Prostatectomy

Deciding on the best course for the management of prostate cancer is not an easy process for most men. The choice to proceed to radical prostatectomy and the alternative options for management of prostate cancer are discussed more fully in the prostate cancer section.

Radical prostatectomy

Radical prostatectomy is an operation which involves the removal of the prostate and reconstruction of the urinary tract by attaching the bladder to the top of the urethra (outflow pipe).

Within this operation, there are subtle modifications that may be made depending on the stage and grade of the tumour. For more advanced and higher grade but localized cancer, wider excision of the prostate (removing more of the surrounding tissues) and lymphadenectomy (removing lymph nodes which act as one of the first landing sites for spreading prostate cancer cells) may be performed.

For smaller and lower grade tumours the operation may be modified to leave the neurovascular bundles intact in an attempt to preserve erectile function. The nerves which control the erection mechanism run just outside the capsule of the prostate (on average 2-4mm away) behind the gland (at the 5 and 7 o'clock positions when looking towards the feet). Removal of these nerves almost always results in loss of erectile function. In selected cases, it may be possible to preserve one or both of these nerves and thereby increases the chances of a return of erectile function either with or without medications such as Viagra, Cialis or Levitra.

Radical prostatectomy has traditionally been performed as an open operation with a 20cm incision in the lower abdomen above the pubic bone. Following open radical prostatectomy, men usually stay in hospital for 3-4 days, have a drain for the first 24 hours and a catheter which remains in place for 10 days (i.e. they go home with it initially). The post-operative recovery period is around 6-8 weeks.

Robotic Radical Prostatectomy

Over the last 20 years, there has been a significant shift in North America, Europe and Australasia towards minimally invasive surgery in an attempt to reduce surgical side effects and speed up post-operative recovery.

Robotic surgery is commonly known as "keyhole surgery”, however although the incisions are small the view is not. Modern equipment produces a wide, bright, clear, three-dimensional and magnified view of the operation, often superior to the traditional open approach. In addition, the gas used to distend the abdomen during laparoscopy also reduces bleeding during surgery.

The abdominal space is accessed via small ports, inflated with CO2 gas and robotic instruments are inserted to perform the operation. The advanced da Vinci Surgical system is used for the procedure allowing the robotic instruments to be directed under the command of the surgeon who sits at a console.

During the operation, the bladder is mobilised to allow access to the prostate. The prostate is then carefully dissected out, controlling blood flow using plastic clips and suturing. Delicate nerve tissue is preserved if appropriate during this process. When completely mobile the prostate is removed in a bag through one of the port sites and sent for pathological assessment. This leaves a gap between the bladder and the urethra (outflow pipe). The sophisticated robotic “endowrist” allows a wide range of movement and precise control of the suturing to reconstruct the urinary drainage system. A temporary drain is routinely placed to remove any fluid from the area after the surgery and a urinary catheter is inserted to measure urine production during and after the operation. The entire operation is performed without the surgeon’s hands entering the body.

After the operation

Minimally invasive procedures are less traumatic than open procedures however this does not mean that they are pain-free. Medication will be given to keep pain at a manageable level to allow you to mobilise. It is important to get out of bed early in the recovery period. The benefits of this include avoiding blood clots and chest infections as well as promoting the return of normal bowel function. The nursing staff are very helpful with this process. Blood tests will be done after surgery and medical staff will review your progress on a regular basis as well. The drain will be removed as your recovery progresses. The sutures are dissolvable and do not need to be removed.

Most patients are able to leave the hospital the day following their operation. The catheter needs to remain in initially to allow the join of the bladder to the urethra to heal, however, this is straightforward to manage and the nursing staff will show you how to do this before you leave the hospital. Follow-up will be discussed before your discharge, typically being arranged around 10 days postoperatively for catheter removal in the clinic.

Leakage of urine (incontinence) occurs for most men following catheter removal and resolves over time. Swelling, the sutures used for reconstructing the join between the bladder and urethra (outflow pipe), changes in bladder function and other factors in the healing process may all contribute to this. Continence may take anything up to a year to achieve (however most men become dry within the first few months). Pelvic floor (Kegel) exercises help with an earlier recovery and should be done regularly throughout the day. Persistent incontinence may be treated with a short, further surgical procedure if necessary.

The sexual function does not return immediately after an operation either. It will usually recover within a two year period if it is going to but reports of recovery after more than 4 years have been recorded. It is safe to experiment with erections and sexual intercourse beyond a week after catheter removal, the old adage "use it or lose it” applies here. A few further tips; lubrication (as can be found in any supermarket or chemist) makes sex much easier; orgasm, climax or "coming” will now be dry (as the semen delivery tubes have been disconnected), it can be achieved without an erection for some men and finally, there are a number of different treatments available that will make the return of sexual function possible for all men if suitably motivated.

Follow-up

Most men can resume normal activities 4 weeks after surgery, however it is best to build into this gradually. You are safe to drive as soon as you are comfortable enough to brake hard and swerve, this point is normally reached within 2 to 3 weeks.

An outpatient appointment is made at the time of catheter removal (somewhere between days 10-14) for review, to discuss any problems and talk about the results of the pathology. An outpatient appointment with an up to date PSA test is arranged 4 weeks later, then 3 monthly for 1 year, 6 monthly for 2 years and yearly after that to at least 5 years postoperatively. After the first year, this follow-up process can usually be taken over by your GP if you wish.