It’s not what you wanted to hear, but your doctor recommended a prostatectomy for your enlarged prostate. He explained it and asked if you had questions. But your head was reeling and you didn’t hear anything he said. So now what? Read on.
Prostatectomy is removal of all or part of your prostate, a “walnut”-sized gland that surrounds the urethra. As it grows, and it does most of your life, it restricts the flow of urine from your bladder, through the urethra, out your penis. If your urologist is recommending surgery, your “walnut” is now the size of a large orange, or worse. You likely have to stop at each hole while golfing to pee in the woods, you are the last one standing at the urinal while all the young guys come and leave, and you might even have to pee sitting down. You have been living with the symptoms of benign prostatic hyperplasia (BPH) for a while, so you know that enlarged prostate is something you would not wish on your worst enemy.
Furthermore, the prostate, although you may not appreciate it much, is important in semen production. Your prostate produces fluid. Testicles produce sperm cells; the seminal vesicle also produces fluid; and a tiny gland below the prostate secretes more fluid. All of these fluids get mixed together in the urethra and voila! semen. Pretty amazing, huh?
The prostate has muscles. One of their jobs is to contract and press all the fluid stored in the urethra out the penis during ejaculation.
And it’s like a traffic cop, too. The prostate’s muscles help keep semen from entering the bladder during ejaculation and urine from entering the seminal ducts during urination. Another pretty slick hand-off.
It is covered by three layers of tissue. The innermost, the one closest to the urethra, itself, is the transition zone, and it is here where benign growth usually occurs.
Fortunately, you have many options for a prostatectomy. To find the best option, it’s important to talk to your doctor and tell him all your symptoms and your medical history. What you two decide to do depends on your individual case.
Options include minimally invasive surgery performed with a laparoscope (no incisions), surgery with robotic assistance, or traditional open surgery.
Your greatest fear about prostate surgery may be being left incontinent or impotent, or both. Take heart.
Minimally invasive surgery: TURP
A transurethral resection of the prostate (TURP) goes through the penis, not through an incision, to remove parts of the prostate gland.
The resectoscope is an amazing tool. It’s about 12 inches long and half an inch wide. Your surgeon inserts it into your penis. It holds a lighted camera, valves that turn irrigating fluid on and off, and an electrical wire loop on the end. The loop cuts away pieces of your prostate and stops bleeding. The fluid washes the pieces of tissue into your bladder and out your body at the end of the procedure. The surgeon controls all the action.
Even though it is minimally invasive, a TURP includes all the apparatus of surgery: operating room, general anesthesia, IV, possibly a breathing tube, possibly an endoscope into your penis, a resectoscope, and a catheter.
A TURP usually lasts about 8-10 years before you might need to have it done again.
Life After TURP
- Catheter (1-3 days)
- Pain meds
- Drinking lots of fluids (preferably water)
- No heavy lifting
- No driving until OKd by your doc
- Checking in with your doc if you notice problems like fever, trouble urinating, changes in your urine, increasing blood in your urine
Complications after TURP
- Bladder injury
- Bleeding
- Blood in the urine
- Electrolyte abnormalities (rare with newer techniques)
- Infection
- Loss of erections (rare)
- Painful or difficult urination
- Retrograde ejaculation (when ejaculate goes into the bladder and not out the penis)
Depending on your condition, you may have other risks. That’s why it’s important to talk to your doctor about your concerns before the procedure.
An alternative to TURP: Prostatic Artery Embolization
Prostatic artery embolization (PAE) is a minimally invasive procedure that helps alleviate symptoms of benign prostatic hyperplasia.
If you go this route, you will see an interventional radiologist (IR), a doctor who uses X-rays, rather than surgery, to treat conditions. This procedure is usually reserved for people who cannot undergo a surgical operation.
According to Johns-Hopkins, the PAE has a lower risk of urinary incontinence and sexual side effects (retrograde ejaculation, erectile dysfunction) than a TURP.
What happens during Prostatic Artery Embolization?
- You may have a Foley catheter (a thin, hollow tube held in place with a balloon at the end) inserted into your urethra. It goes into your bladder as a reference point for the organs around it.
- The surgeon inserts a small catheter into an artery in your wrist or groin. He or she guides the catheter into the vessels that supply blood to your prostate.
- To see them better, the surgeon injects dye into the blood vessels going to the prostate.
- The surgeon reduces the flow of blood to your prostate by injecting particles into the blood vessels.
- The prostate begins to shrink; your symptoms begin to go away.
