Prostatectomy is the ultimate and definitive cure for prostate enlargement (BPH). This blog installment describes my experience with this operation, which I count as a surgery success.

I have divided this blog post on hospital surgery into five installments. They treat different aspects of hospital surgery in general and my surgery in particular.

The first three parts apply to virtually every reader of this blog:
– 1: What Everyone Must Know – hospital documentation and infection prevention
– 2: That Scary Anesthesia – minimizing the risks from anesthesia
– 3: Recovery & Departure – what you can expect after waking from surgery
The final two parts apply to men only, especially men over fifty. They talk about my specific surgery:
– 4: Prostate Enlargement Versus Cancer – problems of the prostate and their cure
– 5: Prostatectomy Cures BPH (This Post) – prostatectomy as the definitive cure for an enlarged prostate, also known as BPH

We’ll now discuss the specific surgery that I experienced to correct my enlarged prostate.

For my positive results I give full credit to my urologist, Dinesh Telang MD. Dr Telang is knowledgeable and completely up to date, and he applies his skills thoughtfully and caringly.

What is a Simple Open Retropubic Prostatectomy?

As noted in Part 4 of this blog post, my prostate enlargement was beginning to show inconvenient symptoms including bleeding and infection. Moreover, my prostate was sufficiently large that abdominal surgery was required.

The formal name of the procedure chosen by my urologist is “simple open prostatectomy retropubic”:
– Simple means that the surgeon removes only the internal tissue of the prostate. This contrasts with radical, the more drastic operation typically called for to excise prostate cancer.
– Open means that the surgeon accesses the prostate through a standard surgical incision. Open surgery provides the doctor with full visual and tactile access to the gland. This contrasts with robot-assisted surgery using laparoscopic instruments and smaller incisions.
– Retropubic means that the surgeon takes the most direct approach to clean out (“enucleate”) the prostate. An incision is made from navel to pubis, in my case about six inches long. This approach gives easy access to the prostate, once the small intestine has been pushed out of the way. It also avoids trauma to the bladder, which is best left alone.

Open Prostatectomy for BPH

As noted above, open prostatectomy to cure BPH is known as “simple prostatectomy,” in which only the inner tissue of the prostate is removed. Prostate cancer, in contrast, may call for “radical prostatectomy,” requiring removal of the entire prostate gland.

The radical procedure disrupts surrounding nerves and is more likely to lead to problems with incontinence and erections. Open prostatectomy, in contrast, has a low incidence of complications: 1% concerning continence, % extreme case of prostate enlargement. My long-time California urologist, Dr Harry Zide, used to mime cutting the rind of an orange, reaching inside, and scooping out a handful of unwanted tissue. He said that every patient having this surgery would say afterwards, “Doc, this is great! I should have had you do that years ago!” The accompanying photos offer my nonmedical interpretation of Dr Zide’s demonstration.

Dr Telang provided me with a prescription to take in case of pain. Thus far, knock on wood, I have experienced no pain and have taken no painkillers. Lack of pain was my biggest surprise from the surgery. Dr Telang tells me that it’s common that patients experience pain after prostate surgery.

The Annoying Parts

Although I experienced no pain from the surgery, the experience was not annoyance-free.

As expected with prostate surgery, I woke from anesthetic to find that the surgical team had installed an indwelling triple Foley catheter. This ingenious invention incorporates three tubes:
– One tube inflates a balloon with saline solution, to anchor the end of the catheter within the bladder so that it won’t slip out.
– Another tube drains the bladder and prostate.
– The third tube is used to wash blood and blood clots away from the surgical area.

The catheter was probably a quarter-inch in diameter, which looked huge to me. Unfortunately, I was not able to tell it good-bye upon checkout. It’s standard to keep the catheter in place for some days following surgery. In the case of my surgeon, “some days” meant one week.

            The Tedious Parts

The catheter, although it looked alarming, was not painful. However, it provided a steady course of inconvenience until the doctor’s assistant removed it:

– Each morning and evening I had to swap the drainage bag from the small daytime bag to the large nighttime one. Each of these exchanges took about an hour. Why so long? Because the recommended procedure included fastidious hand-washing and donning of gloves to reduce the chance of a urinary infection, plus wiping things with alcohol.
– The body expresses its annoyance with foreign objects by oozing pus. [Look, I warned you. This blog post is not for the squeamish.] The detailed instructions provided by the hospital did not mention this possibility. Two alarmed phone calls to my doctor’s office informed me that this is a normal situation. Thus I had to intercept and control a slow reddish ooze, which continued throughout the week.
– Walking and stair climbing caused the catheter to shift position, which felt irritating.

The week at home required great mental fortitude. I counted the days, hours and minutes until my doctor’s appointment when I could get the pesky thing out for good!

