Prostatectomy
A prostatectomy is a surgical procedure in which part or all of the prostate gland is removed. The prostate, a key component of the male reproductive system, is situated in the pelvic region, just below the bladder. It surrounds the urethra, the tube responsible for transporting urine from the bladder to the penis.
Prostatectomy is often performed to treat various prostate-related conditions, with prostate cancer being the most common reason for this surgery.
There are different methods to perform a prostatectomy, depending on the specific condition. In some cases, the surgery can be done using small incisions, known as minimally invasive surgery. Surgeons may even utilize robotic assistance during this type of procedure. Alternatively, certain cases require a larger incision, which is referred to as traditional open surgery.
Why It's Done
Prostatectomy is primarily performed to treat cancer that is likely confined to the prostate gland. In this case, the entire prostate and some surrounding tissue are removed, a procedure known as a radical prostatectomy. During the surgery, any suspicious nearby lymph nodes may also be removed for cancer evaluation. A radical prostatectomy can be utilized on its own or in conjunction with radiation or hormone therapy.
There are various techniques a surgeon can use for a radical prostatectomy, including:
- Robot-Assisted Radical Prostatectomy: The surgeon makes five to six small incisions in the lower abdomen to remove the prostate. They operate from a computer console, controlling surgical instruments attached to robotic arms. This method allows for precise movements, may result in less pain compared to open surgery, and typically offers a shorter recovery time.
- Open Radical Prostatectomy: In this approach, the surgeon generally makes a larger incision in the lower abdomen to remove the prostate.
Prostatectomy can also address non-cancerous health issues. In these cases, often only a portion of the prostate is removed, a procedure referred to as a simple prostatectomy. This option is suitable for individuals experiencing severe urinary symptoms due to an enlarged prostate, known as benign prostatic hyperplasia (BPH).
Simple prostatectomy is frequently performed as minimally invasive surgery with robotic assistance, while open surgery for this procedure is now less common.
When treating BPH, a simple prostatectomy removes only the part of the prostate that obstructs urine flow, alleviating urinary symptoms and complications such as:
- A frequent, urgent need to urinate
- Difficulty starting urination
- Slow or prolonged urination
- Increased urination at night
- Interruptions during urination
- A sensation of incomplete bladder emptying
- Urinary tract infections
- Inability to urinate
Risk
Radical Prostatectomy Risks
Like any surgical procedure, radical prostatectomy carries certain risks, including:
- Bleeding
- Urinary tract infection
- Loss of bladder control, also known as urinary incontinence, which often improves over time
- Difficulty achieving and maintaining an erection (erectile dysfunction)
- Narrowing of the urethra or the bladder neck, where the urethra meets the bladder
- Fluid accumulation (lymphedema)
- Rarely, damage to the intestine or rectum
Simple Prostatectomy Risks
While simple prostatectomy effectively alleviates urinary symptoms, it may have a higher risk of complications and a longer recovery time compared to other treatments for an enlarged prostate, such as transurethral resection of the prostate (TURP), laser prostate vaporization (PVP), and holmium laser prostate surgery (HoLEP).
Risks associated with simple prostatectomy include:
- Bleeding
- Urinary tract infection
- Urinary incontinence
- Retrograde ejaculation (semen entering the bladder instead of exiting through the penis during ejaculation)
- Erectile dysfunction
- Urethra or bladder neck narrowing following open surgery
How Do You Prepare For The Surgery
Prior to surgery, your surgeon may perform a cystoscopy, using a scope to examine the urethra and bladder. This procedure allows them to assess the size of your prostate and evaluate your urinary system. Additional tests, such as blood tests or urine flow measurements, may also be recommended.
Follow the instructions provided by your surgical team regarding pre-operative preparations.
Food and Medications
Discuss the following with your surgical care team:
- Medications: Inform your team about all medications and supplements you take, including prescriptions and over-the-counter drugs. This is especially important for blood-thinning medications, such as warfarin or clopidogrel (Plavix), as well as non-prescription pain relievers like aspirin, ibuprofen (Advil, Motrin IB), or naproxen sodium (Aleve). Your surgeon may instruct you to stop taking medications that increase your bleeding risk several days before the procedure.
