Radical Prostatectomy – 2003

Commentary from an Experienced Urologist
Stanley A. Brosman, M.D., Pacific Urology Institute
Reprinted from PCRI Insights February 2003 vol. 6, no. 1

HISTORY
As shown in Table 1 (below), prostatectomies have been performed for more than a century. In 1891, in Tucson, Arizona, a frontier doctor named George Goodfellow performed the first known prostatectomy, using the perineal approach. Although he worked for many years in Los Angeles, he traveled the country, teaching this operation to many surgeons including the new chief of urology at Johns Hopkins, Hugh Young. Young modified the procedure to treat prostate cancer, and he published the first paper on the subject in 1904. It was not until 1947 that an English surgeon, Terrence Millin, reported on the retropubic approach, which became the predominant technique used to surgically remove the prostate in an effort to eradicate this disease.

Prior to 1982, only 7% of men diagnosed with prostate cancer were considered to be candidates for surgery, and only a fraction of these men could be cured with surgery. The surgery was dangerous because of the large blood loss and the high risk of incontinence. Impotence almost always accompanied this procedure. Then, in 1982, Patrick Walsh, also from Johns Hopkins, described the anatomic, nerve-sparing technique for performing radical prostatectomy.

Dr. Walsh was able to demonstrate that the nerves responsible for erection could be preserved and that potency could be retained. Dr. Walsh’s other contributions to the surgical technique involved the ability to preserve continence and decrease blood loss. His anatomic surgical technique, which is now practiced worldwide, enables the sphincter to be saved so that incontinence has been greatly reduced and major blood loss is rare. The radical retropubic prostatectomy is a technically demanding procedure for the surgeon and a great deal of experience is necessary to perform the surgery safely, to maximize its effectiveness and limit the risk of complications.

However, prior to the 1990’s, the ability to diagnose cancer that was confined to the prostate was extremely limited. More than 75% of men diagnosed with prostate cancer already had the disease growing beyond the prostate and many of these men already had metastatic cancer. The PSA blood test was introduced in 1986, but it was not widely used until the early 1990s. For the first time, it became possible to diagnose men whose cancer was confined to the prostate. The introduction of transrectal ultrasonography accompanied by transrectal needle biopsy in 1988 provided the opportunity for urologists to diagnose and identify men whose prostate cancer could be treated surgically. These diagnostic procedures revolutionized early detection of prostate cancer, and by 2001, 65-85% of men who presented with PC were found to have the cancer still confined to the prostate gland.

In 2002 there were approximately 195,000 men diagnosed with prostate cancer. Radical prostatectomy was performed on 55,000. Nearly 30% of all men found to have prostate cancer are selecting radical prostatectomy as the procedure of choice. In order to help men decide which form of therapy is most appropriate for them and to help them understand what is involved in the surgical procedure, this article will review this subject.

    Table 1. History of RP
    1891  George Goodfellow, Perineal Prostatectomy
    1904  Hugh Young, Perineal Prostatectomy (first paper published)
    1947  Terence Millin, Radical Retropubic Prostatectomy
    1982  7% had surgery. Walsh introduces nerve-sparing RP
    1986  PSA introduced
    1988  Ultrasound-guided biopsies begun
    1995  35% diagnosed had RP
    1998  Laparoscopic Prostatectomy introduced
    2001  65%-85% present with localized cancer. 55,000 RPs performed

Surgical Technique
Until recently there were just two techniques utilized in the surgical removal of the prostate:
1. The retropubic approach
2. The perineal approach.

The most common is the retropubic approach in which an incision is made in the lower abdomen. The incision is usually made up and down extending from the navel down toward the base of the penis. An alternative is an incision that extends transversely across the lower abdomen. There are no muscles cut with either of these incisions. Refer to Figures 1 and 2.

Figure 1: Overhead View of the Prostate Area. In this view of the prostate, the locations of various structures are depicted in relation to the prostate. The base of the prostate is closest to the bladder while the apex is furthest from the bladder. Note the position of the neurovascular bundles on each side of the prostate. They contain the nerves responsible for erections.

Figure 2: Side View of the Prostate Area. This view shows the closeness of the prostate to the rectum. The entire urethra contained within the prostate is removed together with the seminal vesicles.

