Radical Prostatectomy

Background

Radical prostatectomy is the surgical removal of the entire prostate gland, including the seminal vesicles.  The purpose of the surgery is to cure localized prostate cancer.  While most radical prostatectomies are currently done using robotic surgery, open surgical approaches exist and may be recommended for unique situations.  In all cases, the goals of the surgery are the same: to remove the prostate gland and seminal vesicles while preserving sexual function and urinary control.

The prostate gland and attached seminal vesicles are located between the bladder neck above, and, the base of the penis below.  The prostate itself can be likened to a donut that surrounds the urethra at this location.  The secretions of the prostate gland and seminal vesicles are deposited into the urethra at the time of ejaculation.  Urine, stored in the bladder, must pass directly through the prostate gland to get to the penis for expulsion during urination.

The bladder neck is the location of the internal urinary sphincter.  This gate spends most of its time closed maintaining urinary continence or control.  It reflexively opens during urination and then automatically closes (and remains closed) until the next urination cycle. Just below the prostate gland is a second gate, the external urinary sphincter.  This muscle allows for the voluntary starting and stopping of the urinary stream.  Proper function of both gates is necessary for normal urinary control.

Located just behind the prostate are two parallel networks of blood vessels and nerves coursing from the spinal cord above to their end organs below.  Eventually they will enter the base of the penis allowing the ability to achieve and maintain erections.  These neurovascular bundles can be likened to the two rails of a railroad track upon which the prostate is positioned.  Small blood vessels and nerves leave these rails along their course to enter into the prostate.

Understanding the above gives insight into the most common side effects of radical prostate surgery.  First, after radical prostatectomy, semen production ceases.  Therefore when a man climaxes after radical prostatectomy, no fluid will be expelled from the penis.  While not harmful, this is different than normal and occurs in all patients undergoing this surgery.  Orgasm, the pleasurable sensation that typically is associated with ejaculation, remains intact.

Second, damage to the neurovascular bundles during prostate surgery can lead to loss of erections.  Men with pre-existing erectile difficulties are more prone as are those with more advanced cancer of the prostate.  Nerve-sparing surgery is available for select patients and can lessen the likelihood of erectile dysfunction.  Incidence rates vary from surgeon to surgeon and depending on how erectile dysfunction is defined.  The lowest rates of erectile dysfunction are seen in men who are under age 65 who have no pre-existing erectile dysfunction, and, bilateral nerve-sparing surgery can be performed.  60% of these men can be expected to recover their erections without intervention within 12-18 months.  That means 40%, or nearly half of these men, do not recover their erections to their preoperative capacity.  If only one neurovascular bundle can be spared, erectile dysfunction can be expected in 60% of patients.  If non-nerve sparing surgery is necessary, rates of erectile dysfunction exceed 80%.  While the prevalence of erectile dysfunction following radical prostate surgery must be considered high, it is helpful to know that many options exist that can restore erectile function should it occur.

Lastly, malfunction of the internal urinary sphincter can lead to urinary incontinence after radical prostate surgery.  Men with increased body mass index and those over age 65 are at increased risk.  Nerve-sparing surgery is associated with a lower risk of incontinence.  Additionally, bladder neck preservation at the time of surgery impacts favorably on postoperative urinary control.  Incidence rates vary from surgeon to surgeon and depending on how urinary incontinence is defined.  It is important to understand that immediately after surgery, following catheter removal, essentially all men will have significant urinary incontinence.  Wearing pads during this period, which can last from 1-3 months, is to be expected.  Typically control is achieved such that by 3 months after surgery most patients no longer require protective pads.  In those that do wear pads, many are wearing 1 pad per day or less and these men rarely require any further intervention.  In the fraction that do have significant long term leakage, 10-15%, additional therapies are available that can correct the problem.

