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Radical prostatectomy

Definition

Radical prostatectomy is surgery to remove all of the prostate gland and some of the tissue around it, to treat prostate cancer.

See also: Prostate resection - minimally invasive

Alternative Names

Prostatectomy - radical; Radical retropubic prostatectomy; Radical perineal prostatectomy; Laparoscopic radical prostatectomy; LRP; Robotic-assisted laparoscopic prostatectomy; RALP; Pelvic lymphadenectomy

Description

There are four main types of radical prostatectomy surgery. These procedures take about 3 to 4 hours:

• Radical retropubic prostatectomy: Your surgeon will make an incision (cut) starting just below your belly button and reaching to your pubic bone. The entire surgery should take 90 minutes to 4 hours.
• Laparoscopic radical prostatectomy: The surgeon makes several small cuts instead of one big cut. Long, thin tools are placed inside the cuts. The surgeon puts a thin tube with a video camera (laparoscope) inside one of the cuts. This helps the surgeon see inside your belly during the procedure.
• Robotic-assisted laparoscopic prostatectomy: Sometimes laparoscopic surgery is done using a robotic system. The surgeon moves the robotic arm while sitting at a computer monitor near the operating table. Not every hospital can do robotic surgery.
• Radical perineal prostatectomy: Your surgeon makes a cut in the skin between your anus and base of the scrotum (the perineum). The cut is smaller than with the retropubic technique. This makes it harder for the surgeon to spare the nerves around the prostate, or to remove nearby lymph nodes. Perineal surgery usually takes less time than the retropubic way. There is also less blood loss.

For these procedures, you will be asleep (under general anesthesia) or receive medicine to numb the lower half of your body (spinal or epidural anesthesia).

• The surgeon removes the prostate gland from the surrounding tissue. The seminal vesicles, two small fluid filled sacs next to your prostate, are also removed.
• The surgeon tries carefully not to damage nerves and blood vessels.
• The surgeon reattaches the urethra to a part of the bladder called the bladder neck. The urethra is the tube that carries urine from the bladder out through the penis.
• Many surgeons will also remove lymph nodes in the pelvis to check for cancer.
• The surgeon may leave a drain, called a Jackson-Pratt drain, in your belly to drain extra fluids after surgery.
• A tube or urinary catheter is left in your bladder to drain urine.

Why the Procedure Is Performed

Radical prostatectomy is most often done when the cancer has not spread beyond the prostate gland. Healthy men who will probably live 10 or more years often have this procedure.

Other treatment options for prostate cancer are:

• External beam radiation therapy
• Implant radiation therapy (brachytherapy)
• Hormone therapy (androgen deprivation therapy)
• Cryotherapy of the prostate
• Visits with your doctor and tests to check for changes in your prostate cancer (called active surveillance)

Sometimes, your doctor may recommend one treatment for you because of what is known about your type of cancer and your risk factors. Other times, your doctor will talk with you about two or more treatments that could be good for your cancer.

Risks

Risks for any surgery are:

• Blood clots in the legs that may travel to the lungs
• Breathing problems
• Infection, including in the surgical wound, lungs (pneumonia), or bladder or kidney
• Blood loss
• Heart attack or stroke during surgery
• Reactions to medications

Risks of this procedure are:

• Difficulty controlling urine (urinary incontinence)
• Erection problems (impotence)
• Injury to the rectum
• Difficulty controlling bowel movements (bowel incontinence)
• Urethral stricture (tightening of the urinary outlet from scar tissue)

Before the Procedure

You will have many visits with your doctor and tests before your surgery:

• Complete physical exam
• Visits with your doctor to make sure medical problems, such as diabetes, high blood pressure, and heart or lung problems, are being treated well

If you smoke, you should stop several weeks before the surgery. Your doctor or nurse can help.

Always tell your doctor or nurse what drugs, vitamins, and other supplements you are taking, even ones you bought without a prescription.

During the weeks before your surgery:

• You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), vitamin E, clopidogrel (Plavix), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot.
• Ask your doctor which drugs you should still take on the day of your surgery.
• On the day before your surgery, drink only clear fluids.
• Sometimes, you may take a special laxative the day before your surgery. This will clean the contents out of your colon.

On the day of your surgery:

• Do not eat or drink anything after midnight the night before your surgery.
• Take the drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

Prepare your home for when you come home after the surgery.

After the Procedure

You may stay in the hospital for about 1 to 4 days. After laparoscopic or robotic surgery, you may go home the day after surgery.

You may need to stay in bed until the morning after surgery. Afterwards, you will be encouraged to move around as much as possible.

Your nurse will help you change positions in bed, show you exercises to keep blood flowing, and recommend coughing or deep breathing to prevent pneumonia. You should do these every 3 to 4 hours. You may need to use a breathing device to keep your lungs clear. You may also:

• Wear special stockings on your legs to prevent blood clots
• Receive pain medicine in your veins or take pain pills
• Feel spasms in your bladder
• Return from surgery with a Foley catheter in your bladder. Some men will have a suprapubic catheter in their belly wall to help drain the bladder.

Outlook (Prognosis)

The surgery should remove all of the cancer cells, but your doctor will watch you carefully to make sure the cancer does not come back. You should have regular checkups, including prostate specific antigen (PSA) blood tests.

References

Su L, Smith JA. Laparoscopic and robotic-assisted laparoscopic radical prostatectomy and pelvic lymphadenectomy. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 99.

Walsh PC, Partin AW. Anatomic radical retropubic prostatectomy. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 97.

Hartke DM, Resnick MI. Radical perineal prostatectomy. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 98.

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