Radical Prostatectomy

Radical prostatectomy is the surgical removal of the entire prostate gland and, in some cases removal of pelvic lymph nodes. The goal is complete removal of all prostate cancer. Radical prostatectomy is an excellent curative therapy for many men with prostate cancer including those with high risk disease. Compared to radiotherapy the chance of cure is thought to be higher and in addition there are several other advantages such as: the most complete knowledge of prognosis gained from examination of the removed prostate and lymph nodes and early achievement of an interpretable PSA (by three months) which allows early diagnosis of disease recurrence and early delivery of salvage therapy. There is avoidance of side effects from rectal irradiation and androgen deprivation therapy (which is often a component of radiotherapy). Urinary side effects from surgery are usually temporary and sexual function can be preserved in many men.


Procedure

Surgery takes 2 hours and is performed under a general anaesthetic through a 12cm lower abdominal incision. During surgery our aim is complete cancer removal in conjunction with preservation of the urethral sphincter controlling urinary continence and in appropriate cases preservation of the nerves responsible for penile erection. Once the prostate gland is removed the bladder is reconnected to the urethra. Blood loss is usually around 500mL. The risk of a blood transfusion in my hands is <4%. When you wake from the anaesthetic there will be a catheter in the penis draining urine into a bag, two thin rectus sheath catheters in the wound for regular administration of local anaesthetic to reduce pain and in some cases also a wound drain. The skin wound is closed with sutures 'under the skin' and is sealed with skin glue. Patients will be able to eat dinner on the evening of surgery & walk about the ward on day 1. Blood thinners and calf compressors are used to reduce the risk of blood clots forming within veins. Hospital stay is usually two to three nights. The rectus sheath catheters and wound drain are removed before discharge home & the urinary catheter is removed the following week in my office. The catheter is held in place by a 3cm inflatable balloon on the catheter tip so it cannot fall out with normal activity. You will be shown how to care for the catheter before discharge. Urinary continence improves rapidly following removal of the catheter and is usually back to normal within 3 months.

Pre-procedure

Blood thinners such as aspirin, clopidogrel, warfarin and dabigatran need to be ceased prior to surgery. We will advise you when to stop and re-start these medications.

Bowel preparation the day prior to surgery. This empties the bowel which improves the safety of surgery & reduces the risk of post-operative constipation.

Post-procedure

Once you go home you should take the prescribed analgesia regularly and aim to perform light exercise such as walking each day. You can shower and get the wound wet - it is sealed with waterproof glue. There will be some blood and mucus which passes ALONGSIDE the catheter and is particularly noticeable after passing a bowel motion - this is normal. There may also be some blood mixed in with the urine and this is most noticeable in the morning. Keeping a high fluid intake is important as it will reduce the risk of catheter blockage. You may occasionally feel a strong desire to pass urine - this is usually due to bladder spasm from irritation of the inside of the bladder by the catheter and responds well to oxybutynin which is a tablet taken to reduce  bladder spasm. There will be some swelling and bruising around the wound, the penis and the scrotum which takes several weeks to resolve. You may notice two 1cm firm lumps,in the middle of and at one end of the wound - these are normal and are simply the knots in the suture material used to close the muscles. The suture slowly dissolves and will disappear within 3 months.

Return to work

Most men are able to return to a sedentary job at 3-4 weeks. Heavy activity should be avoided for 6 weeks to prevent damage to the healing abdominal wound.

Recovery of urinary control

During prostatectomy, the sphincter muscle surrounding the urethra which controls continence is carefully separated from the prostate gland before being reattached to the bladder. This causes temporary sphincter muscle weakness. Consequently, after catheter removal there will be involuntary urine leakage requiring the use of pads. Recovery of continence is variable, most men are pad free with good control by 2 months. Recovery of continence is faster in younger, slim fit men and slower in older men, overweight men, men who have had previous prostate gland radiotherapy and in cases where wide resection of the prostate is performed in order to remove cancer that may have penetrated the capsule of the prostate gland. Continence will continue to improve out to 12 months post-operatively. Focused pelvic floor physiotherapy may be recommended & if required then I will refer you to a specialist physiotherapist for this.  Ultimately, over 95% of men recover good continence. If there is persistent leakage beyond 12 months then consideration needs to be given to surgically correcting this. Most men suffering from post-prostatectomy incontinence will have permanent resolution of incontinence with placement of a sub-urethral sling. This 45 minute operation involves placing a mesh sling underneath the urethra to elevate and support it. For rare cases of severe  leakage then implantation of an artificial urinary sphincter may be required.

Recovery of sexual function

Surgery to remove the prostate gland interferes with sexual function and reproductive ability- principally the ability to get and maintain an erection and always the permanent loss of ejaculation fluid. There may be penile shortening of 1cm or more, this is likely if nerves have been intentionally resected. It is however possible to have an orgasm without erection.

During surgery we usually aim to preserve the fine nerves which control penile erection. These nerves run over the surface of the prostate gland as they pass to the blood vessels within the penis. These nerves are easily bruised and damaged during surgical removal. The likelihood of recovery of satisfactory function depends upon several factors: pre-operative sexual function, age, necessity for resection of the nerves and surgical experience and expertise in nerve preservation. Younger men with normal pre-existing erectile function who are suitable for nerve preservation and who have surgery by a surgeon experienced in nerve preservation are likely to recover reasonable function. There may be a 12 month period of relatively poor function before recovery occurs. I recommend early 'penile rehabilitation' for men wishing to resume sexual activity. This comprises regular induction of or enhancement of erections through oral or injectable drug therapy. Our clinic nurse will be able to instruct you in these techniques.

Follow up

Following catheter removal I will contact you by telephone once the surgical pathology report is issued. This report gives us information about cancer prognosis and if there are adverse pathologic features then we may discuss the possible benefit of further treatment such as post-operative radiotherapy. You will have a PSA level checked 3 months following surgery and then we meet for a review. From this point, the requirement for ongoing review depends upon your recovery or need for further therapies. For men who have made a smooth recovery follow up from this point is with their GP only. PSA tests are continued six monthly for three years then annually. The PSA level should alway remain 'undetectable'  - which means that the laboratory cannot detect any PSA in your blood. The laboratory expresses this on the report in this way: PSA <0.05ng/mL. If the PSA becomes 'detectable' (>0.05ng/mL) then this indicates residual prostate cancer and we will need to meet again to plan further imaging and management.

Other Risks

Risks recognised as common or serious are listed below but this does not include the rare and extraordinary.

  • Bleeding requiring transfusion <4%
  • Rectal injury - very rare - 1/500
  • Urethral or bladder neck stricture 5%
  • Urinary infection - uncommon but usually easily treated