Prostate Cancer Surgery

Prostate cancer is a cancer that develops in the prostate gland - a small gland placed between the penis and the bladder in men. Prostate is a part of the male reproductive system. It secretes prostate fluid - through the seminal vesicles - that forms a part of semen along with sperms and fluids from other glands. 

The seminal vesicles are a pair of smaller glands present on the sides of the prostate. Prostate cancer may spread to the seminal vesicles too.

The surgery for prostate cancer involves removal of the prostate gland, seminal vesicles and a part of the urethra. This procedure is known as radical prostatectomy. The tissues around these glands may also be removed if cancer cells are observed on them. The following types of radical prostatectomy are available:

• Open surgery: A large incision is made to remove the prostate gland and the tissues that may have cancer cells. 
• Minimally invasive surgery: The prostate and adjacent cancer cells are accessed with the help of a few small incisions. This surgery may be done manually or with robotic assistance.

The surgery for prostate cancer is recommended for the treatment of prostate cancer. Initially, prostate cancer may not show any symptoms. Over time, the following symptoms may be observed:

• Painful ejaculation
• Frequent urination
• Haematuria (presence of blood in the urine)
• Dull pain in the lower pelvic region
• Pain or burning sensation while urinating Read more: Painful urination causes
• Weak flow while urinating
• Weight loss
• Loss of appetite
• Pain in the hips, upper thighs or lower back
• Bone pain

Prostate cancer surgery is beneficial in the treatment of people with prostate cancer, which is either present only in the prostate or has spread to the region just adjacent to the prostate. People undergoing this surgery should also be generally healthy. In some cases, surgery may also help in treating the cancer that may have reoccurred after radiotherapy. 

The surgery is generally not recommended in people with significant health conditions, such as heart disease, as the risks of the surgery increase. This surgery is also not recommended in men above the age of 75 years or life expectancy of less than 10 years.

About a week before the surgery, you will need to undergo some tests to determine if you are fit to undergo surgery - it is called a pre-operative assessment. The tests include the following:

• A blood test to check your blood type, in case a blood transfusion is required during the surgery.
• Other blood and urine tests to determine if you have any risk of infections and if your liver and kidneys are functioning properly.
• Radiological tests, such as magnetic resonance imaging, computerised tomography, ultrasound and bone scan may be done to asses your fitness level. 

Your blood may also be drawn and stored to be used if needed during the surgery. 

A meeting with your surgeon will be arranged for you to discuss the test results of your pre-operative assessment, a requirement for the prostate cancer surgery and risks and benefits of the surgery and to clarify your doubts. 

Discuss with your healthcare provider about any allergies that you have, all the medicines that you are taking and what you can and cannot eat before the surgery. You may be requested to stop taking certain medication, such as warfarin for some time before surgery.

Your doctor will ask you to sign a consent form that states that you are permitting the healthcare team to perform the surgical procedure. 

At least two weeks before the surgery, you will need to quit smoking, which can help in a faster recovery after surgery. 

Performing pelvic floor muscle exercises for a few weeks before the surgery will be helpful in a speedy recovery. 

After the surgery, lifting heavyweight is not recommended, and you will need to rest. For this reason, try the following tips to organise your home before the surgery:

• Ask someone, maybe a friend or relative, to stay with you for a few days after the surgery to help with the basic needs
• Prepare and freeze food items, so you need not cook after the surgery
• Have someone to help you with chores, such as cleaning
• If you have any pets, portion out their food in advance and store them in separate containers so that you need not carry the heavy animal food bags
• Keep loose and comfortable clothes ready to be worn when you are recovering
• Prepare a list of important phone numbers

You may want to arrange for a family member or friend to accompany you to the hospital on the day of the surgery. 

You may be admitted at the hospital either one day before or on the day of the operation. You will need to maintain fasting conditions for about six hours before the surgery but will be allowed water and certain fluids up to two hours before the surgery. You may be given a suppository (a pellet) or an enema (a liquid medicine) to help clear your bowels. These are placed in your rectum. Just before the surgery, a nurse will put knee-length, elasticated socks on your legs, which lower the chance of blood clot formation in your legs. These socks will remain on till you start walking after the surgery. 

The operation is performed under general anaesthetics, and you will be asleep during the procedure. The entire procedure takes nearly two to four hours but may take longer in some cases. 

The surgeon will remove the prostate and all nearby tissues, including the lymph nodes depending on the presence of cancer cells in the lymph nodes. 

The following are the types of surgery:

• Open surgery: It is also known as retropubic surgery. The surgeon will make a single incision from below your navel to just above the pubic bone. They will check to see if cancer has spread to the lymph nodes. This method of surgery can be used for nerve-sparing surgery. In a nerve-sparing surgery, the surgeon removes the prostate tissue away without damaging the nerves that control erections. However, if the nerves are too close to the cancer cells, the doctor will have to remove them as leaving them will not completely treat cancer. Your abdomen will have a scar after the surgery. 
• Minimally invasive surgery (laparoscopy): The surgeon will not make any major incision. Instead, they will make four to six small cuts in your abdomen. They will pass a laparoscope, which is a long, thin tube with a camera and light at one end, through one of the cuts. The other surgical instruments will be inserted through the other cuts. Nerve-sparing surgery can be performed with this technique too (a procedure to protect the nerves). This surgery can also be performed robotically. In robotic surgery, the surgeon sits a little away from the patient and controls the robot that is right next to you. The machine has four arms; one arm has a camera, and the others have surgical instruments. The doctor can view the internal structures of the body on a screen and can control the arms of the robot to perform the surgery.

