What Is A Prostatectomy?

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Overview

A prostatectomy is a surgical procedure whereby a urologist removes the prostate, a small gland that is found in the male pelvis, to either treat a disease of the prostate or to alleviate symptoms associated with that disease.

The prostate is a uniquely male tissue that is a part of the male reproductive system and is found within the pelvis. There are a number of diseases that can develop within the prostate and some of them may require a prostatectomy (removal of the prostate). 

Being diagnosed with a medical condition can be a worrying time for anyone and when you are also given the news that surgery is required you may find yourself anxious about what that means. Some people find that having a deeper understanding of their medical condition and the treatment they may undergo helps alleviate some of the anxiety that they are feeling. This article is designed to give you an overview of what prostate surgery is, why and how it may be done, and what to expect in the long term.

Anatomy of the prostate gland 

The prostate is a gland found in the male pelvis, it lies below the bladder and above the rectum. The urethra, a narrow tube that urine and semen flow through, passes through the middle of the prostate. 

A gland is an organ in the body that produces and releases substances or chemicals that perform a specific function within the body. There are two types of glands, endocrine and exocrine. Endocrine glands secrete hormones directly into the blood supply whereas exocrine glands secrete substances through a duct.1 

The prostate is an exocrine gland, it secretes fluid which contributes to the make-up of semen (ejaculate) and is released through the urethra on orgasm. The prostate muscle also helps to push semen through the urethra during an orgasm. The urethra also carries urine from the bladder to the tip of the penis.

What is a Prostatectomy?

A prostatectomy is an operation whereby part, or all, of the prostate, is removed2 by a surgeon who specialises in the male urinary system, called a ‘Urologist’. In some cases not only is the prostate removed but some of the tissue and possibly lymphatic system surrounding the prostate is also removed, this is termed a ‘radical prostatectomy'.2 

Purpose of prostatectomy 

Prostatectomies are usually performed to treat or to manage one of two conditions, prostate cancer or benign prostatic hyperplasia (BPH). They can be performed either as a curative measure or as a symptomatic reliever depending on the condition.  

Conditions requiring prostatectomy 

Benign prostatic hyperplasia

Definition

The term ‘benign prostatic enlargement’ (BPE) is often used interchangeably with the term ‘benign prostatic hyperplasia’ (BPH). BPE is a term that describes an objectively abnormally enlarged prostate, of which the most common cause is BPH.3 BPH specifically describes the histological (cellular) changes of the prostate that are causing it to grow abnormally. This enlargement of the prostate is due to an increase in cell reproduction rate causing more cells to be formed and the prostate to grow in size. It is important to note that this growth is non-malignant (not cancer).3   

Prevalence

The prevalence of BPH increases dramatically with age. Approximately 50-60% of males in their 60s were found to have BPH, this increases to 80-90% in over 70s.3 Studies have shown that no men under the age of 30 have been found to have evidence of PBH and only 8% of men do by their fourth decade.4 

Symptoms

In the early stages of BPH, the sufferer may not experience any symptoms at all. However as the size of the prostate grows it can begin to compress the urethra, which runs through it, creating a bladder outlet obstruction that can cause lower urinary tract symptoms such as:5

  • Increased urinary frequency: needing to pass urine eight or more times a day
  • Urinary urgency: unable to delay passing urine
  • A weak or interrupted urinary stream (poor stream)
  • Delayed starting of urination
  • Dribbling at the end of urination
  • Nocturnal: increased need to pass urine at night
  • Urinary incontinence
  • Urinary retention
  • Pain on urinating
  • Urine which is an unusual colour or smell

The symptoms of BPH arise from either a compressed urethra or from a bladder which is having to work harder to overcome a blockage in the urethra.

Risk factors

Although the exact underlying cause of prostate hyperplasia is unknown there are a number of factors, both genetic and lifestyle-linked that have been shown to significantly increase the risk of developing BPH3:

  • Age: BPH is strongly correlated with increasing age
  • Genetic predisposition: the exact reasoning is unknown however studies show a strong genetic correlation in the development of BPH
  • Obesity: the underlying pathophysiology is unclear however studies have shown a link with obesity and an increased likelihood of developing BPH.
  • Metabolic syndrome: is a condition whereby a triad of syndromes is present, hypertension, dyslipidemia (high cholesterol), and glucose intolerance/insulin resistance (pre-diabetes). 

