Prostate Cancer Surgery
Surgical treatment for prostate cancer involves removal of the entire prostate and the seminal vesicles. Usually, surgery is considered when cancer appears to be confined to the prostate (localized prostate cancer). In select cases, the pelvic lymph nodes are also removed. Candidates for surgery are usually healthy, active and younger men with at least a 10 year life expectancy.
Advantages: Radical prostatectomy is a well-proven treatment for prostate cancer that has been demonstrated to result in long-term cancer survival. It is the only treatment that has definitively demonstrated a survival advantage over watchful waiting therapy for men less than 65 years old. Surgery allows for complete examination of the prostate and the lymph nodes if indicated. All known prostate cells are completely removed from the body and therefore, the PSA level in the blood should fall to undetectable levels after radical prostatectomy. Thus, after surgery, PSA becomes an excellent test to detect even small amounts of residual or recurrent cancer.
Disadvantages: There are possible side effects with surgical removal of the prostate; most importantly, this includes urinary leakage and erectile dysfunction. While many men can recover function in both of these areas, others may have persistent long-term problems.
Surgical Techniques for Removing the Prostate
Radical Retropubic Prostatectomy (RRP)
RRP has traditionally been the most commonly performed type of radical prostatectomy. It involves a skin incision in the lower abdomen from just below the umbilicus (belly button) to the pubic bone just above the penis. The prostate and seminal vesicles plus the pelvic lymph nodes (if indicated) are removed. Patients are usually discharged from the hospital in two to three days and wear a catheter for about 10 to 14 days. Recovery time is approximately four to six weeks and requires no heavy lifting or strenuous activity/exercise for six weeks.
Radical Perineal Prostatectomy (RPP)
RPP has also been traditionally used as an approach to removing the cancerous prostate and seminal vesicles. While not as commonly performed, in experienced hands, it can be just as effective as the retropubic approach. It involves a skin incision in the perineum (between the scrotum and rectum) and can be advantageous in patients with a very large abdomen or prior abdominal surgery. However, the pelvic lymph nodes cannot be removed through this incision, and preservation of erections may be more difficult with this approach. Patients are usually discharged from the hospital in one to two days and wear a catheter for about 10 to 14 days. Recovery time is approximately four to six weeks and requires no heavy lifting or strenuous activity or exercise for six weeks.
Robotic-assisted Laparoscopic Radical Prostatectomy (RLRP)
Since 2001, robotic or laparoscopic radical prostatectomy has been performed. RLRP involves removal of the prostate and seminal vesicles plus removal of the pelvic lymph nodes (if indicated) just like open surgery except with five or six small one centimeter incisions. Magnified and three-dimensional visualization of the prostate and surrounding structures along with specialized small surgical instrumentation allows precise dissection of the prostate.
The advantages of this technique are a shorter hospital stay, quicker recovery, less blood loss, shorter catheter time and fewer overall complications. Also, studies have suggested improved cancer control, quicker time to continence and possibly improved erectile function after RLRP. While robotic surgical technologies have been helpful, surgeon expertise and experience remain the most important factors to a good outcome.
Robotic Prostatectomy Pre-operative Class
Our prostate cancer patients undergoing a Laparoscopic assisted Robotic Radical Prostatectomy have the opportunity to participate in our Robotic Prostatectomy Pre-operative Class. As part of this program, our patients are highly encouraged to participate in our pre-operative education classes, for it helps improve outcomes and prepares them for surgery.
For information or questions about the class, call 336-832-0314
What to Expect After Surgery
Surgery is followed by an average hospital stay of about one to two days, and the average time away from work or strenuous activity is four to six weeks. Patients undergoing surgery need to wear a catheter for about seven to 10 days to allow the bladder and urethra to heal. Although rare, the risks associated with radical prostatectomy are similar to those of any major surgery including bleeding, infection, blood clots and heart or lung problems. The level of risk depends largely on the age and overall health of the patient.
Following surgery, significant bladder control can return in about eight to 12 weeks. However, this can often take longer and can continue to improve even up to one year after surgery. After the catheter is removed, all men initially leak urine uncontrollably. Patients are instructed on how to perform special exercises called Kegel exercises to help improve urinary control.
Typically, physicians recommend seeing a physical therapist both before and after surgery to help patients perform exercises that can aid in improving bladder control. Ninety to 92 percent of men recover excellent urinary control and will not require pads or others means of protection in the long term. About four percent of patients will have mild stress incontinence that persists after surgery, which is passing a small amount of urine when coughing, laughing, sneezing or engaging in heavy exercise. These men may choose to wear a protective pad to protect against unexpected leakage. However, another four percent of patients who undergo radical prostatectomy may experience severe incontinence that persists after surgery. This group of patients will need to wear pads, take medication or undergo further surgical procedures to treat this side effect.
Sexual dysfunction is a common problem in both men and women. Sexual problems become progressively more common with aging, heart disease, high cholesterol, diabetes and high blood pressure. Prostate cancer and the treatment of prostate cancer can have significant impact on sexual function depending on baseline sexual function, patient age, medical risk factors and disease stage. Patients and their significant other receive counseling about anticipated changes in sexual function, and this may include predicting the likelihood of preserving and recovering sexual function after prostate cancer treatment.
The nerves that help control erections are positioned along each side of the prostate. If there is no indication of tumor involvement within or near the nerves surrounding the prostate, called neurovascular bundles, nerve-sparing surgery is performed. Depending on each patient’s specific situation, the surgeon will discuss whether a nerve-sparing procedure is appropriate. If there is concern about leaving cancer behind, surgeons will usually recommend removing the nerves on the involved side.
Men who have “normal” pre-operative erectile function have about a 75% chance of having erections that are adequate for sexual intercourse following a bilateral (both left and right) nerve-sparing operation. About half of these patients require oral medication such as Viagra®, Cialis®, Stendra® or Levitra® to obtain optimal erectile function. Men who are younger than age 60 and those with the highest levels of pre-surgery erectile function have the best outcomes in terms of being able to have erections post-surgery. Men, who have only one nerve spared, are older than age 65, have pre-existing erectile dysfunction, or have other medical problems that may contribute to erectile problems, have a lower chance of recovering spontaneous erections.
Recovery of erections after surgery is a gradual process that takes several months and can continue to improve up to two to three years after surgery. One way to help improve the chances of return of erections after radical prostatectomy is to participate in “penile rehabilitation.” Within a couple of weeks after removal of the catheter, regular attempts to have an erection with sexual stimulation along with the help of prescribed oral medications or other means can enhance the flow of blood and oxygen to the penile tissue. The most common side effects of the oral medications are headache, flushing, upset stomach, visual disturbance and nasal congestion. By attempting to have at least three erections per week in the months after surgery, patients can maximize post-operative recovery.
Today, there are many options for treating erectile dysfunction. Aside from oral medications, there are also injectable medications, vacuum pump devices and surgical options to help men regain the ability to have erections after radical prostatectomy.