Types of Radical Prostatectomy
There are three main types of radical prostatectomy:
- RetropubicIn this procedure, the surgeon uses an incision in the lower abdomen to remove the prostate and the lymph nodes for examination. This procedure allows for a nerve-sparing approach, which can lower but not totally eliminate the risk of impotence following surgery. In the nerve-sparing approach, the surgeon tries to preserve one or both of the small nerve bundles needed for unassisted erections. However, if the cancer has spread to the nerves, this approach may not be advised.
- LaparoscopicIn this recently developed procedure, the prostate is removed in a fashion similar to a retropubic prostatectomy, but the procedure is performed through five very small (less than 1.0 cm) incisions using lighted, magnified scopes and cameras. The prostate specimen is then removed in a small bag through one of the incisions, which is expanded to 2 to 3 cm to allow specimen removal.
Potential benefits of this procedure are less pain and earlier return to full activities. Nerve-sparing methods and lymph node dissections can be performed with this technique as well.
- PerinealIn this procedure, the prostate is removed through an incision in the skin between the scrotum and anus. The lymph nodes can't be removed through this incision. If the lymph nodes need to be examined, removal can be done through a small abdominal incision or by a laparoscopic procedure. A nerve-sparing approach can be performed perineally.
In addition to removing the prostate gland, the lymph nodes in the area of the prostate may be removed either before or during the same operation. This is done to determine if the prostate cancer has spread to the lymph nodes. The procedure is called pelvic lymph node dissection.
The risk of having cancer in the lymph nodes can be estimated, and only men with a moderate or high risk of pelvic lymph node metastases need to undergo pelvic lymph node dissection. This includes men with PSA values in excess of 15 ng/ml or high-grade cancers.
A salvage radical prostatectomy is the term used for the procedure when it's performed after radiation treatment has failed.
Choosing Radical Prostatectomy
Radical prostatectomy is one of many options for men with prostate cancer that still appears to be localized to the prostate. It allows, in most cases, for complete removal of the cancer.
Once the prostate is removed, tests can tell how advanced the cancer is, the risk for cancer recurrence and whether additional treatment may be needed. It is relatively easy to follow men who have undergone radical prostatectomy to be sure their cancer is gone. Once the prostate is removed, PSA should fall to undetectable levels. In addition, radiation can be given after surgery if necessary, with a limited risk of any additional side effects.
Patients who choose radical prostatectomy should:
- Be in very good health
- Have a life expectancy exceeding 10 years
- Have cancer that appears to be localized to the prostate gland
- Have discussed all available treatment options with their doctors
Preparing for Surgery
Before surgery, a number of tests will be performed to determine the extent of the disease. These tests include blood tests, transrectal ultrasound and a prostate biopsy. Selected patients may receive a bone scan and a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the abdomen and pelvis.
You will also have a physical examination performed and discuss the various types of anesthesia with anesthesiologists. This visit will be arranged by your doctor and will occur the week before surgery.
You will be admitted to the hospital on the day of your surgery. However, you may begin a bowel prep at home on the day before your surgery to cleanse the bowel. Bowel prep may consist of a clear liquid diet, medication to promote bowel movements or an enema, or some combination of these. This is routine preparation before many types of major abdominal surgery.
There are various types of anesthesia. Spinal or epidural anesthesia are techniques whereby medication is instilled into the space around the spinal cord.
- Epidural anesthesia allows for the delivery of medication postoperatively through a small tube or catheter in the back, resulting in continuous levels of pain medication.
- General anesthesia allows patients to be asleep or unconscious during the procedure.
The techniques may be combined. Some anesthesiologists advocate the use of either epidural or spinal anesthesia in addition to a general anesthetic to decrease blood loss during the operation and improve pain management after the operation; others have advocated the use of general anesthesia, with the use of ketorolac, an anti-inflammatory medication, after surgery.
Donation of autologous blood (your own blood) is offered to patients, but given the limited blood loss noted by most experienced surgeons, it may not be necessary. If you do wish to donate blood, 1 to 2 units can be stored and used at the time of surgery if necessary.
Lymph Node Dissection
When prostate cancer spreads, or metastasizes, it often does so into lymph nodes in the area of the prostate. For this reason, the lymph nodes close to the prostate may be removed to check for spreading. The lymph nodes may be removed through an incision or, on occasion, using laparoscopy.
As mentioned, lymph node dissection is not necessary for all patients. Only those at moderate or high risk of lymph node metastases need undergo the procedure.
