Laparoscopic Radical Prostatectomy » The Procedure

The operation

Radical prostatectomy involves removing the entire prostate and seminal vesicles and is considered by many urologists and oncologists to be the 'gold standard' as it allows complete removal of the tumour when organ-confined, as well as definitive staging. Additionally, it allows absolute confidence in interpreting the PSA level after treatment: a zero level confirms complete eradication of prostate cancer. In the small percentage (7%) of men in whom cancer recurs, it is detectable by a rise in the PSA level 3-5 years before it otherwise would cause symptoms, allowing radiotherapy to be administered. Patients who have failed any type of radiotherapy are rarely offered surgery because of tumour progression and the increased complication rate. Finally, surgery corrects obstruction to the drainage of urine from the bladder caused by enlargement of the prostate.

Step 1	Step 2

Step 3

I perform on average 6-8 robot-assisted or pure laparoscopic radical prostatectomies each week, have the largest experience of this procedure in the UK and have one of the largest series in the world (over 1,350 cases). I regularly operate on patients from all over the UK and have operated on patients from most continents. My results are comparable with any large series from the USA and are the best published from the UK.

Key-hole (laparoscopic) radical prostatectomy is much more comfortable for the patient, allows greater precision, virtually eliminates the risk of blood transfusion and has been my preferred technique since March 2000, when I last performed open radical prostatectomy. Several thousand cases have now been done worldwide, the results of which demonstrate that the laparoscopic surgery is at least as effective as the traditional operation (Guillonneau, 2000).

The operation usually takes 2-3 hours to perform. Patients are allowed to drink freely 6 hours after surgery and to eat after 12 hours. Patients are ready for discharge with their catheter in after 2-3 night in hospital are re-admitted for catheter removal after 13 days. Most patients can drive after 10 days and resume normal activities such as playing golf by 3 weeks.

 

Lymph node removal

Any cancer can spread to neighbouring lymph nodes (pea-sized structures belonging to the immune system, which filter cancer and infection out of fluid returning back into the circulation). Removal of these lymph nodes (lymphadenectomy) allows full staging of the cancer so that the probability of cure can be accurately calculated and also identification of those men whose survival can be increased by additional hormonal therapy (Messing, 2006).

In 2008 I pioneered the introduction of extended pelvic lymphadenectomy (ePLND) for prostate cancer as part of keyhole prostatectomy in the UK and have submitted the first European laparoscopic series for publication. I found in 121 patients that this technique increased the rate of detection of cancer in lymph nodes more than ten-fold in men with Gleason 7 or higher tumours and/or a PSA greater than 10 ng/ml. This is estimated to improve cancer survival in men with involved lymph nodes by 23% and in men with no evidence of lymph node involvement by 15% (Heidenreich, 2007). Although laparoscopic ePLND prolongs the operation by about 25 minutes it does not produce any long-term side-effects. As Gleason 7 is the second commonest Gleason grade diagnosed by prostate biopsy, and as 30-50% of Gleason 6 tumours turn out to be Gleason grade 7 at the final analysis, this suggests that treatment by brachytherapy, cryotherapy and HIFU (which does not include ePLND) is likely to under-treat a substantial number of men. ePLND is now a standard part of the treatment I offer these men.

 

Incontinence

Fit, young patients tend to be fully continent when the catheter is removed but this does not apply to the majority, in whom continence recovers during the weeks following surgery. The reason for 'stress' incontinence following radical prostatectomy is that the valve that normally ensures continence has sutures placed in it to attach it to the bladder. Until these sutures dissolve (at about 6 weeks) the valve tends to be tethered and prevented from moving through its normal range of movement.

By 3 months following surgery 75% of patients are fully continent, which increases to 85% by 6 months and 95% by 12 months. The 5% of patients who have not regained satisfactory urinary control by one year following surgery are offered insertion of a urethral sling, which entails another (smaller) operation with a very high success rate.

Impotence The nerves that allow spontaneous erections travel on either side of the prostate towards the base of the penis from the main nerve supply (pelvic plexus) at the back of the pelvis. Preservation of these nerves is performed in patients aged less than 70 years with normal erections and with low risk (of recurrence) prostate cancer i.e. a PSA less than 10 and a Gleason grade of 7 or less, in whom the nerves are found to be healthy during surgery. Nerve preservation is not advisable in higher risk patients because of the risk of involvement of the nerves by prostate cancer and in patients over 70 years because of poor potency rates. In this circumstance, spontaneous erections will not be present following surgery but can be induced using a drug inserted into the urethra as a rice-grain sized pellet of by an injection into the side of the penis. When nerves are preserved on both sides, 2/3 of my patients achieve erections strong enough for penetration either with or without tablets (Viagra, Levitra or Cialis) by 12 months and 1/3 need either a pellet, a vacuum device or an injection to achieve this. As with continence, there is a very strong correlation with age. It can take up to 2 ½ years following surgery for erections to reach their maximum strength.

Location of neurovascular bundle

Cure

Surgery is only offered to patients in whom there is an expectation of permanent cure, based on the pre-operative tests (PSA, Gleason grade and rectal examination). Patients with a PSA > 10 ng/ml will have a bone scan and body (MRI or CT) scan to exclude spread beyond the prostate to the bones and lymph glands, respectively. Ultrasound, MRI and CT scans are not accurate in assessing spread of the prostate cancer through the capsule of the prostate.

