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Radical Prostatectomy surgery for prostate cancer

What is a radical prostatectomy?

Radical prostatectomy is a surgical procedure involving completely removing the prostate gland. Surgery for prostate cancer is commonly used as a standard treatment option for men diagnosed with localised prostate cancer, where cancer has not spread beyond the prostate gland.

During the procedure, the surgeon removes the entire prostate gland, along with the surrounding tissues and lymph nodes, if necessary. The goal is to remove all cancerous cells and prevent the cancer from spreading further.

Surgeon performing radical prostatectomy surgery

What is the difference between prostatectomy and radical prostatectomy?

Simple prostatectomy is a surgical procedure used to treat men with enlarged benign prostate glands and severe urinary symptoms. Unlike radical prostatectomy, which is used to treat prostate cancer, simple prostatectomy involves removing only the obstructing part of the prostate gland that is causing difficulty in urination rather than the entire gland.

Most urologists now use advanced endoscopic techniques to perform simple prostatectomy without the need for open, laparoscopic, or robotic surgery in most cases. The most common technique used is Trans-Urethral Resection of the Prostate (TURP), which involves using a small, lighted scope to remove the obstructing tissue.

What are the types of Radical prostatectomy?

Radical prostatectomy is a surgical procedure used to treat localised prostate cancer. Surgeons can perform this procedure using different techniques, including open, laparoscopic, and robotic surgery.

Understanding the Different Techniques Used for Radical Prostatectomy

Open Radical Prostatectomy: Open radical prostatectomy is the traditional method used to surgically remove the prostate gland. The surgeon makes a single incision below the belly button in the lower abdomen to access the prostate gland for removal.

Laparoscopic Radical Prostatectomy: Laparoscopic radical prostatectomy, also known as “keyhole surgery,” involves making several small incisions in the lower abdomen. The surgeon inserts a camera and specialised instruments through these incisions to remove the prostate gland.

Robotic Radical Prostatectomy: Robotic-assisted radical prostatectomy is a newer technique that has recently gained popularity. This method requires small incisions in the abdomen through which the robot’s arms are inserted. The surgeon then uses a robotic interface to control the robot’s arms, which, in turn, control the camera and surgical instruments.

Discussing the potential risks and benefits with your urologist is important when considering which technique is best for you. While each technique has its advantages and disadvantages, the ultimate goal is to remove all cancerous cells and prevent the cancer from spreading.

Radical Prostatectomy indications:

Radical prostatectomy is a surgical treatment offered by urologists for men diagnosed with localised prostate cancer, where the cancer is contained within the prostate gland. Ongoing studies are exploring the role of surgery for men with a small amount of prostate cancer that has spread to other parts of the body.

Radical prostatectomy is a standalone treatment in most cases, but adjuvant radiotherapy may also be used in some patients with locally advanced prostate cancer. If the cancer recurs after previous radical prostate radiotherapy, a salvage radical prostatectomy may also be offered.

The choice of treatment for prostate cancer depends on several factors, such as age, other medical conditions, and the extent and grade of cancer. Radical prostatectomy is typically recommended for healthy men with a life expectancy of ten years or more. Other treatment options or simple monitoring may be more appropriate for those with a lower life expectancy or low-grade prostate cancer.

Radical Prostatectomy what is removed?

During a radical prostatectomy, the surgeon removes the entire prostate and the seminal vesicles, two glands that store fluid in semen and are connected to the prostate. Additionally, the surgeon may perform a pelvic lymph node dissection, which involves removing the surrounding lymph nodes to check for cancer cells and determine if further treatment is needed. This procedure may also reduce the risk of cancer recurrence in certain cases.

Once the prostate gland and seminal vesicles are dissected, the surgeon removes them along with nearby tissue. The urethra, which is the tube responsible for carrying urine, is then reattached to the bladder neck outlet. To ensure a watertight seal, a catheter is inserted into the bladder through the penis and left in place until the new join has fully healed.

