Surgery – radical Prostatectomy

A surgical operation to remove the whole prostate gland together with the seminal vesicles is called a radical prostatectomy. The prostate is normally taken out through the abdomen (called the 'retro-pubic approach'). For patients with intermediate-risk prostate cancer the pelvic lymph nodes (part of the immune system) may be removed. For high-risk cancers, they should be removed. Radical prostatectomy is normally offered to those with localised cancer, a life expectancy of 10 or more years, and where the man’s age and general health allow. In some cases surgery may be considered for locally advanced cancer.

Nerve-sparing surgery, which aims to preserve erectile function, is normally undertaken where possible. This does not necessarily ensure that erections can be subsequently achieved, as the nerve bundles lie extremely close to the prostate. Surgery is now only performed in larger specialist cancer centres, where a greater number of operations are done. The greater the experience of the surgeon, the greater the likelihood of a satisfactory result.

Methods of Surgery

Three main methods of surgery are now used: open, keyhole, and robotic. Current research is showing no appreciable difference in long-term outcomes, but evidence for robotic surgery is rapidly increasing and distinct differences may well be found in the future.

Open surgery
Until around 2014 open radical prostatectomy was the most common method to remove the prostate gland. It is a major operation which requires 3–6 days in hospital and several weeks of recovery time. The operation takes about 2–2½ hours. The surgeon will make a cut in the lower abdomen to remove the prostate. The catheter is removed after about two weeks. The wound will take 4–6 weeks to heal completely and the scar will fade and shrink over time. Driving can normally be resumed after 4–6 weeks.

Laparoscopic surgery
The removal of the prostate by keyhole surgery is known as a laparoscopic radical prostatectomy (LRP). It is considerably less invasive than open surgery, has less blood loss and less post-operative pain. It has been in use in the UK since 2000. The surgeon will first inflate the abdomen with gas in order to reduce blood loss and to gain a clear view of the area of the operation with a special camera, the image being transmitted to a video screen. Four or five small incisions will be made in the lower abdomen, and the prostate and seminal vesicles will be removed through an incision below the navel. In the hands of an experienced surgeon, the operation typically takes only a little longer than for open surgery.

Robotically assisted laparoscopic surgery
This method uses a ‘Da Vinci’® robot. It uses similar techniques to the laparoscopic method, except that the operation is performed by the surgeon from a remote console, using both rotating handles and foot pedals to remotely control the five arms of the robot. The surgeon is assisted by a team of theatre nurses at the operating table.

Unlike laparoscopic equipment, the machine gives 3D vision and more accurate fine movements. Results so far are proving as effective as, but no better than, the other two methods. The majority of radical prostatectomies are now done using this method and any man choosing surgery as his option is highly likely to have robotic surgery.

     Advantages and disadvantages of surgery

    • The cancer may well be completely eradicated
    • You will know exactly how far the cancer had developed afterwards
    • It will also get rid of any age-related benign enlargement of the prostate (BPH)
    • Follow-up is easier than other options
    • Radiotherapy and/or hormone treatments can follow, if needed

      But:

    • All major surgery has risks. The older you are, the greater the risk
    • Risk of urinary incontinence and/or erectile function
    • As with most radical prostate cancer treatments, you will lose fertility and ejaculatory function (but not necessarily the ability to reach orgasm)

After the Operation

The patient wakes with a urinary catheter in place, an intravenous infusion of fluid in the arm, and may have an abdominal drain. Painkillers are prescribed as needed, and the wound dressings removed. Constipation can sometimes be a problem after surgery. Only prescribed laxatives should be taken, and straining should be avoided. Blood in the catheter can be seen in some cases, often after opening the bowels, but this need not be a concern unless it becomes severe. Advice will be given on using the catheter.

After removal of the catheter (about 10 days later), some slight incontinence should be expected in most cases but, with the pelvic floor exercises that you will be given, this should return to normal over time. This could last from three to six months. You will be given incontinence pads to wear for this period. In very few cases incontinence is permanent. This can, however, be considerably improved by an operation to fit a device to help enable controlled urination – see Urinary Function.

Assessing the Spread of the Cancer

Following the operation, the prostate will be sent to the pathology lab for analysis. This will reveal the extent and grade of the cancer, and whether it was enclosed within the prostate, or whether it extended up to or beyond the cut edge of the prostate. The presence of cancerous cells all the way to the edge of the tissue that was removed is called a positive surgical margin.

If cancer is found just outside the prostate, there is a greater likelihood of a recurrence of the cancer over time. This may not be a cause for concern, dependent on the grade of the cancer found at the edges of the gland. The cancer at the centre of your tumour may have been aggressive, but at the margins may have been of low grade. You should discuss options with your consultant following surgical pathology.

Follow up Care

Following a prostatectomy a high sensitivity PSA (down to 2 decimal places) is usually required. A sustained high sensitivity PSA result after the operation of less than 0.05ng/ml over several years will indicate the likelihood of a cure. (The nationally agreed target standard, however, is <0.2ng/ml.)

PSA levels should be checked no earlier than 6 weeks after treatment, at least every 6 months for the first 2 years and then at least once a year after that (NICE Guideline 2019).

Side effects of surgery

Ejaculation. In addition to the removal of the prostate gland, the seminal vesicles are removed at the same time. These glands help to produce a man’s semen in addition to the prostate itself. Orgasm is always possible, but it will be dry. Although this is a concern, some men report the experience or quality of orgasm as being enhanced. (Should a younger man who wishes to father children consider surgery, opportunities for sperm banking should be discussed.)

Erections. After nerve-sparing surgery partial erections normally occur, and better function can return over time. It is important that efforts are made as soon as practicable after surgery to resume erectile function. ‘Use it or lose it’ is the motto (See Sexual Function.)

Continence. A degree of incontinence may occur for a few months, as the urinary sphincter (the muscle that controls the urine flow) is removed during surgery. Pelvic floor exercises, done before and after the operation, may aid speedier return to normality (See Urinary Function). Weight loss, if appropriate, may help.