At the time of radical prostatectomy, the entire prostate gland and seminal vesicles are removed. The seminal vesicles are glandular structures lying next to the prostate that may be invaded by prostate cancer. Once the prostate gland and seminal vesicles are removed, the bladder is reattached to the urethra. A catheter is left in the bladder to allow drainage of urine while healing takes place. In addition, a drain – a tube that drains fluid accumulations – is left in place for one or two days.
Nerve-Sparing Radical Prostatectomy
The nerves and blood vessels, called neurovascular bundles, that allow the penis to become erect run on either side of the prostate. These bundles may be spared during radical prostatectomy, thereby preserving complete sexual function in some men. Either one or both bundles can be spared. The best results are achieved if both bundles can be spared.
Young men who are sexually active and report having very good erections are most likely to benefit from preservation of the bundles. Older men and men who report limited erections are less likely to benefit.
In some cases, preservation of the bundle may not be advised due to the location or extent of the cancer. As the nerves run very close to the prostate, preservation of the bundles in some men may risk leaving cancer behind. The risks and benefits of nerve-sparing surgery should be discussed with your doctor.
Whereas urinary continence tends to return early after surgery, sexual function returns more gradually in those who have undergone nerve-sparing radical prostatectomy. Return of erections may be facilitated by early use of sildenifil (Viagra) or penile injection therapy. You should discuss these and other options with your doctor.
Recovery After Surgery
Eating and Drinking
After surgery, you will be hospitalized for approximately two to three days. You will begin to drink fluids shortly after the procedure and will be allowed to eat solid food thereafter.
Drains and Dressings
You will have a dressing covering your abdominal incision. The doctors and nurses will check your dressing frequently for drainage. Once the dressing is removed, the doctors and nurses will be checking the incision to see how it is healing. The drains will usually be removed in one to two days. You will be sent home with a catheter draining urine from your bladder into a bag. It is normal for the urine to look bloody for several days after surgery.
The skin incision is closed with absorbable sutures, so there is no need to return to the doctor for removal of clips or sutures. The catheter will be removed in your doctor's office or at the hospital approximately five to 14 days after you are discharged from the hospital.
It is normal to experience pain at the site of the incision after surgery. Immediately after surgery, patients are usually given either epidural morphine – morphine that is given continuously through a small catheter that is inserted during surgery into the spinal canal – or continuous-infusion intravenous morphine that the patient controls. Both methods of pain relief work extremely well in patients with pain after the operation.
Pain may also be minimized by administration of anti-inflammatory medication, called ketorolac, which may decrease pain considerably and diminish the need for either epidural or continuous-infusion morphine.
Before you are discharged, you will be given an oral pain medication. You also will be given a supply of these to take at home as needed. Make sure to inform your doctors of any allergies you may have to narcotics, such as codeine and morphine.
Except for the epidural or intravenous morphine, which is given continuously for the first couple of days, pain medications are usually given on an as-needed basis, so be sure to ask your nurse to medicate you if you are in pain. Do not wait for the pain to become severe before asking for something to relieve it. If you feel you are not getting adequate pain relief, please feel free to discuss this with your nurse or doctor. Each person's experience of pain is different, and although we may not be able to completely eliminate all of your discomfort, we want you to be as comfortable as possible after your surgery.
Initially, your nurse will assist you with a daily sponge or bed bath. Showers are permitted after the dressings have been removed, usually within two or three days. You should let the water run over the incision rather than scrubbing it initially. Pat the incision dry.
The incision was closed with absorbable sutures and "steri-strips." These strips will begin to peel off in seven to 10 days. If they have not peeled off, you may remove them after 10 days.
Ask your nurse or doctor when you can bathe again.
Aiding Your Recovery
In order to prevent complications, such as pneumonia and blood clots, you will be encouraged to do three things as soon as possible after surgery:
- Use your incentive spirometer, a small disposable device that encourages deep breathing
- Do your leg exercises
The nurses will instruct you on how to use the spirometer and do leg exercises, and will assist you in walking after surgery until you can manage on your own. You also may be given support stockings to wear until you are discharged from the hospital.
Diet and Exercise
It is normal to feel tired for several weeks after your surgery. Make sure someone drives you home from the hospital. Get plenty of rest, eat a well-balanced diet with plenty of protein and iron, and do some light exercise, such as walking, every day.
