A radical prostatectomy is an operation where the whole prostate gland and the seminal vesicles are removed. The prostate is normally taken out through the abdomen (called the retro-pubic approach). Some surgeons, however, approach it through the perineum (the area between the anus and the scrotum), but this is now much less common. With abdominal surgery the pelvic lymph nodes, part of the immune system will, except in cases of low risk cancer, be sampled to see if the cancer has spread to them. Radical prostatectomy is offered only to those with localised cancer, a life expectancy of 10 or more years, and where the man’s age and general health allow.
Nerve-sparing surgery, which aims to preserve erectile function, is normally done where possible. If the cancer is found close to the edge of the prostate, this lessens the chance of a complete cure. Nerve preservation does not necessarily ensure that erections can be subsequently achieved, as the nerve bundles lie extremely close to the prostate and some bruising of the sensitive nerves is inevitable. In some cases useful erections can take up to 3½ years after the operation to return.
Surgery is now usually only performed in larger specialist cancer centres, where a greater number of operations are done. The greater the experience of the surgeon, the less likelihood of poorer results.
It is always performed under a general anaesthetic. The urethra is cut during the operation and, after removal of the prostate, is then reconnected to the bladder with stitches. The patient wakes with a catheter in the penis (which stays in place for a period after leaving hospital), a tube in the abdomen and arm drip(s), which are removed during the hospital stay.
Painkillers are prescribed as needed, and the wound dressings removed. Constipation can be a problem after surgery. Only prescribed laxatives should be taken, and straining should be avoided. Blood in the catheter can be seen in some cases, often after opening the bowels, but this need not be a concern unless it becomes severe. Advice will be given on using the catheter.
After removal of the catheter, some slight incontinence should be expected in most cases but, with the pelvic floor exercises that you will be given, this should return to normal over time. This can last from three to six months. You will be given incontinence pads to wear for this period. In very few cases (up to 4%) incontinence is permanent. This can, however, be sorted by an operation to fit a device to enable controlled urination.
After the operation the prostate will be sent to the pathology lab for analysis. This will reveal the extent and grade of the cancer, and whether it remained entirely enclosed within the prostate, or whether it extended up to the cut edge of the prostate. This latter is called a positive surgical margin. If positive margins are found, there is a greater likelihood of a recurrence of the cancer over time. Radiotherapy or hormone treatment may be recommended in this event.
You will normally be seen every 3 months for the first year, every 6 months for the next two years, and annually after that. A PSA test will be needed for these visits, and a special High Sensitivity PSA may be recommended, which can show levels down to 0.001. This test, however, is only accurate to ±0.005, so any small fluctuations are usually insignificant. A sustained result of less than 0.1ng/ml will indicate the likelihood of a cure. Should PSA levels increase over time, further treatment (radiotherapy or hormone therapy) will be advised.
Most surgeons will argue that, until new techniques become more widely available and long-term results from these prove otherwise, a radical prostatectomy remains one of the best options for a complete cure. As with all operations, there can be complications as well as hospital acquired infections. The risks can, of course be lessened by a combination of preparation by the patient, the skill of the surgeon, good nursing and cleanliness, as well as sensible after-care on the patient’s part.
As the seminal vesicles that produce man’s ejaculate as well as the prostate are removed, ejaculatory function is lost, so that the man’s orgasm will be dry. Although this is a concern, many men report the experience as being enhanced. (Should a younger man who wishes to father children consider surgery, opportunities for sperm banking should be discussed). Partial erections after nerve-sparing surgery may occur, but better function can return over time. Urologists are now recommending the use of low-dose Viagra (or similar) on a regular basis with other methods of obtaining erections are available on the NHS.
At the hands of a skilled surgeon, incontinence is rarely permanent, though some incontinence is common for a few months, as the sphincter (the muscle that controls the urine flow) is tethered by dissolvable stitches. Pelvic floor exercises, done before and after the operation may aid speedier return to normality (see p. 33).
Three main methods of surgery are now used: open, keyhole, and robotic. Current research is showing no appreciable difference in outcome for the three methods of surgery.
An open radical prostatectomy has until recently been the most common method. It is a major operation which requires 3–6 days in hospital and several weeks recovery time. The operation takes about 2–2½ hours. The surgeon will make a cut in the lower abdomen. The catheter is removed after about two weeks. The wound will take 4–6 weeks to heal completely and the scar will fade and shrink over time. Driving can normally be resumed after 4–6 weeks.
This is the removal of the prostate by keyhole surgery, known as a laparoscopic radical prostatectomy (LRP). It is considerably less invasive than conventional open surgery. LRP has been used since 2000 in the UK and is now becoming much more common. To perform a laparoscopic prostatectomy, the surgeon will first inflate the abdomen with gas in order to reduce blood loss and to gain a clear view of the area of the operation with a special camera, the image being transmitted to a video screen. He will then make four very small incisions for four ‘ports’ (see picture) in the lower abdomen in order to perform the operation, with a longer incision below the navel of about 2cm, through which the prostate and seminal vesicles are removed. At the hands of an experienced surgeon, the operation typically takes a little longer than for open surgery.
The latest robotic surgery uses a ‘Da Vinci’ robot. It employs similar techniques to the laparoscopic method, except that the operation is performed by the surgeon from a remote console, using both his hands and foot pedals to remotely control the five arms of the Da Vinci robot. The surgeon is, nevertheless, reliant on the expertise of his assistants at the operating table.
Unlike laparoscopic equipment, the machine gives 3D vision and control of tremor, and the learning curve for the surgeon is shorter than for the standard LRP. More centres are investing in this highly expensive equipment. Although comparatively few robotic operations have been carried out so far in the UK, results are proving as effective as the other methods.