Forty percent of all hospital-acquired infections are urinary tract infections associated with a catheter. Because of that high risk, my doctor had me take an antibiotic (Keflex) for one week following catheter removal.

Q&A Following Surgery

Among the questions that occurred to me, Dr Telang’s answers and my comments in brackets:

– Does the prostate enlarge again after you remove its excess tissue? Yes, but it takes just as many years as it did to originally enlarge. So, forget about that!

– Does curing BPH increase or decrease the risk of contracting prostate cancer? It has no effect on cancer risk.

– Do they test the removed tissue for cancer? All removed tissue goes to the lab. [The lab provided a report two days after my surgery. As I had hoped, the lab’s diagnosis included the key word “benign”: (1) Benign glandular and stromal hyperplasia of prostate. (2) Focal chronic prostatitis.]

– Do I need to restrict my activities? Don’t strain, lift weights, or take a trip for a minimum of six weeks following surgery. Don’t drive unless I am totally pain-free.

– Should I expect to see blood in my urine? Yes, I may irregularly see blood and/or clots for perhaps for a month. The urine will show microscopic blood throughout the healing process. [I saw no blood, pinkness or tan coloring my urine after one week.]

– Should I expect some urinary leakage? This varies a lot among patients but should be gone in six weeks. [I had two instances of leakage during the first two days. No noticeable leakage thereafter.]

– Should I change my medications? Yes. Stop taking alfuzosin and tadalafil. Finish dutasteride but do not refill. Refrain from aspirin and any other blood thinner until days after seeing no blood. Take stool softener for one month.

Post-Surgery Recovery

            Pain

As noted in part 2 of this blog and above I experienced no pain after the operation. This happy situation continued during my recovery. However, such is not always the case with surgery.

Patients often have pain following surgery. Typically, the larger the incision, the more potential for pain. Besides the normal healing process, certain complications may also contribute to pain. These include infection, an incompletely closed wound and internal bleeding.

           Appetite Loss

My appetite is down and my weight is down. FYI, I am normally borderline overweight with a BMI around 25.0. I lost five pounds in the four days before surgery. This loss may have been due to anticipatory stress, although I was not conscious of feeling stressed.

During the three weeks after surgery I lost an additional ten pounds and my appetite seemed less than normal. This amount of weight loss is within the 5 to 10% weight loss some websites say to expect after surgery. They suggest consuming protein to help the body recover. This seems consistent with the Obesity Paradox, in which overweight people are better at recovering from surgery and fighting serious disease.

Johns Hopkins describes poor appetite as a common effect following surgery. Although Hopkins’ specific context is cancer surgery, a Google search reveals blogs describing appetite loss after every sort of surgery imaginable. (One of the appetite cures offered is “a square of dark chocolate.” Works for me!)

I noticed one odd feature of my depressed appetite. One glass of wine tastes fine. However, if I sample a second glass I find I have lost my taste for it.

I would guess that loss of appetite arises from a combination of many factors:
– Anesthesia aftereffects.
– Medications during and after surgery.
– Reduced physical activity.
– Interruption of personal routines.
– General disruption of the body’s internal systems.

Based on my reading, I expect to regain my appetite as part of my healing process. However, if I can avoid putting back all the pounds, that’s OK with me. I might as well try to extract a small benefit from the situation!

            Postscript on Appetite Loss

Note added 3/3/2018: My noticeable loss of appetite began about ten days before my May 10, 2017 prostate surgery. I ascribed that to subconscious anxiety about the surgery. However, my cardiologist, whom I saw in April 2017, pointed out to me that my weight had decreased since the previous time she saw me, which was in October 2016. Thus my weight loss preceded the prostate surgery and was likely due to something else.

That something else turned out to be endocarditis, an infection of the heart. I had heart surgery on November 6, 2017, as described in a later blog. Now my appetite is back to normal and my weight is, alas, back to its previous range of the upper 170s.

           Fatigue

My principal exercise consists of walking several miles a day with my wife Nola. I also play the piano for upper body toning. Usually, my longer stride causes me to outpace Nola if I don’t pay attention. Following surgery, I found myself falling behind her when walking, and I also tired more quickly.

In addition to loss of appetite, we know that fatigue is a common side effect of surgery. What we don’t understand is why.

Cancer.net offers these reasons for post-surgery fatigue:
– Aftereffects of anesthesia.
– Energy being used to heal the body.
– How well-nourished you are.
– Reduced appetite.
– The stress of the surgery.

