The goals of prostate cancer surgery are to remove all the cancer, maintain the best possible urinary function, and have no negative impact on sexual function. Removal of the prostate, a procedure called radical prostatectomy, is one of the main treatments for prostate cancer. It is impossible to know however whether a small amount of cancer escaped the prostate, so surgery is not a guaranteed cure.
There are several approaches to radical prostatectomy prostate cancer surgery.
In open radical retropubic surgery, the surgeon makes an incision below the navel down to the pubic bone. The prostate is removed by cutting into the urethra and the part of the bladder surrounded by the prostate. In order to avoid any damage to nerves in the area—and thus help preserve sexual function and urinary control–your doctor will use nerve-sparing techniques. If necessary, the doctor will also remove lymph nodes. The hospital stay after this prostate cancer surgery procedure is two to three days, and you will be sent home with a urinary catheter in place for one to two weeks.
A radical perineal prostatectomy, which is used less often than the open retropubic procedure, involves removing the entire prostate through a half-moon incision made between the anus and scrotum. The upside of this approach is that usually causes less bleeding, but it carries a greater risk of rectal injury, and surgeons generally are not able to remove nearby lymph nodes unless they make another incision. Nerve sparing can be done, but it is more difficult and less successful than in open radical retropubic, minimally invasive laparoscopic, and robot-assisted surgery. The post-surgery hospital stay is one to two days, and again, you will be sent home with a catheter that will stay in place for up to two weeks.
Whereas the retropubic and perineal prostatectomies require a large incision and a long recovery period, minimally invasive laparoscopic surgery involves five tiny incisions, often resulting in less pain and scarring after surgery, a faster recovery, and less risk of infection. In fact, most men stay in the hospital only one night and then have to keep a catheter for only 5 to 7 days.
During this prostate cancer surgery, carbon dioxide is injected into the abdominal cavity through a small tube, which lifts the abdominal wall and allows the surgeon a better view of the abdominal cavity. The surgeon is then guided by the laparoscope, which sends a picture of the prostate onto a video monitor and gives surgeons a sharper view of the prostate and surrounding tissues. The prostate is removed through one of the tiny incisions near the navel. Nerve sparing and lymph node removal can also be done.
The newest type of minimally invasive prostatectomy is robot-assisted laparoscopic prostatectomy, which was first introduced in 1999. This advanced technique is sometimes referred to as the da Vinci technique (trade name da Vinci Surgical System) because Leonardo da Vinci is credited with making the first robot. Robotic-assisted radical prostatectomy was named as “the most widely used form of prostate cancer surgery treatment of localized [but not advanced, metastasized prostate cancer] in the country” in a recent study. (Menon 2010)
Since robotic-assisted prostatectomy was introduced, it has rapidly become “the” radical prostatectomy procedure because it offers the benefits of regular laparoscopic prostatectomy (e.g., faster recovery time, less blood loss, less pain, etc.) plus some important improvements that include:
- Advanced optics that give surgeons better magnification and three-dimensional images of the prostate and surrounding nerves and tissues
- Use of robotic arms that eliminate even the slightest hand tremors by the surgeon
- Instruments that give surgeons superior ability to maneuver using robotic “wrists” that can rotate 540 degrees
One downside of robotic-assisted prostatectomy is the fact that it is relatively new, and therefore there are no long-term study results such as are available for the other types of prostatectomy procedures. A new study published in October 2010 in European Urology, however, was one of the first to report on survival outcomes for the robotic procedure. The authors noted that the five-year recurrence-free survival rate was 86.6 percent, meaning that only 13.4 percent of men showed PSA levels greater than or equal to 0.2 ng/mL within five years of surgery. (Menon 2010) This is comparable to the five-year recurrence-free survival associated with open prostatectomy.
Men who are considering prostate surgery should discuss this option with their physicians. Robotic-assisted prostatectomy is not yet available everywhere, as the equipment and its maintenance costs are extremely high. As a result, the procedure is also more expensive than other radical prostatectomy procedures, and men need to check if their insurance plans cover robotic-assisted prostatectomy.
Nerve-sparing is a technique a surgeon may use while performing a radical prostatectomy. It involves cutting to the edges of the prostate, making every effort to spare the erectile nerves that run alongside the prostate. The nerve-sparing technique offers men the best chance of preserving long-term erectile function.
Surgeons do not know until they have started the radical prostatectomy whether they can spare the nerves, because it depends on whether the cancer has invaded the nerves. If the nerves cannot be spared, the surgeon may be able to surgically attach or graft nerves from other parts of the body.
If you and your doctor decide you need a prostatectomy, look for a surgeon who is familiar with the procedure. A study published in the Journal of the National Cancer Institute states that prostate cancer patients who are treated by highly experienced surgeons are much more likely to be free of cancer five years post surgery than patients who undergo surgery with less experienced surgeons. Finding a highly seasoned surgeon could be a challenge, however: 25 percent of American surgeons who perform radical prostatectomy do only one per year, and 80 percent perform ten or less. (Vickers 2007)