The top of the bladder is exposed and emptied by placing a catheter through the urethra. The lymph nodes on the side walls of the prostate and those closest to the prostate are examined for signs of cancer and often removed. The top and sides of the prostate are cleaned of fat that covers this area. There is a large group of veins known as the ‘dorsal venous complex’ that lies over the top of the prostate and extends down the sides. These veins must be separated and tied to obtain full exposure of the prostate.

In those patients who qualify, and most men do qualify, the nerves that control erections are carefully separated from each side of the prostate.

The apex of the prostate is detached from the urethra by opening the urethra, removing the catheter and cutting across the entire urethra. There is no real capsule at the apex of the prostate. In order to remove all prostate and cancer tissue in this area as well as preserve the nerve bundles that go alongside the prostate and urethra, a delicate dissection is necessary. Occasionally, the surgeon may want to make a biopsy and have the pathologist perform a frozen section to determine if there is any cancer involving the urethra or the neurovascular bundle. If so, additional urethra area and the affected bundle would be removed with the prostate. The external sphincter, which is necessary to preserve bladder control, is not disturbed.

When this portion of the operation is completed, the prostate is lifted up and separated from the rectum. At the base of the prostate are two structures known as the seminal vesicles. They manufacture and store seminal fluid and are removed together with the prostate. Because this is one of the early locations of cancer spread, they are also removed. The bladder neck is opened, and the prostate is dissected away from the muscular wall of the bladder. The entire portion of the urethra extending from the apex of the prostate to the bladder neck is removed with the prostate and seminal vesicles. The bladder neck is reconfigured so that its size matches the open end of the urethra. A new catheter is inserted into the urethra and placed into the bladder. The urethra and bladder are sewn together. This catheter will remain in place 2-3 weeks.

With the perineal approach, an incision is made through the skin between the anus and scrotum. The bottom of the prostate sits on the top of the rectum. These two structures must be carefully separated. This is a delicate part of the operation and occasionally (about 5% of the time) the rectal wall tears and must be closed. If this occurs, the surgeon may decide to stop the operation. but this decision is based on many factors, such as the size and location of the rectal opening. Assuming that there is no rectal injury, the procedure is performed in a manner similar to the retropubic approach. The ‘nerves’ are preserved and the new bladder neck and urethra are sewn together after the prostate and the seminal vesicles are removed.

One of the differences between the perineal and retropubic approaches is that the lymph nodes in the pelvis cannot be examined or removed in the perineal approach. They are located too high in the pelvis to visualize. This is not necessarily a major drawback. Because there has been better selection of patients for surgery, the presence of lymph node metastases has become quite unusual. In my practice, we have found that less than three percent of men in the low to moderate risk categories had metastases in their pelvic lymph nodes. Many urologists are no longer removing these lymph nodes. In the past five years, I have not had a single patient in these risk categories who has had a lymph node metastasis.

In 1998, a new technique using laparoscopic surgery to remove the prostate was introduced in Paris by surgeons Bertrand Guillonneau and Guy Vallancieu of the Institut Montrouris. As shown in Figure 3, the surgeon makes five small incisions in the lower abdomen to introduce a camera and instruments used to perform the surgery. The surgeon thereby has a magnified view of the surgery on a television monitor. The procedure is essentially the same as the retropubic surgical technique. Pelvic lymph nodes can be removed, the neurovascular bundles preserved (their size is greatly enhanced on the monitor), and the bladder neck sewn to the urethra usually with a watertight closure. This surgical technique is becoming more common in the United States and offers the promise of shorter hospital stays (one center is discharging most of their patients the same day as the surgery), a rapid recovery, and a shorter duration of time that the catheter needs to be worn. Moreover, because of the enhanced magnification, the procedure is associated with less blood loss and a better opportunity to preserve the neurovascular bundles.

Figure 3: Laparoscopic Prostatectomy. Five small incisions allow the introduction of the special working instruments and a video camera. The surgeons view the procedure on a monitor. A robot may be attached to the camera and can be controlled by voice commands from the surgeon. A different type of robot can be connected to all of the instruments and controlled by the surgeon at a computer keyboard and monitor. (Reprinted with permission of Krongrad Urology.)

By using special robotic devices which are connected to some or all of the instruments including the camera, the surgeon can manipulate the robot using voice commands. There is one type of robot with which the surgeon is stationed at a computer keyboard and delivers commands while watching on a monitor. The surgeon does not necessarily have to be in the operating room. I watched a demonstration in which the surgeon was in Florida doing a procedure on a patient who was in an operating room in Germany.

