Simple prostatectomy is the surgical removal of the central portion of the prostate gland. Done for select cases of benign prostate enlargement, it is indicated in the surgical management of large volume prostate glands, those measuring greater than 100 cc. in volume (a normal prostate has a volume of about 20 cc, the size of a golf ball). Simple prostatectomy is quite different than radical prostatectomy, a procedure done for prostate cancer in which the entire prostate gland is removed. While typically done using open surgical technique, simple prostatectomy can be done using minimally invasive robotic surgery in most cases. The goal of the surgery is the same in either case: to efficiently remove the bulk of obstructing benign prostate tissue in large volume prostate glands requiring surgical therapy.
The prostate gland is located directly below the urinary bladder and is attached to it. As urine leaves the bladder it must pass through the center of the prostate gland to enter the penile urethra for expulsion to the outside world. In benign prostatic enlargement, it is this central portion of the gland, called the “adenoma” that is disproportionately enlarged. An enlarged prostate can lead to difficulty with urination, urinary infection, urinary tract bleeding, and damage to the kidneys.
The surface of the bladder to which the prostate gland is attached is the site of the internal urinary sphincter. This sphincter muscle is responsible for maintenance of urinary control. Malfunction of this gate will eventuate in some degree of urinary incontinence. The proximity of this gate to the prostate explains why 10% of men who undergo simple prostatectomy have some degree of urinary incontinence postoperatively. While the surgery itself can damage the gate, the massively enlarged gland which pushes upward on the gate effacing it significantly, is also etiologic in the occurrence of urinary incontinence. Additional treatment is available should significant urinary incontinence persist long term.
Prior to surgery you will need to have any preoperative testing (bloodwork, EKG, etc.) completed at least 2 weeks prior to surgery. You will be asked to consent to receive blood transfusion. Transfusion rate is less than 10%. Anticoagulant medications (blood thinners) need to be discontinued well in advance of your surgery. Check with your doctor to determine exactly when you should stop taking them. Additionally, the day prior to surgery you are asked to maintain a clear liquid diet starting at 8 a.m. If you can read newsprint through the liquid, you may drink it. A gentle laxative is recommended that morning. The purpose of this bowel preparation is twofold: to decompress the intestine which aids exposure at the time of surgery, and, to facilitate quicker recovery of bowel function postoperatively. You may continue to drink clear liquids up until 11:45 p.m. the night before surgery. Do not eat or drink anything after 11:45 p.m. with the exception of any medicines you were instructed to continue taking with a sip of water. Sometimes the hospital preoperative nurse, who will call you the day prior to surgery to give you the time to be at the hospital, will instruct you that it is ok to drink certain beverages after 11:45 p.m. DO NOT EAT OR DRINK ANYTHING AFTER 11:45 p.m. OTHERWISE YOUR PROCEDURE COULD BE CANCELLED. The preoperative nurse means well, however, the OR schedule may change unexpectedly resulting in an earlier surgery time than anticipated. By observing the “nothing by mouth after 11:45 p.m.” rule, you can avoid having your surgery delayed or worse yet cancelled.
Explanation of Surgery
Robotic simple prostatectomy is a minimally invasive laparoscopic surgery. Five small incisions called port sites are made in the abdomen, each about 1 cm. (1/2 inch) in length. One of these incisions is in the midline directly above the umbilicus (belly button) and serves to hold the camera by which the surgical field is viewed. The other 4 ports are placed in a line, 2 on the right and 2 on the left, just below the umbilicus and serve to hold various surgical instruments needed to perform the procedure. The “robot” is actually a machine that holds the camera and the instruments, its movements being directed by the surgeon and his or her assistant.
The procedure itself involves opening the top of the bladder such that the top of the prostate, that portion abutting on the urinary bladder – specifically the internal urinary sphincter or bladder neck – is visualized. The lining of the bladder is scored circumferentially around the top of the prostate and the bladder muscle underneath is spread to expose the underlying adenoma. If you can imagine the prostate as a large navel orange, part of the rind has thus been removed to expose the fruit itself. Now, simply shell out the fruit (adenoma) and leave the rind behind. The tissue removed is placed in an impermeable bag for later extraction. The bladder lining is sutured to the capsule or rind of the prostate to complete the repair. The bladder opening is closed with sutures. Because the bladder needs to heal for a few days before it becomes watertight and capable of storing urine, a urethral catheter is placed at surgery and will remain for 7-10 days.
At the termination of the procedure the small incision above the umbilicus is extended just enough to allow extraction of the prostate adenoma. A surgical drain is placed in the pelvis through one of the lower port sites to collect any fluids that accumulate after surgery and to monitor for leakage of urine from the repair site. Skin incisions are closed with absorbable suture and the urethral catheter is connected to a drainage system. Thus, when you awake in the recovery room, you will find a catheter in the penis, a drain coming out of one of the puncture sites, and small band aides on the remaining sites.
Postoperatively you will be provided pain medicines as needed. An advantage of minimally invasive robotic surgery is that the need for narcotic pain medicine is significantly reduced compared to open surgery. You will be allowed sips of clear liquids starting immediately after surgery. Nausea early after general anesthesia is not unusual, and the robotic procedure itself can slow bowel function temporarily. As these resolve, usually 12-24 hours, your diet will be advanced to clear liquids, then eventually solid food. Early ambulation, including the night of surgery, is important in preventing deep vein thrombosis, pneumonia, and stimulates early return of bowel function. Nursing staff will instruct you on how to care for your urethral catheter prior to discharge from the hospital. Your surgical drain will typically be removed before you go home. Rarely patients will be sent home with the drain and if so, you will be instructed on how to manage it before you leave. Most patients will be ready for discharge in 48 hours.
You will be discharged with a urethral catheter. Catheter removal is typically 7-10 days after surgery. Be sure to bring incontinence pads to your appointment for catheter removal as you might be temporarily incontinent of urine immediately after the catheter is removed. Generally this is transient with most men regaining their control within 2-4 weeks. You may shower daily following hospital discharge but no tub baths or pools for 2 weeks. Do not drive for 2 weeks. No lifting over 10 pounds for 4 weeks. Most men are able to resume normal activities without restriction by 30 days post-surgery.