Radical Prostatectomy

Radical prostatectomy can be performed using several surgical techniques but the most important factor is the experience and expertise of the urologic surgeon. A/Prof Peter Royce and Dr Dennis King both have extensive experience with the open prostatectomy and robotic assisted laparoscopic prostatectomy. They have a combined experience of over 3,000 radical prostatectomy procedures.

Radical prostatectomy involves the total removal of the prostate gland with its surrounding fascia, attached seminal vesicles and adjacent lymph nodes, for curative treatment of localised prostate cancer. The pelvic lymph nodes are removed in higher risk prostate cancer where spread is more likely since this can dictate the need for additional treatment and improve the survival of these men.

A 'nerve sparing technique' is performed in order to maximise postoperative sexual potency, this involves careful preservation of the neurovascular bundles which are located between the prostate and rectum, and provide neural stimulation to the penis for erectile function.

Once the prostate has been removed the bladder neck is then refashioned and sutured to the urethra and urinary sphincter muscles over a urethral catheter. The catheter will remain in place for 10 days during which time initial healing takes place. The urethral catheter is removed by the urology nurse in the urology suite.

Surgical Goals

There are 3 principal surgical objectives to remove the prostate cancer with a clear margin of tissue giving the best chance of cure maintenance of long term urinary continence in appropriately selected patients maintenance of erectile function.

The ideal patient for radical prostatectomy is a man who accepts the risks of surgery, is aware of all his options, and has a clinically localised cancer with at least 10 years of life expectancy. For localised cancer, the cure rates for radical prostatectomy (10-year, PSA-progression-free survival) are 90% for organ-confined disease and 82% for specimen-confined disease. These results can be improved further if adjuvant radiotherapy is used in patients who have extracapsular disease or a positive surgical margin.

If a PSA recurrence occurs some time after surgery, the time to death from prostate cancer still averages 13 years and may therefore not impact on the life expectancy of an older man. Even patients with poorly differentiated tumours can be cured surgically if the disease is detected while confined to the organ.

Side effects of treatment (including incontinence and impotence) have become less common with improved surgical techniques and patient selection.

Incontinence is common immediately following surgery and pelvic floor exercises are important. This reduces over time and most men are continent within 6-10 weeks following surgery. During this recovery period you will need to wear a pad and practice pelvic floor exercises as instructed by either our Urology nurses or a continence and pelvic floor physiotherapist.

In a very small percentage of patients, perhaps 1-2%, urinary control may not return to an acceptable level, and this is one of the main risks of the operation. The factors influencing recovery of urinary continence after radical prostatectomy include primarily the technique/expertise of the surgeon with preservation of the urinary sphincter, the use of properly instructed pelvic floor exercises, but is also related to patient age and the underlying urinary sphincter strength and bladder function, as well as the healing process in the individual.

Sexual Function

Erectile function is controlled by the presence of 2 neurovascular bundles. The two nerve bundles are attached to the capsule of the prostate gland and may be involved with the cancer, or inseparable from the prostate gland and therefore not able to be preserved in every case. In appropriate patients (with a low risk of extraprostatic spread) we perform a 'nerve sparing' operation on one or both sides, which will improve the likelihood of preservation of erections post operatively.

Although impotence remains a common problem of surgery, an erectile nerve-sparing procedure can preserve potency in up to 60% of carefully selected patients, especially those in younger age groups.

However a nerve sparing operation is not always possible or appropriate. Furthermore, the return of erections is usually a fairly slow process and may take 12 months before a final assessment can be made. The use of drugs such as Viagra, Cialis and Levitra or penile injection therapies in the months after surgery will usually enhance the return of erectile function, and will be prescribed once you are ready to resume sexual activity. There are alternative means of achieving an erection and sexual satisfaction, and I would be pleased to discuss these options further as appropriate.

Once you resume sexual activity you will notice that there is no ejaculatory fluid produced, this is because the ejaculatory glands have been removed, namely the prostate and seminal vesicles.

The sensation of orgasm will still be present although this may feel a bit 'weird' for a time, but most men claim it is only slightly altered from normal in the longer term.

Some men have reported shortening of the penis after radical prostatectomy, however this is uncommon and seems to bother some men more than others, but does not usually prevent sexual function.

Open Radical Prostatectomy

Open prostatectomy is the traditional method of surgery for prostate cancer and although robotic surgery has become more popular in the last few years, there are situations where open surgery is the preferred option; in particular for treatment of high grade prostate cancer where an extended pelvic lymph node dissection is required.

Currently the evidence indicates that open or robotic prostatectomy performed by very experienced surgeons are equivalent in outcome in terms of the 'patient trifecta' in regard to preservation of urinary control, sexual function and long term cancer cure.