What is a radical prostatectomy?
Radical prostatectomy is surgery for prostate cancer to remove the entire prostate gland for men with localised cancer. It is a standard treatment option for men whose cancer has not spread.
What is the difference between prostatectomy and radical prostatectomy?
Simple prostatectomy is a treatment for men with severe urinary symptoms and enlarged benign prostate glands, rather than prostate cancer. Unlike radical prostatectomy in a simple prostatectomy, the surgeon doesn’t remove the entire prostate, only the obstructing part of the prostate blocking the urine flow.
Most urologists use advanced endoscopic techniques to address enlarged prostate without the need for open, laparoscopic, or robotic surgery in most cases. The most conventional method used is called the Trans-Urethral Resection of the Prostate (TURP).
What are the types of Radical prostatectomy?
Surgeons can perform a radical prostatectomy using different techniques. The three primary methods used today to remove the prostate are open, laparoscopic and robotic.
Open radical prostatectomy:
Open radical prostatectomy surgery is the traditional way of surgically removing prostate cancer. The surgeon makes a single incision below the belly button in the lower abdomen to excise the prostate.
Laparoscopic Radical Prostatectomy:
In Laparoscopic Radical prostatectomy, also known as ”keyhole surgery, the surgeon makes several small incisions in the lower abdomen. Individual ports are placed in these incisions through which the surgeon inserts a camera and specialised instruments to remove the prostate.
Robotic Radical Prostatectomy:
Robotically assisted radical prostatectomy has become popular in the last ten years. Similar to laparoscopic radical prostatectomy, this method requires small incisions made in the abdomen through which the robot’s arms are inserted. With a robotic interface, the surgeon controls the robot’s arms, which in turn control the camera and surgical instruments.
Radical Prostatectomy indications:
Urologists offer radical prostatectomy to men whose cancer has not spread beyond the prostate gland, often termed localised prostate cancer. Studies are currently ongoing to assess the role of surgery in men whose disease is no longer confined to the prostate but have a small amount of prostate cancer that has spread to other parts.
Usually, no further treatment is necessary after radical prostatectomy, but occasionally radiation is used in conjunction with radical prostatectomy in patients with locally advanced prostate cancer, termed adjuvant radiotherapy. Some centres also offer ”salvage” radical prostatectomy to men with recurrent prostate cancer after previous radical prostate radiotherapy.
When choosing the most appropriate type of treatment for prostate cancer, the urologist will look at the patient’s age, other medical problems, and the grade and extent of prostate cancer. Radical prostatectomy is usually only offered to healthy men with a life expectancy of ten or more years after the procedure. Other treatment options, such as radical prostatectomy, may be more suitable for men with localised prostate cancer with a lower life expectancy or simple monitoring for those with low-grade prostate cancer.
Radical Prostatectomy what is removed?
As well as removing the whole prostate, the surgeon will remove the seminal vesicles during radical prostatectomy. These are two glands that, connected to the prostate, store some of the fluid in semen.
The surgeon may also remove the surrounding lymph nodes, and this is called a pelvic lymph node dissection. The reason for removing these lymph nodes is in case they contain cancer cells. It helps your surgeon to decide if further treatment is required. Taking the lymph nodes out can, in certain circumstances, reduce the risk of the cancer coming back in the future.
After carefully dissecting the prostate gland and seminal vesicles, the surgeon removes the prostate along with nearby tissue. The surgeon then has to re-attach the urethra, the tube that carries urine, to the outlet of the bladder called the bladder neck. A catheter inserted into the bladder through the penis is left in until the new join has healed to become watertight.
What is a nerve-preserving radical prostatectomy?
Two bundles of nerves lie alongside the prostate that controls erections of the penis. The surgeon will try to preserve these nerves in a nerve-sparing radical prostatectomy. If the surgeon feels the tumour has spread out of the prostate capsule, they may remove one or both of these bundles to avoid leaving cancer cells behind. However, there is no evidence that a nerve-sparing radical prostatectomy significantly increases the risk of reoccurring prostate cancer, so it is now considered the standard approach.
Even if the nerves are saved, it does not guarantee a return of erections which, in any case, can still take some months to recover.
Surgeons are therefore trying to develop other approaches, such as using electrical nerve mapping during surgery or intentionally removing the nerves, then replacing them with nerve transplants. At present, these approaches are considered experimental and unproven.
What are the potential risks of radical prostatectomy?
The risks associated with radical prostatectomy include those that may occur with any major surgery. These include:
- An allergic reaction to the general or local anaesthesia
- Blood loss during the surgery may necessitate a blood transfusion.
- Deep vein thrombosis
- Wound infections
Internal injury to the rectum. This could lead to an abdomen infection or a urine fistula and might require further surgery to repair. A rectal injury is rare but more frequent with the laparoscopic and robotic techniques than with the traditional open approach.
If the lymph nodes are removed as part of the procedure, a collection of lymph fluid, called a lymphocele, can form and may need to be drained.