Management

Treatment options depend on the presentation of the patient. Some men may present with acute urinary retention3 (sudden inability to pass urine) whilst others are asymptomatic (have no symptoms) and others still are showing signs of chronic kidney problems resulting from a chronic obstruction. There are three different paths that the urologist may take when deciding on the best treatment for BPH.

  • Watchful waiting: This option is usually reserved for those with minimal symptoms or whose BPH was found incidentally.3 Patients are closely followed up and given lifestyle advice to manage symptoms such as weight loss, reduced caffeine intake, and reduced fluid intake in the evening to manage lower urinary tract symptoms.3
  • Medical options:3
    • Alpha-blockers: Improve urinary flow
    • Alpha reductase inhibitors: such as finasteride, work by reducing the size of the prostate, although they can take weeks to months for patients to notice any improvement in symptoms, they have been shown to alter disease progression.
    • Antimuscarinics: help to reduce symptoms of urinary urgency and frequency
  • Surgical options: There are numerous different surgical options that can be considered to manage BPH. These range from open simple prostatectomies to more modern techniques involving laser vaporisation.3 The technique chosen will depend on individual symptoms, surgical preference, and circumstances.

Prostate cancer 

Prostate cancer is the second most common cancer found in men.6 However, despite the high incidence rate of prostate cancer, relatively few men die from it.

Risk factors

  • Age: incidence risk increases with age, however, severity reduces with increasing age.
  • Family history of prostate cancer
  • Ethnicity
  • Diet
  • Obesity
  • Smoking
  • Hormonal consumption e.g androgens2,6

Symptoms 

Symptoms depend on whether the cancer is in early or late stages and which lobe of the prostate the cancer is affecting.2 Some sufferers remain asymptomatic (no symptoms) whilst others may be showing signs of metastatic disease spread rather than the traditional lower urinary tract symptoms. Below are some of the most commonly experienced symptoms:2

  • Haematuria (blood in the urine) 
  • Nocturia (increased urination at night)
  • Painful urination
  • Urinary incontinence
  • Spinal cord compression
  • Sexual dysfunction
  • Chronic bone pain (hips, ribs, back, pelvis)

Diagnosis

One of the most common ways men are diagnosed with prostate cancer, especially those who are asymptomatic is through PSA screening programmes.2 PSA stands for ‘prostate-specific antigen’, and is found in the blood when the prostate is abnormal. The PSA screening program is considered a controversial screening program though as PSA is very non-specific and raised rates do not automatically mean there is prostate cancer, the reverse is also true, a negative result of PSA does not completely ensure there is no prostate cancer.2 

Where there is clinical suspicion and increased PSA levels then a biopsy can be performed which will definitively confirm whether prostate cancer is present or not.2

Management

Management options will depend on individual circumstances, the stage of the cancer, whether metastatic spread is present or not, and the age and general health of the patient. There are three different treatment pathways available:

  • Watch and wait: the urologist will first determine whether any treatment is required at all. Prostate cancer is often extremely slow growing and the majority of sufferers will die ‘with’ prostate cancer as opposed to ‘from’ it.2 A watch-and-wait approach is generally preferred for older patients with less than 10 years of life expectancy who have a low-grade tumour. It requires active surveillance whereby the patient has regular PSA testing to see if the numbers are increasing and a further biopsy at 12-18 months.
  • Medical/pharmaceutical management: This involves the commencement of one or more medications. Which medication is selected depends on whether the goal is to cure the cancer or to manage symptoms and whether there is any metastatic spread.2
  • Surgical management: In patients with localised (not spread) prostate cancer and a life expectancy greater than 10 years or any patient with high-risk prostate cancer, the gold standard curative treatment is a radical prostatectomy.2 There are other forms of prostatectomy that, for various reasons, may also be performed and these will be discussed below.

