Radical prostatectomy

Overview

Surgery is a popular treatment option for prostate cancer that has not progressed beyond the prostate gland. A radical prostatectomy is the most common kind of prostate cancer surgery. The surgeon removes the whole prostate gland as well as some of the surrounding tissue, including the seminal vesicles, during this procedure.

What is Radical prostatectomy?

The prostate gland, seminal vesicles, and, in certain situations, some pelvic lymph nodes are surgically removed during radical prostatectomy. The term 'radical' refers to the removal of your entire prostate rather than just a portion of it.

The objective is to remove all prostate cancer, preserve continence, and, if possible, preserve the erection nerves to your penis. Prostatectomy is a successful curative therapy for many men with prostate cancer, even those at greater risk. The majority of men who are treated for early prostate cancer will survive for many years.

The operation can be performed by a "open" incision in the abdomen (a technique known as a radical retropubic prostatectomy) or via an incision in the perineum, the region between the scrotum and the anus (radical perineal prostatectomy). These techniques are no longer routinely employed in most high-volume prostate cancer facilities in the United States.

The operation can also be performed as a laparoscopic radical prostatectomy. Laparoscopy is a minimally invasive surgical method in which narrow, specially constructed telescopes and other delicate devices are passed via very small incisions.

The da Vinci robotic-assisted surgical system, which has superior magnification and surgical accuracy, is used to execute laparoscopic radical prostatectomies. Patients' results in terms of cancer control and urinary and sexual function are on par with - and frequently better than - those obtained with open radical retropubic prostatectomy.

The robotic technique appears to be similarly effective in removing cancer and is linked with less blood loss and discomfort, fewer problems, and a faster return to regular activities. This method may also be connected with a greater capacity to protect the neurovascular bundles that govern erectile function. Patients may be candidates for a nerve-sparing radical prostatectomy, which helps retain sexual function, depending on their age and other variables.

We may also remove the lymph nodes that drain the prostate in addition to the prostate itself. This procedure, known as pelvic lymph node dissection, is used to detect whether the cancer has progressed to the lymph nodes. The risk of lymph node cancer increases with the severity of the malignancy.

Although major problems from the procedure are uncommon, there are some adverse effects. The most frequent are incontinence (urine leakage caused by stress or exertion) and erectile dysfunction (inability to get or maintain an erection). Although incontinence is prevalent immediately after surgery, it normally resolves. The ability to restore erectile function is dependent on whether the nerves around the prostate can be spared after surgery, the patient's age, and baseline function. Men who are older or who already have erection issues are more likely to have erectile dysfunction as a result of the procedure.

What and where is my Prostate?

Your prostate is a golf-ball-sized gland located at the base of your bladder, just above the urethra tube. Its primary purpose is to add fluids to your ejaculate (semen).

Advantages and Disadvantages of Surgery

What is significant to one individual may be less important to another. The benefits and drawbacks of surgery may vary depending on your age, general health, and stage of cancer.

Advantages of Radical Prostatectomy

Compared with other treatment options, radical prostatectomy offers several advantages:

• Many patients though not all are cured by the surgery.
• The pathologist can more precisely diagnose the aggressiveness of the cancer by removing the complete prostate gland (stage and grade). If more therapy is required, this information can be used to assist select the best course of action. This information is also used to decide how frequently prostate-specific antigen (PSA) testing should be performed following surgery.
• It is immediately obvious whether the therapy was effective. Because the patient's blood PSA level is generally undetectable after surgery, any recurrence can be caught early with frequent PSA testing. An ultrasensitive PSA test can detect values as low as 0.015 ng/mL, assisting in the early identification of prostate cancer. Assessing efficacy of radiation or other initial therapies might take a long time.
• You can still explore salvage (follow-up) therapies with radiation or other modalities. While surgery does not exclude additional radiation therapy, it may be difficult to do surgery after radiation treatments. Having the option of later therapies is especially crucial for higher-risk tumors, when a mix of treatments may be required for long-term survival.
• There is a reasonably low chance of recurrence (after five years), which can be diagnosed with timely PSA testing.

However, radical prostatectomy is only one of several therapeutic choices. You should talk to your doctor or cancer care team about all of your choices.

