Surgery

What surgery can be done for prostate cancer?

Surgery for prostate cancer involves the complete removal of the prostate and some surrounding tissue–including the seminal vesicles, ejaculatory ducts, pelvic lymph nodes, and a small part of a urethra. This is called a radical prostatectomy.  After removal of the specimen the bladder is then connected back to the urethra that would normally sit below the prostate. This is the only type of surgery that is performed with the intent of curing prostate cancer. There are several different ways that the radical prostatectomy may be  performed—including an open prostatectomy (one larger midline incision) or minimally-invasive (laparoscopic or robotic) prostatectomy.

What is the evidence supporting surgery for prostate cancer?

Surgery is one of the ways that prostate cancer may be cured. Not all men are candidates for surgery, but there is good evidence that it is beneficial for those who are. There is also good evidence that surgery may be overtreatment for some men with low-risk disease, who are better served with surveillance. More information about which men should be treated with surgery is available on the Treatment page.

Much of our understanding about how surgery for prostate cancer may benefit patients comes from a long term Swedish study that evaluated the benefits of performing surgery compared to not performing surgery and waiting for the cancer to spread [1, 2]. This trial found that after following hundreds of patients for about 11 years, those who had surgery were 1/3 less likely to die of prostate cancer and have distant metastases than those who did not [2]. When only looking at men under 65 years of age, those who had surgery were 40% less likely to die from any cause,  50% less likely to die from prostate cancer, and 50% less likely to get distant metastases at about 11 years [2]. This trial suggests that performing surgery for prostate cancer is worthwhile, especially for men under 65 years of age. Patients enrolled in this trial were not low-risk patients–so these results are not applicable to patients we now consider active surveillance candidates.

A more recent study called the PIVOT trial looked at 731 men randomized to radical prostatectomy or observation (link). After a median of 10 years follow-up, men with low-risk prostate cancer (Gleason 6 disease, PSA under 10, and very limited or no disease palpable on rectal examination) did not seem to benefit from surgery. Men with higher-risk prostate cancer were not well represented in this study, but do seem like they would benefit from surgery. This trial provided a rationale for active surveillance for men with low-risk prostate cancer as well as suggested that surgery may be beneficial in men with higher-risk prostate cancer.

 

What is laparoscopic surgery?

Laparoscopic surgery is abdominal surgery performed with visualization via a small incision and a laparoscope and not directly through a larger incision. A laparoscope is a camera that is shaped like a rod. It is inserted through small keyhole –sized (1 cm or less) incision in the skin. To provide room to work with in the abdominal cavity, it is inflated with carbon dioxide. Additional small incisions are made to insert long rod-like instruments with which to perform the actual surgery. This laparoscopic technique is an alternative to the traditional technique of a larger central incision. In this traditional technique, the surgeon works under direct vision with no camera and there is no inflation of the abdomen with carbon dioxide.

What is robotic prostate surgery?

Robotic surgery usually refers to the use of a da Vinci® surgical robot to aid in the laparoscopic radical prostatectomy (robotically-assisted laparoscopic prostatectomy or RALP).  Intuitive Surgical, manufacturer of the da Vinci® robot estimates that 80% of radical prostatectomies in the US were robotic assisted in 2008 [3]. Canada has been more conservative in adopting robotic technology than the US. By 2010, only 9 da Vinci surgical robot systems have been installed in Canada in comparison to 916 in the United States in 221 in Europe [3].

The RALP surgical technique does not differ significantly from the laparoscopic technique.  The main difference is that instead of the surgeon operating the laparoscopic instruments directly, the robot operates the instruments and the surgeon operates the robot.  Marketed benefits of this system include improved visibility, maneuverability and ergonomic benefits compared to traditional laparoscopic surgery with a significant cost increase.

Interestingly enough, robots other than the da Vinci system may still be used to help in a plain “laparoscopic radical prostatectomy”—although to a lesser extent than a real “robotically-assisted laparoscopic prostatectomy”.  For example, Dr. Matsumoto does use the da Vinci® system when performing a RALP but also uses an AESOP ® surgical robot to assist in maneuvering the laparoscope even when not performing a RALP.

What is the difference between laparoscopic radical prostatectomy (LRP) and robotically-assisted laparoscopic prostatectomy (RALP)?

Both LRP and RALP are minimally-invasive approaches to radical prostatectomy. In a LRP, the AESOP surgical robot is utilized and most of the surgery is performed with laparoscopic instruments with the surgeon standing next to the patient. In a RALP, the da Vinci system is used and the surgeon uses a robotic console to operate the robot from a short distance. The primary reason RALP has become very popular relates to the challenging learning curve of the LRP procedure from a surgeon perspective.

