Radical Prostatectomy – 2003
Commentary from an Experienced Urologist
Stanley A. Brosman, M.D., Pacific Urology Institute

HISTORY
As shown in Table 1 (below), prostatectomies have been performed for
more than a century. In 1891, in Tucson, Arizona, a frontier doctor
named George Goodfellow performed the first known prostatectomy, using
the perineal approach. Although he worked for many years in Los Angeles,
he traveled the country, teaching this operation to many surgeons
including the new chief of urology at Johns Hopkins, Hugh Young. Young
modified the procedure to treat prostate cancer, and he published the
first paper on the subject in 1904. It was not until 1947 that an
English surgeon, Terrence Millin, reported on the retropubic approach,
which became the predominant technique used to surgically remove the
prostate in an effort to eradicate this disease.
Prior to 1982, only 7% of men diagnosed with prostate cancer were
considered to be candidates for surgery, and only a fraction of these
men could be cured with surgery. The surgery was dangerous because of
the large blood loss and the high risk of incontinence. Impotence almost
always accompanied this procedure. Then, in 1982, Patrick Walsh, also
from Johns Hopkins, described the anatomic, nerve-sparing technique for
performing radical prostatectomy.
Dr. Walsh was able to demonstrate that the nerves responsible for
erection could be preserved and that potency could be retained. Dr.
Walsh's other contributions to the surgical technique involved the
ability to preserve continence and decrease blood loss. His anatomic
surgical technique, which is now practiced worldwide, enables the
sphincter to be saved so that incontinence has been greatly reduced and
major blood loss is rare. The radical retropubic prostatectomy is a
technically demanding procedure for the surgeon and a great deal of
experience is necessary to perform the surgery safely, to maximize its
effectiveness and limit the risk of complications.
However, prior to the 1990's, the ability to diagnose cancer that was
confined to the prostate was extremely limited. More than 75% of men
diagnosed with prostate cancer already had the disease growing beyond
the prostate and many of these men already had metastatic cancer. The
PSA blood test was introduced in 1986, but it was not widely used until
the early 1990s. For the first time, it became possible to diagnose men
whose cancer was confined to the prostate. The introduction of
transrectal ultrasonography accompanied by transrectal needle biopsy in
1988 provided the opportunity for urologists to diagnose and identify
men whose prostate cancer could be treated surgically. These diagnostic
procedures revolutionized early detection of prostate cancer, and by
2001, 65-85% of men who presented with PC were found to have the cancer
still confined to the prostate gland.
In 2002 there were approximately 195,000 men diagnosed with prostate
cancer. Radical prostatectomy was performed on 55,000. Nearly 30% of all
men found to have prostate cancer are selecting radical prostatectomy as
the procedure of choice. In order to help men decide which form of
therapy is most appropriate for them and to help them understand what is
involved in the surgical procedure, this article will review this
subject.
    Table 1. History of RP
    1891  George Goodfellow, Perineal Prostatectomy
    1904  Hugh Young, Perineal Prostatectomy (first paper
published)
    1947  Terence Millin, Radical Retropubic Prostatectomy
    1982  7% had surgery. Walsh introduces nerve-sparing RP
    1986  PSA introduced
    1988  Ultrasound-guided biopsies begun
    1995  35% diagnosed had RP
    1998  Laparoscopic Prostatectomy introduced
    2001  65%-85% present with localized cancer. 55,000 RPs
performed
Surgical Technique
Until recently there were just two techniques utilized in the surgical
removal of the prostate:
1. The retropubic approach
2. The perineal approach.
The most common is the retropubic approach in which an incision is made
in the lower abdomen. The incision is usually made up and down extending
from the navel down toward the base of the penis. An alternative is an
incision that extends transversely across the lower abdomen. There are
no muscles cut with either of these incisions. Refer to Figures 1 and 2.
Figure 1: Overhead View of the Prostate Area. In this view of the
prostate, the locations of various structures are depicted in relation
to the prostate. The base of the prostate is closest to the bladder
while the apex is furthest from the bladder. Note the position of the
neurovascular bundles on each side of the prostate. They contain the
nerves responsible for erections.
