Prostate Surgery: What to Expect on the Day of Surgery

There are a few prostate surgery types and techniques, and what you can expect from your procedure depends on which one your surgeon uses. An incision may or may not be required; all, some, or none of prostate gland may be removed; and some surrounding tissue may or may not be excised as well—just to name a few differences.

The choice in prostate surgery largely comes down to whether you are having it to treat prostate cancer or the urinary symptoms or complications of an enlarged prostate, a.k.a. benign prostatic hyperplasia (BPH).

Before the Surgery

On the day of your prostate surgery, you will arrive at the hospital or surgical center, check-in, and sign an anesthesia and surgery consent form.

After that, you will go to a pre-operative room where you can expect the following:

• You will change into a hospital gown.
• A nurse will record your vitals (heart rate, blood pressure, etc.) and place an intravenous (IV) line into a vein in your arm for administering fluids and medications.
• Your urologist and anesthesiologist will come to say hello and briefly review the surgery plan with you.
• When the surgical team is ready, you will be wheeled into the operating room on a gurney where the anesthesia process will start.

There are two types of anesthesia used for prostate surgery:

• General anesthesia: An anesthesiologist will give you inhaled or intravenous medication that will put you to sleep. Since you are temporarily unconscious, you will not remember anything that occurs during the surgery or experience any pain. After you are asleep, the anesthesiologist will insert a breathing tube (called an endotracheal tube) and deliver oxygen.
• Regional anesthesia: An anesthesiologist will inject a numbing medication into a part of your body, usually your lower back; this is called a spinal or epidural block. You will be conscious, but you will not feel any pain or other sensation in the numbed part of your body. In order to fall into a light sleep, you will also be given a sedative through your IV.

During Surgery for Prostate Cancer

The most common type of surgery to treat prostate cancer is a radical prostatectomy. This surgery involves removing the entire prostate gland along with nearby tissues (the seminal vesicles and, sometimes, surrounding lymph nodes).

Since the prostate gland normally connects the bladder to the urethra—the tube inside the penis—the surgeon must also reattach the bladder to the urethra once the prostate gland is removed.

A radical prostatectomy can be performed in three different ways:

• Open radical prostatectomy: The surgeon accesses the prostate gland by making a larger incision over the lower abdomen. Less commonly, the prostate is accessed through an incision made between the anus and scrotum (the perineum).
• Laparoscopic radical prostatectomy: This minimally invasive approach involves accessing the prostate gland by inserting long, thin instruments through several keyhole-size incisions made in the lower abdomen.
• Robotic-assisted radical prostatectomy: With this approach, the surgeon sits at a computer console to visualize anatomy and manipulates mini robotic arms/instruments (inserted through several keyhole-size incisions into your lower abdomen) to remove the entire prostate gland. Robotic-assisted is the most common way a prostate is removed for cancer today.  

Radical Prostatectomy: Step-by-Step

A radical prostatectomy generally proceeds in the following fashion:

• After anesthesia and an antibiotic is given, you will be positioned on the operating room table. A member of the surgical team cleans the skin over the lower abdomen using an antiseptic solution to kill any bacteria. You will then be positioned. A catheter will be placed into your urethral and bladder. 
• With the robotic and laparoscopic approach, 4-5 small incisions are made in the lower abdomen through which small instruments are placed. In the open approach, a large incision is made from the belly button down to the pubic bone. 
• The surgeon will then identify the prostate gland in the pelvis by moving the bladder away. The entire prostate gland will then be removed and disconnected from the bladder, urethra, and surrounding tissue. With the prostate gland, the ejaculatory ducts and part of the vas deferens will also be removed. The surgeon will try to spare the nerves that allow erections by peeling them off the prostate during the procedure. 
• After the prostate gland is removed, the bladder is reconnected to the urethra with sutures. A catheter, which acts like scaffolding, is then kept in the urethra and penis to drain urine and allow the reconnected urethra to heal.
• The prostate is placed in a bag and sent to pathology for staging. The incisions are closed. Anesthesia is then stopped, the breathing tube (if placed) is removed, and you are taken to a recovery room. You will wake up with a Foley catheter connected to a bag to collect your urine which will be removed in 1-2 weeks. A small drain is kept in your abdomen that helps drain fluid or blood from around the surgery site which will be removed in 1-2 days. 