- Allergies: Share any known allergies or reactions to medications with your surgical team.
- Fasting: You will likely be asked not to eat or drink anything after midnight before your surgery. On the morning of the procedure, only take the medications your surgeon advises with a small sip of water.
- Bowel Preparation: You may receive a kit with instructions for bowel preparation, which may involve administering an enema to clear your bowels before surgery.
Clothing and Personal Items
Avoid wearing the following items on the day of your surgery:
- Jewelry
- Eyeglasses
- Contact lenses
- Dentures
Arrangements After Surgery
Inquire about the expected length of your hospital stay, and arrange for transportation home, as you will not be able to drive yourself immediately after the procedure.
Activity Restrictions
You may need to refrain from work or strenuous activities for several weeks post-surgery. Consult your surgeon regarding your expected recovery time.
What To Expect
Before the Procedure
Most prostatectomies are performed under general anesthesia, which prevents pain and induces a sleep-like state. Your surgeon may administer an antibiotic prior to surgery to help prevent infection.
During the Procedure
- Robot-Assisted Radical Prostatectomy: The surgeon operates from a console a short distance from the operating table, using hand and finger control devices to maneuver surgical tools. The console provides a magnified, 3D view of the surgical area, allowing for more precise movements and smaller incisions. This method can facilitate faster recovery and may help preserve nerves, reducing the risk of erectile dysfunction in younger patients.
- Open Radical Prostatectomy: The surgeon makes an incision in the lower abdomen, from just below the navel to above the pubic bone. They carefully separate the prostate from surrounding nerves and blood vessels before removing it along with adjacent tissue. The incision is then closed with sutures.
- Simple Prostatectomy: The procedure may start with the surgeon inserting a cystoscope through the penis to visualize the urethra, bladder, and prostate. A catheter is then inserted to drain urine during surgery. The approach to incisions will depend on the surgical technique used. If you also have a hernia or bladder condition, your surgeon may take the opportunity to address these during the same surgery.
Once the part of the prostate causing symptoms is removed, 1 to 2 drain tubes may be inserted through small punctures in the skin near the surgical site. One tube will drain the bladder, while the other will allow fluid to escape from the area where the prostate was removed. These tubes are typically removed over time.
After the Procedure
Post-surgery, you can expect:
- Administration of pain medication through an IV, with prescription pain pills provided once the IV is removed.
- Encouragement to start walking on the day of or day after surgery, along with exercises to move your feet while in bed.
- A typical discharge timeframe of 1 to 2 days after surgery, contingent on your surgeon’s assessment of your safety. The pelvic drain will be removed before discharge, and you may need a follow-up appointment in one or two weeks to have staples taken out.
- Most patients will return home with a catheter, needed for about 7 to 10 days post-surgery. Full recovery of urinary control can take up to a year.
Ensure you understand the self-care measures required after surgery, including any activity restrictions related to driving or lifting heavy objects:
- Gradually resume your normal activity level over time, with a general return to routine within about 4 to 6 weeks.
- Expect to have several follow-up visits with your healthcare professional, typically starting about six weeks post-surgery, followed by checkups every three months for the first year and twice in the second year. If any health issues arise, you may need to schedule appointments more frequently.
- You can likely resume sexual activity after recovery. Following simple prostatectomy, you may still experience orgasms, but you might ejaculate little to no semen. Ask your surgeon how long it may take to achieve and maintain erections suitable for sex; some older patients may not regain sexual function after surgery.
Results
Robot-assisted prostatectomy typically offers several advantages over open prostatectomy, including:
- Reduced pain and blood loss
- Less tissue trauma
- Shorter hospital stays
- Quicker recovery
Most individuals can return to regular activities with minimal limitations about four weeks after surgery.
Simple prostatectomy provides long-term relief from urinary symptoms caused by an enlarged prostate. While it is the most invasive treatment option for this condition, serious complications are rare, and most patients do not require further treatment for BPH after the procedure.
