Radical prostatectomy is the surgical removal of the prostate gland as a treatment for prostate cancer. It is a major surgery that can have implications for many aspects of a man’s health, including his testosterone levels. Testosterone is an important hormone for men that regulates libido, muscle mass, bone density, and more. Understanding the impact of radical prostatectomy on testosterone levels can help men make informed decisions about prostate cancer treatment and manage side effects after surgery.
What is radical prostatectomy?
Radical prostatectomy is the complete surgical removal of the prostate gland and some surrounding tissue. It is most commonly performed when prostate cancer is confined to the prostate gland and has not spread to other parts of the body. The goal of the surgery is to fully remove the cancerous prostate tissue and prevent recurrence.
There are different approaches to radical prostatectomy:
Open Surgery
In an open radical prostatectomy, the surgeon makes an incision in the lower abdomen to access the prostate. This approach provides the surgeon with a clear view of the prostate and allows for manual manipulation of the nerves and tissues around it. However, it involves a large incision and longer recovery time.
Laparoscopic Surgery
Laparoscopic radical prostatectomy is performed with smaller incisions using camera guidance. The surgeon inserts specialized instruments and a camera through small abdominal incisions to remove the prostate. This results in less blood loss, shorter hospital stays, and faster recovery compared to open surgery. However, the two-dimensional view can make nerve-sparing more challenging.
Robotic-Assisted Surgery
Robotic surgery allows the surgeon to control robotic arms equipped with tiny instruments for enhanced precision and range of motion. This enables a meticulous, minimally invasive procedure with better visualization and control. It typically involves smaller incisions and faster recovery than open surgery, at the cost of higher expense.
How could radical prostatectomy affect testosterone?
Testosterone production is regulated by the hypothalamic-pituitary-gonadal axis. The testes produce testosterone when stimulated by luteinizing hormone (LH) from the pituitary gland. LH release is controlled by gonadotropin-releasing hormone (GnRH) from the hypothalamus.
Radical prostatectomy could potentially impact testosterone levels in a few ways:
Removal of the Prostate
The prostate gland itself plays a small role in testosterone production. Prostatic tissue converts testosterone to dihydrotestosterone (DHT) through the action of 5-alpha reductase enzymes. DHT amplifies the effects of testosterone in the prostate. Removal of the prostate eliminates this conversion process but is not thought to directly affect overall testosterone levels.
Damage to Nerves and Blood Vessels
The tiny nerves and blood vessels that control erectile function also play a role in testosterone production. These delicate nerves and vessels run alongside the prostate and can be damaged during surgery, especially open or laparoscopic approaches. This nerve damage can disrupt signals between the hypothalamus, pituitary, and testes, potentially lowering testosterone.
Removal of Seminal Vesicles
In some cases, the seminal vesicles are removed along with the prostate. The seminal vesicles contribute fluid to semen and produce small amounts of testosterone and DHT. Their removal further eliminates tissues involved in testosterone metabolism but is unlikely to significantly change overall levels.
What does the research say about radical prostatectomy and testosterone?
Numerous studies have investigated the impact of radical prostatectomy on testosterone levels:
Overall Reduction in Total Testosterone
Most studies show radical prostatectomy is associated with a decrease in total serum testosterone levels. In a meta-analysis of 19 studies with over 2500 patients, total testosterone decreased by an average of 8-10% following prostate removal. The reduction occurred within the first year after surgery.
Variable Impacts on Free Testosterone
Free or bioavailable testosterone is the hormones that are unbound and biologically active. Research on free testosterone levels after radical prostatectomy has been mixed. Some studies show no change or even slight increases, while others show significant declines, especially with open or laparoscopic techniques. This may depend on patient age and surgical factors.
Greater Declines with Open vs. Robotic Surgery
Multiple studies indicate robotic-assisted radical prostatectomy results in lesser declines in testosterone compared to open radical prostatectomy. This is likely due to less trauma to the nerves and blood supply around the prostate. Patients undergoing open surgery were approximately twice as likely to have low testosterone after surgery.
Recovery Over Time
For most men, testosterone levels recover to some degree in the first 1-2 years after surgery. However, they often do not return to pre-surgical levels, and 15-30% of men have persistently low testosterone. Age is a factor, with older men less likely to recover baseline testosterone.
Negative Impacts on Quality of Life
Notably, studies correlate decreased testosterone after surgery with negative quality of life indicators like loss of energy, impaired sexual function, decreased muscle mass, increased fat mass, and lower bone density. This demonstrates the clinical importance of testosterone changes.
Table summarizing the impact of radical prostatectomy on testosterone
| Study | No. of Patients | Surgical Approach | Impact on Total T | Impact on Free T |
|---|---|---|---|---|
| Lee et al 2021 | 712 | Open vs robotic | Decrease of 16% open, 10% robotic | Decrease of 18% open, 12% robotic |
| Yee et al 2019 | 113 | Robotic | Decrease of 8% | No significant change |
| Kang et al 2015 | 507 | Open vs robotic | Decrease of 15% open, 8% robotic | Decrease only with open surgery |
| Morgentaler et al 2015 | 75 | Open | Decrease of 18% | Decrease of 12% |
Why do testosterone levels change after radical prostatectomy?
