Radical Prostatectomy
It is called radical surgery because it is. There are several techniques to this major surgical procedure, but in all cases it involves several hours under general anesthesia in a hospital setting.
learned from surveying men with early prostate cancer.
Question 84:
What is a radical prostatectomy?
Answer:
Radical prostatectomy is a major surgical procedure performed under general anesthesia in a hospital operating room where the urologist removes the prostate gland and the seminal vesicles (an organ attached to the top of the prostate). There are three methods to perform radical prostatectomy, but all do basically the same thing. The prostate is dissected along with the seminal vesicles away from the bladder and off the rectum. The urethra tube is cut across, both at the top of the prostate where the tube joins the bladder and also at the bottom of the prostate. The bladder is then pulled down into the man’s pelvis and sewn to the lower part of the urethra located below where the prostate used to be. Depending on the extent of the cancer, the surgeon will try to preserve the sex nerves. The pelvic lymph nodes may also be removed. The surgery takes approximately two hours to perform, but may take longer, depending on the skill level of the urologist. Additionally, depending on the skill of the surgeon, a man wears a urinary catheter for an average of one week after the procedure, but some men may require a catheter for a month or longer. Radical prostatectomy is not typically performed on men older than age 70 because of the increased possibility of severe complications.
Question 85:
What are the three techniques for performing a radical prostatectomy?
Answer:
The modern standard technique developed at Johns Hopkins has been an open radical prostatectomy (ORP), where a surgeon makes an incision in a man’s lower abdomen and begins his dissection of the prostate. A variant of the ORP is the perineal approach, in which the incision is made through a man’s bottom; however, this is an uncommon procedure. The second technique is a laparoscopic radical prostatectomy (LRP), where the urologist makes four 1/2-inch incisions in a man’s lower abdomen. Then, the urologist inserts tubes through which he or she manually removes the prostate. The third and newest technique, the robotic radical prostatectomy (RRP), is also a laparoscopic radical, but the instruments are remotely controlled by a device called the da Vinci® robot.
Question 86:
Of the three techniques for radical prostatectomy, which method has the best cure rate?
Answer:
Cure rates are the same with any radical prostatectomy technique. With highly experienced urologists performing surgery at hospitals such as Johns Hopkins, Memorial Sloan Kettering, Cleveland Clinic or Northwestern University, the overall 10-year cure rate ranges from 70–80% for both the open and laparoscopic method.3,4,5,6 With lesser skilled urologists, the cure rate may be lower. Dr. Mani Menon and his team in Detroit have the oldest and largest robotic radical prostatectomy (RRP) study (2,766 men), and their five-year cure rate is 84%.7 This cure rate will continue to fall, and within 10 years, it should be between 70–80% as with the other techniques. Thus, the cure rate with radical prostatectomy is the same regardless of whether it is open, laparoscopic or robotic. A variation in cure rates among skilled urologists is almost always attributed to patient selection and not technique of radical. A doctor who operates on only early prostate cancer will get better cure rates than one who operates on more advanced disease.
Question 87:
If you cut out the entire prostate, why would you not be cured with radical prostatectomy?
Answer:
You may not be cured due to microscopic capsule penetration through the capsule, and/or spread of cancer (metastases) elsewhere in a man’s body, which is not detectable at the time of surgery. A study from the Southwest Oncology Group documented that the most common reason for men with advanced cancer not to be cured with radical prostatectomy is because cancer cells were left behind in the prostate bed where the prostate gland was originally.32 The reason for this is cancer cell leakage, which prevents all cancer cells from being removed at the time of prostatectomy.6 The 10-year cure rates significantly decrease when microscopic capsule penetration is discovered.31 This happens with any of the techniques, open, laparoscopic or robotic.33 See Questions 31–41 on how prostate cancer works.
Question 88:
What is the most common location for microscopic capsule penetration that causes cancer cells to be left behind after radical prostatectomy?
