Surgical treatment for prostate cancer involves removing the entire prostate and seminal vesicles, a procedure called radical prostatectomy (RP). When the cancer is confined within the tissues, surgery alone can cure localized prostate cancer.
What to Expect During Radical Prostatectomy
Surgery is followed by an average hospital stay one to two days and an average time away from work of two to six weeks. Patients are given an opportunity to donate their own blood before surgery, which can then be given back to you during the operation, if needed. (Less than five percent of patients require blood transfusion during or after radical prostatectomy.) Doctors will insert a catheter through the penis and into the bladder at the time of surgery. The catheter stays in place for six to 14 days and allows the bladder anastamosis (attachment to the urethra) to heal.
Patients undergo one of two types of radical prostatectomies:
Radical Retropubic Prostatectomy (RRP)
In the retropubic operation, the surgeon makes a skin incision in the lower abdomen. In some cases, surgeons perform a lymph node dissection (PLND) prior to removing the prostate. The lymph node dissection is a staging procedure to more accurately determine if prostate cancer has spread to the lymph nodes.
Following the PLND, the prostate is removed from both the bladder and the urethra. With the prostate removed, the bladder is sewn to the urethra. Then, physicians place a catheter through the penis, which remains in place while the tissues heal, and remote it in the clinic 10 days later. An RRP typically takes one and a half to two and a half hours to perform.
Robotic Assisted Laparoscopic Radical Prostatectomy (LRP)
LRP is a minimally-invasive technique used to remove the prostate. The surgeon performs the procedure through five 1-cm incisions spread in a fan shape across the abdomen. Surgical fields are viewed using a laparoscope, a camera inserted through one of the incisions.
At Virginia Mason, surgeons performing LRP use a robotic surgical assist device called "The da Vinci® Surgical Robot.” This robotic system employs the latest advancements in surgical robots.
Virginia Mason Hospital was the first hospital in the Northwest to obtain the da Vinci® robot in 2001. Since then, our team routinely performs a variety of surgical procedures including LRP.
Patients considering surgical treatment for their prostate cancer have common concerns: cure, recovery, urinary continence and sexual function.
While the LRP is as effective in treating patients with prostate cancer as open surgery, patients who undergo an LRP can expect a quicker return to daily activities, less surgical scarring, and less postoperative pain when compared to traditional open surgery. Patients undergoing LRP can expect a hospital stay of 24 to 48 hours.
Return of urinary continence and sexual function following LRP has shown excellent results (see below).
Operative times are two and a half to three and a half hours.
While not all patients with prostate cancer are a candidate for the laparoscopic approach, most are and should discuss this with their surgeon.
Virginia Mason Pain Management Service helps patients manage their pain after operations. We expect that the post-operative period will be relatively comfortable. Usually, we insert an epidural catheter or intravenous patient-controlled anesthetic device (PCA) first 24 hours after surgery. Following that period, we determine the best medication for each patient based on their level of pain.
Side Effects of Radical Prostatectomy
Risks associated with all radical prostatectomies are similar to those of any major surgery. The level of risk depends in large part on the patient's overall health and age. Rare risks include cardiac or pulmonary events, blood clots or injuries to structures surrounding the prostate. The primary side effects unique to a radical prostatectomy are incontinence and impotence
Following surgery, significant bladder control returns within 11 weeks and continues to improve over 12 months. Four percent of patients have persistent, severe post-operative incontinence. Mild stress incontinence, passing a small amount of urine when coughing, laughing or sneezing, may persist in four percent of patients.
Of patients who undergo a prostatectomy at Virginia Mason, 92 percent have excellent urinary control.
Sexual Function After Radical Prostatectomy
Prostate cancer and the treatment of prostate cancer can have significant impact on sexual function. At diagnosis, we assess voiding and sexual function based upon baseline sexual function, patient age, risk factors and disease stage. We provide counseling to the patient and his partner about anticipated changes in sexual function and try to predict the likelihood of preserving and recovering sexual function after prostate cancer treatment.
Some patients will be eligible for a nerve-sparing operation, preserving the nerves on one side of the prostate. Men who have "normal" pre-operative function (International Index of Erectile Function Score of >20) have a 72 percent likelihood of having erections that are adequate for penetration following a bilateral nerve-sparing operation. Twenty-five percent of these patients do require Viagra® in order to obtain their maximal level of potency. If a unilateral nerve-sparing procedure is performed, 38 percent of men will have erections that are adequate for sexual activity. Fewer than 10 percent of men who undergo a non-nerve-sparing procedure have erections that are adequate for penetration.
In our experience, men who are younger than age 60 and those who have the highest levels of pre-operative sexual function have the best outcomes in terms of potency. Men who have less aggressive tumors also have a better outcome in terms of potency.
Sural Nerve Graft
At Virginia Mason, we perform a new technique for preserving sexual function in situations where a patient needs either unilateral or bilateral nerve resection.
This technique involves the transplanting a short section of the sural nerve from the ankle to the space previously occupied by the prostate's neurovascular bundle. The transplanted sural nerve functions as a scaffold through which the cavernosal nerve (a main nerve of the penis) re-grows. The procedure adds about 45 minutes to the typical operative time of a standard nerve-sparing RP. Additional side effects include numbness along the side of the foot and discomfort from the healing wound on the outside of the ankle.
At Virginia Mason, over 50 percent of men undergoing a unilateral sural nerve graft have post-operative erections that are adequate for penetration.
Several studies have shown that even with bilateral nerve-sparing surgery, it often takes months to restore sexual function. Our team can speed up that process by:
- Employing a careful surgical technique minimizing nerve damage
- Providing a comprehensive preoperative counseling program for the patient and his partner, addressing postoperative concerns and minimizing the psychological impacts of surgery
- Providing early, pharmacologic erections with various medications
Successfully recovering erectile function is highly dependent on the patient and his partner's education about treatment-related sexual problems. Open sexual communication between partners is essential. Other issues, such as loss of sexual desire, difficulty reaching orgasm, ejaculatory problems or sexual pain also should be addressed.