What is a nerve-preserving radical prostatectomy?

During a radical prostatectomy, there are two bundles of nerves that run alongside the prostate that control erections. To preserve these nerves, surgeons may perform a nerve-sparing radical prostatectomy. However, if the tumour has spread beyond the prostate capsule, one or both bundles may need to be removed to avoid leaving cancer cells behind. It is now considered the standard approach because there is no evidence that nerve-sparing surgery increases the risk of prostate cancer recurrence.

Even with nerve-sparing surgery, there is no guarantee of the return of erections. It can still take several months to recover, and there are no proven approaches to increase the chances of success. Surgeons are investigating alternative approaches, including electrical nerve mapping during surgery or nerve transplants. However, these approaches are still experimental and unproven.

What are the potential risks of radical prostatectomy?

During radical prostatectomy, there are several risks associated with any major surgery. These may include:

  • An allergic reaction to general or local anaesthesia.
  • Blood loss during surgery, which may require a blood transfusion.
  • Deep vein thrombosis, a blood clot that forms in a deep vein, usually in the leg.
  • Wound infections.
  • Internal injury to the rectum could lead to abdominal infection or urine fistula and require additional surgery to repair. Laparoscopic and robotic techniques may have a higher risk of rectal injury than the traditional open approach.
  • Removal of lymph nodes can result in the formation of a collection of lymph fluid called a lymphocele, which may require drainage.
  • Scarring at the join of the urethra to the bladder neck can cause obstruction with difficulty urinating, known as a bladder neck contracture. This may require a further procedure to open up the scar tissue.
  • A prostatectomy increases a man’s chances of developing an inguinal hernia in the future.

Radical prostatectomy side-effects

The main side effects of radical prostatectomy are urinary incontinence and erectile dysfunction (impotence). There is no real evidence so far that any particular method of radical prostatectomy significantly reduces this risk. There is evidence that the experience and skill of the surgeon have an effect.

Urinary incontinence after radical prostatectomy

Urinary incontinence occurs due to problems with the urinary sphincter, which controls the valve that keeps urine in the bladder. Surgery disrupts the valve and the nerves that supply it. Stress incontinence is common after radical prostatectomy, causing leakage when coughing, laughing, sneezing, or exercising. Most men experience difficulty with urinary control after catheter removal and require incontinence pads until control returns. Recovery time varies, with older men tending to take longer than younger men.

There is good evidence that performing regular pelvic floor or Kegel exercises before surgery and after the removal of the catheter can speed up the return of urinary control.  

 Occasionally urinary control will be unsatisfactory even after a year.  Although rarely needed, there are techniques for restoring control, such as the placement of an artificial urinary sphincter.  

A few men may find it difficult to urinate a few weeks or months after surgery. This is caused by scarring around the join of the bladder to the urethra, termed bladder neck contracture. This often requires a secondary procedure to dilate open the join.

Watch these helpful and informative videos on managing incontinence after radical prostatectomy:

Erectile dysfunction after radical prostatectomy

After undergoing radical prostatectomy, most men experience a decrease in their ability to have an erection, also known as erectile dysfunction (ED). Although nerve-sparing surgery may increase the likelihood of recovering erectile function, it is not guaranteed.

Even if erections do return after surgery, it can take several months up to two years to recover. Age and pre-surgery erectile function are also factors that affect the likelihood of regaining erectile function.

Men who are under the age of 60 and had good erectile function before surgery are more likely to regain their erectile function after the surgery. Even if unassisted erections don’t return, these same men are also the ones more likely to respond to medication for ED.

There are a number of treatment options for erectile dysfunction after radical prostatectomy:

Radical prostatectomy can decrease a man’s ability to achieve an erection, known as erectile dysfunction. To address this, several medications are available, such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis), which work by opening up blood vessels to the penis. However, these drugs can cause side effects such as headaches, facial flushing, and upset stomach. Alprostadil is another drug that can be used to produce erections by dilating penile blood vessels. It can be injected into the penis or placed as a pellet into the urethra of the penis.