How does the surgeon decide which surgical method to use? This is largely based on the training and experience of the surgeon. Most surgeons are only trained to do the retropubic approach. As a result, more than 90% of all the surgeries have been done using this technique. Currently, more and more surgeons are learning the laparoscopic procedure, and in the next 5-10 years when the medical field has determined and published long-term results in the areas of PC recurrence, nerve-sparing capabilities, and side effects such as incontinence, this is likely to become the dominant form of surgery.

This evolution of radical prostatectomy procedures has produced such improved safety that the operative mortality is less than 0.1%. As shown in the results from 1,860 of my patients who had their surgery in the last 25 years (Table 2), intraoperative complications such as anesthetic problems and bleeding (when more than three units of blood are transfused) occurred in less than 10% of the patients; in the past eight years this has decreased to less than 3%. Postoperative complications such as infection, bleeding and malfunctioning catheters in the first 30 days after surgery occurred in less than 1% of these patients. The hospital stay averaged 2.8 days. Urethral strictures (scars that form at the site where the urethra and bladder neck are sewn together) occurred in 7.5% of these patients although none have occurred in the last five years. Strictures are corrected by stretching or incising the scar.

    Table 2. RP Results in 2002 (n= 1860)
    •  Surgical mortality: 0.1%
    •  Intraoperative complications: 9.7% (>3 units of blood)
    •  Post-op complications (first 30 days): 0.8%
    •  Hospital Stay: 2.8 days
    •  Stricture: 7.5%

What You Can Now Expect If You Have an RP

Planning for Surgery
Once you have decided to proceed with surgery, there are preparations to be made. You need to get yourself in good condition both mentally and physically. Having a strong positive attitude that you have made the right decision and are supported by your family will help you to be in the best mental condition. It is never too late to start an exercise program or begin a good nutritional program. Usually there will be several weeks before surgery, so there is time to initiate these programs. It is helpful to stop smoking and reduce alcohol intake. You should plan for a recovery period of a month before returning to work although you will resume many of your other activities within a shorter period of time. The better condition you are in prior to surgery, the more rapid will be your recovery.

Some surgeons will ask you to donate several units of your own blood to be available should a transfusion be needed. Others recommend the use of blood from the American Red Cross. Family members may donate blood if they match your blood type.

Several days prior to surgery, your surgeon may request blood tests, an EKG and a chest X-ray. Your internist is likely to want to examine you as well. It is usually helpful to have your bowels cleaned out before surgery. You don’t want to have to worry about having to have a bowel movement during the first few days after surgery.

You will be asked to avoid having anything to eat or drink for 6-8 hours prior to the scheduled time of the surgery. If you are taking any medications, check with your physician as to whether or not they should be taken the day of surgery. Any medications, herbal supplements or anything else that might interfere with blood clotting should be stopped 10-14 days prior to surgery.

The day before surgery, the anesthesiologist will call and ask about your health, any allergies you might have, the medications you are taking, and any previous experience with anesthesia. You will have a general anesthetic, but some surgeons and anesthesiologists also prefer an epidural anesthetic, which is administered through the back and provides good pain control after the surgery.

What to Expect During the Hospitalization
You should arrive at the hospital two hours before surgery. The nurse who checks you in will ask what type of procedure you are having and request that you sign a consent form giving the surgeon permission to perform the specific surgery. An intravenous solution of salt water will be started in your arm and an antibiotic may be given. If all of the previously requested blood tests have not been obtained, new tests may be ordered.

The anesthesiologist will talk to you again about the type of anesthesia. This is the time to ask any last minute questions. Intravenous sedation will probably be given and you will be moved to the operating room. The time you are scheduled for surgery is actually the time that the anesthesiologist begins to work. The actual surgery may not begin for a half hour after that.

You will recognize your surgeon who will be wearing a mask and meet the assistant surgeon. Shortly thereafter, you will be sound asleep. When you wake up about 2-3 hours later, you will be in the recovery room. You will have an intravenous line in your arm, a catheter in your bladder, a drain tube exiting from the side of the incision to carry away excess serum and fluids which collect from the area of the surgery, and special wrappings on your legs to prevent blood clots. You will remain in the recovery room for 1 to 2 hours before being transferred to your room. This is when you can visit with your family.