Types of Prostatectomy

There are two different types of prostatectomy, radical and simple. 

Radical Prostatectomy

Description 

This is when both the prostate and tissue surrounding the prostate are removed.2 This can include the removal of lymph nodes.                           

Indication

A radical prostatectomy is the gold standard treatment for men with localised prostate cancer and a life expectancy of more than 10 years as well as anyone with high-risk prostate cancer.2 The aim is to cure the patient of prostate cancer. 

Surgical techniques 

Different surgical techniques to remove the prostate exist depending on the underlying disease, patient preference, and surgical skills.

During surgery, a catheter will be placed in the bladder which will be removed in the days to weeks following surgery depending on the patient's recovery.

Open radical prostatectomy: These require the surgeon to make a larger incision in the patient and thus have a longer recovery time with a longer stay in hospital, they also have a higher rate of postoperative infection at 5-9%.2 Due to advancements in technology, open prostatectomies are performed far less frequently these days2, however in cases where the surgeon wishes to remove surrounding lymph nodes this method may be preferred as the open technique allows for easier access to surrounding structures and thus easier removal. There are two types of open radical prostatectomy that can be performed:

  • Radical retropubic prostatectomy: the incision is made in the lower abdomen.2
  • Radical perineal prostatectomy: the incision made in the perineum which is skin fold between the anus and the scrotum.2
Benefits of an open radical technique compared to laparoscopic2 Drawbacks of an open technique compared to laparoscopic2 
Allows better viewing of surrounding structures
Easier for the surgeon to remove surrounding lymph nodes if required
Larger incision
Longer recovery time
Longer stay in hospital
Catheter has to stay in the bladder for a longer period of time and increases the risk of urinary infections
Higher risk of postoperative wound infection

Laparoscopic radical prostatectomy: Advancements in technology and surgical techniques over the years have led to laparoscopic surgery taking the place of many forms of open surgery and that is no different for the prostate. This means that smaller incisions are made in the skin and surgical instruments are inserted along with a camera allowing the surgeon to operate without having to open the patient up to see inside themselves. There are two methods by which a surgeon can do this:2

  • Laparoscopic radical prostatectomy: the surgeon makes multiple small cuts in the skin and uses a camera to see.
  • Robotic-assisted laparoscopic radical prostatectomy: this technique is now the most commonly used surgical technique to perform radical prostatectomies. The surgeon sits at a control panel and uses robotic arms to operate through small incisions in the abdomen.2 The robotic arms allow for greater mobility and precision in removing the prostate.
Benefits of Laprascopic technique compared to open2Drawbacks of laparoscopic technique compared to open2
Smaller incisions in patient's abdomen
Shorter recovery time
Shorter stay in hospital
Catheter removed quicker thus reducing infection risk
Lower risk of postoperative infection at 1%
Less blood loss
Less pain
Reduced visibility may mean surgeon is unable to remove some of the surrounding tissues leading to a relapse of prostate cancer
Success is dependent on individual surgeon's skills in laparoscopic and robotic techniques 

Simple Prostatectomy

Description

A simple prostatectomy is the removal of all or part of the prostate but does not include removing any surrounding tissue. It is usually performed to alleviate symptoms associated with an enlarged prostate due to BPH. As BPH is not cancer and there is no risk of metastatic spread, only the part of the prostate causing compression of the urethra or bladder is removed and the rest can be left.

Indication

Surgery is indicated if medical management for BPH has failed or if the patient refuses it. It is also the first line of management in patients with urinary retention, those passing large amounts of blood in the urine that cannot be managed with medication, overflow incontinence, recurrent urinary tract infections, or bladder stones.5

Surgical techniques

As with radical prostatectomies, there are a variety of different techniques a surgeon can use to perform a simple prostatectomy. The technique chosen will depend on the patient's physical state, comorbidities, and ability to withstand anaesthesia as well as the skill of the surgeon, available resources, and patient wishes.5

