Prostatectomy

OUTLINE
• Introduction
• Types of prostatectomy
• Indication for radical prostatectomy
• Risks/complications of prostatectomy
• Procedures of prostatectomy
• General management of prostatectomy
• Physiotherapy management of prostatectomy
INTRODUCTION

• The prostate is a walnut-size male reproductive gland located in front

of the rectum. It lies below the urinary bladder and surrounds the
upper part of the urethra.
• The main purpose of the prostate is to produce fluid for semen, which
transports sperm during the male orgasm or releases sperm during
ejaculation.
• A prostatectomy is the surgical removal of the prostate gland.
A male reproductive organ showing the
prostate gland.
 TYPES OF PROSTATECTOMY

PARTIAL PROSTATECTOMY
It is used to treat severe urinary symptoms and enlarged benign prostate glands in men
and only the obstructing part that is blocking the flow of the urine is removed.

RADICAL PROSTATECTOMY
Radical prostatectomy includes removal of the whole prostate gland,
including the cancerous cells. They may also remove the seminal vesicles,
which are glands that secrete many components of semen. The incision is
usually made through the lower abdomen (retropubic) but also can be
made in the groin (perineal).
TYPES OF RADICAL PROSTATECTOMY

• Retropubic prostatectomy
• Perineal prostatectomy
• Nerve sparing prostatectomy
• Laparoscopic prostatectomy
• Retropubic prostatectomy: A surgeon removes the prostate
through an incision in the wall of the abdomen(incision is
made from below the umbilical cord to the pubic area). They
may also remove nearby lymph nodes through the same
incision to reduce the risk of cancer cells spreading.

• Perineal prostatectomy: A surgeon removes the prostate

through an incision in the region between the testicles and
anus.
• Radical perineal prostatectomy is used less frequently than the
retropubic approach. This is because the nerves can’t be spared
as easily, nor can lymph nodes be removed by using this
surgical technique.

• However, this procedure takes less time and may be an option if

the nerve-sparing approach isn’t needed. This approach is also
appropriate if lymph node removal isn’t required. Perineal
prostatectomy may be used if other medical conditions rule out
using a retropubic approach.
• Nerve-sparing prostatectomy; In nerve-sparing prostatectomy, doctors
avoid cutting nerves near the prostate. This gives a better chance of
keeping normal erections and urinary function when you recover.

• Laparoscopic prostatectomy; The surgeon makes several smaller

incisions and uses special long surgical tools to remove the prostate ,a
thin tube with a video camera (laparoscope) is placed inside one of the
cuts. This helps the surgeon see inside during the procedure. The surgeon
either holds the tools directly, or uses a control panel to precisely move
robotic arms that hold the tools. (Robotic-assisted laparoscopic
prostatectomy).
Robotic assisted laparoscopic radical prostatectomy
INDICATION FOR RADICAL PROSTATECTOMY

Radical prostatectomy is typically performed in men who have early stage prostate
cancer. Early stage prostate cancer is confined to the prostate gland and has not yet
spread beyond the prostate or to other parts of the body.
Attempts are made prior to surgery, through medical tests such as bone scans,
computed tomography (CT), and magnetic resonance imaging (MRI), to identify
cancer outside of the prostate.
Radical retropubic prostatectomy may also be used if prostate cancer has failed to
respond to radiation therapy.
Other less common reasons for radical prostatectomy include:
• Inability to completely empty the bladder
• Recurrent bleeding from the prostate
• Bladder stones with prostate enlargement
• Very slow urination
• Increased pressure on the ureters and kidneys from urinary retention
(called hydronephrosis)
RISKS OF PROSTATECTOMY
Some possible complications of prostatectomy includes;
• Urinary incontinence; Incontinence involves uncontrollable, involuntary
leaking of urine, which may improve over time, even up to a year after
surgery. This symptom may be worse if you’re older than age 70 when the
surgery is performed.

• Erectile dysfunction ,also known as impotence. Recovery of sexual

function may take up to two years after surgery and may not be complete.
Nerve-sparing prostatectomy lessens the chance of impotence, but doesn’t
guarantee that it won’t happen
• Retrograde ejaculation; Radical Prostatectomy cuts the connection
between the testicles and the urethra and causes retrograde ejaculation.
This results in a man being unable to provide sperm for a biological child.
A man may be able to have an orgasm, but there will be no ejaculate. In
other words, the orgasm is "dry”.

• Lymphedema; It is a condition in which fluid accumulates in the soft

tissues, resulting in swelling. Lymphedema may be caused by
inflammation, obstruction, or removal of the lymph nodes during surgery.

• Change in penis length; A small percentage of surgeries will result in a

decrease in penis length
Before the procedure
Some things you can expect before the procedure include:
• The doctor will explain the procedure and offer the opportunity to ask any
questions you might have about the procedure.

• You’ll be asked to sign a consent form that gives your permission to do

the procedure. Read the form carefully and ask questions if something
isn’t clear.

• In addition to a complete medical history, your doctor may perform a

physical examination to ensure you’re in good health before you undergo
the procedure. You may also undergo blood tests and other diagnostic tests
• You'll be asked to fast for eight hours before the procedure, generally after
midnight.

• Notify your doctor if you’re sensitive to or are allergic to any medications,

latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

• Notify your doctor of all medications (prescribed and over the counter)
and herbal supplements that you’re taking

• Notify your doctor if you have a history of bleeding disorders or if you’re

taking any anticoagulant (blood-thinning) medication. It may be necessary
for you to stop these medications prior to the procedure
• If you smoke, you should stop smoking as soon as possible prior to the
procedure in order to improve your chances for a successful recovery from
surgery and to improve your overall health status.

• You may receive a sedative prior to the procedure to help you relax.

