Metro Urology

WHAT IS A RADICAL PROSTATECTOMY? WHAT MAKES IT RADICAL?

A radical prostatectomy removes a prostate for the purpose of treating cancer that is believed to be confined to the prostate. The word radical refers to the removal of the entire prostate, and it is different than prostate operations that treat enlarged prostates without cancer. Typically the radical prostatectomy also removes some of the lymph nodes around the prostate.

The surgical treatment of prostate cancer has gone through an evolution in the past. Currently the approach to the radical prostatectomy is typically done through a small incision below the belly-button (Radical Retropubic Prostatectomy or RRP). In the past it was common to perform the procedure from an incision underneath the scrotum (Radical Perineal Prostatectomy or RPP), but this operation is performed less commonly now because of the advantages of using an incision in the abdomen. The RRP allows a surgeon to remove some of the lymph node tissue around the prostate to try to determine whether the cancer has spread. The abdominal approach also allows a surgeon to carefully dissect the nerves to the penis away from the prostate, increasing the chances that a man will have good erectile function after the operation. The RRP is continuing to evolve, and some physicians are experimenting with using very small incisions and a robot camera to remove the prostate (Robot-assisted Laparoscopic Prostatectomy), shortening recovery time.

Metro Urology Prostate Cancer Center currently has surgeon experts in the Radical Retropubic Prostatectomy and the Robot-assisted technique as well.

AM I A CANDIDATE FOR A RADICAL PROSTATECTOMY?

You are a candidate if your surgeon believes that your prostate cancer is confined to the prostate. Your doctor will help you determine this. Typically, men with PSA levels below ten, Gleason Scores below 8, and normal prostate exam on digital rectal exam will have organ-confined (in the prostate only) cancers, but many men who do not meet these criteria will benefit from this technique.

WHAT HAPPENS DURING THE RADICAL PROSTATECTOMY?

For the Radical Prostatectomy, a general anesthesia (fully unconscious with a breathing tube) is typically used, although some patients can have a spinal anesthesia (numb from the waist down). Your stomach below your belly-button will be sterilized and an incision will be made about 4-8 inches long in your lower stomach. The surgeon will examine the tissue around your prostate to insure that no cancer has spread, and the main lymph glands that drain from the prostate are removed and examined by the surgeon to make sure there is no gross evidence of cancer spread, the lymph glands are later examined by a pathologist to determine if any microscopic cancer is seen. If the surgeon feels that the cancer is confined to the prostate he will proceed with your surgery.

The prostate sits between the bladder and the penis, and the urethra (urine channel) runs through the middle of the prostate. The entire prostate and the Prostatic urethra are removed, to insure that all of the cancer is removed. The semen storing organs connected to the prostate (seminal vesicles) are also removed, as cancer can easily spread to those organs as well. All of the removed tissue is sent to the pathologist so that she can determine under the microscope the extent of the cancer within the prostate, as well as determine whether the cancer has started to spread.

Because part of the urethra is removed, the two free ends of the urethra must be sewn together, and a catheter must be worn for 10-14 days to allow the connection to heal. Sometimes this connection will leak for a short time, so a drain is placed in your stomach when your stomach is closed so the urine does not collect. When the prostate is removed, the urethra sewn together, and the catheter placed the surgeon the incsions is closed, the anesthesia is reversed, and you will be taken to the recovery room.

WHAT IS THE RECOVERY LIKE?

You will betaken the recovery room for only a short period and then you will go to a surgical ward for patients who have had surgery. The main elements of your 2-4 day hospital stay center around controlling your pain, getting you moving, slowly resuming food intake, teaching you how to care for yourself once you go home, and monitoring closely for complications that rarely occur. Once you are able to eat, walk, take care of the catheter in your penis, and have good pain control with pills you will be sent home.