Figure 2: Side View of the Prostate Area. This view shows the closeness
of the prostate to the rectum. The entire urethra contained within the
prostate is removed together with the seminal vesicles.
The top of the bladder is exposed and emptied by placing a catheter
through the urethra. The lymph nodes on the side walls of the prostate
and those closest to the prostate are examined for signs of cancer and
often removed. The top and sides of the prostate are cleaned of fat that
covers this area. There is a large group of veins known as the 'dorsal
venous complex' that lies over the top of the prostate and extends down
the sides. These veins must be separated and tied to obtain full
exposure of the prostate.
In those patients who qualify, and most men do qualify, the nerves that
control erections are carefully separated from each side of the
prostate.
The apex of the prostate is detached from the urethra by opening the
urethra, removing the catheter and cutting across the entire urethra.
There is no real capsule at the apex of the prostate. In order to remove
all prostate and cancer tissue in this area as well as preserve the
nerve bundles that go alongside the prostate and urethra, a delicate
dissection is necessary. Occasionally, the surgeon may want to make a
biopsy and have the pathologist perform a frozen section to determine if
there is any cancer involving the urethra or the neurovascular bundle.
If so, additional urethra area and the affected bundle would be removed
with the prostate. The external sphincter, which is necessary to
preserve bladder control, is not disturbed.
When this portion of the operation is completed, the prostate is lifted
up and separated from the rectum. At the base of the prostate are two
structures known as the seminal vesicles. They manufacture and store
seminal fluid and are removed together with the prostate. Because this
is one of the early locations of cancer spread, they are also removed.
The bladder neck is opened, and the prostate is dissected away from the
muscular wall of the bladder. The entire portion of the urethra
extending from the apex of the prostate to the bladder neck is removed
with the prostate and seminal vesicles. The bladder neck is reconfigured
so that its size matches the open end of the urethra. A new catheter is
inserted into the urethra and placed into the bladder. The urethra and
bladder are sewn together. This catheter will remain in place 2-3 weeks.
With the perineal approach, an incision is made through the skin between
the anus and scrotum. The bottom of the prostate sits on the top of the
rectum. These two structures must be carefully separated. This is a
delicate part of the operation and occasionally (about 5% of the time)
the rectal wall tears and must be closed. If this occurs, the surgeon
may decide to stop the operation. but this decision is based on many
factors, such as the size and location of the rectal opening. Assuming
that there is no rectal injury, the procedure is performed in a manner
similar to the retropubic approach. The 'nerves' are preserved and the
new bladder neck and urethra are sewn together after the prostate and
the seminal vesicles are removed.
One of the differences between the perineal and retropubic approaches is
that the lymph nodes in the pelvis cannot be examined or removed in the
perineal approach. They are located too high in the pelvis to visualize.
This is not necessarily a major drawback. Because there has been better
selection of patients for surgery, the presence of lymph node metastases
has become quite unusual. In my practice, we have found that less than
three percent of men in the low to moderate risk categories had
metastases in their pelvic lymph nodes. Many urologists are no longer
removing these lymph nodes. In the past five years, I have not had a
single patient in these risk categories who has had a lymph node
metastasis.
In 1998, a new technique using laparoscopic surgery to remove the
prostate was introduced in Paris by surgeons Bertrand Guillonneau and
Guy Vallancieu of the Institut Montrouris. As shown in Figure 3, the
surgeon makes five small incisions in the lower abdomen to introduce a
camera and instruments used to perform the surgery. The surgeon thereby
has a magnified view of the surgery on a television monitor. The
procedure is essentially the same as the retropubic surgical technique.
Pelvic lymph nodes can be removed, the neurovascular bundles preserved
(their size is greatly enhanced on the monitor), and the bladder neck
sewn to the urethra usually with a watertight closure. This surgical
technique is becoming more common in the United States and offers the
promise of shorter hospital stays (one center is discharging most of
their patients the same day as the surgery), a rapid recovery, and a
shorter duration of time that the catheter needs to be worn. Moreover,
because of the enhanced magnification, the procedure is associated with
less blood loss and a better opportunity to preserve the neurovascular
bundles.