• Based on your medical condition, your doctor may request other specific
preparation.
During the procedure
Procedures may vary depending on your condition but generally, a radical
prostatectomy follows this process:
• You’ll be asked to remove any jewelry or other objects that may interfere
with the procedure.

• You’ll be asked to remove your clothing and will be given a gown to wear.

• You’ll be asked to empty your bladder prior to the procedure.

• An intravenous (IV) line will be started in your arm or hand.

• If there is excessive hair at the surgical site, it may be clipped off.

• The skin over the surgical site will be cleansed with an antiseptic
solution

• The anesthesiologist will continuously monitor your heart rate, blood

pressure, breathing, and blood oxygen level during the surgery.

• Once you're sedated, a breathing tube may be inserted through your

throat into your lungs and you'll be connected to a ventilator, which will
breathe for you during the surgery.
• The doctor may choose regional anesthesia instead of general
anesthesia. Regional anesthesia is medication delivered through an
epidural (in the back) to numb the area to be operated on. You'll
receive medication to help you relax and analgesic medication for
pain relief. The doctor will determine which type of anesthesia is
appropriate for your situation.

• A catheter will be inserted into your bladder to drain urine .

After the procedure

• After the procedure, you may be taken to the recovery room to be closely
monitored. You’ll be connected to monitors that will constantly display your
heart beat (electrocardiogram—ECG or EKG) tracing, blood pressure, other
pressure readings, breathing rate, and your oxygen level.

• You may receive pain medication as needed, either by a nurse, or by

administering it yourself through a device connected to your intravenous line.

• Once you’re awake and your condition has stabilized, you may start liquids to
drink. Your diet may be gradually advanced to more solid foods as you’re able to
tolerate them.
• The drain will generally be removed the day after surgery.

• Your activity will be gradually increased as you get out of bed and walk
around for longer periods of time.

• The urinary catheter will stay in place upon discharge and for about one
to three weeks after surgery. You’ll be given instructions on how to care
for your catheter at home.

• Arrangements will be made for a follow-up visit with your doctor.

General management
• Incontinence Pads
Unlike women, men are most likely unfamiliar with sanitary pads. There
are specific pads made for incontinence and also more specifically for
men. For radical prostatectomy patients, who will most likely have initial
incontinence after surgery, it can be helpful to preoperatively prepare them
for the use of pads after his catheter is removed postoperatively.

• Clothing
Simple advice such as wearing darker colored shorts or long pants that
may not show fluid can also be helpful in case of an accident of leakage of
urine.
• What to drink/what not to
Certain fluids and foods can attribute to the worsening of symptoms.
Coffee, green tea, and beer are examples of fluids that may increase
symptoms of incontinence.

• General Sexual Rehabilitation

Use of medications to attain erection, There are a variety of erection-
enhancing medications, each with their own mechanism of action.
Intracorneal injections to promote an erection can also be used.
Psychological Counselling
A diagnosis of cancer is in itself, a significant cause of psychological
distress. Pair that with disabling side effects of incontinence and sexual
dysfunction from the treatment for cancer and the need for psychological
support and counselling is essential in a holistic approach to treatment.

.
• While physiotherapy interventions may help a significant amount of
men, it is also important to remember that recovery is very dependent on
the severity of cancer as well as the treatment they received. Treatment to
cure a very severe cancer can often leave a man with severe side effects
of sexual dysfunction and incontinence from which they are unable to
recover. A lot of men are grateful that their life has been spared and can
learn to deal with their disability, but in other men, it can result in
depression and other mental health conditions
PHYSIOTHERAPY MANAGEMENT
GOALS

• To optimize the pattern of pelvic floor muscle contraction

• To train Urinary incontinence

• To improve erectile dysfunction

• Bladder training
PHYSIOTHERAPY MANAGEMENT cont’d
INTERVENTIONS

Preoperative Pelvic Floor Exercises;

Strengthening the pelvic floor muscles before a prostatectomy was shown to
significantly improve post-prostatectomy urinary continence, post-
micturition dribble and erectile function. It would be prudent for all men to
exercise their pelvic floor muscles preoperatively to maintain normal pelvic
floor function postoperatively
 Physiotherapy Management cont’d
Pelvic Floor Muscle Exercise

• Kegel Exercise: These are pelvic floor exercises that helps to strengthen the
pelvic floor muscles. Kegel exercises for men can be done in 3 different
position but it should be done on the floor or a large surface area.

(1) LYING PRONE(On the back):

• Start by lying on the back, hands should be layed flat on the floor and the
knees should be comfortably bent and pointing upwards(knee should be in
flexion position).
• Tighten the penis and pulling it inwards into the body and hold for 5
seconds then relax.

• Squeeze the anus(contract/tighten the anus) and hold for 5 seconds then
relax.

• It should be done for 8-10 reps and 3-5 sets.

 Physiotherapy Management cont’d
2) SIDE-LYING:
• Lie on the flat surface but on the side
• Place a pillow between the knees so as to spread the legs apart
• Squeeze/ tighten the legs together and hold for 5 seconds then relax
• It should be done with 8-10 reps and 3-5 sets

3) SITTING:
• Sit comfortably in a chair
• Squeeze/ tighten the penis muscles(Trying to hold your urine). Hold for 5
seconds then relax
• It should be done for 8-10 reps and 3-5 sets
• Pelvic Floor Muscle Training for Erectile Dysfunction (ED);
Physiotherapist has repeatedly been proved successful in treating ED of
various etiologies. It is cost-effective, non-invasive, and straightforward
and could be used as a first-line approach. A weak pelvic floor, as well as a
pelvic floor in spasm, can both contribute to erectile dysfunction, and it is
important to determine the exact cause before giving pelvic floor
strengthening. Strengthening exercises given to someone with a pelvic
floor in spasm will exacerbate symptoms.
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