Radical Prostatectomy

Surgery to remove the prostate and the neighboring seminal vesicles is called radical prostatectomy. Radical prostatectomy is one option for treating prostate cancer, although there are at least four distinct types of radical prostatectomies: radical retropubic, radical perineal, laparoscopic (robot-assisted) radical retropubic, and mini-lap radical retropubic. All four types of prostatectomy involve removing the prostate gland and the neighboring seminal vesicles. Prostatectomies are called for when the cancer is thought not to have spread outside the prostate gland. And the type of prostatectomy chosen is based on the size of the prostate, the need for sampling lymph nodes, previous abdominal conditions or surgery, and the surgeon's preference. Compared with watchful waiting, patients undergoing radical prostatectomies have lower incidence of spread of the disease and may have improved survival rates.

Before the surgery, patients may be given general anesthesia so they will remain unconscious during the procedure, or they instead may be given a sedative along with regional anesthesia, such as spinal or epidural anesthetics, to block any sensation. Women often receive spinal or epidural anesthetics during childbirth.

The morbidity associated with radical prostatectomy has declined greatly in the past 25 years with minimized risks of anesthesia and blood loss, as well shorter hospital stays. The average hospital stay is approximately 1 to 2 days. Furthermore, centers that perform relatively more prostatectomies per year have significantly better surgical outcomes as shown by recent Medicare data. Transfusions are usually unnecessary, and treatment-related mortality at leading prostate cancer centers is very low (< 0.05%). Urinary incontinence is common within the first several months after surgery; however, most men recover urinary control within 1 to 2 years. At leading centers, 90 to 98 percent of men report few or no long-term urinary problems.

Radical retropubic prostatectomy
After anesthesia has been given, the surgeon will make an incision from the lower abdomen to the pubic bone. Sometimes only the prostate gland is removed, whereas other times the lymph nodes near the prostate are also taken out if the cancer is thought to have spread. Whether to remove the lymph nodes depends on how high your PSA level and Gleason scores are.

Your urologist will also consider whether to spare or save the nerve bundles located on both sides of the prostate. These nerve bundles are important in controlling erections and urinary control, but may need to be removed if the cancer has spread into the prostate capsule. Prostatectomies that leave the nerve bundles intact are known as nerve-sparing radical prostatectomies. It offers men with good potency prior to surgery the best probability of recovering that function following the operation. The nerve sparing approach is also associated with less blood loss and improved urinary continence. In selected individuals the nerve sparing approach confers no greater risk of prostate cancer recurrence. In general, 50 to 90 percent of men who are fully potent prior to a nerve-sparing procedure recover erections afterwards, but the quality may be reduced. A recent study has suggested that early post-operative use of Sildenafil (Viagra) may facilitate the return of erections more quickly. In general, potency may return 2 to 24 months following surgery. Regardless of potency, the sensation of the penis is unchanged after surgery, and men can still experience a climax, although there is no ejaculate.

Radical perineal prostatectomy
A radical perineal prostatectomy involves an incision made to the perineum, the area between the anus and scrotum. Because the large prostates cannot be removed through this approach, this type of prostatectomy is less frequently performed than the retropubic type. A nerve-sapring procedure can be performed with this approach, but the larger prostates may require more stretching of the nerve bundles, and thus more nerve injury, to remove the prostate. However, it is an important option to consider if you have coexisting medical conditions that would make retropubic surgery more difficult, such as obesity or prior laparoscopic hernia surgery. However, the operation itself is usually shorter than a retropubic prostatectomy, less painful, and the recovery time slightly shorter. Postoperative stays for radical perineal prostatectomies are usually overnight 1 day.

Laparoscopic radical prostatectomy (LRP) or Robot-assisted LRP
Initially described in 1997, laparoscopic radical prostatectomy(LRP), was not often used because of its technical difficulty and long operative time. But just as LRP has beginning to be used more often because of improved instruments and technical refinements,the robot was introduced, and now, very few LRP are being done.  The robotic-assisted LRP (RALRP) technique allows for three-dimensional visualization of the retropubic area and improved range of motion for surgical instruments and suturing the bladder to the urethra. In experienced hands, both the robotic and laparoscopic prostatectomy are as effective as the retropubic and perineal open procedure. There is less blood loss, but there is no difference in transfusion rates.  Recovery time is quicker. In terms of sexual and urinary health(continence), the robotic-assisted LRP may be equivalent to open surgery, but cancer control may not be as effective, as most early studies show higher positive surgical margins with RALRP. As with any newer procedures, long-term patient follow-up of RALRP has been limited.  With increasing use and experience, RALRP may produce similar oncologic outcomes to open surgery.   Emory Urology has been offering the daVinci robotic surgery since mid 2008.

Mini-lap radical retropubic prostatectomy
For treatment of localized prostate cancer, technical improvements in the nerve-sparing radical retropubic prostatectomy have been achieved with the mini-lap retropubic prostatectomy. This procedure requires a small 7 to 8 cm incision rather than an incision three times that length. The mini-lap also uses a new retractor system that functions as a robot so there is no need for a second surgical assistant. Extensive experience with this operation has been developed over the past few years.  More than 1,000 Emory patients have undergone mini-lap radical retropubic prostatectomys (RRP) for clinically localized prostate cancer. Most of these patients are hospitalized for two days, and most report mimimal pain following discharge. These patients reported continence rates of 90 to 95 percent and potency rates of 66 to 75 percent.

The mini-lap RRP takes less time to perform than the laparoscopic radical prostatectomy, with the same discomfort and length of hospital stay as the RRP. But a reduction in bowel and abdominal problems has been reported. Potency rates have not yet been well defined in most of the laparoscopic series.  The Emory University urology department continues to explore this new laparoscopic approaches, but Emory experts believe the mini-lap RRP compares favorably to the standard radical open prostatectomy, the perineal prostatectomy, and the laparoscopic prostatectomy.

Advantages and disadvantages of the Radical Prostatetctomy

Advantages:

• Best 15-year disease-free survival for organ-confined disease
• Best option for younger patients
• Can receive additional external beam radiation therapy safely if needed
• Robotic-assisted LRP more rapid recovery time than standard radical retropubic prostatectomy

Disadvantages:

• Incontinence in 5 to 8 percent of patients.
• Erectile dysfunction in 50 percent or more of patients. However, sexual function may be attained with drugs such sildenafil (Viagra) or vardenafil (Levitra) or tadalafil (Cialis), injection therapy, vacuum devices, or penile implants.
• About 30 to 40 percent of patients may have undetected cancer that is not confined to the prostate disease (extracapsular extension); which means they will be at higher risk for future recurrence.