Figure 3: Laparoscopic Prostatectomy. Five small incisions allow the
introduction of the special working instruments and a video camera. The
surgeons view the procedure on a monitor. A robot may be attached to the
camera and can be controlled by voice commands from the surgeon. A
different type of robot can be connected to all of the instruments and
controlled by the surgeon at a computer keyboard and monitor. (Reprinted
with permission of Krongrad Urology.)
By using special robotic devices which are connected to some or all of
the instruments including the camera, the surgeon can manipulate the
robot using voice commands. There is one type of robot with which the
surgeon is stationed at a computer keyboard and delivers commands while
watching on a monitor. The surgeon does not necessarily have to be in
the operating room. I watched a demonstration in which the surgeon was
in Florida doing a procedure on a patient who was in an operating room
in Germany.
How does the surgeon decide which surgical method to use? This is
largely based on the training and experience of the surgeon. Most
surgeons are only trained to do the retropubic approach. As a result,
more than 90% of all the surgeries have been done using this technique.
Currently, more and more surgeons are learning the laparoscopic
procedure, and in the next 5-10 years when the medical field has
determined and published long-term results in the areas of PC
recurrence, nerve-sparing capabilities, and side effects such as
incontinence, this is likely to become the dominant form of surgery.
This evolution of radical prostatectomy procedures has produced such
improved safety that the operative mortality is less than 0.1%. As shown
in the results from 1,860 of my patients who had their surgery in the
last 25 years (Table 2), intraoperative complications such as anesthetic
problems and bleeding (when more than three units of blood are
transfused) occurred in less than 10% of the patients; in the past eight
years this has decreased to less than 3%. Postoperative complications
such as infection, bleeding and malfunctioning catheters in the first 30
days after surgery occurred in less than 1% of these patients. The
hospital stay averaged 2.8 days. Urethral strictures (scars that form at
the site where the urethra and bladder neck are sewn together) occurred
in 7.5% of these patients although none have occurred in the last five
years. Strictures are corrected by stretching or incising the scar.
    Table 2. RP Results in 2002 (n= 1860)
    •  Surgical mortality: 0.1%
    •  Intraoperative complications: 9.7% (>3 units of
blood)
    •  Post-op complications (first 30 days): 0.8%
    •  Hospital Stay: 2.8 days
    •  Stricture: 7.5%
What You Can Now Expect If You Have an RP
Planning for Surgery
Once you have decided to proceed with surgery, there are preparations to
be made. You need to get yourself in good condition both mentally and
physically. Having a strong positive attitude that you have made the
right decision and are supported by your family will help you to be in
the best mental condition. It is never too late to start an exercise
program or begin a good nutritional program. Usually there will be
several weeks before surgery, so there is time to initiate these
programs. It is helpful to stop smoking and reduce alcohol intake. You
should plan for a recovery period of a month before returning to work
although you will resume many of your other activities within a shorter
period of time. The better condition you are in prior to surgery, the
more rapid will be your recovery.
Some surgeons will ask you to donate several units of your own blood to
be available should a transfusion be needed. Others recommend the use of
blood from the American Red Cross. Family members may donate blood if
they match your blood type.
Several days prior to surgery, your surgeon may request blood tests, an
EKG and a chest X-ray. Your internist is likely to want to examine you
as well. It is usually helpful to have your bowels cleaned out before
surgery. You don't want to have to worry about having to have a bowel
movement during the first few days after surgery.
You will be asked to avoid having anything to eat or drink for 6-8 hours
prior to the scheduled time of the surgery. If you are taking any
medications, check with your physician as to whether or not they should
be taken the day of surgery. Any medications, herbal supplements or
anything else that might interfere with blood clotting should be stopped
10-14 days prior to surgery.
The day before surgery, the anesthesiologist will call and ask about
your health, any allergies you might have, the medications you are
taking, and any previous experience with anesthesia. You will have a
general anesthetic, but some surgeons and anesthesiologists also prefer
an epidural anesthetic, which is administered through the back and
provides good pain control after the surgery.