Most men will take 4-6 weeks of work off after the surgery. At home you will slowly resume your normal activity. We recommend a short walk every day to prevent blood clots in the legs, eating small frequent meals, allowing plently of time for rest during the day and night. You will recover better and faster if you resume normal activities slowly. Because of a long recovery time, we recommend that you finish important projects (including paperwork) before surgery; you may not have the energy to do those things afterward.

Your catheter is usually removed 10-14 days after surgery. The removal of the catheter is not difficult, and can be done easily at home, but some (most) surgeons will have you return to the office for a follow-up appointment with a nurse or the surgeon to remove the catheter, skin staples, and see how you are doing.

It takes six weeks of recovery before you are cleared to begin lifting weight above 20 pounds. You can walk as much as you like after surgery. Stairs are ok but should be taken carefully.

I’VE HEARD THAT MEN BECOME INCONTINENT AND CANNOT CONTROL THEIR URINE AFTER THIS SURGERY.

Most men will have excellent control of their urine after this operation. It’s true that some men cannot control their urine after this operation, but this complication is uncommon. Some men wear a small pad in their underwear after the operation as “security”after the operation if they are going out in public to avoid any embarrassing spotting of clothes or underwear; most don’t need it, but feel that the will lose a little control if the cough or sneeze unexpectedly.

Not surprisingly, younger men (under 70) are more likely to have better urinary control after the operation, but the vast majority of older men can still have good urinary control after the operation. You will be instructed in pelvic floor exercises after the operation to help strengthen the sphincter muscle that controls your urine to help you regain urinary control.

I’VE HEARD THAT MEN CAN LOSE ERECTIONS AFTER THIS OPERATION

The nerves to the penis run along the backside of the prostate and can be injured during this operation. Most surgeons are able to spare these nerves by carefully dissecting them off of the prostate during the operation. Sometime, for the purposes of cancer, these nerves are not able to be spared. Nerve-sparing operations do not guarantee the a man will be able to get an erection after the surgery, but increases the chances significantly of spontaneous erections or getting erections with medications (Viagra, Levitra, Cialis).

Men who lose spontaneous erections can still get erections and maintain a healthy sex life. Metro Urology employs a Physician Assistant dedicated specifically for men with erectile dysfunction. Your surgeon will help you determine what other options are available to you.

IMPORTANT: Your prostate and seminal vesicles are responsible for making semen. After this operation you will have no fluid come out during orgasm (dry orgasm). You will still reach a satisfying climax and be able to please your partner.

WHAT ARE SOME OTHER POTENTIAL COMPLICATIONS?

Bleeding: As with any procedure, bleeding is a potential complication. Most men will have some blood loss that their body will replenish, but some rare men will have enough bleeding to require a blood transfusion.

Pain: The pain on the incision is usually easily controlled in the hospital with Intrvenous medications and at home with pain pills. Your surgeon will give you plenty of pain medicine to help you control your pain.

Infection: Most surgeons will keep you on an antibiotic during the time that you have a catheter in place to prevent infection. Some surgeons prefer not to give you an antibiotic unless an infection develops because of the potential for developing infection which resists antibiotics. Your surgeon will help you determine which approach is best for you.

Bladder Injury: The prostate is carefully dissected off of the bladder. The draining tubes (ureters) that connect to the bladder can be injured during the surgery. This is a rare complication, is usually recognized during the surgery, and is usually easily repaired during the operation.

Rectal Injury: the prostate rests on the front of the rectum, and the rectum can be injured when the prostate is removed. This complication is very rare.

Nerve injury: There is a nerve to the leg that can be injured during the removal of the lymph nodes. Injury to these nerves makes it difficult for you to bring your legs together. This is a rare injury.

HOW DO I KNOW IF I AM CURED?

The PSA test is usually the main factor in determing that the cancer is removed completely. PSA is made only by prostate tissue, normal and cancerous. Because the prostate and the cancer is removed completely, the PSA should be undetectable. A detectable PSA might indicate the cancer has returned. The PSA is followed very closely by your surgeon after the operation.