Mechanical pumps, called vacuum devices, can also be used to draw blood into the penis to produce an erection. A rubber band placed towards the base of the penis maintains the erection until removed after sex. Penile implants are another option, including malleable silicone rods and inflatable devices that are inserted surgically. Some urologists believe that using these treatment options as soon as possible after surgery can aid in regaining spontaneous erectile function, a process known as penile rehabilitation. However, evidence regarding its effectiveness remains limited.

Another effect of radical prostatectomy is a decrease in penile length due to the removal of the portion of the urethra that passes through the prostate. Additionally, men will not experience ejaculation of semen after surgery because the glands that make the fluid for semen, the seminal vesicles, are removed. While the sensation of orgasm should still be pleasurable, for some men, orgasm becomes less intense or goes away completely after surgery. Men may also report painful orgasms. Furthermore, since the vas deferens, which carry sperm from the testicles, are cut during surgery, men can no longer conceive naturally. Therefore, younger patients may consider “banking” their sperm before the operation.

Preparing for radical prostatectomy

Performing pelvic floor muscle exercises for a few weeks before radical prostatectomy may aid in quicker recovery from urinary problems caused by surgery. Evidence suggests that such exercises help improve urinary control and may reduce the risk of incontinence after surgery.

Before the operation, patients will typically undergo pre-op tests at the hospital to ensure they are healthy enough for surgery. Certain medications, such as warfarin, may need to be stopped before surgery as they can increase the risk of bleeding.

Preparing for life after discharge is important. Stocking up the freezer with easy-to-prepare meals, arranging for help with cleaning and shopping, and having some absorbent pads on hand can help make the recovery process more manageable. Having some comfortable, loose-fitting clothes to wear is also essential while any soreness settles down.

Fasting before surgery is typically required, and patients will receive instructions from their surgeon or hospital regarding when to stop eating or drinking before the procedure.

Before heading to the hospital, patients should make sure they have a list of current medications, personal items such as a toothbrush and shaving equipment, loose-fitting, comfortable clothing, and any necessary eyeglasses, hearing aids, or dentures. It may also be helpful to bring items that can help with relaxation, such as portable music players or books.

Radical prostatectomy recovery

After a radical prostatectomy, most patients stay in bed until the morning after surgery and are then encouraged to start moving. Following open surgery, patients are typically ready to go home after three days, while those who undergo robotic or laparoscopic surgery may be discharged after just 1 to 2 days.

Upon discharge, patients will have a urinary catheter in place, which is typically removed at the hospital within two weeks. However, it’s common to experience urine leakage once the catheter is removed, so patients are advised to bring along some absorbent incontinence pads and spare underwear to the hospital.

Watch this helpful video on how to look after your catheter after a radical prostatectomy:

To avoid constipation, patients should maintain proper hydration and eat foods rich in fibre. Due to the effects of painkillers and decreased mobility, regular bowel habits may take a few weeks to return. In some cases, patients may need to take mild laxatives.

Perineal discomfort, which is the discomfort between the rectum and scrotum, may last several weeks after surgery but generally resolves independently.

Swelling in the scrotal and penile areas may occur for a few days after surgery, but it is not a cause for concern. It should subside on its own within one to two weeks.

Feeling fatigued for a few weeks or months after surgery is not uncommon, but most men return to their normal activities within four to twelve weeks after radical prostatectomy.

Returning to Work after Radical Prostatectomy

The recovery time following a radical prostatectomy varies for each patient and depends on their physical condition and the nature of their job. Generally, those who undergo open surgery may need more time to recover before returning to heavier physical activities compared to those who have keyhole surgery.