In up to 11% of patients the tumour will extend up to the cut edge of the prostate, producing a positive surgical margin. This is not surprising because 2/3 of prostate cancers arise in the outer part of the prostate. Although most patients with a positive surgical margin are cured, the risk of relapse requiring radiotherapy is slightly higher in this group. Patients are followed up with regular PSA blood tests every 3 months for the first year, 6 monthly for the next 4 years and then annually by their GP for another 5 years. This protocol is similar to that employed by most urologists experienced in laparoscopic prostatectomy, including the USA's Arnon Krongrad (www.laprp.com) and Australia's Charles Chabert (www.laparoscopicurology.org).

Comparison with open radical prostatectomy

The British Association of Urological Surgeon’s Section of Oncology statistics show that although the average operating time for open surgery is 19 minutes less than for keyhole prostatectomy blood loss is 2x greater and hospitalization is 1.2x greater.

Comparison with cryotherapy and HIFU

'...cryosurgical ablation of the prostate and high-intensity focused ultrasound have emerged as alternative therapeutic options in patients with clinically localized prostate cancer who are not suitable for surgery. Because there are only very few data on the long-term outcome in terms of cancer control, patients with a life expectancy > 10 yr should be informed accordingly.'
European Association of Urologists Guidelines on Prostate Cancer, 2008.

Comparison with observation and radiotherapy

'At an average follow-up of 13.3 years…our findings (in 1,618 patients) suggest that patients undergoing surgery for clinically localized prostate cancer may have a cancer specific survival advantage compared to those electing radiation or observation. However, only a randomized trial can control for the many known and unknown confounding factors that can affect long-term outcomes.'
Albertsen, 2007

Outcome comparison: surgery vs. radiotherapy
Outcome	Radical prostatectomy*	Radiation**
Survival duration compared to conservative disease management1	8.6 years	4.6 years
15-year prostate cancer survival rate2	92%	87%
Survival rate for high-grade cancer patients3	45% increase in overall survival rate vs. radiotherapy	-
Risk of cancer-specific death for high-grade cancer patients4	49% less risk vs. radiotherapy	-
Cancer recurrence5	Easy to detect	Difficult to detect
Risk of rectal cancer (Within 10 year follow-up)6	5.1 out of 1000	10.0 out of 1000
Risk of bladder cancer7	0.8% developed bladder cancer	1.3% developed bladder cancer
Bowel function impairment8	-	Significantly greater vs. surgery
Disease-specific long-term quality of life9	Stable	Unstable
Painful urination (at 18 month follow-up)10	1% of patients	30% of patients
Long-term erectile dysfunction11	Lower risk	Higher risk
* Open surgery; comparable long-term data not yet available on da Vinci® Prostatectomy. ** External Beam Radiation Therapy (EBRT) unless otherwise noted in the citation.

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References for chart:

[1] Tewari A, Raman JD, Chang P, Rao S, Divine G, Menon M. Long-term survival probability in men with clinically localized prostate cancer treated either conservatively or with definitive treatment (radiotherapy or radical prostatectomy). Urology. 2006 Dec;68(6):1268-74.
[2] Tewari A, Raman JD, Chang P, Rao S, Divine G, Menon M. Long-term survival probability in men with clinically localized prostate cancer treated either conservatively or with definitive treatment (radiotherapy or radical prostatectomy). Urology. 2006 Dec;68(6):1268-74.
[3] Tewari A, Divine G, Chang P, Shemtov MM, Milowsky M, Nanus D, Menon M. Long-term survival in men with high grade prostate cancer: a comparison between conservative treatment, radiation therapy and radical prostatectomy--a propensity scoring approach. J Urol. 2007 Mar;177(3):911-5. Erratum in: J Urol. 2007 May;177(5):1958.
[4] Tewari A, Divine G, Chang P, Shemtov MM, Milowsky M, Nanus D, Menon M. Long-term survival in men with high grade prostate cancer: a comparison between conservative treatment, radiation therapy and radical prostatectomy--a propensity scoring approach. J Urol. 2007 Mar;177(3):911-5. Erratum in: J Urol. 2007 May;177(5):1958.
[5] Di Blasio, C. J., A. C. Rhee, et al. (2003). Predicting clinical end points: treatment nomograms in prostate cancer. Semin Oncol 30(5): 567-86.
[6] Baxter NN, Tepper JE, Durham SB, Rothenberger DA, Virnig BA. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology. 2005 Apr;128(4):819-24.
[7] Boorjian S, Cowan JE, Konety BR, DuChane J, Tewari A, Carroll PR, Kane CJ; Cancer of the Prostate Strategic Urologic Research Endeavor Investigators. Bladder cancer incidence and risk factors in men with prostate cancer: results from Cancer of the Prostate Strategic Urologic Research Endeavor. J Urol. 2007 Mar;177(3):883-7; discussion 887-8.
[8] Litwin MS, Sadetsky N, Pasta DJ, Lubeck DP. Bowel function and bother after treatment for early stage prostate cancer: a longitudinal quality of life analysis from CaPSURE. J Urol. 2004 Aug;172(2):515-9.
[9] Miller, D. C., M. G. Sanda, et al. (2005). Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy. J Clin Oncol 23(12): 2772-80.
[10] Buron, C., B. Le Vu, et al. (2007). Brachytherapy versus prostatectomy in localized prostate cancer: Results of a French multicenter prospective medico-economic study. Int J Radiat Oncol Biol Phys 67(3): 812-22.
[11] Di Blasio, C. J., A. C. Rhee, et al. (2003). Predicting clinical end points: treatment nomograms in prostate cancer. Semin Oncol 30(5): 567-86.