Preoperative Preparation

Prior to surgery you will need to have any preoperative testing (bloodwork, EKG, etc.) completed at least 2 weeks prior to surgery.  You will be asked to consent to blood transfusion.  Transfusion rate is less than 10%.  Anticoagulant medications (blood thinners) need to be discontinued well in advance of your surgery.  Check with your doctor to determine exactly when you should stop taking them.  Additionally, the day prior to surgery you are asked to maintain a clear liquid diet starting at 8 a.m.  If you can read newsprint through the liquid, you may drink it.  A gentle laxative is recommended that morning.  The purpose of this bowel preparation is twofold: to decompress the intestine which aids exposure at the time of surgery, and, to facilitate quicker recovery of bowel function postoperatively.  You may continue to drink clear liquids up until 11:45 p.m. the night before surgery.  Do not eat or drink anything after 11:45 p.m. with the exception of any medicines you were instructed to continue taking with a sip of water.  Sometimes the hospital preoperative nurse, who will call you the day prior to surgery to give you the time to be at the hospital, will instruct you that it is ok to drink certain beverages after 11:45 p.m.  DO NOT EAT OR DRINK ANYTHING AFTER 11:45 p.m. OTHERWISE YOUR PROCEDURE COULD BE CANCELLED.  The preoperative nurse means well, however, the OR schedule may change unexpectedly resulting in an earlier surgery time than anticipated.   By observing the “nothing by mouth after 11:45 p.m.” rule, you can avoid having your surgery delayed or worse yet cancelled.

Explanation of Surgery

Robotic radical prostatectomy is a minimally invasive laparoscopic surgery.  Five small incisions called port sites are made in the abdomen, each about 1 cm. (1/2 inch) in length.  One of these incisions is in the midline directly above the umbilicus (belly button) and serves to hold the camera by which the surgical field is viewed.  The other 4 ports are placed in a line, 2 on the right and 2 on the left, just below the umbilicus and serve to hold various surgical instruments needed to perform the procedure.  The “robot” is actually a machine that holds the camera and the instruments, its movements being directed by the surgeon and his or her assistant.

The procedure itself involves disconnecting the prostate gland (and seminal vesicles) from the bladder neck above, and, the base of the penis below.  Preservation of the urinary sphincters and neurovascular bundles are important goals of the surgery that aid in preserving normal urinary control and sexual function.  However, the primary objective is to cure the prostate cancer by removing it, all of it.  This may require of necessity that the mechanisms of urinary control and sexual function are violated.  After the gland is detached it is placed in a small impermeable bag inside the abdomen to be extracted at the end of the procedure.  The bladder neck is very mobile and will easily reach the base of the penis thus bridging the gap left by prostate removal.  The bladder neck is then attached to the base of the penis using suture material.  This repair requires a urethral catheter be present postoperatively while the healing process is underway.  Finally, if lymph node sampling is indicated it will be performed at this time.

At the termination of the procedure the small incision above the umbilicus is extended just enough to allow extraction of the prostate and any lymph nodes that were collected.  A surgical drain is placed in the pelvis through one of the lower port sites to collect any fluids that accumulate after surgery and to monitor for leakage of urine from the repair site.  Skin incisions are closed with absorbable suture and the urethral catheter is connected to a drainage system.  Thus, when you awake in the recovery room, you will find a catheter in the penis, a drain coming out of one of the puncture sites, and small band aides on the remaining sites.

Hospital Stay

Postoperatively you will be provided pain medicines as needed.  An advantage of minimally invasive robotic surgery is that the need for narcotic pain medicine is significantly reduced compared to open surgery.  You will be allowed sips of clear liquids starting immediately after surgery.  Nausea early after general anesthesia is not unusual, and the robotic procedure itself can slow bowel function temporarily.  As these resolve, usually 12-24 hours, your diet will be advanced to clear liquids, then eventually solid food.  Early ambulation, including the night of surgery, is important in preventing deep vein thrombosis, pneumonia, and stimulates early return of bowel function.  Nursing staff will instruct you on how to care for your urethral catheter prior to discharge from the hospital.   Your surgical drain will typically be removed before you go home.  Rarely patients will be sent home with the drain and if so, you will be instructed on how to manage it before you leave.  Most patients will be ready for discharge in 48 hours.

Postoperative Instructions

You will be discharged with a urethral catheter.  Catheter removal is typically 7-10 days after surgery.  At that appointment your pathology report will be reviewed with you.  Be sure to bring incontinence pads to your appointment for catheter removal as you can expect to be incontinent of urine immediately after the catheter is removed.  You will need a pad for the ride home from that visit.  Be prepared that urinary control may take several weeks and up to 3 months to recover.  You may shower daily following hospital discharge but no tub baths or pools for 2 weeks.  Do not drive for 2 weeks.  No lifting over 10 pounds for 4 weeks.  Most men are able to resume normal activities without restriction by 30 days post-surgery; however, 50% will still have significant urinary control issues which will limit practically what they can do.