Radical prostatectomy is one of many options for men with prostate cancer which still appears to be localized to the prostate. It allows, in most cases, for complete removal of the prostate cancer. Even where it may not remove all of the cancer, some doctors feel there is value to reducing the cancer load within the body.
Once the prostate is removed, your doctor should be able to determine how advanced the cancer is, what the risk for cancer recurrence is and whether or not 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 (prostate specific antigen) should fall to undetectable levels.
Radiation can be given after surgery, if necessary, with a very limited risk of any additional collateral damage, as it is likely that surgery will be the primary cause of any impotence or incontinence that the patient suffers. Patients who choose radical prostatectomy should be in very good health, have a life expectancy exceeding 10 years, have cancers that appear to be localized to the prostate gland and have discussed all available treatment options with their doctors.
What will happen before 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. In selected patients, a bone scan, and a CT or MRI scan of the abdomen and pelvis may be done. You will 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. This is done to cleanse the bowel and may consist of a clear liquid diet, medication to promote bowel movements, and/or an enema. This is routine preparation before many types of major abdominal surgery.
What type of anesthesia should I have and do I need to donate blood?
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 is a technique whereby the anesthesiologists give medication, which allows patients to be asleep or unconscious during the procedure.
The techniques may be combined. Although anesthesiologists advocate the use of either epidural or spinal anesthesia in addition to a general anesthetic to decrease intraoperative blood loss and improve post-operative pain management, others have advocated the use of general anesthesia with the use of ketrolac, 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 of blood can be stored and used at the time of surgery if necessary.
What happens during surgery?
Lymph node dissection
When prostate cancer spreads (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 tumor spread. The lymph nodes may be removed through an incision or, on occasion, using laparoscopy. As mentioned, lymph node dissection is not necessary in 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 which 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 (tube that drains fluid accumulations) is left in place for one or two days.
Nerve-sparing radical prostatectomy
The nerves and blood vessels (.neurovascular bundles.) which allow for 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 nervesparing surgery should be discussed with your doctor.