Radical prostatectomy is the treatment of choice for localized prostate cancer, and some cases of benign prostate hyperplasia (BPH). The procedure is not the same as it was years ago.
Over the last 140 years, it has evolved according to the latest technologies. New techniques are now available, and robotic surgery has gained prominence in recent years.
It was advantageous since the advent of the prostate-specific antigen (PSA). This test is still used to screen for prostate cancer and detect an early and still localized disease.
After so many prostate surgeries, an extensive database has been built, and we know what to expect from each technique and procedure. However, similar to any other surgery, there are still consequences and side effects.
Patients should receive post-operative care to support recovery and minimize potential complications.
In this article, we’re exploring the field of prostatic surgery in different ways. In the first half of the article, we’re discussing the benefits of surgery, the available techniques, and what is up next in the field of prostatic surgery.
Then, we’re discussing the lifestyle adjustments that you need to consider after surgery.
You will also have the information you need to understand and manage incontinence and erectile dysfunction after prostate surgery.
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Benefits of surgery
Prostate surgery is only beneficial in some cases, not for all prostate problems.
The indications of radical prostatectomy include:
- Organ-confined disease: They are small tumors and T1 cancers. They are not always palpable in a digital rectal examination. Not all T1 cancers should be surgically removed, though. If we’re talking about benign prostatic hyperplasia, this is an organ-confined disease. As such, it benefits from surgery.
- Locally advanced disease: Sometimes prostate cancer spreads out of the capsule. However, it is a local spread that only invades surrounding tissue and the seminal vesicles. Some of these patients may benefit from radical prostatectomy. However, distant metastasis should be ruled out.
In these patients, the benefits of surgery include the following.
- Improvements in lower urinary tract symptoms: Patients with BPH and prostate cancer display urinary symptoms. They include frequent urination, urinary urgency, and straining to start urination. They also report terminal dribble, weak urine flow, and a sensation of incomplete bladder emptying. These symptoms develop because the enlarged prostate gland is pressing upon the bladder neck. Not having the prostate relieves these symptoms and improves the quality of life.
- Relief of other symptoms: People with prostate cancer and BPH may also develop other symptoms. For example, pain upon ejaculation and rectal pain or a sensation of heaviness. These symptoms improve significantly after surgery.
- Cancer control: Symptomatic relief is positive, but one of the main indications of prostate surgery is cancer control. Localized cancer patients won’t have further tumor growth. There is a lower risk of complications due to cancer, and the patient has a better prognosis. This benefit is more remarkable when cancer is still in an early stage. In some cases, surgery can be combined with hormone therapy, radiation therapy, or chemotherapy for better results.
Possible future surgeries
Throughout the years, prostate surgery has changed and developed gradually. Some methods are still in use, and others are pretty recent. For example (2):
Open radical prostatectomy
This is the most common approach for prostate removal surgery. Open surgery means that an incision is made to reach the prostate gland. The incision can be suprapubic or located in the perineum. The perineal approach of open prostatectomy is not frequently used because it is harder to spare the nerves. The suprapubic approach is more common and requires a smaller incision.
Transurethral resection of the prostate
It is also known as TURP surgery and involves an endoscope. This is a flexible and tiny tube with a lens and a light. The endoscope is inserted in the urethra, and the procedure is completed through the penis. TURP is not a curative approach for prostate cancer, but it is used to relieve the patient’s symptoms. A part of the prostate tissue is removed, but not all of it. Lymph nodes are spared.
Laparoscopic radical prostatectomy
In this modality of radical prostatectomy, no long incision is required. It is laparoscopic surgery in which a few minor cuts are made to fit small tools and tubes with lenses and lights. Through the tiny incisions and using a video camera, the surgeon removes the prostate.
Nerve-sparing prostatectomy approach
This is a modern technique designed to preserve the nerves surrounding the prostate. By doing so, the likelihood of erectile dysfunction and other complication is lower. This technique may not be available for the patient when prostate cancer is very close to the nerve tissue.
Robot-assisted radical prostatectomy
This is a relatively new method of prostatectomy. In this case, the procedure is done through a robotic system. In this case, the surgeon is using a robotic arm and sitting in front of a monitor.
Laparoscopic prostatectomy, nerve-sparing, and robotic-assisted prostate surgery have been improving over the years.
It will be easier to spare the nerves by a fluorescent dye being developed. This will be a visual way to avoid cutting the nerves during surgery through fluorescent light. It will enable surgeons to see the limits of cancer and prevent cutting healthy tissue (3).
Advancements in robotic prostatectomy are on the horizon. New robotic arms with improved features and video technology are in development.
It’s expected these technical developments will come to the market for the following years. However, they need to be tested, and their implementation depends on the costs and clinical applicability (4).
Adapting to changes in lifestyle
After surgery, and depending on the type of surgery, you will be recommended a few lifestyle adjustments (5):
Right after surgery, getting out of bed can be a bit challenging. You need to use a wheelchair for some time until the wound heals.
You can’t drive after surgerey, and you need someone to take you home. Ask your doctor when you will be able to drive once again.
Right after surgery, your breathing function may feel a bit different. You will have a nurse helping you with simple things such as deep breathing and coughing. In some cases, you will be given an incentive spirometer to achieve deeper breaths. Use it as instructed and make it a part of your routine.
After surgery, you could have some circulation problems. To prevent forming clots, you may need to use pressure stockings or pneumatic stockings. Keep using them until you’re walking normally.
Change your position if you’re in bed, and do it often. Every two hours is appropriate timing. Walk as soon as you can, and your doctor recommends.
Your digestive system could feel different after surgery. Only eat and drink when you’re instructed because your bowels may not be ready for that yet. When you’re ready, you will start with fluids, followed by a light diet. After that, you can start eating regular food.