Physiotherapy Care Follwoing Surgery
Physiotherapy Care
Physiotherapy intervention following Prostatectomy is often underutilized. However, effective physiotherapy management can significantly enhance a man’s quality of life. The primary objectives of physiotherapy for post-prostatectomy patients are education, rehabilitation, and referral.
Clinical Reasoning after Assessment
The assessment is the cornerstone of a physiotherapist’s interaction with their patient. Understanding the unique clinical picture, including symptoms, disabilities, and personal experiences, is essential for tailoring effective treatment. Every individual’s clinical profile is distinct; thus, a comprehensive assessment is critical for delivering optimal management.
Education
Education is grounded in the assessment and is often tailored to the type of prostate surgery the patient received. It’s important not to underestimate a patient’s ability to learn. Some patients may be well-informed about issues like incontinence and erectile dysfunction, while others may require basic education on these topics. Always approach each patient with an open mind and avoid making assumptions.
General Management of Incontinence
Incontinence Pads
Men, unlike women, are typically unfamiliar with sanitary pads designed for incontinence. For patients who undergo radical prostatectomy, it can be beneficial to be prepared preoperatively for the use of pads after catheter removal. Patients are educated on the following:
- How to use the pads, including the sticky side and the need to wear underpants instead of boxers.
- Proper disposal methods, as many public restrooms lack disposal bins.
- The importance of carrying extra pads and a disposal bag when out, given that public restrooms often do not accommodate this need.
Clothing
You are encouraged to wear darker-colored shorts or pants can help conceal any leakage accidents.
Dietary Considerations
Certain foods and beverages can exacerbate incontinence symptoms. You are advised to limit your intake of coffee, green tea, and beer, as these may worsen symptoms.
General Sexual Rehabilitation
Rehabilitation for sexual dysfunction in men requires a multidisciplinary approach, involving pharmacological, physical, and behavioral treatments, facilitated by appropriately trained professionals. Regular erections are vital for penile health, promoting blood flow and tissue oxygenation, which is essential for maintaining penile structure and function.
Use of Medication
Erection-enhancing medications are encouraged during and after rehabilitation phases as they promote circulation and tissue health. Various medications exist, each with distinct mechanisms, but the details of prescription and administration fall outside the scope of this discussion.
Vacuum Erection Device (VED)
A vacuum erection device helps create an erection manually. It comprises a cylinder that fits over the penis and a constrictive band that fits at the base. The vacuum effect engorges the penis, while the band maintains the erection.
The use of a VED can be crucial in preserving penile tissue length during rehabilitation, enhancing blood flow, and maintaining smooth muscle integrity. Furthermore, it may assist you in achieving erections firm enough for penetration, facilitating a healthy return to sexual function.
Psychological Counseling
A cancer diagnosis often brings significant psychological distress. The combined impact of incontinence and sexual dysfunction necessitates psychological support as part of a holistic treatment approach. While physiotherapy can benefit many men, recovery varies based on cancer severity and treatment received. Some men may find it challenging to cope with the long-term effects of surgery, leading to depression and anxiety.
Statistics indicate that 50% of men experience depression one year after prostate surgery, and half of patients undergoing radiotherapy have erectile dysfunction after five years. Long-term survivors of prostatectomy often continue to struggle with sexual dysfunction, depression, and anxiety. Providing comprehensive information about anticipated side effects and resources for managing sexual dysfunction and mental health is critical for enhancing treatment satisfaction and promoting intimacy.
Peyronie's Disease
Peyronie’s disease is characterized by penile symptoms, including pain, curvature, shortening, and erectile dysfunction. Traditionally, treatments have been invasive and painful. Research by physiotherapist Joanne Milios suggests that therapeutic ultrasound may effectively reduce pain and improve erectile function in men with Peyronie’s disease. Although these findings have not yet been published in a peer-reviewed journal, they represent promising developments in treatment options.
Pelvic Floor Muscle Rehabilitation
Verbal Cues for Pelvic Floor Contraction
Effective pelvic floor exercises rely heavily on technique. Mastering pelvic floor contraction techniques can improve continence and erectile function. Recent research indicates that specific verbal cues can enhance the recruitment of pelvic floor muscles. For instance, cues such as “shorten the penis,” “elevate the bladder,” “elevate the scrotum,” “stop the flow of urine,” and “tighten the anus” have been shown to be effective in targeting the appropriate muscles..
