluid to the ejaculate and helps in maintaining the semen’s health.

What is Radical Prostatectomy?

Radical Prostatectomy is a major surgical procedure in which the whole of the prostate gland, the seminal vesicles and, in some cases, surrounding lymph nodes are removed. The urethra (waterpipe) is directly attached to the bladder. In open surgery, it is performed through a small midline incision extending from the belly button to the pubic bone.

OVERVIEW

Why is Radical Prostatectomy Performed?

This surgery is performed in cases of cancer of the prostate. Prostate cancer is the second-most common malignancy in men. When cancer is localised to the prostate gland, treatment is carried out with curative intent.

⇒ Radical Prostatectomy is the procedure where early localised cancer can be treated entirely.

⇒ Removal of the entire prostate gland allows the pathologist to assess the cancer’s aggressiveness (stage and grade) more accurately. This information can help determine a course of treatment if, at some point, additional treatment is recommended.

⇒ Radical Prostatectomy provides long-term cancer control in 75% of patients with clinically localised prostate cancer and is effective in the majority of those with high-risk cancer.

⇒ After surgery, if the disease recurs locally, treatment with salvage radiation is still available.

Who Needs a Radical Prostatectomy?

⇒ It is generally performed for patients who are diagnosed with cancer of the prostate, in whom the disease is confined to the prostate gland with no spread. The spread is usually evaluated by doing a bone scan and pelvic MRI.

⇒ Patients who have a lower PSA value.

⇒ Patients who are physically fit to undergo the surgical procedures.

⇒ Patients whose life expectancy is generally more than ten years.

Can one live without a Prostate Gland?

Yes, it is not a vital organ. Men are unable to ejaculate afterwards, and it is harder for them to achieve an erection.

PROCEDURE DETAILS

What Happens Before The Surgical Procedure

⇒ As a significant surgical procedure, all patients undergo detailed history and clinical examination.

⇒ Patients and families are involved in informed decision-making. All the reports, investigations and scans are discussed with patients and families and consent is obtained only after they are appropriately informed and educated regarding the pros and cons of the procedure.

⇒ An internist and anaesthetist do a routine assessment before surgery

⇒ All co-morbidities are noted, and pre-operative assessment by cardiology/pulmonology is made where necessary.

⇒ Any necessary changes with the medication made before the surgery, like holding of blood thinners, etc

⇒ Patients are admitted a day before surgery.

⇒ Necessary gut preparation is done

⇒ All the routine blood investigations are performed, and two blood units are usually cross-matched.

⇒ Patients are kept nil by mouth after midnight, the night before surgery, and usually given gentle sedatives to have a comfortable night’s sleep.

What Happens on the Day of Surgery?

The surgery starts early in the morning. Patients are transferred to the theatre an hour before the procedure time. A nurse in the holding bay receives the patients. After checking the necessary documents and identification, the patient is shifted to the operating theatre, where the anesthesia team takes over.

It is performed under general anesthesia, and the usual operating time is between two and a half hours to four hours.

The surgery is performed through a lower midline incision starting from below the belly button to the pubic bone. During this surgery, the abdominal cavity is not entered, which makes life much easier for the patient in the postoperative period.

After the surgery, the patient has one urinary catheter, a tube draining the urine coming out of the urethra, and another tube, called a drain coming out from the lower part of the abdomen

What Happens After Prostatectomy?

The patient is transferred to the recovery room after the surgery. Here, they are closely monitored by the recovery nurse and anaesthesia team.

A patient who does not have any severe co-morbidity does not need ICU care and is transferred to his room after a few hours.

He is usually not given any fluids or solid diet through the mouth for 6-8 hours. Afterwards, clear restricted fluids are started and build up to free fluids and a soft diet over the next 24 hours.

All patients have silicone foley’s catheters. Catheter care is explained to the patient and caretakers. The patient is mobilised after 24 hours. Walking encourages healing and promotes blood flow, which helps prevent blood clots in lower limbs and many other complications.

The patient is discharged with the catheter on the 3rd or 4th post-operative day. Catheter care is explained in detail.

At discharge, he was also given instructions regarding medication, follow-up, diet and activity.

After Discharge

After discharge, the caretaker is needed for nearly two weeks to help with mobilisation. A soft diet is advised for a few days, and a regular diet may be started.

Patients are advised to increase oral fluid intake to avoid constipation.

They are not supposed to do any activity or exercise where abdominal muscles are stressed. They are advised to do regular gentle walks and deep breathing exercises.

Patients are reviewed at two weeks to remove the stitches and at three weeks to remove the catheter. The patient resumes regular activity at two weeks but strenuous activity between 6-12 weeks.

What to expect After Removing the Catheter

Almost all patients face a brief period of impaired urinary control. In 70-80%, it recovers quickly within days; the remaining may take a few weeks. A minor degree of incontinence might persist for up to six months in a few patients.

Advantages Of Radical Prostatectomy

The main advantage is treating prostate cancer. The high-grade or aggressive cancer may be deadly without treatment. The risks of having prostate cancer without treatment greatly outweigh any risks associated with radical Prostatectomy.

Recovery Time After Radical Prostatectomy

Most people recover within 6-8 weeks of surgery, but usually, they are good to carry out routine chores in about 2-3 weeks, and most people can go to work after about one month of surgery.

Specific Problems Related to Radical Prostatectomy

Both these functions improve with time.

Patients are advised to use treatment for sexual dysfunction as soon as they recover from the surgery. Usually, it is at 6-8 weeks after the procedure.

Follow UP after Radical Prostatectomy

A regular follow-up is scheduled for all the patients, and the most important test, which is routinely done to see the disease control, is serum PSA.

Author:

Dr Irfan Ahmed

Consultant Urologist & Cancer Surgeon