Laparoscopic radical prostatectomy
A radical prostatectomy ia an operation performed to treat cancer of the prostate gland. It is most suited for otherwise healthy, younger men (generally those under 70) whose cancer appears not to have spread to either lymphnodes or bone.
A recent randomised controlled trial showed a significant improvement in mean survival in patients treated by radical prostatectomy compared to those managed by watching and waiting and a 50% reduction in the development of metastases (Bill-Axelson A, Holmberg L et al., New Engl J Med 2005:352:1977-84.
Laparoscopic surgery minimises the trauma required to remove the prostate and associated tissues, includes the skin and muscles. Studies have also shown that the complication rate is much lower for keyhole surgery as compared to standard open surgery (see below).
Whilst the laparoscopic approach to prostatectomy has attracted great interest since its introduction in 2000 there are only a few urologists in the UK who offer this technique. BLA have performed over 100 sucessfull laparoscopic prostatectomies.
Laparoscopic prostatectomy combines all the advantages of a retropubic approach with the addition of much more improved vision for the surgeon. As a result there is little blood loss (transfusion is now a thing of the past), there is no need for an epidural and its inherent risks, hospital discharge is usually within 2 days, catheterisation time and recovery are also reduced. The surgery is performed through five tiny incisions in the lower abdomen. Its only disadvantage is that it takes longer to perform and is technically demanding.
- The laparoscopic technique causes the least discomfort. The stage (extent) of the cancer can be better determined.
- If confined to the prostate and the gland is removed, surgery should be curative.
- Prostate-specific antigen (PSA) blood test should fall to zero within 4 weeks of surgery and remain undetectable.
- If the cancer recurs, a PSA rise will detect this before symptoms occur.
- Surgery corrects any obstruction to the flow of urine from the bladder
Leakage of urine can occur on coughing, sneezing, laughing and usually occurs following removal of the catheter. This is known as ‘stress’ incontinence and is managed by wearing pads. It arises because the urethra (pipe that you urinate through) and bladder are stitched together. This causes bruising, swelling and impaired function of the sphincter. The younger and fitter the patient, the faster continence returns. Exercises to strengthen the pelvic floor help. Continence rates differ between surgeons. Good continence rates would be 70% of patients pad-free at 3 months after surgery, 85% after 6 months and >95% after 12 months. For the 2-5% of patients not pad-free at 12 months we may think about offering an artificial sphincter.
Ask your surgeon what is their audited rate of incontinence - they should know it.
Risk of impotence
Most surgeons advise against preserving the neurovascular (nerve & blood vessel) bundles which travel on either side of the prostate. It is these nerves which are responsible for spontaneous erections). They argue that if the man is not already impotent and is over 70 years impotence is impending. There is also an oncological argument about not bothering to preserve the nerves as the nerves are one of the first direct roots for escaping cancer cells.
We however offer nerve-preserving prostatectomy in all men who are potent preoperatively. Again, the younger and fitter the patient, the faster the erections return. This process may take over a year in some patients. Postoperative potency (erection) rates differ amongst surgeons. Good potency rates would be 50% of patients, at 12 months after surgery. Ask you surgeon what are their audited results!
We will discuss erectile dysfunction treatments with you before your surgery.
All patients with prostate confined cancer, a PSA of 15ng/ml or less and a Gleason score of 8 or less are suitable for nerve preserving laparoscopic radical prostatectomy. Patients with a PSA of over 10ng/ml need a CT and MRI scan. Patients who are in poor general health, are very overweight or have existing cardiovascular or breathing problems may be better suited to other forms of treatment.
Patients who have had previous prostate surgery, such as a TURP, or who have troublesome urinary symptoms, such as a poor urine stream, are often best suited for this form of treatment.
Patients are given written instructions on pelvic floor exercises and advised to start them before surgery. Routine blood, urine and ECG tests are done in the week before surgery. The nurses will teach you breathing and leg exercises (helps prevent chest infections and blood clots).
Surgery, depending on the degree of difficulty will in general take 2-3 hours. A telescopic instrument called a laparoscope is inserted into the abdomen through a small incision at the belly button. A camera attached to the laparoscope allows surgeons to view inside the abdomen and perform the surgery without having to make a large incision. Usually 3 more small incisions are made in the abdomen to accommodate surgical instruments. The aim of the surgery is to remove the prostate, the seminal vesicles and regional lymph nodes whilst preserving the neurovascular bundles responsible for potency. The bladder neck and urethra are then sutured together over a catheter and a drain inserted. The prostate gland is then removed in a bag through a small incision. When you wake from the anaesthetic you should expect some discomfort. This can be easily controlled, using the drugs you will be offered. You will be given oxygen via some nasal specs overnight. Once you are fully awake and comfortable you will be transferred back to the ward.
We allow our patients to eat and drink on the first day and provided all is well go home with their catheter after 2-3 days. The sutures are all dissolvable.
We than readmit our patients 10 days later for catheter removal. An appointment for this will be sent to you in the post if it has not been made before you leave the ward. A urine sample will be taken from the catheter prior to its removal and some patients may be started on antibiotics after its removal. It is not uncommon for men to experience some leakage when the catheter is removed. If necessary continence pads will be provided. We will tell you how to get further supplies once you get home. You will be taught pelvic floor exercises to help control this leakage. Patients are allowed home once it is established that they can pass urine. Only about 1% of patients develop urinary retention (cannot pass urine) and need to have their catheter reinserted for another 10 days or so.
Common postoperative side-effects include constipation, blood in the urine and short term incontinence.
As with any surgery other complications can arise. These include bleeding, chest, urinary and wound infections. Others include blood clots forming in the legs (we will fit you up with anti embolism stockings and administer drugs to thin the blood before your surgery). Sometimes it becomes necessary to convert to an open operation (less than 10%).
Do not be afraid to experiment with erections, but remember that it can take up to 2 years for erections to fully return. The old maxim "use it or loose it" really does apply. Whilst the sensation of orgasm will still be enjoyable you will not ejaculate and will be sterile, so contraception is unnecessary.
Remember also that if erections do not return naturally, all men can be made potent somehow.
Take it easy and build up your strength gradually over four to six weeks. Start with short walks and gentle exercise until you are fully back to normal.
Try to eat a healthy diet with plenty of fluids, fresh fruit and vegetables. These are important to keep your bowels regular as this operation can make your bowels “lazy” for a few days.
Avoid heavy lifting, strenuous exercise and heavy housework during this period.
Once you feel that you are back to normal it is safe to do house hold tasks and to drive. If you work it depends on how you feel and the type of job that you do, but four weeks convalescence is recommended.
If you have any problems following your discharge from hospital you can contact your GP for advice. A letter will be given for your GP when you leave the ward. A district nurse will be asked to visit you at home to check that your stomach wounds are healing.
Expect to return to most activities 4 weeks after laparoscopic and 12 weeks after open surgery. You are safe to drive as soon as you can safely perform an emergency stop. Check with your insurance company.
Pelvic floor exercises
- To do these effectively, relax your abdominal and buttock muscles.
- To identify and correctly contract the pelvic floor muscles, imagine that you are trying to hold back bowel movements.
- During this action, you should feel the opening of the rectum contract.
- Tighten the muscles for 3-5 seconds and then relax for 6-10 seconds. Repeat this sequence 20-25 times.
- Do the set of 20-25 contractions 3-4 times daily.
Remember, the only important factor influencing the result of your radical prostatectomy which you can change is your surgeon. Choose him or her with care.
The alternatives are conventional open surgery or radiotherapy. No data is available to show that one option is better than the other. There is no reliable data available as yet to suggest whether surgery or radiotherapy improve survival.