Do not do any heavy lifting – anything more than 10 to 20 pounds – or strenuous exercise for three weeks following surgery.
You can increase your exercise schedule gradually thereafter. Light exercises such as walking, jogging and stretching should be done initially. Golf or tennis can be played within two to three weeks. If you feel comfortable, you can increase your activity. Heavy abdominal exercise such as sit-ups as well as cycling on an upright bicycle should be avoided for six weeks.
Driving is usually permitted after the catheter is removed, if you feel comfortable.
It is important that you do exercise that feels comfortable. Any activity that causes pain should be avoided.
Caring for Your Incision
The incision runs from above the base of the pubic area to below the navel. It is important to keep it clean and dry. Showering once a day should be sufficient. If you notice extreme or increasing tenderness, progressive swelling, more than a small amount of drainage (a teaspoon) or any pus or redness, notify your doctor right away.
Going Home With a Catheter
You will be discharged from the hospital with a catheter in place to drain urine from your bladder into a bag. The doctor will remove this in the office in five to 14 days. Be sure to clean the catheter where it exits your penis twice a day with soap and water and to empty the bag frequently. The bag should always be positioned lower than your bladder.
On occasion, the catheter may irritate the bladder, causing bladder spasms that can be quite uncomfortable. If these occur, your doctor can prescribe medication that can help. Leakage of urine around where the catheter exits the penis also may occur and can be managed by wearing incontinence pads as described in the next section.
It is normal for your urine to look cloudy for a few weeks after surgery. Occasionally, bleeding may occur around the catheter or be noticed within the urine. This also is common. If you see large clots – more than an inch in length – or if the catheter becomes plugged, contact your doctor. No anesthesia is required for catheter removal, and most patients experience only a little discomfort.
After your bladder catheter is removed, you may have leakage of urine, called incontinence. Initially, the leakage may be significant, such as leaking all the time. Your doctor will teach you exercises to strengthen your bladder muscles.
In addition, you can buy incontinence pads, such as Attend or Depends, to protect your clothing and waterproof underpads to protect bedding at your local pharmacy. These can be obtained without a prescription and are available in a variety of sizes and absorbencies. Please bring one or two pads to your doctor's office on the day your catheter is to be removed.
Your ability to maintain bladder control should improve significantly with time. Normally, continence returns in three phases:
- Phase I: You are dry when lying down.
- Phase II: You are dry when walking.
- Phase III: You are dry when you rise from a seated position, cough or exercise.
Most patients regain very good control by three months. However, it may take more time for some patients. If adequate urinary control does not return by six months, consult your doctor.
If you believe that the force or diameter of your urinary stream is slow or narrow, or if you have any difficulty or pain on urinating, notify your doctor immediately. On occasion, scarring may cause blockage to the normal flow of urine. Most often, this can be treated easily by dilating the urethra. This is a brief procedure that can be done using local anesthesia in an outpatient setting.
If you have any incontinence, your skin may become irritated depending on the amount of urinary leakage. You may need to protect your skin with a barrier such as Desitin or A&D ointment. If you develop a rash, notify your doctor.
Constipation is a common side effect of pain medications. While you are taking them, increase your fluid intake and drink at least eight glasses of water a day, take stool softeners and eat lots of roughage, such as whole grains, fruit and vegetables. Use laxatives only as a last resort.
Being Sexually Active
Some men find it difficult to have an erection after radical prostatectomy. The nerves and blood vessels, called neurovascular bundles, that control erection are located on either side of the prostate. Sometimes one or both of these nerves and vessels can be preserved during surgery, called nerve-sparing radical prostatectomy, thereby maintaining the ability to have a normal erection. However, depending on your age, your preoperative ability to obtain and maintain an erection, and the extent of the cancer, natural erections may not return.
In some cases, the neurovascular bundles need to be removed because cancer may extend close to them. Therefore, complete cancer excision may not be possible without removing them.
Please feel free to discuss any concerns with your doctor, who will provide information about alternative ways to manage impotence such as sildenafil (Viagra), penile injections, vacuum pumps and, rarely, penile implants.
Since the prostate has been removed, there will be no semen released. Whether or not you are able to obtain an erection, you should still be able to have an orgasm with stimulation to the penis. An excellent booklet titled Sexuality & Cancer: For the Man Who Has Cancer, and His Partner is available from the American Cancer Society free of charge. Please call your local chapter for a copy.