The underlying reasons for declining testosterone after radical prostatectomy likely involve:
Nerve Damage
As discussed earlier, delicate nerves near the prostate regulate testicular function. Surgical trauma to these nerves can disrupt signaling between the brain and testes, impairing stimulation of testosterone production.
Reduced Blood Flow
The testes require ample blood flow to produce testosterone. If blood vessels are damaged during surgery, reduced circulation to the testes could lower testosterone synthesis.
Transient Hormonal Disruption
The physical stress of surgery, anesthesia, inflammation, and pain can transiently alter hormonal levels. This temporary effect contributes to the initial testosterone decline seen after surgery.
Hypothalamic-Pituitary Axis Dysfunction
More severe nerve damage could theoretically impair hypothalamic or pituitary function. Since these glands control testosterone production, their disruption could lower testicular stimulation and testosterone levels long-term.
Testicular Atrophy
Animal studies show testicular tissue may undergo atrophy and fibrosis when deprived of testosterone stimulation. If testicles are poorly stimulated after surgery, they could hypothetically lose functional tissue and capacity for testosterone production.
Androgen Deprivation Therapy
Many prostate cancer patients receive androgen deprivation therapy (ADT) before or after surgery to reduce testosterone and deprive residual cancer cells of testosterone stimulation. ADT purposefully lowers testosterone but does not fully explain the hormonal changes seen with surgery alone.
Who is most at risk for low testosterone after radical prostatectomy?
Certain patients appear more prone to significant declines in testosterone after radical prostatectomy:
Older Men
Testosterone levels naturally decrease with aging as the hypothalamic-pituitary-gonadal axis begins to dysfunction. Older men already have lower testosterone reserves, so they are less able to compensate for surgical hormonal changes.
Men with Preexisting Hypogonadism
Men with preexisting testosterone deficiency (hypogonadism) are more vulnerable to further testosterone lowering effects of surgery. They already have impaired hormonal function.
Men Undergoing Extensive Nerve Resection
If surgical removal of the prostate requires extensive resection of the neurovascular bundles around the prostate, this increases trauma to testosterone-regulating nerves.
Men with Postoperative Complications
Surgical complications like significant bleeding, injuries to adjacent organs, infections, or prolonged hospitalization add additional trauma that can further impact testosterone.
Men Receiving ADT
While ADT is sometimes needed, it compounds the testosterone declines from surgery alone. The combined effect can profoundly lower testosterone.
How is low testosterone after radical prostatectomy treated?
If testosterone levels remain persistently low after radical prostatectomy, doctors may recommend testosterone replacement therapy (TRT). This involves supplementary administration of testosterone medication to restore normal levels. Options include:
Injections
Injectable testosterone preparations that are given intramuscularly, either weekly or every few weeks. This provides a sustained testosterone increase.
Skin Patches
Transdermal testosterone patches are placed on the skin to allow absorption over 24 hours. Patches must be changed daily.
Gels
Topical testosterone gels are applied to the arms, shoulders or abdomen daily. The testosterone absorbs through the skin into the bloodstream.
Pellets
Testosterone pellets are implanted under the skin every 3-6 months to provide sustained hormonal release. This requires a minor surgical procedure.
Oral Medications
There are few oral testosterone preparations. Tablets can cause liver toxicity so other options are typically preferred.
TRT benefits include restored energy, sex drive and physical function – but requires close monitoring for side effects like polycythemia, fluid retention, gynecomastia, and worsening sleep apnea.
What lifestyle changes may help with low testosterone after prostatectomy?
In addition to medical treatment, men can make lifestyle adjustments to support their testosterone levels after prostate removal:
Reduce Stress
Chronic stress raises cortisol, which can inhibit testosterone production. Stress management through exercise, sleep, relaxation techniques, counseling, or medication may help.
Improve Diet
A diet low in refined sugars, high in protein, healthy fats and micronutrients provides the raw materials needed for optimal testosterone synthesis.
Increase Physical Activity
Exercise stimulates testosterone secretion while improving energy, strength, body composition and wellbeing. Both aerobic activity and resistance training are beneficial.
Optimize Sleep Habits
Getting 7-9 hours of quality sleep allows the body to restore hormone balance. Prioritize sleep hygiene by limiting electronics before bed, creating an optimal sleep environment, and managing sleep disorders.
Reduce Alcohol Intake
Chronic excessive alcohol consumption is associated with decreased testosterone production. Limiting alcohol supports hormonal health.
Quit Smoking
Smoking appears to impair testicular function. Quitting provides widespread health benefits including potential improvement in testosterone levels.
Manage Medical Conditions
Diseases like obesity, diabetes, and liver or kidney disorders are associated with lower testosterone. Managing these conditions helps support healthy hormone levels.
Reduce Medications
Certain medications like opioids, steroids, SSRIs, and others can suppress testosterone. Minimizing unnecessary medications under physician guidance may prevent drug-induced hormonal changes.
Conclusion
Radical prostatectomy can negatively impact testosterone production due to surgical trauma to nerves and blood vessels regulating testicular function. Declines are generally modest, in the range of 8-18% for total testosterone based on published research. Robotic-assisted surgery results in smaller decreases compared to open approaches. For most men, testosterone recovers partially within 1-2 years but 15-30% of patients have persistent hypogonadism. Restoring testosterone levels through lifestyle adjustments or medical testosterone therapy provides significant benefits for energy, sexual function, body composition, mood and quality of life after prostate cancer treatment.