Risks of PAE
PAE should only be performed by knowledgeable and trained interventional radiologists. Patients may experience
- “Post-PAE syndrome”; could last for days following the procedure
- can include nausea and vomiting
- fever
- pelvic pain
- painful or frequent urination
- Possible other side effects
- hematoma (collection of blood caused by a broken blood vessel) at the incision site
- Necrosis of the prostate – dying tissue in the prostate that causes constant pain and recurrent infections
- bladder spasm
- bladder infection
Laser surgery (mayoclinic.org)
Three types of laser surgery address BPH.
- If your prostate is mild to moderately enlarged you might have photoselective vaporization of the prostate (PVP): A laser melts (vaporizes) excess prostate tissue and enlarges the urinary channel. It is like star trek, vaporizing the prostate into dust.
- Holmium laser ablation (HoLAP) uses a different type of laser that PVP, otherwise it is similar to PVP.
- If your prostate is severely enlarged, you might be a candidate for holmium laser enucleation of the prostate (HoLEP). It is similar to PVP with an addition: After the laser removes excess prostate tissue, another instrument cuts the prostate tissue into small pieces for removal. This is a challenging surgery and requires a surgeon with extensive experience.
- Laser surgery usually treats the prostate tissue, but the tissue grows back. It usually last 5-8 years before you need another treatment, except HoLEP which can last much longer.
Advantages of laser surgery
- Lower risk of bleeding especially if you take blood thinning medication
- Shorter or no hospital stay
Risks
- Temporary difficulty urinating requiring a catheter
- Burning and pain with urination which can last for months, but ultimately resolves
- Narrowing of the urethra caused by scars
- Dry orgasm (retrograde ejaculation). During ejaculation semen goes into the bladder rather than out the penis. Not harmful, but decreases fertility
- Erectile dysfunction (rare)
- Need for retreatment after vaporization surgery, but not often necessary after enucleation surgery.
Life after surgery
- You may have a catheter to enable urination. When you have likely healed, the doctor will remove it.
- You may see blood in the urine, which is normal, for a few days to weeks afterwards.
- You may feel burning at the tip of the penis and near the end of the flow during urination. This may last for weeks or months after some types of laser surgery.
- You will pee with a good stream, but many men still have to urinate all the time. Most men see improvement over time.
Robotic-assisted Simple (Suprapubic) Prostatectomy
In robotic laparoscopic surgery the surgeon makes several small “keyhole” incisions in the abdomen and passes tiny robotic instruments through these incisions. The image processing equipment provides a three-dimensional magnified view of delicate structures surrounding the prostate (e.g., nerves, blood vessels and muscles), allowing optimal preservation of these vital structures. The surgeon removes the prostate through one of the keyhole incisions. This surgery is much less invasive than a conventional open prostatectomy.
From a computer console the surgeon controls instruments that move more delicately and with greater precision than human hands.
Simple prostatectomy
“Simple” means that only the prostate or part of it is removed, as opposed to the prostate and adjacent structures, as would be the case in prostate cancer surgery. A simple prostate removal can be performed with a laparoscope (no incision) or through an open incision. The surgeon removes the inner portion of the prostate and leaves the outer portion unchanged.
A traditional open surgical prostatectomy includes making an 8- to 10-inch incision and removing the prostate gland (or part of it). The incision may be suprapubic (from the lower abdomen to the pubic bone) or a perineum incision (between the scrotum and the rectum).
If you have severe urinary symptoms and a very enlarged prostate (more than 100gm), your doctor may recommend this method.
The surgery eases urinary symptoms and complications resulting from blocked urine flow, including all the symptoms of benign prostatic hyperplasia.
You will have drains and a catheter after surgery.
Side effects
- Pain from the incisions lasting days to a few week
- Possible erectile dysfunction (rare)
- This requires a hospital stay of 1-2 days if done with the robot, longer if done open.
It takes you longer to recover from open and simple prostatectomies than other enlarged prostate procedures such as transurethral resection of the prostate (TURP), laser PVP, or holmium laser prostate surgery (HoLEP). However, the long term benefits are significant. After simple prostatectomy you can often stop taking all of your prostate medications and the prostate will not grow back for 30-40 years.
Risks
- Bleeding
- Urinary tract infection
- Urinary incontinence (rare)
- Dry orgasm
- Erectile dysfunction (rare)
- Narrowing (stricture) of the urethra or bladder neck
Life after surgery
- Prescription pain pills to take after the IV is removed
- One night in the hospital
- Return to the doc in 1-2 weeks for wound check
- Catheter. You will most likely need a urinary catheter for 7- 10 days after surgery.
- Take it easy the first 4-6 weeks. After that, ease into your normal activity level.
- Go back to the doc as instructed to make sure you’re healing well.
- Dry orgasm. After you heal you can have sex. But you won’t ejaculate much semen.