Radical Prostatectomy

Robotic assisted Laparoscopic Radical Prostatectomy (RALRP)

Radical prostatectomy is a major operation to remove the whole prostate containing cancer cells and seminal vesicles. Laparoscopic (keyhole) radical prostatectomy performed through small incisions, has been shown to have less discomfort, lower blood transfusion rates and shorter post-operative recovery compared to open radical prostatectomy. Laparoscopic and Robotic Prostatectomy performed by an expert surgeon has equivalent outcomes to open surgery; in terms of cancer control, urinary continence and potency. I have performed over 250 laparoscopic prostatectomy cases with good outcomes comparable to large published series.

Since 2015, I switched to performing Robotic assisted (DaVinci) laparoscopic radical prostatectomy with the added benefits of 3D vision, articulated instruments and improved ergonomics.

Robotic prostatectomy takes 2 to 3 hours to complete and patients are generally discharged from hospital after 2 days. The urinary catheter is removed by our Urology nurse consultant 10 days later in our clinic.



What to expect from surgery?

Cure

Several investigations will be undertaken to stage your prostate cancer. If there is no spread of cancer outside the prostate, the entire prostate is surgically removed to cure you of prostate cancer and prevent future spread into lymph glands and bones. The likelihood of surgical cure for early non-aggressive (low risk) prostate cancer is greater than 90%. Naturally, the cure rates for more advanced and aggressive disease is less impressive. This will be discussed with you prior to surgery.

Up to 10% of patients will have positive surgical margins, which means cancer extending into the cut edge of the gland. This is not surprising as >70% of prostate cancer arises from the outer section of the gland. Only 40% of patients with positive margins will experience cancer recurrence. All patients are monitored closely with PSA testing after surgery. Generally any sign of cancer recurrence is treated with radiotherapy and or hormonal therapy.


Incontinence

You are unlikely to be dry immediately after catheter removal. The muscles essential for continence take time to readapt and are probably still traumatized from surgery. Urinary control recovers quickest in young patients and is usually noticeable improved after 6 weeks. However, you may not be fully dry until 3-4 months after surgery. 2% of patients have long-term urinary incontinence. Those who have not regained satisfactory urinary control after a year are offered insertion of an artificial urinary sphincter or a urethral sling, another small operation with excellent success to regain continence.

 

Impotence

Impotence is another significant major complication of surgery. The nerves that control erection run closely and parallel to the prostate, running into the penis. If conditions are favorable, attempts are made to protect these nerves during surgery. If the nerves are affected by cancer, they are removed. Preserving nerves may increase the risk of leaving cancer behind and compromising cure.

Even when nerves are preserved, scarring after surgery can interfere with its function. The likelihood of potency after nerve preserving surgery with or without erectile dysfunction medications (e.g. Viagra) is 60%. Potency can take up to 2 years to recover after surgery. If recovery of erection is unlikely, potency can be restored with medical or surgical treatment.

The removal of the prostate and seminal vesicles will result in dry ejaculations but orgasm is not affected during sexual intercourse.

Other benefits

Surgery can also relieve obstruction to the drainage of urine from the bladder by an enlarge prostate

PSA can be used reliably to monitor success of treatment. PSA can take up to 18 months to reach its lowest level following radiotherapy, which may confuse monitoring of treatment success.

What are the Risks of Laparoscopic radical prostatectomy surgery?

1.Impotence

40% risk of impotence with nerve sparing procedure. Impotence can be managed with medical or surgical treatments.

2.Incontinence

2% risk of long-term incontinence

3.Rectal injury 0.5 %

4.Haemorrhage and blood transfusion 0.5%

5.Bladder neck stenosis 2%

6.Lymphocoele 2%

Only with resection of lymph glands

7.Urinoma 1%

8.Conversion to open surgery 1%

9.General risks of surgery <3%

Wound infection

Urinary tract infection

Thromboembolic event

Cardio respiratory event


References

1. Todd et al. J.Urology 2005; 174: 912-914

2. Guillonneau et al. J.Urology 2005; 173: 1072-1079

3. Joseph et al. BJU International 2005; 36: 39-42

4. Lu Yao et al. Lancet 1997; 346: 906-910

RESULTS

A review of 180 cases performed from 2006 - 2012 confirms comparable outcomes with  published radical prostatectomy series.

More information

Undergoing Surgery for Prostate cancer