On the other hand, MedicineNet seems to have been reading a completely different set of sources. They blame post-surgical fatigue on these factors:
– Sleep deficit prior to surgery, caused by worry.
– Anemia due to blood loss during surgery.
– Fasting and loss of electrolytes and minerals, both prior to surgery and while recovering in the hospital.
– Medications given during and after surgery. In fact, they mention as a cause of fatigue the antibiotic Keflex, which I took for a week after my surgery.
– Exercise and physical stress.
– Aging and overall health. Since I’m “older than dirt” this might apply to me.
– Depression. I don’t feel depressed, and the trigger factors mentioned for depression don’t seem to apply to me.

Two weeks after surgery, my walking pace caught up with Nola’s and I seemed less tired. I am still improving, although I have not yet recovered my full level of energy.

           Postoperative Cognitive Dysfunction (POCD)

A scary possibility is that surgery might trigger cognitive decline. The effect seems strong enough that researchers have given it a name: postoperative cognitive dysfunction, or POCD.

POCD is a highly controversial topic, with many scientists skeptical that it even exists. A survey article¹ in Science summarizes the state of current research.

Post-surgery mental impairment is unpredictable. Many patients have no mental problems, while others experience memory deficit or haziness that may be temporary or may last for years. Cognitive problems seem most prevalent in heart surgery patients. But mysteriously, patients who have bariatric surgery for obesity perform better on mental tests after their operation. Isn’t that confusing?

I don’t feel as if my brain is either sharper or duller than before my surgery. And after all, the prostate is located pretty far away from the blood vessels serving the brain. I will trust you my readers to judge when I have lost my marbles!

Researchers have tried yet failed to pinpoint the causes of POCD and why it affects only some patients. They hypothesize some factors that might contribute:
– The trauma of surgery may cause body-wide inflammation, which also affects the brain.
– The disease that made the surgery necessary might be already causing cognitive decline.
– Cognitive impairment might be a side effect of anesthesia for some patients.
– Some surgery, especially heart operations, might temporarily curtail blood flow to the brain. This could lead to cognitive problems after the surgery.

POCD, if it exists, is still poorly understood. Nor do we know whom it might affect, nor how to forestall its impact. Fear of cognitive decline is not a reason to avoid surgery that you otherwise need to have. However, this is an area that deserves our attention until we better understand it.

            How Long to Recover?

For my own surgery, my doctor has advised restricting my activities for at least six weeks. This means no heavy lifting, exertion or stress in the torso area. I believe that his estimate is based on the particular surgery and his assessment of my overall health.

Advice from medical bloggers seems in line with this time frame. Typical advice from a doctor suggests:
– Expect fatigue for 6 weeks.
– After 6 months, you are only 80% healed from any significant surgery.
– For full healing, allow one year!

In general, the time to recovery from surgery is hard to predict. Even for a specific type of surgery, different patients recover at quite different rates.

           Predicting Recovery Time

A New York Times article summarizes a Stanford University study² meant to tease out the reasons for different recovery rates. The researchers studied 20 men and 12 women, ages 54 to 68, having hip replacement surgery. The post-surgery recovery time for these patients ranged all the way from zero to six weeks!

The study measured blood proteins that serve as messengers for the immune system. The researchers found that the signals from three of these proteins were correlated with the patient’s rate of recovery. Because of the small number of test subjects, the results are only tentative. However, they seem to show that the immune proteins are about 50% effective in predicting post-surgery recovery time.

If additional research confirms and extends these results, we might expect the following:
– A blood test prior to surgery might advise whether the surgery is OK or should be postponed, based on the current health of the patient’s immune system.
– Doctors might use the predicted recovery time to fine-tune physical therapy, medications and physical restrictions on recovering patients.

In the meanwhile, your best estimate for post-surgery recovery depends on the factors available to your surgeon:
– Your overall level of physical health.
– The specific type of surgery.
– Your doctor’s experience and judgment as applied to your particular situation.

Bottom-Line Assessment

At this point, some weeks after surgery, my assessment matches the optimistic reactions patients gave to my former urologist Dr Zide (“Great! Should have had it years ago!”). In other words, surgery success.

I have experienced practically no pain. My urine is under control, although the sphincters have yet to recover their complete tightness. Erections cannot be tested for several more weeks but I have no reason to believe they will be any more difficult (or any easier!) than before. There is clearly less obstruction: my urine flow rate has increased from ~5 ml/sec to over 15 ml/sec.

I give full credit to Dr Telang for this full solution to my prostate enlargement. It appears to be 100% successful and I look forward to an absence of BPH symptoms in the future.

This concludes Part 5 of this five-part blog on hospital surgery.

My sincere hope for my readers is that you will not need prostatectomy or other prostate treatments. However if you do, I can say that in my experience the cure is greatly superior to putting up with the disease.

Image Credit: Photos taken by Art Chester

Other References:
¹ http://www.sciencemag.org/news/2017/05/will-surgery-sap-your-brain-power?
² http://stm.sciencemag.org/content/6/255/255ra131