It is important to realize that one can continue to be sexually active despite even extensive prostate cancer treatment. Be open-minded, seek treatment for impotence if it occurs and realize that sexual gratification can be achieved for you and your partner in many ways.
Swelling of the penis and scrotum occurs commonly after radical prostatectomy. This is temporary and should resolve within four to seven days. Swelling of the feet or legs is uncommon and your doctor should be notified if this occurs.
The Pathology Report
Once the prostate gland and lymph nodes are removed, a pathologist will preserve and examine these tissues under a microscope to detect the extent of the cancer. The prostate gland is coated with ink to allow the pathologist to determine how close any cancer comes to the edge of the prostate.
There are at least three important features in the pathology report:
- GradeCancer grade refers to how malignant cancer cells look through the microscope. Most often grades are assessed using the Gleason grading system, named after the pathologist who developed it. Gleason grade is a numerical value given to prostate cancers that quantitates tumor grade. Grades are assigned to the most common pattern of cancer as well as the second most common. Grades for each pattern range from 1 to 5. A grade of 1 denotes a cancer that closely resembles benign or normal tissue. A grade of 5 is assigned to cancers that appear aggressive and differ significantly from benign tissue.
Two grades are given: a primary and secondary grade. When added together, a total sum or Gleason sum is obtained. This sum can range from 2 to 10, with 2 through 6 representing low-grade cancers and 7 through 10 representing high-grade cancers.
Cancers with both primary and secondary grades of 1 to 3 (sums of 2 to 6) tend to have a better outcome, lower chance of recurrence, compared to cancers of higher grades. Cancers with grades of 4 and 5 (sum of 7 to 10), tend to have a higher chance of recurrence. A word of caution about Gleason sum 7 cancers (3/4 or 4/3): Gleason grade 3/4 cancers are associated with a lower risk of recurrence than grade 4/3 cancers.
- StageCancer stage is a measure that defines the extent of a tumor. T2 cancers are those completely confined to the prostate. T3 cancers are those that have gone beyond the prostate, either through the capsule of the prostate, T3a, or into the seminal vesicles, T3b. T4 cancers are very rare and include those which have invaded nearby organs such as the bladder. Patients with T3 cancers are at an increased risk of cancer recurrence compared to those with T2 cancers.
- Margin StatusThe goal of surgery is to remove all the cancer. A positive margin means that the pathologist notices that cancer cells are at the very edge of the prostate, touching the ink that was applied during initial processing of the prostate gland. The pathologist will note the number and location of any positive margins.
Patients with positive surgical margins are at an increased risk of cancer recurrence. Patients with more than one positive margin are more likely to have cancer recur compared to those with a single positive margin. Patients with an extensive positive margin – where large area where the cancer is in contact with the edge of the prostate – are more likely to have a recurrence of their cancer compared to those with a very small area, or focal positive margins, where the cancer just touches the edge.
It is important to note that most patients with positive margins are cured. Depending on the number and extent of margins, your doctor may recommend radiation after your operation to decrease the risk of recurrence.
Usually, patients don't need any additional treatment after a radical prostatectomy. You and your doctor will make a decision on the need for additional treatment based on the pathology report and your PSA level after surgery. Your PSA should drop to undetectable levels after surgery. Patients with cancer in the lymph nodes, T3 cancers, high-grade cancers and positive margins are at an increased risk of recurrence and should discuss the type and timing of any additional treatment with their doctors.
On occasion, radiation, hormonal therapy or any one of a number of new agents being evaluated in clinical trials may be given if the cancer removed was extensive or recurs in the future.
All patients should have regular check-ups including PSA blood tests, and in selected cases imaging tests such as a bone scan, CT or MRI scan.
Follow-Up With Your Doctor
You will see your doctor initially to be sure that your recovery and return of urinary continence is occurring normally. For those who are sexually active and have not regained potency, your doctor will discuss various options for management.
The frequency of doctor visits and serum PSA tests will be determined based on the risk of cancer recurrence. Most often, serum PSA is obtained at four- to six-month intervals for the first three years. Serum PSA is measured less frequently thereafter.
Communication and Support
The diagnosis and treatment of prostate cancer evoke strong emotions in patients and their loved ones. It is important that you share your concerns, fears and frustrations with your doctor and those around you. Good communication is important to recovery. Visit UCSF's Cancer Resource Center for helpful information on a wide range of topics. You may find participation in a support group very helpful. Information on support groups including ones close to you can be obtained from the Cancer Resource Center.