A bladder neck contracture can occur due to scarring at the join of the urethra to the bladder neck. This can cause obstruction with difficulty urinating and may necessitate a further procedure to open up the scar tissue.
A prostatectomy increases a man’s chances of developing an inguinal (groin) 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 valve that keeps urine in the bladder, the urinary sphincter. Surgery disrupts this valve as well as the nerves that supply the valve. Men with stress incontinence after radical prostatectomy may leak urine when they cough, laugh, sneeze, or exercise. They typically leak more while standing, moving, and straining and less when lying down and sleeping.
Immediately after the urinary catheter is removed, most men will have difficulty with urinary control. Patients usually have to wear absorbent incontinence pads for a while until urinary control returns. The length of time to regain control can be unpredictable. Some men regain control in a few days, and some take a few months. In general, older men tend 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 this helpful and informative video on managing incontinence after radical prostatectomy:
Erectile dysfunction after radical prostatectomy
Most men, after radical prostatectomy, can expect some decrease in the ability to have an erection. Erectile dysfunction is this inability to achieve an erection sufficient for sexual penetration. Men who have had nerve-sparing operations are more likely to recover their erectile function, but there’s no guarantee. If the ability to have erections does return after surgery, it often returns slowly and can take from a few months to up to two years. Erectile function is more likely to return for men younger than 60 and or men who had good function before surgery. And even if unassisted erections don’t return, these same men are also the ones more likely to respond to medication.
There are a number of treatment options for erectile dysfunction after radical prostatectomy:
Drugs such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) known as Phosphodiesterase-5 (PDE5) inhibitors are pills can help with erections by opening up the blood vessels to the penis. Side effects of these drugs include headaches, facial flushing, upset stomach, light sensitivity, and runny or stuffy nose.
The drug Alprostadil is a synthetic version of the naturally occurring substance prostaglandin E1 produces erections by dilating the penile blood vessels. It can be injected into the penis with a small needle 5 to 10 minutes before intercourse or placed as a pellet into the urethra of the penis.
Vacuum devices are mechanical pumps placed over the penis, which draws 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. Some men find the lack of blood flow to be uncomfortable.
Penile implants restore your ability to have erections mechanically. There are different types of penile implants, including malleable silicone rods and inflatable devices that are inserted surgically.
Some urologists feel that regaining spontaneous erectile function is aided by using some of these treatment options as soon as possible after surgery. This is called penile rehabilitation. Evidence as to its efficacy remains limited.
After surgery, there is no ejaculation of semen, even though the sensation of orgasm should still be pleasurable. This ”dry” orgasm occurs because the glands that make the fluid for semen, the seminal vesicles, are removed during the prostatectomy. For some men, orgasm becomes less intense or goes away completely after surgery. Less often, men report painful orgasms.
Radical prostatectomy also cuts the vas deferens, which carry sperm from the testicles meaning men can no longer conceive naturally. Usually, this is not an issue, as men with prostate cancer tend to be older. But younger patients may wish to consider “banking” their sperm before the operation.
Another possible effect of surgery is a small decrease in overall penile length, which occurs due removal of the portion of the urethra that passes through the prostate.
Preparing for radical prostatectomy
There is evidence that performing pelvic floor muscle exercises for a few weeks before a radical prostatectomy may aid in quicker recovery from urinary problems caused by surgery.
A week or more before the operation, ”pre-op” tests are performed at the hospital to ensure you are fit enough for surgery. Some drugs, such as warfarin, may need to be stopped before surgery.
Getting organised at home before surgery helps to make life easier after discharge. Simple things like filling the freezer with food and arranging for people to help with things like cleaning and shopping can make all the difference. Have some absorbent (incontinence) pads ready, and ensure you have comfortable, loose clothes to wear while any soreness settles down.
Fasting before surgery. The surgeon or hospital will provide instructions such as not to eat anything after midnight or to drink only clear fluids up to a few hours before surgery.
Items to take into hospital items include:
- A list of current medications
- Personal items such as a toothbrush and shaving equipment.
- Loose-fitting, comfortable clothing
- Eyeglasses, hearing aids or dentures
- Items to help relax, such as portable music players or books
Radical prostatectomy recovery
Most patients stay in bed until the morning after surgery and are encouraged to mobilise afterwards.
After open surgery, patients are ready to go home after three days. After robotic and laparoscopic surgery, most will be discharged after 1 to 2 days.
Patients are discharged home with a urinary catheter, usually removed back at the hospital within two weeks. It’s common to leak urine when the catheter is removed, so patients are encouraged to take some absorbent incontinence pads and spare underwear to the hospital.
How to look after your catheter after radical prostatectomy:
Patients should drink enough water and eat plenty of fibre to avoid constipation. Regular bowel habit often takes a few weeks to return due to the effects of painkillers and reduced mobility. Patients occasionally need to take mild laxatives.
Perineal discomfort between the rectum and scrotum may last for several weeks after surgery. It almost always resolves on its own.
