Part 2 – Prostatectomy: Approaches, Side Effects and Impact on Function

Part 2 – What Happens When I Have Prostate Surgery?

As with other pelvic surgeries such as hernia repairs or hysterectomies, radical prostatectomies can be performed with a laparoscopic technique or with an open incision. Most laparoscopic prostatectomies are now performed in a robotic-assisted technique where several small incisions are made. Then, long robotic arms are inserted through these openings in the abdomen to complete the procedure. If an open procedure is chosen, it can be performed via a retropubic approach with an incision from the umbilicus to the pubic bone. Less commonly, open prostatectomies are performed with a perineal incision. A perineal approach can lead to a shorter recovery time, but this method does not allow for lymph node removal if the cancer has spread into the pelvic lymphatic system. Patients also have a greater chance of developing erectile dysfunction with the perineal approach. There is currently no difference in surgical outcomes when comparing urinary continence and erectile dysfunction after open and robot-assisted laparoscopic methods.1

Recovery time, blood loss and pain levels, however, are lower with laparoscopic methods. Younger age at time of surgery and the experience of the surgeon, regardless of surgical approach, are correlated to increased speed of recovery and fewer long-term issues with sexual function or continence, as well. Unfortunately, even with the increasing popularity of robotic approaches, post-surgical urinary incontinence rates are still around 80%.2

While the term prostatectomy denotes that the prostate is removed, other local anatomical structures are also impacted. Seminal vesicles and surrounding lymph nodes can be resected depending on the extent of neoplasm growth. The seminal vesicles and prostate create the majority of fluids released during ejaculation, so post-operative orgasms can still be pleasurable but will be “dry.” The vas deferens are also dissected during a radical prostatectomy. Recall that these structures transport sperm from the testicles to the urethra, and consequently, postoperative infertility occurs. In addition, the cutting and subsequent shortening of the urethra can decrease penile length. Other possible side effects include increased risk of erectile dysfunction: the prostatic nerve plexus, a branch of inferior hypogastric plexus off the hypogastric nerve, surrounds the prostate. The plexus is involved in erection, which is almost always difficult after surgery. Normally, erectile function improves. However, lingering issue may be due to damage of this innervating structure.3

Post-operatively, a one or two-night hospital stay is standard, and catheterization is common for 7-14 days after the surgery. Pain medication and antibiotics are frequently prescribed during this period. Activities such as golf, calisthenics, and weightlifting are advised against for the first two months as tissues which are cut heal from the procedure, and urine leakage is common during the first few weeks. Leakage generally gradually decreases over the first year of recovery; consequently, adult diapers or pads are commonly required during this time while the continence is regained. Pelvic floor physical therapy can help with persistent, unresolved leakage.4

One of the greatest structural impacts to urinary continence is the loss of the prostatic urethra with its associated smooth muscle: a shortened residual urethra means there is less surface area left for the pelvic floor muscles to compress to prevent leaking. The striated urethral sphincter (external urethral sphincter) can also be impacted by the surgery. This muscle generates the greatest urethral pressure of all the striated pelvic floor muscles. Urinary continence can only be maintained when the pressure in the urethra exceeds that of the bladder. As a result, damage to the striated urethral sphincter can be particularly problematic, especially when intra-abdominal pressure is increased during movement or coughing.5

References:
Mungovan, S. F., Huijbers, B. P., Hirschhorn, A. D. & Patel, M. I. Relationships between perioperative physical activity and urinary incontinence after radical prostatectomy: an observational study. BMC Urol. 13, 67 (2013).
Wilson LC, Gilling PJ. Post-prostatectomy urinary incontinence: a review of surgical treatment options. BJU Int 2011;107(Suppl 3):7–10.
Surgery for Prostate Cancer. Accessed July 11, 2021. https://www.cancer.org/cancer/prostate-cancer/treating/surgery.html
What Is A Radical Prostatectomy? Prostate Cancer Foundation. Accessed July 18, 2021. https://www.pcf.org/about-prostate-cancer/prostate-cancer-treatment/surgery-prostate-cancer/
Hodges PW, Stafford RE, Hall L, et al. Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. Urol Oncol. 2020;38(5):354-371. doi:10.1016/j.urolonc.2019.12.007

Authors: Nick Rainey, PT, DPT and Brandie Freeman

Dr. Nick Rainey, PT, DPT is an Academy of Pelvic Health Physical Therapy member who is Board-Certified Clinical Specialist in Orthopaedic Physical Therapy. He is the owner of Rainey Pain & Performance, P.C., co-founder- Functional Pain Management Society. Nick is a Fellow of the American Academy of Orthopaedic Manual Physical Therapy and Certified Cervical & Temporomandibular Therapist (CCTT) by the Physical Therapy Board of Craniofacial & Cervical Therapeutics (ptbcct.org). He is a Certified Strength and Conditioning Specialist and has competed in the USA Weightlifting Sports Performance Coach Level 1.

Brandie Freeman is a Doctoral Candidate at Baylor University who is currently completing her Pelvic Health Certification through Evidence in Motion. She is also a 500-Hour Registered Yoga Teacher and Registered Prenatal Yoga Instructor. Her interest in wellness inspired her to step away from her career as a state and national award-winning chemistry educator, and she now hopes to marry her passion for teaching and pelvic health for all by serving her community as a physical therapist.