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Prostate surgery

Mr Tevita Aho and Mr Nimish Shah describe normal recovery and possible complications resulting from recent prostate procedures

Mr Tevita Aho and Mr Nimish Shah describe normal recovery and possible complications resulting from recent prostate procedures

Surgery for both prostate cancer and lower urinary tract symptoms (LUTS) presumed to be caused by benign prostatic hyperplasia (BPH) remains common despite advances in medical treatment. Most GPs will have male patients on their list who have had recent urological surgery.

Radical prostatectomy to cure prostate cancer entails the complete removal of the prostate gland and seminal vesicles and reconstruction of the urinary tract. Surgeons traditionally used an open approach via the lower abdomen or the perineum, but more and more are using laparoscopic techniques. Robot-assisted laparoscopic radical prostatectomy is the latest advance, resulting in shorter hospital stay, reduced blood loss and better postoperative urinary control and erectile function1.

Transurethral resection of the prostate has been the gold standard surgical treatment for obstructive BPH for more than 30 years. Surgery for BPH is almost exclusively performed endoscopically through the urethra. A wider channel is created through the prostate to relieve obstruction to the flow of urine. Laser techniques are gaining in popularity; holmium laser enucleation of the prostate (HoLEP) is the most rigorously investigated and judged to have great potential2. The newer surgical techniques for prostate cancer and BPH have cut hospital stays and recovery periods. Morbidity is reduced but there is still a recovery period after discharge and complications may occur.

Normal recovery

Catheters

Following prostate removal patients are typically discharged with a urethral catheter which is removed seven to 10 days after surgery by a urologist.

After BPH surgery urethral catheters are usually removed after one to three days. Fewer than 20% fail the initial trial without catheter (TWOC) and those who do are discharged with a catheter. A second TWOC may occur anytime from a few days to several weeks later and very few patients fail this. Those who do should have further management determined by the urologist. Penile tip pain, bladder spasms with bypassing of urine, haematuria and pericatheter discharge are common consequences of catheters and do not usually indicate any underlying problem (see table).

Haematuria

Gross haematuria may persist (often intermittently) for up to six weeks after prostate surgery. Unless the haematuria is heavy (not transparent to any degree) or there is difficulty passing urine because of clots, the patient should be reassured that it is highly likely to be self-limiting. The advice is to rest and maintain a high fluid intake.

Urinary symptoms

Patients with LUTS secondary to BPH usually have a mixture of obstructive and overactive bladder (OAB) symptoms. The obstructive symptoms (poor stream, incomplete bladder emptying and intermittency) typically resolve rapidly after transurethral surgery, but the OAB symptoms (frequency, urgency and urge incontinence and nocturia) may take weeks to months to resolve, and in up to 20% they may not. Anticholinergic treatment and bladder training can be used in these patients and further intervention may be necessary (see table).

Dysuria is fairly common after prostate surgery and usually resolves in six weeks.

Urinary incontinence

Some degree of urinary incontinence is experienced initially in up to 30-40% after surgery for BPH and in most men after radical prostatectomy3. In most cases it is transitory, resolving with time, pelvic floor exercises and resolution of bladder overactivity. Long-term urinary incontinence (persistent after one year) occurs in <1% of BPH patients and approximately 7% of prostate resection patients depending on the patient age, surgical approach and surgeon3,4. If incontinence worsens, urinary tract infection should be excluded (see table opposite).

Sexual dysfunction

Erectile dysfunction is common in patients after prostate resection. Its incidence depends on pre-operative erectile function, age, surgical approach and whether periprostatic nerves are preserved. In many cases (except when nerves have not been able to be preserved) the problem is temporary and sexual rehabilitation programmes involving the early use of PDE-5 inhibitors may facilitate the return of erectile function5.

Erectile dysfunction may also occur after surgery for BPH. However, recent studies suggest that persistent adverse alteration in erectile function is uncommon6. Retrograde ejaculation occurs in 30-100% of men who have prostatic surgery (depending on the extent of surgery) and does not usually resolve.

Postoperative pain

Patients typically have a degree of wound pain after a prostate resection (particularly after open surgery), but this should be controllable with regular analgesia. Following laparoscopic surgery, shoulder tip pain may occur for up to 36 hours because of irritation of the diaphragm by the carbon dioxide used during surgery.

Pain is not expected after endoscopic surgery for BPH except for catheter-related discomfort and dysuria (see table).

Identifying complications

Similar types of complications may occur after all kinds of prostate surgery, although the incidence and severity of complications depends on the type of surgery. The table opposite lists potential complications following discharge, how these can be recognised and managed in the community and when to refer back to the hospital.

Returning to activity

After a prostate resection, patients should be discharged only when they can look after themselves. At discharge they are encouraged to undertake gentle daily walking. After laparoscopic and perineal surgery most patients should be able to resume driving around two weeks post-surgery, gentle aerobic exercise after four weeks, and heavy lifting after six weeks. Return to work depends on what the work is, but most patients can return in some capacity within two to four weeks. An additional two weeks may be necessary for the above activities to be resumed after open retropubic surgery.

The limiting factor in returning to normal activities after endoscopic surgery for BPH is often the degree of haematuria (or potential for bleeding), and the severity of overactive bladder symptoms. Early significant rebleeding after a period of clear urine can occur any time up to two weeks after surgery (this is less common after laser surgery). It is advisable for patients to avoid heavy lifting or any overexertion for the first two weeks. After this period common sense prevails and all normal activities can be resumed gently.

Mr Tevita Aho is consultant urological surgeon at Addenbrooke's Hospital, Cambridge, with special interest in benign prostatic hyperplasia and laser prostate surgery

Competing interests None declared

Mr Nimish Shah is consultant urological surgeon at Addenbrooke's Hospital, Cambridge, with special interest in robotic laparoscopic radical prostatectomy

Competing interests None declared

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