Radical Prostatectomy

Removing the whole prostate gland along with its appendages (seminal vesicles and vas) is described as radical prostatectomy. After the removal, the bladder neck is joined with the urethra (urine pipe). This operation can be performed using open , laparoscopic or by robotic technique. The principles of the operation are the same irrespective of the technique. This includes

  • Good cancer clearance
  • Functional preservation esp regards continence
  • Neurovascular bundle preservation / clearance depending upon cancer clearance as priority
  • No damage / least damage to other tissues

Open method involves a long cut in the lower part of the abdomen. Laparoscopy involves putting 5-6 holes in the abdomen to do the operation. Robot assisted laparoscopy is similar to laparoscopic method, but the surgery is performed through a robot interface. Surgical robot is special equipment which helps surgeons in performing precise abdominal operation using minimally invasive technique, but overcomes the limitations of standard laparoscopy. In a standard laparoscopy, the vision is 2D in nature and the instruments are limited in its movements. The robot uses a 3D vision and the instruments are articulate (capable of moving like a hand and in fact can move and rotate more than a hand and yet very small in nature). Hence operating in the prostate area, which otherwise is difficult, is overcome using a surgical robot. The differences between the techniques are mainly on the recovery time and blood transfusion rates. Patients who had robot assisted surgery recover faster from the operation are back to home and work in less time compare to open method. However, at 3 months all the three methods have similar results. As regards cancer outcomes, robot assisted surgery cancer outcomes are similar to open method, if not slightly superior.

What to expect when a patient come for
Radical prostatectomy?

Patients who are deemed fit for radical prostatectomy, is usually admitted a day before the operation. The preparation including shaving the area of operation, receiving an enema and fasting for 6 hours. Patients will reach the operation theatre with TED stockings and flowtron boots.

After operation, they will usually have a catheter and a drain tube. The patients are started on feeding 4-6 hrs after operation. They are ambulated and given normal diet on the same day. They are discharged in a day or two. Catheter is removed usually after 14 days ( or sometimes earlier or later depending on the situation). Subsequently they need to do pelvic floor exercise to recover their continence. They may also get medications or vacuum pump for recovery of the sexual function. Further cancer care depends on the final histology and 3 months post operative PSA test.

Even though radical prostatectomy is now established as a safe operation, it is important to understand that it is a major operation. Complications of this operation includes bleeding, infection, injury to rectum (may require colostomy for short while), lymph or urine leak. Most of the issues are managed conservatively and extremely rarely requires another operation. After radical prostatectomy incontinence is usually noticed. All the patients will require wearing pads at least for the initial few days to weeks. On an average, the recovery happens in 2-6 weeks time. Incontinence, objectively, is measured by the no of pads used. To start with patients use 3-4 pads/ day. This reduces to one protective pad/ day in a few weeks. From that point to becoming completely pad free, depends on patients confidence, ability to practice pelvic floor exercise and patients motivation. Vast majority of patients will become pad free at some stage. Rarely, incontinence requires another surgery.

Impotence is inevitable with this operation. However with a combination of nerve sparing operation along with PDE 5 inhibitors and vacuum pump a reasonable number of patients will recovery erectile function. Even then ejaculation will be dry. Further treatment after radical prostatectomy depends on various factors including

  • Pathology – Gleason grade, margin status , node status
  • 3 months PSA result
  • Any future increase in PSA values