Driving after Radical Prostatectomy

There are no official guidelines for when patients can resume driving following radical prostatectomy. However, most surgeons advise patients to wait until after the catheter is removed and they have stopped taking strong painkillers before driving. Patients are also advised to check with their insurance company to see when they are insured to drive after surgery for prostate cancer. It’s recommended to avoid long journeys for the first couple of weeks after the catheter is removed to allow time to adjust to any issues, such as urine leakage.

Follow up after radical prostatectomy.

The prostate gland, seminal vesicles, and lymph nodes removed during a radical prostatectomy are sent to a pathologist for analysis under a microscope. The results of this analysis can provide valuable information about the aggressiveness of the prostate cancer, its grade, and whether it has spread beyond the prostate (stage).

If cancer cells are found on the edge of the tissue removed, it is called a “positive surgical margin.” This suggests that some cancer cells may have been left behind, and further treatment may be necessary in the future.

On the other hand, if the tumour was surrounded by a layer of healthy tissue, it is considered a “negative or clear surgical margin,” indicating that all the tumour has been successfully removed. Understanding the surgical margin status is critical in determining the appropriate treatment plan and monitoring for recurrence.

What is undetectable PSA after radical prostatectomy?

After a radical prostatectomy, the PSA level drops to very low levels, typically less than 0.05 ng/mL. However, due to the limited sensitivity of the PSA test, it is considered undetectable rather than zero. Monitoring PSA levels after surgery for prostate cancer is crucial to detect any recurrence of cancer.

The first three months after surgery, PSA levels are usually checked every three months, then every 6 to 12 months thereafter. A confirmed PSA level ≥0.2 ng/mL is widely accepted as a recurrence. In such cases, urologists might use imaging scans, such as an MRI, bone scan, or CT, to locate recurrent cancer cells. However, these scans may not always detect small clusters of prostate cancer cells, particularly when the PSA level is very low.

Pelvic radiotherapy may be offered based on the probability of cancer cells being present rather than seeing tumour recurrence on scans.

 Some newer molecular imaging scans, such as C11-choline, F18-fluciclovine, and PSMA PET scans, can identify prostate cancer metastases in the body with greater precision than traditional bone and CT scans, but they may not always find tumours when the PSA level is very low.

Watch Dr Eric Klein from The Cleveland Clinic discuss PSA follow-up after prostate cancer:

Radical prostatectomy survival rates

According to a study conducted on 10,332 men who underwent radical prostatectomy between 1987 and 2004, the procedure offers a high survival rate and low recurrence rates, with only 3% of patients dying from prostate cancer, 5% experiencing metastasis, and 6% having localised recurrence between 5 and 20 years post-surgery.

A large Scandinavian study comparing active surveillance with radical prostatectomy showed that the latter offers a definite survival advantage over the long term for younger men with higher-risk tumours.

Data from a study at Johns Hopkins Hospital in Baltimore (USA) revealed that 82% of men who underwent radical prostatectomy were recurrence-free after 15 years. The study also found that if the PSA level rises after surgery for prostate cancer, only around one-third of men experience prostate cancer spread. Unless the cancer was aggressive, the prostate cancer spread would not become life-threatening for several years and would respond well to treatment.

Further treatment after radical prostatectomy

After surgery for prostate cancer, two other therapies may be recommended based on the pathology report and PSA response: radiation therapy and hormone therapy.

Radiation therapy may be offered to men with high-risk prostate cancer whose cancer has penetrated the prostate capsule or has positive margins after surgery. Studies show that recurrence rates drop by 50% in these men if they receive radiation therapy after surgery. However, some men may not develop recurrent tumours even without further treatment and may also suffer the additional side effects of radiation therapy. Therefore, radiation therapy is used only if PSA levels rise above 0.2 ng/mL.

Hormone therapy may be recommended for men with cancer found in their lymph nodes at the time of surgery. Studies show that hormone therapy helps some of these men live longer.

Author: Mr Neil A Haldar MBBS MD FRCS

Consultant Urological Surgeon

The Pelvic Specialists

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