Deciding on the best course for management of your 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 is an operation which involves 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 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.
Laparscopic Radical Prostatectomy
Over the last 10 years there has been a significant shift in North America and Europe towards minimally invasive surgery in an attempt to reduce surgical side effects and speed post operative recovery.
Laparoscopy is commonly known as "keyhole surgery”, however although the incisions are small the view is not. Modern equipment produces a wide, bright, clear 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.
Laparoscopic radical prostatectomy, using an optical scope and instruments placed via 5 small ports, takes longer to perform but the hospital stay is usually 2-3 days with a post-operative recovery period around 3-4 weeks. Drain and catheter placement and duration are the same as for an open procedure.
Following the operation
Men are able to drink within 6 hours following the operation and eat a normal diet the next day. They can mobilize out of bed the day after surgery. Constipation may be a problem following all significant abdominal operations however medications will be given regularly to help prevent and/or relieve this.
The catheter is removed between days 10-14 following the operation. Leakage of urine (incontinence) occurs for most men following this 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 through the day as described in other sections Persistent incontinence may be treated with a short, further surgical procedure if necessary.
Sexual function may 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.
Most men can resume normal activities within 3 to 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 post-operatively. After the first 2 years this follow-up process can be taken over by your GP if you wish.