  • Open simple prostatectomy: This technique is also called a ‘Supra pubic enucleation’ and is the gold standard for enlarged prostates greater than 80ml.5 New techniques that don’t require a large incision in the skin (an open approach) are starting to gain popularity and it is likely that, down the road, the open surgical technique will become largely obsolete.
  • Laparoscopic prostatectomy: The enlarged lobe of the prostate can also be removed laparoscopically just like with a radical prostatectomy. These provide a minimally invasive alternative to the open simple prostatectomy and can be performed on prostates larger than 80ml, just like with a radical prostatectomy they can also be robotically assisted.7
  • TURP: Transurethral resection of the prostate is the gold standard surgical treatment for prostates under 80ml.7 This method does not involve incisions in the skin instead, it requires the use of a resectoscope, which is inserted through the tip of the penis and down the urethra until it reaches the site of the compression caused by the enlarged prostate. Once in place, excess tissue is cut away with an electrically heated wire.5
  • Transurethral enucleation technique: These techniques are rapidly gaining in popularity as they have better safety profiles than open alternatives.5 There are a variety of different methods that can be performed, similar to a TURP, they use a resectoscope passed down through the urethra to access the enlarged prostate and then an energy source, such as a laser, is used to vaporise tissue from the enlarged prostate.5 Examples include, HoLEP (holmium laser enucleation of the prostate), ThuLEP (thulium laser enucleation), or BipoLEP (bipolar enucleation of the prostate). Unlike a TURP however, they can be used on prostates larger than 80ml.5
  • UroLift: This is one of the newest techniques and can be performed on an outpatient basis. It requires no incisions, cuts, or general anaesthesia. In this procedure, implants are inserted to compress the lobes of the prostate and to reduce the obstruction within the urethra.5 There is no risk to sexual function and they can be used on prostates greater than 70ml however have a number of significant drawbacks.5

Below we will discuss the pros and cons of the different simple prostatectomy techniques.2,5,7

ProcedureBenefitsDrawbacks
Open simple prostatectomyCan be used on prostates >80mlLonger recovery
Longer hospital stay
Increased blood loss
Increased pain
Laparoscopic simple prostatectomyCan be performed on prostates >80ml
Shorter hospital stay than open surgery
Reduced bleeding compared to open surgery
Requires hospital stay
Risk of perioperative bleeding
Longer recovery than TURP
TURPShorter hospital admission than open/laparoscopic techniquesCan only be used in prostates <80ml
Risk of peri-operative bleeding
Many require a second TURP down the line
Transurethral enucleation techniqueBetter safety profile in general compared to TURPRevision may be required after a number of years
Similar risk of long-term complications (see below) as TURP
UroLiftNo anaesthesia
No bleeding risk
Best safety profile
Preservation of sexual function
Not a long-term solution as generally fails after a number of years

Common long-term post-prostatectomy complications

Long-term post-prostatectomy complications fall into two categories, those affecting urinary function and those affecting sexual function.

Urinary function

Due to the prostate's position around the urethra and below the bladder, long-term urinary incontinence can be an unfortunate side effect. This usually presents as an inability to control urinary flow which results in leakage or dribbling.2 Stress incontinence is the most common type of incontinence following prostate surgery and is defined as having urinary leakage when laughing, coughing, exercising, or otherwise straining.2 A mixture of pelvic floor muscle training and medication can be used to manage urinary incontinence, although there is no cure.

Sexual function

Post-prostatectomy sexual dysfunction is another complication that can arise from prostate surgery. There are three different types of sexual dysfunction that can arise:

  • Erectile dysfunction: This is the most common sexual dysfunction complication.2 Erections are controlled by bundles of nerves that run alongside the prostate. A surgeon can attempt a nerve-sparing approach if conservation is something the patient desires however, with prostate cancer, this may not always be possible if the cancer has grown too close to the nerves.2 An erection however is not necessary for a male to orgasm so this should still be possible after surgery, if it was before.
  • Infertility: Due to the age profile of men who usually suffer from prostate cancer or BPH this is not often a concern. However it is something patients need to be aware of, it results from the reduction in seminal fluid meaning the sperm is unlikely to be able to impregnate a woman.2
  • Orgasm changes: This may present as a decrease in fluid during ejaculation. The prostate contributes 15% of seminal fluid, the removal of it as well as possibly the removal of other tissues of the male reproductive system, will reduce or completely eradicate the amount that is present during ejaculation.2

Preparing for a Prostatectomy

Once it has been decided that the most appropriate method of treatment is a prostatectomy, either simple or radical, there are a few things you can do to get ready for both the operation and in preparation for your recovery.