Disadvantages of Radical Prostatectomy

• As with any major procedure, there are dangers associated with surgery.
• You may have negative effects such as erection and urinary difficulties.
• You'll have to stay in the hospital for a few days, generally between one and five days depending on the type of operation.
• If the cancer has progressed beyond the prostate, the surgeon may not be able to remove all of it, and you may require further therapy.
• You won't be able to have children or ejaculate after surgery since you won't be able to create sperm, but you can preserve sperm prior to surgery for fertility therapy.

Preparing for Surgery

Your doctor may request a number of tests before surgery to identify the extent of your cancer. Blood tests and imaging tests such as MRI, CT, bone scans, and PET are examples of these. If you were already diagnosed, your surgeon may want to redo certain tests and go at your biopsy slides.

In addition, we will schedule a "preparation" session - either by phone or in person - to review your physical condition, medication usage, pertinent medical history, and upcoming anesthetic. One of the urology nurses, nurse practitioners, or physician assistants will discuss everything you need to know to prepare for your operation, including food and drinking guidelines and other details.

If you've ever suffered vomiting or nausea following surgery, notify your anesthesiologist or surgeon. Inquire about taking a medicine the night before the surgery to avoid post-op nausea and vomiting.

You could give your own blood prior to surgery, although this is rarely done for radical prostatectomies because there is little blood loss and the chance of needing a transfusion is low (less than 1 %).

During the Operation

You will be admitted to the hospital on the day of your surgery, or potentially the day before. You won't be able to eat anything for roughly six hours before the procedure, but you may be able to drink water or some other liquids until two hours before. You will be informed of this.

To evacuate your intestines, you may be given an enema (liquid medication) or a suppository (a pellet). These are installed in your rear passage (rectum).

You will be given a general anaesthetic, which will put you to sleep during the procedure and prevent you from feeling anything. The procedure normally takes two to four hours, although it might take longer at times.

In addition to the prostate, your surgeon will remove the seminal vesicles. These are two glands that are related to and reside behind the prostate. Some of the fluid is stored in the sperm (the fluid that carries sperm).

There are two nerve bundles linked to the prostate that aid in erections. If feasible, your surgeon will strive to preserve these nerves. This is known as nerve-sparing surgery.

If your surgeon believes your cancer has progressed to your nerves, one or both of these bundles may need to be removed. This will make it difficult to obtain an erection without medical assistance. Even if your nerves are protected, your erections may take some time to return. Although these nerves are involved in erections, they do not govern penile sensation. So even if they are injured or eliminated, you will not lose sensation and should be able to enjoy orgasms.

What should I expect when I get home?

You will awaken in the rehabilitation area. You'll be wearing an oxygen mask since you'll be breathing more slowly than normal when the anesthesia wears off. A drip will be placed in your arm to provide fluids and pain treatment, and a catheter will be placed to remove pee from your bladder.

A small catheter in your lower abdomen may also be used to drain fluid from the location where your prostate used to be. This is often removed 24 to 48 hours following the procedure.

• Catheter

While the area heals, a tiny, flexible tube (called a catheter) will be inserted up your penis to empty pee from your bladder. It will be installed while you are sleeping throughout the procedure. It may feel awkward or uncomfortable at first, and you may have a constant desire to urinate. However, the catheter should drain all of the pee without you having to do anything, and this sensation normally goes away within a few hours.

Most guys return home with the catheter in place. Your nurse will instruct you how to care for it, and it will be removed one to three weeks later at the hospital.

• Pain

If you require pain medication following the procedure, you will be given it. These should relieve any pain you are experiencing, but please notify your doctor or nurse if you are experiencing any discomfort.

The medications are frequently injected into a vein in your arm or hand through a drip (intravenous infusion). You may have a pump so that you may administer pain medication to yourself without having to wait for someone to bring it to you. The pump has a restriction so that you don't accidentally give yourself too much drugs.

For a few days after keyhole surgery, you may have soreness at the point of your shoulder. This is due to the use of carbon dioxide during surgery. The gas irritates the nerves, which might result in pain. Your stomach may feel bloated, and you may have cramping and stiffness. It is generally relatively minor and fades with time.

• Swelling

Bruising and swelling in and around your testicles and penis are possible. This can make sitting on hard surfaces unpleasant. It should only be for a few weeks. Inform your doctor if you have a lot of swelling or if it is becoming worse.

