Prostate Cancer (cont.)
Radical prostatectomy is the surgical removal of the entire prostate. This operation is indicated for cancer that is limited to the prostate and has not invaded the capsule of the prostate, any other nearby structures or lymph nodes, or distant organs.
- The entire prostate, seminal vesicles, and ampulla of the vas deferens are removed, and the bladder is connected to the membranous urethra to allow free urination.
- Radical prostatectomy is used to treat men with clinically-localized prostate cancer who have a life expectancy of at least 5 years. Although there are not specific or universally accepted age limits for radical prostatectomy, the life expectancy of men above 70 to 75 years of age is low enough that few men in this age range undergo radical prostatectomy.
- Anesthesia for radical prostate surgery has been provided using general, spinal, and epidural approaches; however, most surgeons today prefer regional anesthesia, which has been reported to be associated with less blood loss and a lower risk for pulmonary emboli.
- Complications of this procedure include urinary incontinence and impotence. Newer techniques spare the nerve that controls urination and erection. Of men who undergo these newer techniques, 98% are continent, and 60% are able to have an erection.
- Radical prostatectomy can be combined with radiation therapy in men with cancer that is even further isolated in the prostate area. There is an excellent survival rate if cancer has not spread.
- A man should be certain to understand the risks and benefits of this procedure before deciding to go ahead.
- Surgical techniques include open retropubic radical prostatectomy, open perineal radical prostatectomy, and minimally invasive radical prostatectomy (laparoscopic radical prostatectomy and robotic-assisted radical prostatectomy [RARP]).
- Both retropubic and perineal radical prostatectomy techniques are widely used “open” surgical approaches. They both include skin incisions.
- Minimally-invasive techniques have become popular over the past decade and are largely replacing open prostatectomy in most large U.S. centers.
- Laparoscopic radical prostatectomy: This type of surgery follows the same oncological principles as "open" radical prostatectomy. Rather than a large incision, laparoscopic methods make use of abdominal insufflation that allows a working space using surgical instruments that are introduced through small abdominal incisions.
- Robot-assisted radical prostatectomy (RARP): This technique gives the surgeon better operative site visualization and more natural hand motions to control the surgical instruments. Currently, almost 70% of radical prostatectomy surgeries in the U.S. are performed with the help of the da Vinci robotic system. For robot-assisted surgery, five small incisions are made in the abdomen through which the surgeon inserts tube-like instruments, including a small camera. This creates a magnified three-dimensional view of the surgical area. The instruments are attached to a mechanical device, and the surgeon sits at a console and guides the instruments through a viewing device to perform the surgery. The instrument tips can be moved in a variety of ways under the control of the surgeon to achieve greater precision in surgery. So far, studies show that traditional open prostatectomy and robotic prostatectomy have had similar outcomes related to cancer-free survival rates, urinary continence, and sexual function. However, in terms of blood loss during surgery and pain and recovery after the procedure, robotic surgery has been shown to have a significant advantage.
- Quality of life after radical prostatectomy:
- The complications of most concern to men who undergo these procedures are urinary incontinence and impotence, which are due to operative damage to the urinary sphincter and penile nerves. The frequency of incontinence and erectile dysfunction depends in part upon the experience and expertise of the surgeon.
Transurethral resection of the prostate (TURP) is an alternative to radical prostatectomy.
- Only part of the prostate is removed by an instrument inserted through the urethra.
- An electric current passes through a small wire loop at the end of the instrument. The electrical current cuts away a piece of the prostate.
- This procedure is used to remove tissue that is blocking urine flow in patients with extensive disease or those that are not fit enough to undergo radical prostatectomy. It is not considered a procedure for cure.
Pierre-Alain Hueber, MD, PhD
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