From a patient perspective, there is no conclusive evidence that there is a difference. Specifically, there is no conclusive evidence that there are any differences in:

• cancer control
• postoperative pain
• erectile dysfunction
• urinary incontinence
• other surgical complications
• length of procedure or hospital stay

What the benefits of laparoscopic surgery compared to open prostatectomy?

In addition to a more cosmetically appealing outcome, a recent search of the published literature found 37 trials demonstrating that laparoscopic prostatectomy resulted in lower rates of blood loss, transfusion rates, catheterization time, hospitalization time and overall complications [5]. The rates of blood loss and requirement of a blood transfusion are sizably reduced with laparoscopic surgery—a recent study found a 2.7% rate of transfusion with a minimally invasive prostatectomy compared to 20.8% with open surgery  [6].

What actually happens during a laparoscopic radical prostatectomy?

The basic steps of the procedure involve:

1. Putting the patient to sleep.
2. Filling the patient’s belly up with air to stretch out the space that we will be working with.
3. Inserting several ports in the belly through small 5mm – 1 cm incisions. These allow for the camera and long working tools to be inserted.
4. Taking out some lymph nodes that may drain cancer cells from the prostate.
5. Carving out the prostate and seminal vesicles from the surrounding area. This leaves the bladder and urethra disconnected.
6. Removing the prostate, seminal vesicles and some surrounding tissue for pathological analysis under the microscope.
7. Rejoining the bladder and urethra. A tube (urinary catheter) is placed across this joint area to allow for it to heal.
8. Removing all the ports, instruments and camera. Another tube is placed in the belly that drains to a bulb outside the body. This drains fluid left over after the procedure for a couple of days.

A YouTube video animating the basic steps of the procedure may be found here. Note that this is a generic video to which we have no association. Dr. Matsumoto’s operative technique varies slightly from this video.

What are the most common complications of surgery?

In the long run, laparoscopic prostate surgery has 3 major common complications that all men should be aware of:

• Cancer recurrence

Cancer recurrence after surgery will depend on several factors including preoperative PSA, Gleason grade and final pathologic staging of the cancer. The following is a calculator that allows a patient to calculate their risk of cancer recurrence after surgery if they know these parameters: link.

• Erectile Dysfunction

Erectile dysfunction affects almost all men initially after having a laparoscopic radical prostatectomy. Men then regain erectile function over the first 6 months – 2 years. Return of erectile function will depend on preoperative erectile function and whether nerve sparing could be performed in the procedure. Several effective options exist to help men attain adequate sexual function after laparoscopic radical prostatectomy should they wish to.

• Incontinence

Most men regain continence within the first few months after the procedure. Incontinence after surgery is less common than erectile dysfunction and also depends on  nerve sparing and preoperative function. Several effective options also exist to help men regain continence after laparoscopic radical prostatectomy.

What other complications may occur?

Rabbani and colleagues have published some recent data on some of the additional complications of laparoscopic radical prostatectomy based on 1134 patients treated at their hospital [7]. The most common complications of surgery are listed below.

 

Time period	Medical complications	Surgical complications
Early (30 days from operation or less)	Urinary tract infection 6.0% Ileus 1.9% Deep vein thrombosis 1.1% Hypotension 0.5% Pulmonary embolism 0.4% Myocardial infarction/ischemia 0.3%	Urinoma/urine leak 7.4% Wound infection 3.5% Urinary retention 2.4% Urinoma/urine leak requiring intervention1.3% Lymphocele requiring intervention 1.1% Abscess requiring intervention 1.1%
Intermediate (30 to 90 days from the operation)	Urinary tract infection 1.4% Respiratory distress 0.2%	Lymphocele 1.1% Obturator nerve injury/palsy 0.4% Inguinal hernia 0.3% Lymphocele requiring intervention 0.4% Incisional hernia requiring intervention 0.2% Urethral stricture requiring intervention 0.2%
Late (more than 90 days of the operation)	Urinary tract infection 0.4% Deep vein thrombosis 0.09%	Incisional hernia 0.6% Inguinal hernia 0.4% Lymphocele 0.3% Incisional hernia requiring intervention 1.1% Bladder neck contracture requiring intervention 0.7% Inguinal hernia requiring repair requiring intervention 0.5%

 

What can patients do to minimize complications?

• Adopting and maintaining a healthy lifestyle before and after surgery can be very beneficial in reducing surgical complications. This includes eating a balanced diet and exercising regularly. Weight loss (if overweight) will make surgery easier and reduce the chance of postoperative complications such as hernias. Controlling blood sugar (in diabetics) will reduce the chance of infection from surgery and improve wound healing. Quitting smoking will reduce the risk of cardiovascular and respiratory complications from surgery, improve wound healing, reduce the chance of hernia, and improve recovery time.
• Pelvic floor (Kegel) exercises may result in earlier continence after a laparoscopic radical prostatectomy. Please see the following videos for a (detailed) explanation of what the pelvic floor is and how to perform pelvic floor exercises (Video part 1, Video part 2).