Preoperative Pelvic Floor Exercises
Engaging in pelvic floor muscle exercises before prostatectomy has been shown to significantly improve post-operative urinary continence and erectile function. One study found that only 18% of patients who engaged in pre-operative pelvic floor muscle rehabilitation reported sexual bother at one year, compared to 66% of those who did not participate in such exercises. Early acquisition of motor skills is achievable and tends to yield better outcomes when implemented before surgery.
Pelvic Floor Muscle Training for Erectile Dysfunction (ED)
Physiotherapy has demonstrated efficacy in treating ED across various causes. It offers a cost-effective, non-invasive first-line approach. Both weak pelvic floor muscles and pelvic floor muscle spasms can contribute to ED; thus, it’s crucial to accurately diagnose the underlying issue before implementing strengthening exercises.
Some concepts regarding how pelvic floor physiotherapy aids in ED treatment include:
- Enhancing the strength of the ischiocavernosus muscle may increase intracavernosal pressure, improving erection rigidity.
- Muscle spasms can restrict blood flow to the penis, impairing erectile function. Teaching relaxation techniques or manual muscle release can improve blood flow and erectile function.
- While this area requires more research, relaxing the bulbospongiosus and ischiocavernosus muscles may help inhibit the ejaculation reflex, assisting men with premature ejaculation.
Pelvic Floor Muscle Training for Incontinence
Pelvic Floor Muscle Training Program
Hodges et al. proposed a specific training program to optimize pelvic floor function for post-prostatectomy incontinence treatment:
- Optimizing Muscle Contraction Patterns: Ensuring the correct muscles engage involves using proper verbal cues and feedback techniques, including EMG biofeedback and real-time ultrasound.
- Functional Control: Progressing to functional exercises is crucial once patients can contract and relax their pelvic floor muscles correctly. Activities should reflect the individual’s challenges, such as practicing pelvic floor contractions while transitioning from sitting to standing.
- Bladder Training: It’s essential to maintain bladder compliance and volume. Strategies like restricting fluids or frequent toilet visits can harm bladder health. Implementing a comprehensive bladder training program early on is advisable.
- Low-Intensity Tonic Hold Training: Teaching the external sphincter to maintain low-intensity contractions is crucial, especially during periods of fatigue when leakage may worsen.
- High-Level Strength and Endurance Training: This stage focuses on enhancing contraction strength, endurance, and speed.
- High-Performance Training: The final stage incorporates pelvic floor rehabilitation into high-demand activities, addressing increased intra-abdominal pressure during exercise.
Additional Considerations for Optimizing Results
To see improvements, pelvic floor rehabilitation requires active participation from patients. Additional considerations include:
- Managing any bowel dysfunction, as this can adversely affect pelvic floor and bladder function.
- Addressing mental health issues, as they can impact recovery.
- Encouraging general exercise, which has been shown to improve overall outcomes.
- Promoting weight loss in overweight men, as obesity is linked to poorer recovery outcomes.
Post-prostatectomy Care at Vigor Men’s Pelvic Health Centre
Your Vigor Care Team
At Vigor Men’s Pelvic Health Centre, our team includes specialists with advanced training in bladder and urinary function. They focus on rehabilitating and treating complications followed by prostate surgery, bringing extensive experience to patients who have previously undergone unsuccessful treatments.
Advanced Diagnosis and Treatment
Our researchers are dedicated to enhancing the diagnosis and treatment of post-prostatectomy care. We are actively investigating the effectiveness of different exercises and protocols to effectively treating your issues.
Location
We are located at Mid Valley Kuala Lumpur:
Vigor Men’s Pelvic Health Centre
Unit 1-10, Level 10, Boulevard 1&3,
Mid Valley City, Lingkaran Syed Putra,
59200, Kuala Lumpur,
Malaysia.
WhatsApp Care Line: 019-282 8813
Email: care@vigor.my