If you don’t have bowel movements for a few days, don’t panic and report this to your doctor. In some cases, you can have up to 5 days without bowel movements.
When you’re back eating, you need to adopt a very healthy eating pattern. A high-fiber diet is essential to get your bowel movements back to normal. Drink plenty of fluids and always prefer fresh food to processed foods.
You could experience a lack of energy and fatigue for a few weeks. This sensation should go away after no more than 6 weeks. Then, you will be able to return to work.
During the first 6 weeks, you need to avoid strenuous activity or lifting more than 10 pounds. Walking is an excellent exercise to start when you’re ready. You can go back to your housekeeping and regular exercise after 8 weeks.
As a part of your routine, you need to take analgesics and other medications as instructed.
Keeping your incision clean is also an essential part of the routine to avoid urinary tract infections and other complications.
Shower and do not bath before your catheter removal. Gently pat your incision dry with a towel. You will stay with the urethral catheter for 1-3 weeks, but it depends on your recovery
Urinary continence can be lost after prostate surgery. It is temporary and improves after some time. Once you’ve removed your urinary catheter, you may experience urine leaks every now and then.
The recovery time varies from one person to another. Throughout this time, you can develop coping strategies to manage the inconveniences.
Urinary incontinence is usually maintained for a few months. It is usually 3 to 6 months. In some cases, it takes more than 6 months to recover your complete urine function.
However, it depends on catheter complications such as infections and other individual problems. Talk to your doctor if it is taking too long to recover (5).
How to manage incontinence
As a common symptom after prostate surgery, you need to understand how to manage urinary incontinence at home. Here’s a list of tips on what to do about urine leakages (5):Be patient: Patience is key to cope with incontinence after prostate surgery. Remember that this is a temporary situation. In the long-term, surgery solves urinary symptoms, including incontinence.
Empty your bladder more frequently
You don’t need to hold your urine until you have a leak. Instead, empty your bladder every 4 hours or less, especially if you’re outside. If you’re at home, you can test yourself and train your bladder to hold for a longer time.
Drink plenty of fluids
It is not wise to stop drinking fluids to reduce urinary output. Doing this may trigger additional consequences such as constipation and urinary infections.
Exercise your pelvic floor
Doing pelvic floor exercises is helpful to reduce incontinence. However, they are only appropriate after you’ve removed catheter.
Treat your constipation
Not having frequent bowel movements can contribute to incontinence. Eat high-fiber foods and talk to your doctor if your constipation problems do not go away.
Learn to control the urge to urinate
When you’re at home and you can train your bladder, try relaxing and breathing when you have a sudden urge to urinate. Counting back and doing pelvic floor exercises may also help. Try to achieve a minimum of 2 hours between every voiding.
Learn to use incontinence pads
Incontinence pads are handy if you’re going out. They can also cover your chair and bed to prevent damages to your furniture.
Similar to incontinence, erectile dysfunction is another possibility after radical prostatectomy. It is not as common, especially after nerve-sparing techniques were developed. Still, stretching of the prostate and the adjacent nerves can cause a temporary erectile dysfunction.
If you had nerve-sparing surgery, you’re likely to recover your erectile function after a while. The time depends on your health, age, sexual behavior, and other psychological aspects.
How to manage ED
Erectile function is likely to come back after a while. It sometimes takes a few months to recover, but usually no more than one year. To manage erectile dysfunction, you can try these recommendations (5):
Resume sexual behavior with non-penetrative sex
You can please your partner and yourself with non-penetrative sex for the initial part of the recovery. Manual stimulation and achieving a mild orgasm can help release sexual tension.
Counseling and psychological evaluations
In some cases, causes of erectile dysfunction are a combination of organic and psychological factors. For example, you could be achieving a partial erection, and since you’re used to more rigid erections, it makes you insecure, and the problem gets worse over time. Counseling can be helpful in these cases.
Rehabilitation for erectile function
Talk to your doctor about erectile dysfunction and explore the options and their pros and cons. There are many treatments available to help you as you recover natural erections. Pills, for example, and injections. There are also vacuum devices and penile implants if nothing else works.
Follow up care
After surgery, your doctor will give you a few dates to check on you. Follow-up with your doctor is essential after surgery to prevent complications.
The initial part of the follow-up will focus on caring for your wound and preventing infections. After a few weeks, you will have an appointment to remove your catheter. Then, you will get other follow-ups to check on your urinary symptoms and the outcomes of surgery.
If you have a problem or concern, talk to your doctor about it. Keeping a list can be a good idea unless it is an alarm sign that requires immediate attention. For example, heavy bleeding, urinary retention, and severe pain.
Even if you’re healthy and have no problems after surgery, another appointment with your urologist is critical to check on your PSA level and evaluate your current health condition.
Prostate surgery recovery times are variable, and the outcome also depends on the patient and his health conditions.
There are different types of prostate surgery, and each one has its particular follow-up. Most of them are used as a part of prostate cancer treatment, usually after a prostate biopsy.
Patients recovering from prostate cancer surgery usually have to deal with temporary symptoms such as bloodstains in the urine, pain in the wound area, and tiredness.
However, incontinence and erectile dysfunction are probably the most concerning issues.
Incontinence results from changes in the sphincter muscle after taking out the urinary catheter. However, you will regain bladder control and need to be patient, train your bladder, and use incontinence pads in the meantime.
Erectile dysfunction results from stretching of the nerves adjacent to the prostate.
Depending on the surgery technique, you’re likely to recover your erectile function after a few weeks or months.
In the meantime, you can use non-penetrative sex and penile rehabilitation methods such as pills and injections.