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.
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I perform on average 6-8 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 1,000 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.
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 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 9 days. Most patients can drive after 10 days and resume normal activities such as playing golf by 3 weeks.
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. |
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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.
Comparison with open radical prostatectomy
The British Association of Urological Surgeon’s Section of Oncology statistics for 2006 showed that although the average operating time for open surgery was 19 minutes less than for my 222 cases, their blood loss was 2x greater and hospitalization was 1.2x greater.
Robotic surgery
‘What is chiefly needed is skill rather than machinery.’
Wilbur Wright, 1902.
Some explanation is necessary regarding robotic surgery. Firstly, a surgical robot is not a robot at all since it does nothing automatically, but a link between the surgeon and the instruments inside the patient – the surgeon still needs to do the operation. Secondly, and following on from this, the outcome of the operation depends much more on the expertise and experience of the surgeon than it does on what equipment is used. Although performing a large number of prostatectomies a year does not guarantee good results it is not possible to obtain the best results without a high caseload.
Although the manufacturers of surgical robots have marketed them aggressively and have been keen to emphasise the benefits of 3D vision, motion-scaling and tremor-filtering, these are advantages only to surgeons inexperienced in minimal access (keyhole) surgery. Having performed robotic, laparoscopic and open prostatectomy in over 1,000 men I remain concerned about the reduced control the surgeon has during robotic surgery as he/she is not present at the operating table, and also about the tendency to use a smaller range of instruments during robotic surgery because of the relative difficulty and greater time needed to change them. An example of this is the tendency to perform the nerve dissection using cautery, which would never be acceptable during open or laparoscopic surgery because of the potential for thermal nerve damage.
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Robotic dissection using cautery |
Laparoscopic surgery without cautery |
For these reasons I believe that best laparoscopic prostatectomy is the best method available today for performing prostatectomy and is likely to remain so for some time to come.
This view is shared by almost all urologists experienced in laparoscopic prostatectomy, including the USA's Arnon Krongrad (www.laprp.com) and Australia's Charles Chabert (www.laparoscopicurology.org).
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
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.
