A radical prostatectomy is a common operation for treating prostate cancer. It used to be called total prostatectomy. This means using surgery to remove all of the prostate gland through a cut in your abdomen or the area between the testicles and the back passage (perineum). The aim of this type of surgery is to cure the cancer.
Your surgeon may suggest radical prostatectomy if : -
Your cancer has not spread from your prostate
You are younger, rather than older, and have a high grade tumour
Q. Who has radical prostatectomy ?
Radical prostatectomy is done more often in younger men because they are more likely to : -
Be fit enough for such major surgery
Have a faster growing tumour that needs radical treatment
Die from their cancer rather than other health conditions if it is not successfully treated
If your specialist suggests this operation is not suitable for you because you are an older man with a slow growing prostate cancer, they are not discriminating against you. Surgery may not be necessary because your cancer may be so slow growing that you are more likely to die of old age or other causes than from the prostate cancer. Radical prostatectomy is major surgery with many possible side effects. In many cases, it isn't worth putting you through the side effects if the treatment will not lengthen your lifespan.
Before surgery
It is important to tell your doctor if you have had any unusual problems with bleeding in the past (from dental work, for example).
Aspirin can cause excessive bleeding during surgery. If you regularly take aspirin or a product containing aspirin, make sure you stop taking it at least 10 days before surgery. If you take aspirin for heart or blood problems, you need to get permission from your doctor to stop taking aspirin. If you are not sure about any of your medications, ask your doctor.
Although they don't carry the same risk as aspirin, anti-inflammatory medications should be avoided around the time of surgery. If you are not sure about any of your medications, ask your doctor.
In case you need a transfusion during surgery, the best blood you can get is your own. If possible, donate one to two units of your own blood within 30 days of your surgery.
The night before surgery, you may be given an enema and some laxatives to clean out your colon.
Your doctor may put you on a liquid diet the day before surgery. If you are not put on a liquid diet, eat a light meal the night before surgery and do not eat anything after midnight right before surgery.
During surgery
The surgeon makes an incision in the lower abdomen, from the pubic bone to the navel.
Before reaching the prostate gland, the surgeon may remove a small amount of tissue on either side of the bladder. This tissue contains lymph nodes, bean-shaped collections of infection-fighting cells located throughout the body. If prostate cancer has spread outside the prostate gland, one of the first places it may travel is to lymph nodes in the pelvis.
In selected cases, a pathologist (a doctor specializing in identifying disease through noting changes in organs, tissues and fluids) examines the lymph nodes under a microscope to see if they are cancer-free. If the lymph nodes are cancerous, the operation is usually stopped. If no cancer is found in the lymph nodes, the operation continues.
The veins traveling over the prostate and urethra are carefully cut so the operating area is free of blood. These veins will be removed with the prostate gland.
The urethra is the tube that carries urine from the bladder through the penis and out of the body. It also carries semen out through the penis during ejaculation. The urethra runs right through the middle of the prostate gland. Before the prostate can be removed, the urethra must be cut both above and below the prostate. The urethra will be reattached to the bladder later in the operation.
The nerve bundles on either side of the prostate are responsible for erections. If they appear to be cancer-free, the surgeon may not remove them. This modified operation is called a nerve-sparing radical prostatectomy. If the nerves must be removed, the bundles are cut near the urethra and next to the rectum.
The prostate gland is detached from the bladder; the overlying veins, seminal vesicles and vas deferens are also removed.
The urethra is reconnected to the bladder. While the patient is still under anesthesia, a Foley catheter, a hollow, flexible tube to drain urine, is inserted into the penis through the urethra and into the bladder. It is left in place until the reconnection heals.
[Diagram 1: A cut in the abdomen is made ]
[Diagram 2: The entire prostate and seminal vesicles are removed (shaded area) ]
[Diagram 3: The urethra is rejoined to the bladder and a catheter inserted for a period of 3 week. ]
Q. How long will I be in the hospital after surgery ?
You are usually discharged once your bowels starting moving again and you can eat a regular diet. A typical hospital stay for a radical retropubic prostatectomy is two to three days, including the day of surgery.
Follow-up testing after surgery
Follow-up PSA testing is performed six weeks after surgery. At this point, if the cancer was completely removed, the blood should show no detectable PSA levels.
Advantages of the retropubic technique : -
The surgeon is able to remove both the prostate gland and nearby lymph nodes at the same time, through the same incision.
The surgeon is better able to see and feel the nerves needed to get and maintain erections. If these nerves appear to be cancer-free, then they do not have to be removed and may be saved in a nerve-sparing procedure.
The surgeon is able to cut out more tissue, providing a better chance of removing all the cancer and not leaving any behind.
Risks of radical prostatectomy
The risks after surgery are similar to those of any major surgery.
They include : -
Impotence
Heart attack
Stroke
Blood clots in the legs
Infection at the incision site
Post-operative bleeding
Death (rare)
Recovery time for radical prostatectomy
Since a radical prostatectomy is major surgery, patients may require blood transfusion. Prostatectomy patients typically stay in the hospital for 2-4 days. Full recovery can take up to 12 weeks.
Side effects of radical prostatectomy
Common side effects of a radical prostatectomy include : -
Swelling of penis and scrotum : - This swelling is a short-term effect of the surgery and usually subsides by the end of your hospital stay.
Incontinence : - By incontinence we mean a small leak of urine that can occur if you cough, sneeze or laugh, when pressure in the pelvis is raised and urine can then be forced out of the bladder. This occurs in about 10% (1 in 10) of men after the operation. We will teach you some exercises before the operation which you can do after the operation to strengthen your pelvic floor muscles. These exercises, when correctly done, are known to help with continence.
For some men this small leak of urine lasts for a short time after the operation, other men may need to continue their exercises in the long-term. See pelvic floor exercise information at end of booklet. The long-term risk of significant leak of urine is less than 1% (1 in 100).
Impotence (inability to get an erection for sexual intercourse) : - Impotence can be a permanent consequence of surgery in about 50% (5 in 10 ) to 100% (10 out of 10) of men.
The risk is variable due to certain factors. You should discuss your individual risk with your urologist. For some men who have become impotent as a result of surgery there may be treatment to restore erections. This is usually given in the form of tablets. You can discuss this at your follow up appointment after the operation.
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