After the surgery

After the surgery, you will wake up to find yourself in the recovery room. You will have the following attached to your body:

• A catheter (a thin, flexible tube) to drain your urine
• An oxygen mask as you will be breathing slowly due to anaesthesia 
• An intravenous line to administer fluids and painkillers

An additional tube may be attached for a day or two to drain any fluid from the place where your prostate was present.

The catheter will be attached during the surgery. Initially, you will feel an urge to urinate all the time, and you will feel uncomfortable, but in a few hours, this feeling will pass. The catheter is attached so that all the urine is drained without you doing anything. You will be allowed to go home with the catheter attached, and a nurse will explain how to care for it. About one to three weeks later, it will be removed at the hospital. 

If a laparoscopic surgery was performed, you might feel a little pain in your shoulder for a few days. The carbon dioxide gas used during the surgery irritates the nerves and causes shoulder pain. You may also feel bloated and some cramping, which goes away with time. 

The surgery may cause some bruising and swelling around the penis and testicles, which could make it uncomfortable to sit on hard surfaces. This problem usually settles in a few weeks. If the lymph nodes were also removed, it might rarely cause your scrotum (the skin that holds the testicles) and either one or both legs to swell. You may need special compression socks, which help in draining the fluid from the legs. 

You will be made to start walking as soon as you can. This keeps up blood circulation and reduces the risk of clotting. 

Depending on your recovery, you may be discharged within a day or a week of the surgery.

Before leaving, you will be given a phone number to contact in case of an emergency. 

You will be asked to relax for a few weeks after the surgery. Maintain a healthy diet with lots of fiber rich food and gradually, start with easy exercises such as slow and short walking. Avoid lifting heavy weights , climbing stairs or doing manual labour for about two months after the surgery.

You will still have the catheter for upto three weeks after the surgery. The catheter will be attached to a collection pouch that can be worn hidden in your pants. Make sure the tube of the catheter is not blocked otherwise the urine will not get collected in the pouch. While handling your catheter, keep these tips in mind to prevent a urinary tract infection:

• Drink lots of water (about 2 L a day).
• Wash the catheter and the tip of your penis (with warm water and unscented soap) at least two times per day. Make sure to wipe the catheter downward and away from your body, and let it dry properly.
• Rinse your hands with soap and warm water before and after touching the catheter. 

You may notice a little bleeding while the catheter is attached to your body and immediately after its removal - it is nothing to worry about and generally stops itself. Your healthcare provider will check if you can properly urinate before you leave the hospital. 

If you have had open surgery, the incision will be closed with the help of stitches or staples. These stitches need to be removed after a week or two by a general practitioner or in the hospital. If you underwent laparoscopic surgery, the incisions are generally sealed with the help of stitches, clips or special glue. Within a few days, as the wound heals, the stitches fall out on their own. However, the muscles and internal tissues may need up to a year to heal. 

Your bowel movements will take some time to get normal. Fibre-rich foods with lots of water may help prevent constipation. However, if you are unable to pass stool and are uncomfortable, do not strain yourself too much. Instead, take some laxatives (medicines that will help you pass stool). 

Prostate cancer surgery has the following benefits:

• If cancer is present only in the prostate, the surgery will completely remove it. 
• The doctor can look at the prostate under a microscope to determine if cancer has spread to other parts, how aggressive it was and decide if further treatment is required. 
• It gives the mental satisfaction to some patients that the cancer is removed, However, additional tests may be required to know if cancer had spread.

When to See the Doctor?

In the following situations after the surgery, inform your doctor immediately:

• If your urine has a strong smell, blood clots, cloudy appearance or red colour
• If you feel nauseous or vomit
• If you have a fever
• If your catheter is not draining the urine
• If your catheter falls out or leaks
• If the wound area or tip of the penis becomes painful, red or swollen
• If you have any pain or swelling in the muscles in the lower part of your leg
• If you get stomach cramps that do not subside

The risks of the surgery include the following:

• Bleeding during or immediately after the surgery with the need for blood transfusion
• Formation of blood clots in the lower part of the leg that could be transported to the lungs
• Injury to surrounding tissues, including the pelvic floor muscles, blood vessels and nerves
• Scarring at the site of incision
• Infection
• Reactions to anaesthesia
• If lymph nodes are removed, there may be pooling of lymph called lymphocele, which needs to be drained

Some of the side effects of the surgery are as follows:

• Urinary incontinence (inability to control urine)
• Erectile dysfunction (problem in getting an erection)
• Changes in orgasm (you will feel the same pleasure, but will not be able to ejaculate any semen)
• Loss of fertility 
• Lymphoedema (collection of lymph in the genital region and legs)
• A slight decrease in the length of the penis

Between the first to three weeks after the surgery, you would have to go to the doctor to get the catheter removed and the stitches removed. 

The follow-up visits generally start six to eight weeks after the surgery at a frequency of once every three to six months. Gradually, you may have to visit less often, and about two to five years after the surgery, you may start getting your checkup every year from a general practitioner. 

In the follow-up visit after the surgery, the doctor will check your test reports for the levels of prostate-specific antigen, which should be too low to be detected.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.