What happens on the day of surgery?

Patients will have an appointment with an anesthesiologist a few days before their operation where the process of being put to sleep for surgery will be discussed.  Patients should refrain from having anything by mouth (eating AND drinking) from midnight on the night prior to surgery. Life threatening complications resulting from aspirating food may result if patients have not refrained from eating and drinking for an appropriate time prior to surgery.

Although the actual laparoscopic radical prostatectomy usually takes under 3 hours, time spent in transit or being prepared for general anesthetic may exceed 4 hours.

After surgery, patients are usually sore and using intermittent pain medication. On the first night, moving to sit in a chair and shifting position usually possible. Patients usually don’t eat much right after their operation as their bowels are still recovering from surgery.

What happens during the hospital stay?

On the first day after surgery

On the day after surgery, patients usually feel much better.  The gastrointestinal system, stunned by the operation, starts working again and a regular diet can be consumed once flatus is passed. Patients are usually mobile by themselves by this day.

On the second day after surgery

Patients are frequently well enough to go home by the second day after surgery. They are eating well and the bowels are usually working. The bulb-shaped drain (Jackson-Pratt drain) placed during surgery can be removed and patients are discharged home with a tube (Foley catheter) draining their bladder. This tube needs to stay in for at least a week such that the wound where the bladder and urethra join can heal properly. Patients are given a bag that may be attached to their leg, as well as a larger bag for the night time.

What happens after discharge from hospital following surgery?

During the first week

Patients usually feel their strength return and pain is usually minimal during this time. Patients should still remain off work and not do any heavy lifting (nothing heaver than 10lbs for 4 weeks).

The bladder tube (Foley catheter) should stay in place. Should the tube fall out, please call Dr. Matsumoto’s office immediately. Don’t let anyone but a urologist with knowledge of your recent procedure remove the catheter or attempt to replace it should it fall out.

Common issues arising during the first week include:

• catheter bypassing. It is common for there to be leakage around the catheter, as long as the majority of urine is coming through the catheter. This occurs due to bladder spasms from the indwelling catheter and/or recent surgery. This is a normal postoperative occurrence.
• constipation. Due to the surgery and anesthetic, constipation is common postoperatively. Over-the-counter stool softeners like colace may be helpful. Additional over-the-counter laxatives like Sennokot, Lactulose, and Restoralax may also be helpful.
• minor bleeding and incisional discharge. Small amount of blood in the catheter bag and/or from the incision may be normal. Significant bleeding is very uncommon but should this occur, seek medical attention promptly.

The following symptoms are not normal and should be discussed with a physician:

• Fevers & chills
• Chest pain, shortness of breath, fainting
• Leg swelling, especially if only on one side and associated with pain and redness
• Significant and worsening abdominal pain
• Significant nausea & vomitting
• Lack of drainage from the catheter or catheter displacement
• Any other concerning new symptoms

During the first year

About 8 days after surgery, patients are seen in the urology clinic for their catheter and staple removal. The pathology results are often available at this time as well. Patients are then seen at 6 weeks, 3-months, 9-months, and 1-year after the operation.

Patients slowly regain continence and erectile function. Well over 90% of patients should require 1 pad or less per day after 1 year [5]. The majority of patients will also regain erectile function, conditional on pre-surgery erectile function and whether or the erectile nerves were spared [5].

Starting from the 3-month visit, PSA levels are routinely assessed and need to be completed 2-weeks before each visit. Undetectable PSA levels suggest the absence of cancer. Detectable PSA levels may be an indication to dsicuss further treatment for prostate cancer.

During the first 5 years

Patients are seen at 18-months, 24-months, then yearly. Follow-up takes place in the urology clinic with a PSA test done at least 2-weeks before each visit. If erectile function and continence has not returned by 1-2 years, options for further medications or surgery to correct these problems may also discussed.

 

References

1.            Bill-Axelson, A., et al., Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med, 2005. 352(19): p. 1977-84.

2.            Bill-Axelson, A., et al., Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J Natl Cancer Inst, 2008. 100(16): p. 1144-54.

3.            Su, L.M., Robot-assisted radical prostatectomy: advances since 2005. Curr Opin Urol, 2010. 20(2): p. 130-5.

4.            Kang, D.C., et al., Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature. Eur Urol, 2010. 57(6): p. 930-7.

5.            Ficarra, V., et al., Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol, 2009. 55(5): p. 1037-63.

6.            Hu, J.C., et al., Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA, 2009. 302(14): p. 1557-64.

7.            Rabbani, F., et al., Comprehensive standardized report of complications of retropubic and laparoscopic radical prostatectomy. Eur Urol, 2010. 57(3): p. 371-86.