Prostate Cancer: Radical Prostatectomy

Radical prostatectomy is an operation to remove the prostate gland and tissues surrounding it. This usually includes the seminal vesicles and some nearby lymph nodes. Radical prostatectomy can cure prostate cancer in men whose cancer is limited to the prostate.

Who Should Undergo Radical Prostatectomy?

Men younger than age 75 with limited prostate cancer who are expected to live at least 10 more years tend to get the most benefit from radical prostatectomy.

Before performing radical prostatectomy, doctors first try to establish that the prostate cancer has not spread beyond the prostate. The statistical risk of spread can be determined from tables comparing the results of a biopsy and PSA levels. Further testing for spread, if needed, can include CT scans, bone scans, MRI scans, and ultrasound.

If it appears that the prostate cancer has not spread, a surgeon (urologist) may first offer other options besides surgery. These can include radiation therapy, hormone therapy, or simply observing the prostate cancer over time, since many prostate cancers grow slowly. Depending on how high the risk of cancer spread, pelvic lymph node dissection may be considered, as well.

Types of Radical Prostatectomy

The prostate gland lies just under the bladder, in front of the rectum. Surgeons choose from two different approaches to reach and remove the prostate during a radical prostatectomy. One is a traditional approach known as open prostatectomy. The other, more recent approach is minimally invasive. There are two minimally invasive procedures used in radical prostatectomy: laparoscopic prostatectomy and robot-assisted laparoscopic prostatectomy.

Open prostatectomy

In this traditional method of radical prostatectomy, the surgeon makes a vertical 8- to 10-inch incision below the belly button. Radical prostatectomy is performed through this incision. In rare cases, the incision is made in the perineum, the space between the scrotum and anus.

Laparoscopic prostatectomy

In laparoscopic prostatectomy, surgeons make several small incisions across the belly. Surgical tools and a camera are inserted through the incisions, and radical prostatectomy is performed from outside the body. The surgeon views the entire operation on a video screen.

Robot-assisted laparoscopic prostatectomy

Small incisions are made in the belly, as in regular laparoscopic prostatectomy. A surgeon controls an advanced robotic system of surgical tools from outside the body. A high-tech interface lets the surgeon use natural wrist movements and a 3-D screen during radical prostatectomy.

Open Radical Prostatectomy vs. Minimally Invasive Radical Prostatectomy

In 2003, only 9.2% of radical prostatectomies were done using a minimally invasive procedure. By 2007, that number had jumped to 43.2%. In 2009, researchers in Boston reported on a study that compared outcomes, benefits, and complications of open surgery vs. minimally invasive surgery:

• No difference was found in deaths or in the need for additional cancer therapy between the two approaches.
• The median hospital stay was two days for minimally invasive surgery and three days for open surgery.
• 2.7% of men having laparoscopic surgery required a blood transfusion compared with 20.8% of men having open surgery.
• There was more anastomotic stricture -- narrowing of the suture where internal body parts are rejoined -- for open surgery (14%) than for minimally invasive surgery (5.8%).
• There were fewer respiratory complications with minimally invasive surgery (4.3%) than with open surgery (6.6%).
• There were lower rates of incontinence and erectile dysfunction with open surgery. The overall rate was 4.7% for laparoscopic surgery and 2.1% for open surgery.

Risks of Radical Prostatectomy

Radical prostatectomy has a low risk of serious complications. Death or serious disability caused by radical prostatectomy is extremely rare.

Important nerves travel through the prostate on the way to the penis. Skilled surgeons can usually protect most of these nerves during radical prostatectomy. Still, complications from inadvertent nerve damage do occur after radical prostatectomy. They include:

• Urinary incontinence: More than 95% of men younger than age 50 are continent after radical prostatectomy. Around 85% of men aged 70 or older maintain continence after the operation.
• Erectile dysfunction (ED): Problems with erections are common after prostatectomy. Still, most men are able to have sex after prostatectomy while using medicines for ED (such as Viagra or Cialis), an external pump, or injectable medications. The younger the man, the higher the chance of maintaining potency after prostatectomy. A period of penile rehabilitation is often necessary.

Much of the skill involved in radical prostatectomy centers on sparing these nerves during the operation. A man undergoing radical prostatectomy by a surgeon at an advanced prostate cancer center has a better chance of maintaining sexual and urinary function.

Other complications of radical prostatectomy include:

• Bleeding after the operation
• Urinary leaks
• Blood clots
• Infection
• Poor wound healing
• Groin hernia
• Narrowing of the urethra, blocking urine flow

Less than 10% of men experience complications after prostatectomy, and these are usually treatable or short-term.

Success of Radical Prostatectomy

The goal of radical prostatectomy is to cure prostate cancer. However, prostate cancer cure is only possible from prostatectomy if prostate cancer is limited to the prostate.

During radical prostatectomy, the removed prostate is examined under a microscope to see if prostate cancer has reached the edge of the prostate. If so, the prostate cancer has probably spread. In these cases, further treatments may be needed.

Men with no evidence of prostate cancer spread have an 85% chance of surviving 10 years after radical prostatectomy.

What to Expect After Radical Prostatectomy

Most men stay in the hospital for one to three days after radical prostatectomy. A urinary catheter is inserted during the surgery, and some men may need to wear the catheter home for a few days to a few weeks. Another catheter inserted through the skin also may need to stay in place for a few days after returning home.

Pain after radical prostatectomy can generally be controlled with prescription pain medicines. It can take weeks or months for urinary and sexual function to return to their maximum levels.

After radical prostatectomy, regular follow-up is essential to make sure prostate cancer does not return.

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