Before the operation

Before the day of the operation, you will need to see a member of the anaesthetic team. This is called a ‘pre-op assessment’ and your medical history will be reviewed as well as any allergies, current medications, or healthcare concerns. You may require some further tests at this stage to check that your body is strong enough to undergo general anaesthesia.

You will also be told about which medications you can and can't take in the run-up to the operation, eating and drinking rules before your operation and you may be given some medication to clean out your bowels before the surgery.

On the day of the operation

On the day of the operation, you will be given a time to arrive at the hospital. You will also have been told when you need to have last eaten and drank, make sure to closely follow the directions you have been given. 

Once you have woken up after your surgery you will be given pain relief and the day after surgery you will start getting back on your feet.

Aftercare

  • You will likely need to spend some time in the hospital recovering from the operation so ask your doctor how long this is expected to be
  • You may require a catheter to be left in place after your operation for several days so ask your doctor how long this could be for and whether you will return home with one.
  • If you work, you will not be able to return to work straight away so speak to your doctor about how much time it is likely to be before your return. The same goes for strenuous activities and sports.
  • If you are concerned, ask about when you can resume sexual activity and what you can expect.

Summary

  • Prostatectomy is the removal, either in part or in whole of the prostate. It may also include the removal of some surrounding tissue.
  • Prostatectomy is performed as part of the management of prostate cancer or benign prostatic enlargement.
  • There are two types of prostatectomy, radical or simple. Each one can be performed via a number of different techniques and each technique has its own unique benefits and drawbacks.
  • Your surgeon will decide on which type of surgery and which technique is best for your individual case and discuss the pros and cons of them.
  • There are a number of different complications that can arise, either during surgery, in the immediate aftermath or in the long-term
  • Long-term complications include urinary incontinence and sexual dysfunction

References

  1. Freeman S. Physiology, Exocrine gland [Internet]. Available from: https://europepmc.org/article/nbk/nbk542322
  2. Kaler J, Hussain A, Haque A, Naveed H, Patel S. A comprehensive review of pharmaceutical and surgical interventions of prostate cancer. Cureus [Internet]. [cited 2023 Dec 8];12(11):e11617. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7681941/
  3. Ng M, Baradhi KM. Benign prostatic hyperplasia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Dec 8]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK558920/
  4. Cju - article abstract: [Internet]. [cited 2023 Dec 8]. Available from: https://www.canjurol.com/abstract.php?ArticleID=&version=1.0&PMID=26497338
  5. Miernik A, Gratzke C. Current treatment for benign prostatic hyperplasia. Dtsch Arztebl Int [Internet]. 2020 Dec [cited 2023 Dec 8];117(49):843–54. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021971/
  6. Merriel SWD, Funston G, Hamilton W. Prostate cancer in primary care. Adv Ther [Internet]. 2018 [cited 2023 Dec 10];35(9):1285–94. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133140/
  7. Sosnowski R, Borkowski T, Chłosta P, Dobruch J, Fiutowski M, Jaskulski J, et al. Endoscopic simple prostatectomy. Cent European J Urol [Internet]. 2014 [cited 2023 Dec 14];67(4):377–84. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310888/

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Natasha Larkin

Doctor of medicine - BM BS, Peninsula Medical School UK
Master of Public Health - MSc, London School of Hygiene and Tropical Medicine

Natasha worked for a number of years as a junior doctor in the NHS before undertaking a MSc in Public Health and the world-renowned London School of Hygiene and Tropical Medicine. Realizing her passion and strengths lie within medical writing she is utilizing her strong medical knowledge and experience in medical research to produce high quality medical content that is aimed at and accessible to the general public.

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