Scrotal and penile swelling is not abnormal for a few days after surgery and is not cause for serious concern. It should dissipate on its own in a week or two.
It is not unusual to feel fatigued for a few weeks or months after surgery; however, most men return to normal activities within 4 to 12 weeks after radical prostatectomy.
Going back to work after radical prostatectomy
The amount of time a patient needs to take off work following a radical prostatectomy will depend on how quickly they recover and how much physical effort their job involves. Patients undergoing open surgery might need a little longer to get back to heavier physical activities than after keyhole surgery.
Driving after radical prostatectomy
There are no official guidelines as to when one can return to driving. Most surgeons are happy that their patients return to driving once the catheter is out and have stopped taking strong painkillers. Patients should check with their insurance company how soon after surgery they are insured to drive. It is better to avoid long journeys for the first couple of weeks after the catheter is removed to get used to dealing with any problems, such as leaking urine.
Follow up after radical prostatectomy.
The prostate gland, seminal vesicles and any lymph nodes removed will be sent to a pathologist to be looked at under a microscope. The results can give a clearer idea of how aggressive the prostate cancer might be, the grade, and whether it has spread beyond the confines of the prostate, the stage.
A ”positive surgical margin” means there are cancer cells on the edge of the tissue removed. It leaves the possibility that some cancer cells may have been left behind, requiring further treatment in the future.
A ”negative or clear surgical margin” means that the tumour removed was surrounded by a layer of healthy tissue, suggesting that all the tumour has been removed.
What is undetectable PSA after radical prostatectomy?
After the surgical radical prostatectomy, the prostate-specific antigen (PSA) drops to virtually undetectable levels (less than 0.05), depending on the lab performing the PSA test. This reading is effectively zero, but given the limited sensitivity of the test, it is simply termed undetectable.
PSA monitoring after radical prostatectomy
PSA monitoring after radical prostatectomy is essential to understanding whether or not all the cancer cells have been removed. The PSA is usually checked every three months for the first one to three years and then 6 to 12 months thereafter. Following a radical prostatectomy, the most widely accepted definition of a recurrence is a confirmed PSA level ≥0.2 ng/mL.
If the PSA does rise above this level, the urologist may try to determine where the recurrent cancer cells are located. This may involve arranging MRI, bone scan or CT scans. In cases where the PSA is very low, the clusters of prostate cancer cells might be too small to detect on any imaging tests. So sometimes pelvic radiotherapy is offered based on the probability of cancer cells being present rather than actually seeing tumour recurrence on scans. Newer molecular imaging scans, including C11-choline, F18-fluciclovine, and PSMA PET scans, can be done at select centres. These scans can more precisely identify prostate cancer metastases in the body and are significantly more sensitive than traditional bone and CT scans. However, all scans can have difficulty finding 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
Men who undergo radical prostatectomy have a high survival rate and low rates of cancer recurrence, cancer spread and death, according to a study of 10,332 men who had surgery between 1987 and 2004. The research showed that between 5 and 20 years after having the surgery, only 3% of the patients died of prostate cancer, 5% saw their cancer spread to other organs, and 6% had a localised recurrence.
Another large Scandinavian study compared men who chose active surveillance with those treated by radical prostatectomy. The results suggest that at over the long term radical prostatectomy offer a definite survival advantage for younger men with higher-risk tumours.
Results from another study at Johns Hopkins Hospital in Baltimore (USA) confirmed that 82% of men undergoing radical prostatectomy were free of recurrence at 15 years. The data from the research also indicated that in those men whose PSA level starts to rise again after surgery, recurrent prostate cancer spreads in only around one-third of the men. In addition, unless a man had an aggressive grade of prostate cancer, spreading the disease would not become life-threatening for several years and would be amenable to treatment.
Further treatment after radical prostatectomy
Two other therapies are occasionally recommended after surgery, based on the pathology report after the surgery as well as the subsequent PSA response.
Radiation therapy may be offered to some men with high-risk prostate cancer who have cancer that has penetrated the prostate capsule or positive margins after surgery. Studies have shown that recurrence rates drop by approximately 50% if these men receive radiotherapy after surgery. However, some of these men may not develop recurrent tumours without further treatment and may suffer additional side effects from radiotherapy. The most standard strategy, therefore, is to use radiation therapy only if PSA levels rise above 0.2 ng/mL.
Hormone therapy may be recommended for men who have cancer found in their lymph nodes at the time of surgery. Studies have shown that hormone therapy helps patients live longer in some of these men.
BAUS radical prostatectomy audit
The British Association of Urological Surgeons (BAUS) now publishes the results of radical prostatectomy for surgery performed in the UK. Details of the operations performed by each surgeon and centre are given, with information about the technique used, transfusion rates, postoperative complications and length of stay for individual surgeons and units. However, the responsibility of entering the data lies with the individual surgeons and is not always complete.
https://www.baus.org.uk/patients/surgical_outcomes/radical_prostatectomy/
Author: Mr Neil A Haldar MBBS MD FRCS UROL
The Pelvic Specialists