Radical prostatectomy

taken from Small Gland, Big Problem 4th Edition
by Professor Roger Kirby, Health Press 2011

A radical prostatectomy is a surgical procedure in which the prostate, seminal vesicles and, sometimes, a sample of some nearby lymph nodes are removed. It is quite a technically demanding operation and, as a result, is usually carried out only in certain hospitals by surgeons with particular expertise and experience. Because it is a fairly major operation, and pelvic surgery always carries certain risks, a radical prostatectomy is most suitable for otherwise healthy, younger men (generally those under 70) whose cancer appears not to have spread to the distant lymph nodes or bones.

radical prostatectomy
In a radical prostatectomy, the entire prostate and seminal vesicles are removed through an incision in the abdomen. Sometimes nearby lymph glands are also removed. The urethra is joined to the bladder and a catheter is inserted to drain urine

The traditional ‘open’ operation is carried out under a general anaesthetic, and usually takes 1–3 hours; you should expect to stay in hospital for 3–7 days. An 8–10 cm lateral or vertical cut will be made through your abdomen above the pubic bone (or less commonly through the perineum), and your prostate and seminal vesicles will be removed. Samples from the lymph nodes nearest to your prostate will also be taken to check whether the cancer has spread. The so-called cavernous nerves, which lie close to the prostate and are important for achieving an erection, will be identified and the surgeon will take particular care not to disturb them (this may not be possible if the cancer has spread very close to the nerves); this is called a nerve-sparing approach. A catheter will be inserted into the penis so that urination can continue while the join (technically called the anastomosis) between the bladder and urethra heals. The catheter will usually have to stay in place for up to a fortnight (so you will often have to keep it for a week or so after you go home). The scar from the operation heals quite quickly and after a few months will be almost invisible.

After a radical prostatectomy
Returning to work
  • Possible after 4-6 weeks
  • A longer period of absence will be necessary if your job involves heavy lifting
  • Your doctor will give you a sick note
Driving
  • Do not drive for 2-4 weeks after the operation
Sexual activity
  • You can attempt to have sex whenever you feel ready
  • Orgasm can usually be reached, but there will be no ejaculate and your erection will be weak initially. A low daily dose of Viagra or Cialis may help your sexual recovery
Drinking
  • Try to drink more (non-alcoholic drinks) than you would do normally. The resulting increase in the volume of urine produced can help protect against infection
  • You can drink alcohol (but, of course, for your general health, this should be in moderation)
Exercise
  • Rest as much as possible for the first 2 weeks
  • Avoid any heavy work, such as lifting, carrying or digging, for several months
  • Sports and exercise can be resumed after about 1 month, but be guided by how you feel and start off very gently (swimming is a good exercise to begin with)

You will need to take it easy when you return home from hospital; the usual period of convalescence is 6–8 weeks, but you may still feel tired even after this time. Avoid lifting heavy objects for several months. Some guidelines as to what you should and should not do after the operation are shown in the table opposite.

Laparoscopic and robotic radical prostatectomy

Recent technological developments have enabled the prostate to be removed using telescopes and 4–6 small incisions (‘minimally invasive’ or ‘keyhole’ surgery). The advantages of this technique include reduced blood loss and a quicker recovery time, but the disadvantages may be a longer operating time and the difficulty in training surgeons to perform what is a technically demanding procedure. The abdominal wall is punctured and the abdominal cavity is distended with gas (carbon dioxide). The surgery is then performed by a surgeon who is guided by the magnified image on a television monitor.

da vinci
The da Vinci robot enables very precise control of movement, which can help to preserve the nerves that lie close to the prostate and are important for sexual function

The latest development is the use of the da Vinci robot to assist with the laparoscopic operation. This device, which costs around £1.5 million, allows three-dimensional visualization at 10 times magnification and very precise control of movement, which may reduce blood loss and enable better preservation of the nerve bundles that are important for erections. The American surgeons who originally developed the technique recently reported that more than 80% of their patients were able to have satisfactory intercourse some months after surgery. The number of robots in action in the UK is likely to increase as results are impressive and surgeons are very enthusiastic about this new technology.

