Introduction
A radical prostatectomy involves the removal of the prostate gland itself along with tissues around it, which ordinarily comprise the seminal vesicles, a section of the urethra and lymph nodes close to the prostate.
Depending on the circumstances, there are alternative treatments to surgery, depending on whether the cancer has spread to other parts of the body (see alternative treatments below).
Indications
The primary indication for a radical prostatectomy is the presence of prostate cancer and is generally most suitable men under the age of 75.
Preoperative Instructions
All patients are given full instructions on how to prepare for the procedure well ahead of the day of surgery. In most cases the following preparation is required:
- Inform the surgical team of what medications you are currently taking and follow any guidelines given by the team.
- If any symptoms of illness occur before the procedure (e.g. cold or fever) inform the surgical team.
- If you smoke, you should cease smoking ideally several weeks before the procedure.
- You should not eat or drink anything after midnight the night before the procedure.
Procedure
The procedure can be carried out using different approaches. These are:
Open surgery
This is also referred to as 'conventional surgery', where an incision is made to the lower abdomen below the umbilicus to access the prostate.
Laparoscopic surgery
Also referred to as 'keyhole' or 'minimally invasive' surgery, this involves the creation of a number of much smaller incisions in the abdomen through which a camera and light and specialised surgical instruments are inserted into the body cavity to complete the procedure.
Robot-assisted surgery
Robot-assisted surgery is based on laparoscopic surgery, where a robotic system is used, which gives the surgeon a 3D image of the prostate and surrounding tissue and utilises advanced surgical instruments. This approach is also known as RARP ('Robotic Assisted Laparoscopic Radical Prostatectomy').
Nerve sparing surgery
In this procedure the prostate and the seminal vesicles are removed, while preserving the nerves that control an erection. This approach is suitable for lower grade cancer and for younger men. Patients may still have some issues even where nerve-sparing surgery is used.
A large number of all radical prostatectomies are performed using robotic surgery. The benefits of a robotic approach is that it is generally associated with quicker recovery times, as well as generally a lower rate of complications both intraoperatively and post-surgery.
Postoperative Instructions
After the procedure it is normal to have to stay in hospital for 2-5 days. There will be some postoperative pain which can be managed with pain medication. After surgery a catheter is placed to allow urine to drain; the catheter will need to remain in place for 1-2 weeks after the procedure, and patients are shown how to use it and look after it.
Full recovery from a radical prostatectomy generally takes 4-6 weeks. During this time, you are advised to avoid strenuous exercise or any heavy lifting. You can start driving again at the 2-week mark. If at any point you experience any indication of infection, such as fever, redness around the incision, swelling or difficulty urinating, you should contact Dr Liddell immediately, visit your doctor or go to the nearest hospital emergency department.
Risks
Less than 1 in 10 patients who undergo a radical prostatectomy suffer any postoperative complication, and these are generally short-term issues or are treatable. There are some potential risks that are associated with all surgical procedures and these are:
- Bleeding.
- Blood clots (Deep Vein Thrombosis or 'DVT').
- Infection.
- Nerve damage (with this procedure, specifically related to the nerves that control erectile and urinary function).
- Injury to other organs / tissue (with this procedure, specifically the rectum, the bladder and the ureters).
- Wound healing issues.
The following potential risks are specifically related to radical prostatectomy:
Infertility
The one unavoidable side effect of the procedure is infertility, as the vas deferens (the tubes connecting the testicles to the urethra) are sealed and with the removal of the seminal vesicles and the prostate itself no seminal fluid is produced. There are options for patient undergoing the procedure who would still like to have children, including sperm banking.
Bladder control issues (incontinence / urine leakage)
This generally improves within 2-12 months, although in around 5% of cases it may be permanent and may be able to be treated with further surgery.
Erectile dysfunction (ED)
Impotence is a possible side effect of the procedure. This can affect 75% of men undergoing to the procedure to some extent, however ED may only be temporary and improve over time. There are several treatment options for ED.
Shortening of the penis
In some cases, the penis may shorten after the procedure.
Urinary obstruction
In a very small number of cases, scar tissue can form where the urethra is joined back up to the bladder. This can in turn cause issues with urine flow. In this case, further surgery may be required to remove scar tissue.
Treatment Alternatives
In some cases of prostate cancer, surgery may not be required. Alternative treatments may include:
- Regular PSA (Prostate Specific Antigen) tests, called 'active surveillance'.
- Watchful watching – monitoring the disease and only instigating treatment once the patient develops metastases.
- Radiotherapy.