Prostatectomy - for cancer

The prostate gland is part of the male reproductive system and is a small gland that surrounds the urethra. The prostate produces some of the fluid that makes up semen, which enriches and protects sperm.

Prostate cancer occurs when abnormal cells develop in the prostate. These cells have the potential to continue to multiply, and possibly spread beyond the prostate. Cancers that are confined to the prostate are called localised prostate cancer.

If the cancer extends into the surrounding tissues near the prostate or into the pelvic lymph nodes, it is called locally advanced prostate cancer. Sometimes it can spread to other parts of the body including other organs, lymph nodes (outside of the pelvis) and bones. This is called advanced or metastatic prostate cancer.

Around 5,000 Victorians will be diagnosed with prostate cancer each year.

What is prostate cancer surgery?

Surgery to remove the prostate is called a radical prostatectomy. The aim of the surgery is to remove the entire prostate and all the prostate cancer. The operation is carried out by a urologist.

Who can have surgery for prostate cancer?

You may be offered surgery to treat your cancer if you:

• have localised or locally advanced prostate cancer that has not spread too far outside of the prostate gland
• are medically fit for surgery and don’t have health conditions that may put you at significant risk during or after surgery
• are expected to live for 10 years or longer.

The operation is completed in 2 to 4 hours. You will stay in hospital for a few days and have a recovery period for several weeks after. Most men will need time off work.

Is a prostatectomy right for me?

There are often several options to treat localised or locally advanced prostate cancer.

These include surgery, external beam radiation therapy (with or without hormone therapy), brachytherapy or monitoring the cancer. Making a decision about which treatment is right for you can be challenging. It is helpful to see both a urologist and radiation oncologist to get a full understanding of the treatment options, possible side effects, benefits and costs of treatment.

Support and information can also be obtained from your GP, a Prostate Cancer Specialist Nurses and/or the Prostate Cancer Foundation of Australia.

Benefits of a prostatectomy

• Surgery is an effective and potentially curative treatment for prostate cancer.
• Once the prostate has been removed, the pathologist can provide detailed information about the cancer.
• Some men take comfort knowing that the whole of the prostate gland, including the cancer within it, has been removed.
• If men have urinary difficulties due to a narrow or partially blocked urethra, surgery may improve urinary symptoms.

Risks of a prostatectomy

It is important to talk to your surgeon about the risks, benefits and limitations of radical prostatectomy before undergoing treatment. Surgical risks that occur at or soon after the surgery may include:

• Bleeding as a result of the surgery – this may require blood transfusion. In rare cases, another operation is required
• Infection – this may occur at the site of the wound, in the urinary tract or chest, or through an intravenous (IV) needle or drip. Treatment may include antibiotics.
• Deep vein thrombosis (DVT) – this is when blood clots form. DVT can be life-threatening if the clot dislodges within a blood vessel and travels to the lungs (pulmonary embolism). People are given special stockings to wear during the operation and recovery period. They are also given blood-thinning medication to prevent this complication. If DVT does occur, treatment may include having more blood-thinning medication.
• Injury to nearby organs or structures – the rectum, bladder and ureters (two slender tubes that drain urine from the kidneys into the bladder) are close to the prostate and may be accidentally injured by surgical instruments. Further surgery to repair the damage may be required.

Types of prostatectomies

There are three possible ways a radical prostatectomy can be done. During a radical prostatectomy, the surgeon removes the prostate gland along with the seminal vesicles and vas deferens. The surgeon cuts the urethra just above and below the prostate. They then move the bladder down and re-join it to the urethra. Sometimes, the surgeon will remove the lymph nodes near the prostate to check if the cancer has spread.

• Open radical prostatectomy: The surgeon makes a cut approximately 8cm in length in the lower abdomen (tummy) to remove the prostate. The cut can be from below the belly button to the top of the pubic hair line, or across the top of the pubic hair line.
• Laparoscopic radical prostatectomy: The surgeon performs keyhole surgery, where several small cuts are made in the lower abdomen. The surgeon inserts a small camera and the surgical instruments so they can clearly see and remove the prostate.
• Robotic-assisted radical prostatectomy: The surgeon performs keyhole surgery with the aid of a robot from a console in the operating theatre. This provides the surgeon with a better view during the operation.

Your recovery time and how long you need to stay in hospital may be shorter with laparoscopic or robotic prostate surgery compared to open surgery, but all three forms of radical prostatectomy have similar rates of cancer control and side effects.

Recovering at home

Planning for your discharge home will start within the first day of your surgery. The hospital will give you information about who to contact if you have any problems following your discharge. Make sure you know about your follow-up arrangements for removal of the catheter and when to see your urologist.

Gentle activities are recommended at home while the catheter is still in place. When the catheter is removed, you can slowly return to normal activities that do not involve straining. It is also important to re-start your pelvic floor exercises at this point.