Later the same day or the next day you will probably be able to start drinking small amounts of fluids. You will also be helped out of bed and can start walking. Although it doesn’t seem possible, you are not likely to experience much pain. In fact, many patients report that they experience a sense of exhilaration that the surgery is over and they feel so good. Pain control is provided by giving a long acting narcotic through the epidural catheter or by allowing the patient to administer his own pain medication intravenously using a system known as Patient Controlled Anesthesia. As soon as your stomach is comfortably accepting fluids, the intravenous fluids are discontinued. On the average, patients are ready to leave the hospital 2.8 days after the surgery. The drain tube is usually removed prior to discharge. The catheter that was placed during surgery goes home with you. It is connected to a bag that can be strapped to your leg. Also, you will be provided with a large bag that can hold several quarts of urine and is particularly useful for use during the night. You will be given prescriptions for pain medicine and antibiotics prior to your discharge.

At Home
You can expect to feel tired and to sleep a lot but each day your physical activity should be increased. There is no need to spend large amounts of time in bed. if they have not already been removed prior to discharge from the hospital, the skin staples/sutures will be removed 5-7 days following surgery. This will probably be done in the urologist’s o office. During this visit you can review the pathology report and look at the Kattan postoperative nomogram. The urologist will give you an idea as to what to expect in terms of future outcome and discuss the need for any additional therapy.

The catheter will remain anywhere from a week to three weeks. It is important that the connection between the urethra and the bladder be well healed before the catheter is removed so that urine does not leak out and cause scarring.

You can resume your regular diet but should avoid foods that are likely to produce gas. One of the most common problems people experience is ‘gas pains’. It takes a while before the intestines resume normal function and it is wise to progress slowly.

You can shower at any time. Soap and water does not hurt the wound. Any activity that would require straining, including bowel movements, should be avoided until the incision is solidly healed.

Following removal of the catheter, you can expect to leak urine. Usually an absorbent pad placed inside jockey underwear will be sufficient, and they are easy to change. Most men notice that they are drier at night when lying down. Bladder control improves in the morning when the muscles are fresh and tends to get worse as the day goes on and the muscles get weaker. It often takes several months before bladder control is good enough to give up the pads although many men still wear one when they go out – just in case. There are several effective aids to countering incontinence. Consult your physician to learn the alternatives.

About a month after surgery, many urologists prescribe Viagra to help prime the system. Although it is unlikely that you will begin experiencing natural erections at this time, you may be able to speed up the process with this “priming” effort. There are several different methods of assisting erections. Consult your physician to learn the alternatives.

From this point on, it is just a matter of time before all of the systems have stabilized. You are likely to recognize differences in bladder and bowel function for months.

Everyone is eager to know their PSA level, but in the first month this is done more to satisfy curiosity rather than to make any decisions about therapy. Your physician will probably schedule your first post-operative PSA test about 2-4 weeks after your surgery.

Conclusion
We are at a point in managing prostate cancer where we can give better advice to patients regarding the ability of surgery to eliminate the cancer and estimate the chances of incontinence and impotency. Our goal is to eradicate the cancer with a minimum of adverse effects so that every man can maintain a high quality of life. Although surgery offers many benefits, it is not for every man. It is incumbent for each man and his doctor to work together in order to select the most appropriate therapy.

References:
• Walsh PC, Lepor H: The role of radical prostatectomy in the management of prostate cancer. Cancer 60:526, 1987.
• Iversen P, Madsen PO, Corle DK: Radical prostatectomy versus expectant treatment for early carcinoma of the prostate: twenty-three year follow-up of a prospective randomized study. Scand J Urol Nephrol Suppl. 172:65, 1995.
• Gerber GS, Thisted RA, Scardino PT, et al: Results of radical prostatectomy in men with clinically localized prostate cancer. JAMA 276:615, 1996.
• Stanford JL, Feng Z, Hamilton AS et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer. JAMA 283:354, 2000.
• Siegel T, Moul JL, Spevak M, et al: The development of erectile dysfunction in men treated for prostate cancer, J Urol 165:430, 2001.
• Steinech G, Helgesen F, Adolfsson J, et al: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 347:790, 2002.
• Holmberg L, Bill-Axelsen A, Helgesen F, et al: A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 347:781, 2002.
• Lepor H, Nieder AM, Ferrandino MN:. Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol. 166:1729, 2001.
• Bacon CG, Giovannuci E, Testa M, Kawachi I: The impact of cancer treatment on quality of life outcomes for patients with localized prostate cancer. J Urol. 166: 1804, 2001.

 

Prostate Cancer Research Institute (PCRI)

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