When you go home, you may discover that underpants provide more support and are more comfortable than baggy boxer shorts. Supportive underwear, such as a jock strap or testicular support, can also be purchased.

If you have lymph nodes removed during the procedure, you may experience swelling in the scrotum (the skin covering your testicles) and one or both legs (lymphoedema). If compression stockings are required, they will be supplied to you to aid in the drainage of fluid from your legs.

• Eating and drinking

When it is safe to begin eating and drinking, your team will notify you. Sips of water are generally the first thing you do.

• Getting out of bed 

To reduce the chance of blood clots, you will be advised to get out of bed and move about as soon as possible. Injections may also be recommended to lower the risk of blood clots. You will be discharged one to five days following your procedure, depending on your recuperation and the advice of your doctor.

Recovery of Sexual Function

Prostate gland removal surgery interferes with sexual and reproductive function. The capacity to obtain and sustain an erection, as well as the irreversible loss of ejaculation fluid. Penile shortening of 1cm or more is possible if nerves have been purposely severed.

During surgery, we try to keep the tiny nerves that govern penile erection intact. These travel along the surface of the prostate gland before connecting to the blood vessels in the penis. During surgical removal, these nerves are easily injured.

The possibility of regaining acceptable sexual function is determined by various factors, including pre-operative sexual function, age, the need for nerve excision, and surgical competence. Other risk factors for erectile dysfunction include high blood pressure, diabetes, obesity, and smoking.

Younger men with normal sexual function who are candidates for nerve preservation and have surgery performed by a surgeon with nerve preservation experience are more likely to regain reasonable erectile function. As long as you feel comfortable, you can resume sexual activity two weeks after your procedure.

Before recovery, there may be a 12-month period of pretty impaired function. For males who want to resume penetrative sexual intercourse, I propose early "penile rehabilitation." This includes frequent erection induction or augmentation using a vacuum pump and oral or injectable medicines. Our clinic nurse will be able to teach you these methods.

Open or Laparoscopic Radical Prostatectomy

In the more conventional form to prostatectomy, known as an open prostatectomy, the surgeon removes the prostate and surrounding tissues by a single lengthy skin incision (cut). This sort of surgery is performed less frequently than in the past.

A laparoscopic prostatectomy involves the physician making numerous tiny incisions and removing the prostate with special long surgical equipment. The surgeon either physically handles the tools or utilizes a control panel to precisely maneuver robotic arms holding the tools. This method of prostatectomy has grown more popular in recent years. When performed by skilled surgeons, laparoscopic radical prostatectomy can produce results comparable to open surgery.

What will the follow-up be like?

Following a radical prostatectomy for prostate cancer, your doctor will schedule regular follow-up appointments with you. The standard follow-up period is at least 5 years. The doctor will measure the amount of prostate-specific antigen (PSA) in your blood at each appointment. In some circumstances, a digital rectal examination (DRE) may be required. Follow-up is necessary to monitor your recovery following surgery, to assess your overall health, and to identify any return of the malignancy.

Risks of Radical Prostatectomy

A radical prostatectomy is a serious procedure, and there are dangers associated, as with any major surgery. These are some examples:

• Bleeding during or shortly after surgery and maybe requiring a blood transfusion - this is extremely uncommon if you have keyhole surgery (fewer than 1 in every 100 men)
• Damage to surrounding tissue, such as the colon, blood vessels, nerves, and pelvic floor muscles
• Blood clots in the lower leg that may go to the lungs (less than two out of every 100 men)
• Infection (about one to five out of every 100 men)
• Scarring around the wounds made by the surgeon in your abdomen
• The anesthesia can cause complications, however significant complications are uncommon.

The following factors can have an impact on how your operation goes, your risk of adverse effects, and whether or not you require additional treatment:

• Whether your cancer has spread
• How aggressive your cancer is?
• Your general health
• Your surgeon’s experience and skill. 

According to research, surgeons who conduct a large number of prostatectomies each year had better outcomes and fewer adverse effects. Your surgeon should be able to tell you how many surgeries they've performed, as well as the outcomes and rates of adverse effects.

Conclusion 

After a prostate cancer diagnosis, a radical prostatectomy is surgery to remove the prostate gland and seminal vesicles (and occasionally adjacent lymph nodes). It is one of the therapeutic options available to people with localized prostate cancer. Candidates for the operation should be in good health and anticipate to live for at least the next ten years.