PSA level after surgery

After the operation, your PSA level will be checked every 3 months for at least a year. It should drop below 0.1 ng/mL, but this will depend to some extent on the laboratory that performs the analysis; some laboratories have machines that only measure PSA as low as 0.2 ng/mL, whereas others have machines that can measure as low as 0.1 or even 0.01 ng/mL.

If your PSA starts to rise because the cancer has not been completely removed (remember that almost all prostate cancer cells manufacture and secrete PSA), you will usually need further treatment. Slight flickers in the PSA may occur, however, and do not always need treatment.

When further treatment is needed

One-tenth to one-third of all men who undergo radical prostatectomy are found to have cancer that has spread to the margin of the prostate. This finding, which is known as a ‘positive margin’, is particularly likely in men whose PSA level is above 10 ng/mL. As a consequence, the operation will sometimes not be 100% successful in these men as the cancer has not been wholly removed from the body. If this is the case for you, your doctor may recommend a ‘mop-up’ course of radiotherapy or some long-term drug therapy with anti-androgens (see pages 60 and 61).

Possible side effects and risks

A radical prostatectomy, even using the latest laparoscopic and robotic technology, is major surgery and, as such, has side effects that you should consider carefully when deciding whether this is the appropriate course of action for you. For men who may have wanted children, infertility from the surgery needs to be talked through thoroughly with their doctor and partner. Sperm banking is one option that could be considered.

Many men also experience a degree of temporary stress urinary incontinence after the operation. For most, incontinence is mild – a leakage of a small amount of urine on, for example, coughing. A very small proportion of men have severe incontinence requiring further treatment, but very few have a permanent problem, other than having to wear a small pad for security.

Impotence or erectile dysfunction (difficulty achieving an erection) is another side effect and affects many men who have undergone a radical prostatectomy. The risk is reduced where a surgeon uses a nerve-sparing approach but, even so, potency cannot be guaranteed. Although impotence can usually be treated reasonably effectively, the surgeon should discuss this with you in detail before surgery, and you should discuss it with your partner. Recent evidence suggests that early active rehabilitation using Viagra (sildenafil) or similar agents, such as such as Cialis (tadalafil) or Levitra (vardenafil), can help to restore sexual function after surgery.

Internal scarring from the operation is a further potential complication. If your urine flow deteriorates after surgery, it may mean that you will have to undergo dilatation (stretching) of the join between the bladder and urethra; this is usually curative, but sometimes has to be repeated. Some patients will require a period of self-catheterization to ensure that the join between the bladder neck and the urethra remains wide open as it heals. The risk of this is now thankfully much lower after laparoscopic or robot-assisted surgery.

On the positive side, for men who have BPH as well as prostate cancer, radical prostatectomy can potentially offer a ‘double cure’ as the prostate, the source of the BPH symptoms of frequency and poor flow, is removed.

The risks associated with radical prostatectomy are those that are generally associated with major surgery – blood loss or blood clots, an adverse reaction to the general anaesthetic, and infection. With both laparoscopic and robotic types of surgery, bowel injury may occur, but is rare.

Your chance of experiencing side effects and the likely success of the operation are governed largely by the expertise of your surgeon. If you are offered this operation, you should ask your urologist a number of questions.

  • How many radical prostatectomies have you performed (more than 100 is a respectable number) and how many in the last year?
  • What were the results of these operations, in terms of removing the cancer, and what was the proportion of patients who were free from the major side effects of impotence and incontinence at, for example, 1 year after surgery? (More than 50% of patients younger than 60 years of age able to have intercourse, with or without medication, and fewer than 2% of patients with severe incontinence are good results.)
  • Will you be performing my surgery personally?
  • Will you be there to help if I have postoperative problems?
  • When will the pathology report be available and will you be there to explain it to me?
  • How often will I be seen for follow-up?
  • Will I be given help with sexual rehabilitation and stress incontinence?

If you are not happy with the answers, you can always seek a second opinion.