Prostate Cancer Surgery
Unlike surgery for BPH, which removes only the prostate tissue that is pressing on the urethra, radical prostatectomy removes the entire gland, along with the seminal vesicles and some surrounding tissue. It is the only treatment for localized prostate cancer (cancer confined to the prostate) that has been proven to reduce deaths from the disease when compared with no treatment.
Radical prostatectomy offers the possibility of a cure only if the cancer has not spread to the lymph nodes in the pelvis or to other parts of the body. As a result, when the risk of spread is high, some surgeons perform a laparoscopic lymph node biopsy before the planned prostatectomy; others sample the lymph nodes at the time of surgery and discontinue the operation if the cancer has spread. Because PSA testing is widespread, it is uncommon to find cancer that has spread to the lymph nodes at the time of diagnosis.
Radical prostatectomy was developed at Johns Hopkins at the beginning of the 20th century. The operation was not popular at first because of the high rate of ED and urinary incontinence associated with the procedure. But in the early 1980s, Johns Hopkins urologist Patrick Walsh, M.D., developed a new approach to the operation. He devised a "road map" that allows surgeons to remove the prostate with less risk of damaging the nerves and tissues that are essential for erections and urinary control. This anatomic approach has reduced the risk of severe incontinence to 1 to 3 percent and the risk of mild incontinence to around 10 percent.
The risk of ED varies according to a man's age, the quality of erections before surgery, and the surgeon's skill at performing the procedure. The majority of men who have good-quality erections before surgery and a skillfully performed operation have return of erectile function. Full recovery can take more than a year in some instances, however. When ED does occur after surgery, it usually can be treated successfully.
Nerve-sparing radical retropubic prostatectomy begins with a vertical incision in the abdomenfrom the pubic area to the navel. (Some surgeons make the incision in the perineum, which is located between the scrotum and rectum; this approach is called a perineal prostatectomy.) If appropriate, samples of tissue from the pelvic lymph nodes may be removed and tested for signs of cancer.
To minimize bleeding, which can obscure the surgeon's view and increase the risk of complications, the surgeon then cuts and ties off the group of veins that lie atop the prostate and urethra. Next, the surgeon severs the urethra, taking care to avoid the urethral sphincter muscles in order to preserve urinary continence.
At this point, the "nerve-sparing" aspect of the procedure comes into play. The tiny nerve bundles on either side of the prostate are required to produce an erection. These nerves are carefully dissected away from the prostate but are otherwise left intact (unless the cancer is suspected to have spread to these nerves, in which case they will be removed).
The surgeon then cuts through the bladder neck (the junction between the bladder and the prostate) to completely separate the prostate. Next, the surgeon removes some of the surrounding tissues, including the seminal vesicles and vas deferens (the main duct that carries semen). Finally, the bladder neck is narrowed with stitches and reconnected to the urethra.
A Foley catheter is inserted through the urethra to drain urine from the bladder. The catheter is left in place for about one week to allow the rebuilt urinary tract to heal.
Rare complications of radical prostatectomy at the time of surgery include damage to the rectum or ureter (the tube carrying urine to the bladder from the kidneys) and the surgical and anesthetic risks that accompany any operation. Postoperatively, narrowing of the urethra (urethral stricture) by scar formation can cause a decrease in the force of the urinary stream or cause urinary retention. This is most likely to occur between one and three months after surgery.
After radical prostatectomy, PSA testing is performed to evaluate the success of the surgery and to monitor for disease recurrence. An undetectable PSA level (usually less than 0.2 ng/mL) after radical prostatectomy indicates that all the prostate tissue (both benign and malignant) has been removed. A detectable PSA immediately after surgery means that the tumor had already spread to other tissues before the surgery and thus could not be totally removed. A subsequent rise in PSA levels indicates that residual cancer that could not be removed at the time of surgery has grown to an extent that PSA production can be detected in the blood.
It usually is not possible to know whether the cancer is in the area of the prostate or at another site because the microscopic residual disease causing the elevated PSA cannot be seen with conventional radiographic imaging techniques. For men with cancer confined to the prostate (stage T1 or T2) before treatment, the chance of a detectable PSA level indicating residual cancer 10 years after treatment is around 30 percent. A detectable PSA (biochemical recurrence) indicates the presence of residual prostate cancer months to years before the cancer would be visible on a CT or bone scan.
For men with a biochemical recurrence, a recent study from Johns Hopkins demonstrates that the risk of dying of prostate cancer can be reduced by radiation therapy administered at the time of detectable PSA (salvage radiation therapy). Hormone therapy would be considered for men with a biochemical recurrence, especially if the PSA doubling time is less than one year (indicating a rapidly growing cancer). On the other hand, a rising PSA more than two years after surgery in a man who showed no invasion of the seminal vesicles or lymph nodes at the time of surgery suggests that residual cancer is localized to the pelvis and that radiation therapy will more likely eradicate the disease.
Researchers at Johns Hopkins have studied the outcomes of men who had a detectable PSA after surgery. They monitored the course of nearly 2,000 patients whose cancer was confined to the prostate and who underwent radical prostatectomy performed by the same surgeon.
Among the 304 men who had detectable PSA levels in the years following surgery, the five-year disease-free survival rate following the first detectable PSA level was 63 percent. Metastatic cancer (cancer that has spread to other parts of the body) was not apparent in these men for an average of eight years and in those with metastatic disease, death from cancer occurred on average 13 years after PSA became detectable.
These results should reassure men who experience rising PSA levels following surgery. At the same time, they serve as a reminder that continued monitoring is essential after surgery.
Some surgeons are using laparoscopy rather than open surgery to perform radical prostatectomy. Laparoscopy involves performing a procedure through small incisions in the abdomen using special instruments and a tiny camera. There appear to be few advantages of laparoscopy over open surgery.
A variation on the laparoscopic procedure is robotic-assisted laparoscopic radical prostatectomy, using the da Vinci robotic system. In this approach, the surgeon performs the surgery by manipulating robotic arms with attached cutting and suturing tools. The procedure appears to have the same complication rate and operative time as open prostatectomy, with a slightly shorter time in the hospital: one or two versus three days.
A major problem with laparoscopic prostatectomy, including the robotic variation, is the lack of studies showing whether it works as well as standard open surgery at eradicating all of the cancer. A study in the Journal of Clinical Oncology found that when compared with open surgery, men who underwent laparoscopic surgery had a threefold greater risk of later needing an additional prostate cancer treatment.
It's possible that recurrence rates might be higher for laparoscopic surgery because surgeons are unable to touch and feel the tissue, which helps ensure that all of the prostate tissue has been removed. Another problem is cost: Laparoscopic procedures take longer to perform than standard ones, and the da Vinci system is extremely expensive to purchase and use. Robotic prostatectomy is being performed at Johns Hopkins and continues to be evaluated.