Radical prostatectomy is curative treatment method for localized prostate cancer. In radical prostatectomy surgery the whole prostate gland together with its capsule is surgically removed. Patients with a more aggressive disease by histology (Gleason score ≥ 8) or high PSA (>10 µg/l) have local lymph nodes surgically removed as well (lymphadenectomy).
WHEN IS SURGERY JUSTIFIED?
Radical Prostatectomy has been demonstrated to be effective treatment of localized prostate cancer by increasing the life expectancy of patients with moderate to high risk localized prostate cancer. Surgical treatment of locally advanced (T3) prostate cancer is also feasible with consideration case by case.
Radical prostatectomy can be performed as a robotic-assisted laparoscopy or as open surgery. In 2015, close to 400 radical prostatectomies were performed at Helsinki University Hospital, 352 of which were robotic-assisted laparoscopic radical prostatectomies (RALP) using the da Vinci robotical system.
The laparoscopic technique lessens bleeding during surgery, enables handling of tissue and organs during surgery with greater accuracy through 3D view and small instruments, lessens postoperative pain, and speeds up patient recovery back to normal after surgery. Cancer treatment results are equally good with open surgeries and laparoscopies, but laparoscopies involve fewer side effects associated with surgery and significantly reduced hospitalization and recovery time.
ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALP)
Robotic surgery is ideal for prostate gland removal. Being protected by pelvic bones, the surgical site is confining it is where, for instance, the urinary bladder, rectum and erectile nerves are located. Hence, surgery is associated with the risk of deterioration of urinary continence and erectile function. Precise, but gentle surgery is important to ensure the patient’s quality of life.
RALP refers to prostate gland removal performed with the help of the da Vinci surgical robot. The procedure is performed under general anesthesia, and it lasts 1.5–3 hours. An incision 3-5 centimeters in length is made in the abdomen along with five other incisions of approximately one centimeter each for setting up ports to insert instruments and a camera and to remove the prostate from operation area. The surgeon works from a console located near the patient, moving and guiding the instruments in the abdominal cavity.
The prostate gland and seminal vesicles are surgically removed. Depending on the stage and grade of the disease, regional lymphatic tissue outside the prostate gland and on parailiacal regions in pelvis may also be removed surgically. The removed tissues are then examined by a pathologist to determine the stage and grade of the cancer in prostate and to determine any metastasis in lymph nodes.
The urethra within the prostate gland is removed at a point next to the sphincter and bladder neck. After the prostate gland has been removed, the bladder is reattached to the urethra with stitches (anastomosis between bladder neck and urethra). A catheter running through the urethra is left in the bladder for one week to ensure that the seam heals.
The benefits of RALP include substantially smaller surgical incisions, minor blood loss (200 ml on the average) and good conditions for the surgical technique that spares the erectile nerves. Recovery is faster and the length of sick leave is shorter than after open surgery. Postoperative erectile dysfunction and poor urinary continence are however potential risks of radical prostatectomy. Care is taken to spare the nerves that are of importance for erectile function if this is possible without compromising the curative treatment of the cancer. If the erectile function has been normal before the operation and the erectile nerves can be saved during the operation, most of the patients will be able to have erections with or even without erectile dysfunction medications. The functioning of the sphincter affecting urinary continence is generally restored to the normal level within a few weeks to a few months. Urinary continence is restored in 90–95% of patients after recovering from surgery
Even though a single surgery with robotic system is more expensive, savings are gained especially from the shorter period of patient treatment in hospital. Usually, the patient is discharged already on the day following robotic surgery, whereas open surgery is followed by 3–6 days of hospital treatment. Savings are also gained by the fact that patients undergoing robotic surgery need no blood transfusions, since patients lose only an average of 200 milliliters of blood during surgery. The volume of blood loss in open surgery is 0.5–1.5 liters. Clinically remarkable blood loss during or after the operation is covered by red cell transfusion.
Helsinki University Hospital is clearly Finland’s largest center for radical prostatectomy. The first surgical robot was introduced at the hospital in 2009 precisely due to the increasing prevalence of prostate cancer. The robotic-assisted surgical unit of Peijas Hospital is currently one of the most effectively operating surgical units of its kind in Europe.
ADEQUACY OF SURGICAL TREATMENT AND SUPPLEMENTARY TREATMENTS
Surgically removed tissue is examined with a microscope by a pathologist. This provides an accurate evaluation of the prostate cancer histology and local advancement as well as any spreading to the lymphatic system or lymph nodes. Surgery is an curative and adequate treatment if there is no cancerous tissue on the edges of the surgically removed area and if the PSA value is reduced to a undetectable level (< 0.05µg/l). Surgical treatment may be supplemented with radiation therapy or pharmacotherapy if the cancer has grown through the prostatic capsule or edges of the surgically treated area, or if cancer cells are found in the lymph nodes.
PROS AND CONS OF SURGERY
For a small number of patients, potential acute side effects of surgical treatment include, for instance, blood loss, bacterial infection and vein thrombosis. Intestinal damage is also possible especially if there are adhesions in the abdominal area from previous surgeries. Significant postoperative complications are found in < 1% of all patients. Potential long-term side effects of radical prostatectomy include urinary incontinence and impotence. Urinary continence is restored in 90–95% of patients after recovering from surgery. Erectile function can be spared most likely in patients having small, localized cancers; the erectile nerves are well spared in surgery. Most of the side effects associated with surgery are temporary.
Most patients are discharged from the inpatient ward within 1–2 days after robotics-assisted surgery. Catheterization is needed normally for one week. Need of sick leave varies from two to four weeks depending on the work (office work vs. physically hard work).