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Radical Prostatectomy

Surgical removal of your prostate gland, called radical prostatectomy, is an option to treat cancer that's confined to your prostate gland. For more than two decades, radical prostatectomy has been considered the gold standard for the surgical management of prostate cancer. During this procedure, your surgeon uses special techniques to completely remove your prostate and local lymph nodes, while trying to spare muscles and nerves that control urination and sexual function.

Several approaches are available for a prostatectomy. These include:

  • Perineal surgery. With the perineal approach, an incision is made between your anus and scrotum. There's generally less bleeding with perineal surgery, and recovery time may be shorter, especially if you're overweight. With this procedure, your surgeon isn't able to remove nearby lymph nodes.
  • Retropubic surgery. In this approach, the gland is taken out through an incision in your lower abdomen. It's the most commonly used form of prostate removal for two reasons. First, your surgeon can use the same incision to remove pelvic lymph nodes, which are tested to determine if the cancer has spread. Secondly, the procedure gives your surgeon good access to your prostate, making it easy to save the nerves that help control bladder function and erections.

Since its original description, radical retropubic prostatectomy has evolved over the last three decades to a precise, sophisticated procedure with minimal mortality and excellent surgical outcomes. Numerous techniques and approaches have evolved to perform radical prostectomy, including:

Open ApproachOpen approach

With a traditional open procedure, your surgeon uses an 8-10 inch incision to access the prostate. This approach often results in substantial blood loss and a lengthy, uncomfortable recovery.

Pure laparoscopic approach

Conventional laparoscopy uses a specialized surgical camera and rigid instruments to access and remove the prostate using a series of small incisions. This approach provides your surgeon with better visualization than an open approach. In addition, it provides patients the benefits of a minimally invasive procedure.

Robotic-Assisted Laparoscopic ApproachRobotic-assisted laparoscopic approach

Despite many advantages, conventional laparoscopy relies on rigid instruments and standard 2D video, technical limitations that can be challenging for the surgeon. Posture and body ergonomics are also fatiguing to the surgeon with pure laparoscopy. Because of these drawbacks, conventional laparoscopy doesn't lend itself well to complex procedures like prostatectomy. Therefore, very few urologists use this approach for prostatectomy. Moreover, neither laparoscopy nor open surgery can provide adequate visualization for a very precise, nerve-sparing prostatectomy.

Overview of Robotic Prostatectomy Technique

Robotic-Assisted SurgeryDespite its efficacy, open surgical treatment is inherently associated with blood loss and significant pain. As a result, many men have sought other, less invasive forms of treatment. With its development in the late 1990s, minimally invasive surgery has significantly and irrevocably changed the surgical treatment of prostate cancer. Robotic-assisted technology has further propelled the utilization of the laparoscopic approach for radical prostatectomy, particularly for non-laparoscopic trained surgeons.

The implementation of robotic technology has been rapid. Presently, seven years after its approval by the FDA, many hospitals have established robotic-assisted radical prostatectomy programs. This trend will undoubtedly continue to grow as more surgeons become familiar with the procedure, more robotic systems become available, and increasingly mature data is published.

Robotic-assisted laparoscopic radical prostatectomy allows patients the benefits of minimally invasive surgery with functional and oncological results comparable to those from open and standard laparoscopic procedures. Consequently, we believe that robotic-assisted laparoscopic surgery will become the standard surgical approach for localized prostate cancer in the very near future.

Side Effects of Radical Prostatectomy

During your operation, a catheter is inserted into your bladder through your penis to drain urine from the bladder during your recovery. The catheter will likely remain in place for one week after the operation while the urinary tract heals.

After the catheter is removed, you'll likely experience some bladder control problems (urinary incontinence) that may last for weeks or even months. Pre-operative Kegel exercises and early development of the Kegel reflex can help accelerate this process. Most men eventually regain control. Many men experience stress incontinence, meaning they're unable to hold urine flow when their bladders are under increased pressure, such as when they sneeze, cough, laugh or lift. In some men, major urinary leakage persists, and secondary surgical procedures may be needed in an attempt to correct the problem.

Impotence is another common side effect of radical prostatectomy, because nerves on both sides of your prostate that control erections may be damaged or removed during surgery. Most men younger than age 50 who have nerve-sparing surgery are able to achieve normal erections afterward, and some men in their 70s are able to maintain normal sexual functioning. Men who had trouble achieving or maintaining an erection before surgery have a higher risk of being impotent after the surgery.

Benefits of Radical Prostatectomy

While most currently diagnosed prostate cancers are localized, radical prostatectomy remains the gold standard treatment. The benefits of surgical removal include:

  • Pathological assessment of the entire prostate.
  • Identification of any high risk pathological features which would require closer follow up and potential adjuvant therapy.
  • Blood PSA becomes undetectable (<0.01 ng/mL) forever.
  • Future PSA values are specific towards disease recurrence (biochemical recurrence, as per the American Urological Society (AUA) is a rising PSA >0.20 ng/mL).
  • Secondary therapy, if needed (such as radiotherapy) can still be safely given in the unlikely event of a local disease recurrence.

History of Radical Prostatectomy

1891

Dr. George Goodfellow, Perineal Prostatectomy

1904

Dr. Hugh Young, Perineal Prostatectomy (first paper published)

1947

Dr. Terence Millin, Radical Retropubic Prostatectomy

1982

Dr. Patrick Walsh introduces nerve-sparing RP

1986

PSA blood test introduced

1988

Ultrasound-guided prostate biopsies introduced

1995

35% of diagnosed patients had RP

1998

Laparoscopic Radical Prostatectomy introduced

2002

Robotic Radical Prostatectomy introduced