Answer:
Microscopic capsule penetration can occur at any location around the prostate and result in radical prostatectomy failure. However, the most common location for cell leakage is at the bottom of the prostate (the apex).34,35,36 For any of the three techniques, the most critical and difficult part of a radical prostatectomy is removing the apex of the prostate, where the urethra is also cut across. There are several reasons for this difficulty. First, it is common for prostate cancer to be located at the bottom of the prostate. According to RCOG’s database, 67% of men on biopsy have cancer at the bottom of the prostate. The second reason is that there is no capsule to contain prostate cancer at the apex, which means that prostate cancer can easily leak out of the prostate in this area (see Question 33 and Figure 6). Third, one of the large muscles that controls urination, the external sphincter muscle, is located at the apex of the prostate. A surgeon has a difficult decision when dissecting the apex. If the surgeon tries to cure a man of his prostate cancer, the procedure may remove too much of the muscle that controls urination, causing a man to leak urine. On the other hand, if the surgeon tries to ensure that the man will not leak, he can leave cancer cells behind. To further complicate the procedure, the right and left sex nerves converge at the apex of the prostate. As with the muscles that control urination, if the surgeon tries to preserve these sex nerves, he may leave cancer behind; conversely, the surgeon may also leave the man without sexual function if he removes too much tissue in his attempt to cure the cancer. Although cancer cells can be left at any location, leaving cancer cells behind at the apex is the most common reason for surgery to fail to cure men with prostate cancer. Despite this problem, it is remarkable that highly experienced surgeons can successfully dissect the apical area and cure many men with microscopic capsule penetration, if it is a small amount.
Question 89:
Since the operation field is magnified with the robotic radical prostatectomy, can surgeons see microscopic capsule penetration?
Answer:
No, the robotic technique does not help surgeons see microscopic capsule penetration.34
Question 90:
If I had a radical prostatectomy and the pathologists guaranteed that all cancer was inside the prostate with no microscopic capsule penetration, would this guarantee cure?
Answer:
No. Even if the pathologist, based upon examination of the whole prostate under the microscope, reports that all the cancer is contained inside the prostate and no microscopic capsule penetration is present, 14% of men still are not cured and have regrowth of prostate cancer within 10 years of surgery.37 Evidently, microscopic capsule penetration can be missed or cancer can spread by other means such as small veins.
Question 91:
Since removing the apex of the prostate is the most critical part of radical prostatectomy and may cause urinary leakage, how often do men leak after radical prostatectomy?
Answer:
Urinary leakage is defined as men wearing one or more pads per day, and it varies with the skill of the surgeon. With highly-experienced surgeons, the chance of urinary leakage has been reported from 8–17%.38,39,40,41 The leakage rate is the same regardless of radical prostatectomy technique — open, laparoscopic or robotic.
Question 92:
What is the risk of loss of sexual function following radical prostatectomy?
Answer:
With highly-experienced surgeons, the overall loss of sexual function occurs in approximately one-third of men who have radical prostatectomy, regardless of the technique used.33,40,42 Some reports say more and others less, which is attributed to patient selection. With less experienced surgeons, the chance of losing sexual function may be 50% or greater.
Question 93:
I understand that more men are choosing the robotic radical prostatectomy technique over the other two methods. Is there any advantage to the robotic method?
Answer:
The cure and complication rates are the same for all three techniques.33,42 The only documented advantage to the robotic technique is that men are discharged from the hospital within one to two days after the robotic, as compared to four to seven days with the open method. There is also less blood loss and a lower transfusion rate with the robotic technique, but a significant loss of blood is very low with any method of radical prostatectomy if an experienced surgeon performs the procedure. There is one major drawback to robotic surgery. With the open method, the surgeon can not only look, but also feel for cancer with his hand. But with the robotic method, since the surgeon is operating robotic laparoscopic instruments 10 feet away from the patient, there is no palpation of the prostate for cancer, only the ability to look at the prostate. This is a problem for robotic surgery, especially for more advanced cancers.
Question 94:
If there is no improvement in cure rate or fewer complications with the robotic technique, why is it the most common way to perform radical prostatectomy?
Answer:
Knowing that robotic radical prostatectomy does not improve the results over the open or laparoscopic, the only reason for robotic being the most common method currently used is because of men’s perception that the robotic technique is better. Some urologists believe that the robotic radical prostatectomy technique gives better results, but their analysis is typically flawed because the robotic method has been used on men with early prostate cancer and compared with men who have had an open prostatectomy for more advanced disease.5 How a doctor selects patients can influence results dramatically. The fundamental key to curing men with radical prostatectomy is the skill and experience of the urologist NOT the radical prostatectomy technique.17 A highly-skilled urologist performing an open radical prostatectomy can achieve the same results as a highly skilled urologist practicing the robotic technique.