It is normal to feel tired and fatigued after surgery, so take time to rest if you need. Your healthcare team will advise you when you can go back to driving and physical exercise.
See the surgeon immediately if you notice any signs of infection such as fever, discharge, redness, swelling or problems with urination. If you can’t see the surgeon, visit your local doctor or attend the emergency department of your nearest hospital.

Possible side effects of surgery

All prostate cancer treatments, including surgery, come with possible side effects. Generally, the types of side effects can be predicted but how severe they are can be different for each person. The important thing is for you to find out as much information as you can about your treatment and the possible side effects before you start, so that you can be better prepared.

Urinary side effects

Most men will have some degree of urinary leakage (incontinence) after the catheter is removed. This can be managed by wearing pads. For most men, incontinence improves quickly within 2 to 12 weeks. But for some men it can take longer (3 to 12 months). Occasionally, it can become a permanent and chronic problem. In this case, further surgery may be performed to improve continence.

In general, continence comes back more quickly in younger men and in men who have done pelvic floor exercises before surgery. In small numbers of men, scar tissue can develop where the urethra was re-joined to the bladder (called anastomosis). If this happens, the urine stream may be weaker, it may be harder to start the urine stream and it may be difficult to empty the bladder. If these symptoms occur, a telescope is passed into the bladder (cystoscopy) to look at the anastomosis. Occasionally further surgery is required.

Lymph gland side effects

Men who have had lymph glands removed at the time of the prostatectomy may experience a number of side-effects including, a collection of fluid (lymphocoele) at the site that the lymph glands were removed. This may need drainage or may get better on its own. In addition, minor swelling in the legs (lymphoedema) can occur. While it’s rare, it can help to see a physiotherapist to manage any swelling.

Remember to talk to your healthcare team about any symptoms you have so that they can provide the treatment and support you need.

Sexual side effects

A number of sexual side effects can occur after surgery. These include:

• Erection problems (also called erectile dysfunction) are a common side effect of surgery for prostate cancer. Erectile dysfunction is when you cannot achieve or maintain an erection firm enough for sexual activity or penetration. It may be temporary or permanent. It is common to lose the ability to have an erection in the short term. Erections can take 18 to 24 months to recover after surgery. There are a lot of treatment options available which you can talk to your treating specialist or healthcare team about.
• Dry orgasm: This is an orgasm without ejaculating. The prostate and seminal vesicles make most of the fluid that accompanies sperm (to make up semen) when you ejaculate. Removal of these organs during surgery means there will no longer be any ejaculation of semen when you orgasm; this is a dry orgasm. Men report different experiences with dry orgasm. Some describe a more intense orgasm, while others feel their orgasms are less pleasurable.
• Infertility occurs in all men after having a radical prostatectomy. If you plan to have children following treatment, discuss this with your partner and healthcare team.
• Climacturia: Surgery can cause some men to leak urine during orgasm. This is called climacturia. It can help to empty your bladder before sex. You can also use a condom if this is a worry for you or your partner and speak with your doctor.
• Change in penis size: Men may report shortening or shrinkage of their penis following surgery. On average this is about 1.2cm. This may be due to scar tissue and/or poor functioning of the nerves or blood supply.

Ongoing care

As part of your ongoing care, follow-up appointments will be offered to make sure you are recovering or have recovered from surgery. You may have a follow-up appointment with your urologist within the first 6 to 8 weeks following surgery as well as your first PSA blood test after surgery.

After surgery, the prostate gland and surrounding tissue is examined by a pathologist to determine the grade and stage of the cancer, whether it has spread through the walls of the gland and if the cancer has been completely removed. Your urologist will use this information and the result of your 6-to-8-week PSA blood test as a baseline for your continuing care. Ask your healthcare team about your ongoing follow-up care.

Managing your wellbeing

If you have prostate cancer, it is normal to have a wide range of feelings and emotions such as shock, deep sadness, anxiety, anger, fear and frustration. You may also experience physical effects of stress like nausea, stomach upsets, feeling irritable or on edge, and trouble sleeping. Some days will be worse than others.

It can help to talk through your problems with a partner or good friend, gather information and advice from trusted sources, and focus on keeping well.

If you are very distressed and struggling to the point that it’s affecting your life, talk to your GP or a member of your healthcare team, or call PCFA Telenursing service for further support on 1800 22 00 99.

Where to get help

• Your GP (doctor)
• Urologist
• Cancer Council Helpline. Providing professional telephone and online support, information and referral service. Tel. 13 11 20
• Healthy Male
• Prostate Cancer Foundation of Australia (PCFA). Tel. 1800 22 00 99
• Beyond Blue – providing information about, and support for, anxiety and depression. Tel. 1300 22 46 36
• Continence Foundation of Australia: providing information about bladder and bowel health and accessing support. National incontinence helpline: Tel. 1800 33 00 66
• Dietitians Australia: find an accredited practising dietitian. Tel. (02) 6189 1200
• Exercise & Sport Science Australia (ESSA): find an accredited exercise physiologist. Tel. (07) 3171 3335
• Lifeline Australia: personal crisis support and suicide prevention.Tel. 13 11 14 (24-hour service)