During Surgery for BPH

The vast majority of BPH surgeries are performed using a transurethral technique, of which there are several types. With each, a tube-like instrument called a cystoscope or resectoscope reaches the prostate gland via the urethra.

Some transurethral techniques include:

• Transurethral resection of the prostate (TURP): An electrified wire loop is used to remove prostate tissue. This is the most common surgery used to treat BPH.
• Transurethral electrovaporization of the prostate (TUVP): Electrical energy applied through an electrode is used to heat and vaporize an area of enlarged prostate tissue.
• Transurethral incision of the prostate (TUIP): No prostate tissue is removed, but two deep cuts are made starting in the bladder neck (where the urethra and bladder join). The purpose of these cuts is to widen the urethra in order to improve urine flow.
• Photoselective vaporization of the prostate (PVP or laser TURP): Laser energy is used to vaporize prostate tissue.
• Laser enucleation of the prostate: A holium or thulium laser is used to remove large chunks of excess prostate tissue that is blocking urine flow.
• Prostate urethral lift: Implants are placed in the prostate to lift the prostate and keep the urethra open.
• Prostate water vapor therapy: Targeted, controlled doses of stored thermal energy in water vapor are used to decrease prostate tissue. 

TURP: Step-by-Step

The details of each of these procedures obviously differ. As an example, a TURP proceeds with the following steps:

• After anesthesia is given, the penis and surrounding skin are cleaned with a solution to sterilize the area as much as possible.
• A resectoscope that contains an electric wire loop is then inserted into the urethra via the penis until the prostate gland is reached.
• The surgeon uses the electric wire loop to cut away pieces of prostate tissue that are blocking the urethra. During the procedure, the surgery site is frequently flushed with an irrigation solution to push any removed pieces of the prostate into the bladder. These are removed before the end of the procedure.
• When the surgery is completed, the instruments are removed and a urinary catheter is inserted into the bladder to allow healing and to drain the bladder.  
• Anesthesia is stopped, the breathing tube is removed (if applicable), and you are taken to a recovery room.

Less commonly, a simple prostatectomy may be performed to treat BPH. This surgery consists of removing the core of the prostate gland while leaving its capsule or shell intact. This option is often reserved for large prostate glands.

After the Surgery

In the recovery room after prostate surgery, you will wake up from the anesthesia or sedating medication. A nurse will monitor your vital signs and manage any post-operative symptoms like pain. Once you are awake and ready, you will be discharged (possible if surgery done with cystoscopy for BPH) and likely overnight if for prostate cancer. In the latter case, you will be taken to a hospital room where you will stay until released.

During your hospital stay, the following will occur:

• The catheter placed during surgery will remain. You may notice mild blood in your urine and experience bladder spasms.
• You will be transitioned from IV pain medication to oral pain medication.
• You will begin drinking liquids and advance to solids as tolerated.
• You will begin walking around and increase your activity level as tolerated.

If you have no temperature and are keeping down fluids, walking around, and have made the switch to oral pain medication, your surgeon will likely give you the OK to be discharged home.

As you recover there, you will have various post-operative instructions to follow related to keeping your incision site(s) clean, physical activity, and diet. You will also be told when to follow-up for your catheter removal (around one to two weeks).

Avoid driving until you are off all pain medications and your catheter has been removed.

It is imperative that you follow all of the instructions you are given closely and contact your surgeon with any questions or concerns.

A Word From Verywell

When undergoing prostate surgery, it's important to select a highly skilled surgeon, preferably one with extensive experience performing hundreds or even thousands of procedures like the one you're planning. The more skilled the surgeon, the less likely you are to experience complications like urinary incontinence and sexual side effects (most notably, erectile dysfunction due to nerve damage).