Prostatectomy is the surgical procedure involving removal of all or a part of the prostate gland (Pic. 1). It is most commonly performed to treat benign hyperplasia (enlargement, Pic. 2) of the prostate or prostate cancer. These conditions have significant negative effect on male fertility and overall quality of life.
There are two main types of prostatectomies:
1. A simple prostatectomy
A simple prostatectomy (also known as a subtotal prostatectomy) is when only part of the prostate is removed. Simple prostatectomies are typically only done for benign conditions.
2. A radical prostatectomy
A radical prostatectomy, the removal of the entire prostate gland, the seminal vesicles and the vas deferens, is performed for malignant cancer.
There are multiple ways the operation can be done: as an open surgery (with a large incision through the lower abdomen), laparoscopically with the help of a robot (a type of minimally invasive surgery), through the urethra or through the perineum.
In an open prostatectomy, the prostate is accessed through a large single incision through either the lower abdomen or the perineum. Further descriptive terms describe how the prostate is accessed anatomically through this incision (retropubic vs. suprapubic vs. perineal). A retropubic prostatectomy describes a procedure that accesses the prostate by going through the lower abdomen and behind the pubic bone. A suprapubic prostatectomy describes a procedure cuts through the lower abdomen and through the bladder to access the prostate. A perineal prostatectomy is done by making an incision between the rectum and scrotum on the underside of the abdomen.
Laparoscopic radical prostectomy
Laparoscopic radical prostatectomy (LRP) is a modern form of radical prostatectomy (Pic. 3), an operation for prostate cancer. Contrasted with the original open form of the surgery, laparoscopic radical prostatectomy does not make a large incision. Instead, laparoscopic radical prostatectomy is minimally invasive and relies on modern technologies, such as fiber optics and miniaturization. Laparoscopic radical prostatectomy is not a new treatment for prostate cancer. It is a modern form of the oldest treatment for prostate cancer. The procedure takes at least five hours and as long as eight hours for the average urologist, without a bilateral lymph node dissection, compared to 2.5–3 hours when done by an open technique with an incision, with a completed lymph node dissection.
Transurethral resection of the prostate
Transurethral resection of the prostate (commonly known as a TURP, plural TURPs, and rarely as a transurethral prostatic resection, TUPR) is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. This is considered the most effective treatment for BPH. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 80-90% of BPH patients.
Robotic assisted prostatectomy (RARP)
Robotic-assisted instruments are inserted through several small abdominal incisions and controlled by a surgeon. The computer-assisted device gives the surgeon more dexterity and better vision, but no tactile feedback compared to conventional laparoscopy. When performed by a surgeon who is specifically trained and well experienced in RALRP (robotic-assisted laparoscopic radical prostatectomy there can be similar advantages over open prostatectomy, including smaller incisions, less pain, less bleeding, less risk of infection, faster healing time, and shorter hospital stay. The cost of this procedure is higher, whereas long-term functional and oncological superiority has yet to be established.
Radical prostatectomy (RP) is the gold standard for the treatment of localized prostate cancer. Robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP) are widely used, and have been associated with lower positive surgical margin rates (proportion of cases when a residual tumorous infiltration has been found in the margin of the removed tissue), shorter hospitalizations, lower post-operative leakage rates, lower transfusion requirements and a shorter period of urinary catheterization.
Prostatectomy is most commonly performed due to benign prostatic hyperplasia or prostate cancer. Symptoms of these conditions may include:
Surgical removal of the prostate contains an increased likelihood that patients will experience erectile dysfunction. Nerve-sparing surgery reduces the risk that patients will experience erectile dysfunction. However, the experience and the skill of the nerve-sparing surgeon, as well as any surgeon are critical determinants of the likelihood of positive erectile function of the patient. Following a prostatectomy, patients will not be able to ejaculate semen due to the nature of the procedure, resulting in the permanent necessity of assisted reproductive techniques in case of desires of future fertility. Preservation of normal ejaculation is possible after TUR-Prostatectomy. However, retrograde ejaculation is a common problem.
Early urinary incontinence remains one of the most common complications after RP. Post-operative urinary incontinence is severely bothersome and is associated with a decreased quality of life. Urinary incontinence is often perceived as more bothersome than erectile dysfunction. Several methods of pelvic floor reconstruction have been introduced to reduce the risk of urinary incontinence.
The most common risk factors for developing one of the conditions treated by prostatectomy are:
There is no sure ways to prevent the conditions that may require a prostatectomy to be performed. Especially benign prostatic hyperplasia, which occurs due to stimulation of the prostate by testosterone, the main male sex hormone, is almost impossible to prevent.
However, there are some measures that may be taken to lower the risk of prostate cancer. Diet low in fat and processed meat, high in fiber and in dairy products, maintaining a healthy body weight and not smoking are all ways to decrease the risk of prostatic cancer.
Surgical removal of the prostate contains an increased likelihood that patients will experience erectile dysfunction. Impotence is common when nerve-sparing techniques are not used. Although erection and ejaculation are affected, penile sensation and the ability to achieve orgasm remain intact. Continence and potency may improve depending on the amount of trauma and the patient's age at the time of the procedure, but progress is frequently slow. Potency is greatly affected by the psychological attitude of the patient. The sensation of orgasm may be altered and no semen is produced, but there may be a few drops of fluid from the bulbourethral glands.
On the other hand nerve-sparing surgery reduces the risk of erectile dysfunction. Nerve-sparing surgery attempts to protect the cavernous nerves of penis, which control erection. These nerves are very fine and fragile and run next to the prostate and may be destroyed during surgery, leading to impotence. If the cancer is clinically unlikely to have spread beyond the prostate, nerve-sparing surgery should be offered to minimize impotency and to speed up urinary control. Following a prostatectomy, patients will not be able to ejaculate semen due to removal of a part of the male genital tract, resulting in infertility.
Following a prostatectomy, patients will not be able to ejaculate semen due to the nature of the procedure, resulting in the permanent necessity of assisted reproductive techniques in case of desires of future fertility. Preservation of normal ejaculation is possible after TUR-Prostatectomy, open or laser enucleation of adenoma and laser vaporisation of prostate.
Once the prostate and vesicles are removed, even if partial erection is achieved, ejaculation is a very different experience. Very few surgeons will claim that patients return to the erectile experience they had prior to surgery.
Remedies to the problem of post-operative sexual dysfunction include:
The pathological inability to ejaculate in males, with (orgasmic) or without (anorgasmic) orgasm.
A class of sexual disorders defined as the subjective lack of normal ejaculation.
The inability (that lasts more than 6 months) to develop or maintain an erection of the penis during sexual activity.
The semen, which would normally be ejaculated via the urethra, is redirected to the urinary bladder.