Surgery to remove the prostate, the most commonly used treatment to cure prostate cancer. There are several different types of prostate removal surgery. A radical prostatectomy includes the removal of the entire prostate gland, the seminal vesicles, a section of the urethra, the ends of the vas deferens, and a portion of the bladder neck, through an incision from the navel to the pubic bone, an incision between the scrotum and the anus (perineal incision), or laparoscopically.
After the prostate and other structures are removed, the bladder is then reattached to the rest of the urethra and a catheter is inserted into the penis and bladder, to allow urine to drain while the bladder and urethra heal. A small drain is often placed through the abdomen into the pelvis to help remove mild bleeding, lymph drainage, and urine drainage. The drain is removed as the fluid level decreases. During a radical prostatectomy, the pelvic lymph nodes are often removed as well, since they are a common location of prostate cancer cell migration.
The best candidates for a radical prostatectomy are men whose prostate cancer is confined to the prostate, who are healthy enough to withstand surgery, and who are expected to live for at least seven to 10 years. However, it is sometimes difficult to estimate correctly whose disease is really confined to the prostate; between 20 and 60 percent of men who have a radical prostatectomy have a more advanced stage of prostate cancer than previously believed.
The decision to perform surgery depends not just on the stage of cancer, but on the man’s lifestyle and the potential impact of the surgery on his life.
More than 70 percent of men whose cancer was confined to the prostate remain free of tumor more than seven to 10 years after radical prostatectomy.
Types of Radical Prostatectomy
There are three different ways to perform a radical prostatectomy: the retropubic, the perineal, and the laparoscopic prostatectomy. The choice of approach depends on the urologist’s preferences, the patient’s body characteristics, and whether or not a pelvic lymph node dissection is planned.
Retropubic prostatectomy The most common type is the retropubic prostatectomy, in which the surgeon removes the entire prostate gland and seminal vesicles through the lower abdomen, making an incision from the navel to the pubic bone. The benefit of this option is that it allows the doctor easy access to the pelvic lymph nodes. Moreover, the blood vessels and nerves controlling the patient’s sexual potency are easily seen.
The disadvantage of this approach is that it requires an abdominal incision, which can lead to a longer recovery time and more discomfort.
Laparoscopic radical prostatectomy A radical prostatectomy also may be performed by using a laparoscope and several small incisions in the abdomen. This relatively new procedure is similar to the retropubic method, but because of the smaller incision there is less discomfort and quicker recovery. Early reports of this technique were criticized due to high rate of positive margins and the steep learning curve associated with the procedure.
Perineal prostatectomy Alternatively the perineal approach utilizes an incision in the area between the scrotum and anus. The benefit of this method is that it does not require an abdominal incision and is therefore less uncomfortable and has a shorter recovery period. Although this method allows the surgeon to see the outlet of the bladder and the urethra clearly nerves that control potency are less easily visualized than in the retropubic approach. In addition, the pelvic lymph nodes cannot be removed through the perineal incision. Removal of these lymph nodes requires a separate incision. The perineal method is best suited for overweight men or men with pre-existing erectile dysfunction and low probability of spread to pelvic lymph nodes.
Nerve-Sparing Radical Prostatectomy
Because the nerves responsible for penis erections thread along each side of the prostate and the urethra, damage during a prostatectomy may cause erectile dysfunction — the inability to have an erection. If the nerves are not preserved, the chance of retaining the ability to have an erection is small. If both nerves are preserved, the chance of maintaining erections with or without the use of sildenafil (Viagra) is about 50 percent, depending on the patient’s age. (Men younger than age 50 are much more likely to recover erections than those older than 65.) However, even after a bilateral nerve-sparing prostatectomy, a man may still experience erectile dysfunction.
In a nerve-sparing prostatectomy, the urologist tries to push aside the nerves while removing the prostrate. The surgeon may perform a bilateral nerve-sparing radical prostatectomy, in which the nerves on each side are spared, or a unilateral nerve-sparing prostatectomy, in which one group of nerves from one side are removed with the prostate.
It is critical to decide who is best suited for a nerve-sparing procedure. The decision as to whether or not to preserve the nerves near the prostate depends on the patient’s age, his potency before surgery, the location and extent of the tumor determined by the biopsy information, and the Gleason score. If these factors suggest that the cancer is confined to the prostate and the patient is potent, then a nerve-sparing procedure is performed.
Men at high risk for having cancer at the edge of the prostate are better off if the nerves and tissue on that side are all removed, since this provides a better chance of removing all the cancer.
Preparing for Surgery
Before the surgery, the patient is given a physical examination, blood tests, and a chest X-ray or electrocardiogram to make sure he is healthy enough to undergo surgery. The urologist may prescribe a bowel preparation to clean out the lower intestines.
Men who have laparoscopic radical prostatectomy usually go home the day following the surgery; other methods usually require at least one- or two-day hospital stay. Men are usually discharged with a Foley catheter to drain urine for 10 days to three weeks, which, allows the area where the bladder has been reattached to the urethra to heal. Full recovery may take up to a month. Once the catheter is removed, kegel exercises strengthen the pelvic muscles to help control urine flow. Most men regain control of their urine within a month of catheter removal.