What to Expect During the Hospitalization
You should arrive at the hospital two hours before surgery. The nurse
who checks you in will ask what type of procedure you are having and
request that you sign a consent form giving the surgeon permission to
perform the specific surgery. An intravenous solution of salt water will
be started in your arm and an antibiotic may be given. If all of the
previously requested blood tests have not been obtained, new tests may
be ordered.
The anesthesiologist will talk to you again about the type of
anesthesia. This is the time to ask any last minute questions.
Intravenous sedation will probably be given and you will be moved to the
operating room. The time you are scheduled for surgery is actually the
time that the anesthesiologist begins to work. The actual surgery may
not begin for a half hour after that.
You will recognize your surgeon who will be wearing a mask and meet the
assistant surgeon. Shortly thereafter, you will be sound asleep. When
you wake up about 2-3 hours later, you will be in the recovery room. You
will have an intravenous line in your arm, a catheter in your bladder, a
drain tube exiting from the side of the incision to carry away excess
serum and fluids which collect from the area of the surgery, and special
wrappings on your legs to prevent blood clots. You will remain in the
recovery room for 1 to 2 hours before being transferred to your room.
This is when you can visit with your family.
Later the same day or the next day you will probably be able to start
drinking small amounts of fluids. You will also be helped out of bed and
can start walking. Although it doesn't seem possible, you are not likely
to experience much pain. In fact, many patients report that they
experience a sense of exhilaration that the surgery is over and they
feel so good. Pain control is provided by giving a long acting narcotic
through the epidural catheter or by allowing the patient to administer
his own pain medication intravenously using a system known as Patient
Controlled Anesthesia. As soon as your stomach is comfortably accepting
fluids, the intravenous fluids are discontinued. On the average,
patients are ready to leave the hospital 2.8 days after the surgery. The
drain tube is usually removed prior to discharge. The catheter that was
placed during surgery goes home with you. It is connected to a bag that
can be strapped to your leg. Also, you will be provided with a large bag
that can hold several quarts of urine and is particularly useful for use
during the night. You will be given prescriptions for pain medicine and
antibiotics prior to your discharge.
At Home
You can expect to feel tired and to sleep a lot but each day your
physical activity should be increased. There is no need to spend large
amounts of time in bed. if they have not already been removed prior to
discharge from the hospital, the skin staples/sutures will be removed
5-7 days following surgery. This will probably be done in the
urologist's o office. During this visit you can review the pathology
report and look at the Kattan postoperative nomogram. The urologist will
give you an idea as to what to expect in terms of future outcome and
discuss the need for any additional therapy.
The catheter will remain anywhere from a week to three weeks. It is
important that the connection between the urethra and the bladder be
well healed before the catheter is removed so that urine does not leak
out and cause scarring.
You can resume your regular diet but should avoid foods that are likely
to produce gas. One of the most common problems people experience is
'gas pains'. It takes a while before the intestines resume normal
function and it is wise to progress slowly.
You can shower at any time. Soap and water does not hurt the wound. Any
activity that would require straining, including bowel movements, should
be avoided until the incision is solidly healed.
Following removal of the catheter, you can expect to leak urine. Usually
an absorbent pad placed inside jockey underwear will be sufficient, and
they are easy to change. Most men notice that they are drier at night
when lying down. Bladder control improves in the morning when the
muscles are fresh and tends to get worse as the day goes on and the
muscles get weaker. It often takes several months before bladder control
is good enough to give up the pads although many men still wear one when
they go out – just in case. There are several effective aids to
countering incontinence. Consult your physician to learn the
alternatives.
About a month after surgery, many urologists prescribe Viagra to help
prime the system. Although it is unlikely that you will begin
experiencing natural erections at this time, you may be able to speed up
the process with this "priming" effort. There are several different
methods of assisting erections. Consult your physician to learn the
alternatives.
From this point on, it is just a matter of time before all of the
systems have stabilized. You are likely to recognize differences in
bladder and bowel function for months.
Everyone is eager to know their PSA level, but in the first month this
is done more to satisfy curiosity rather than to make any decisions
about therapy. Your physician will probably schedule your first
post-operative PSA test about 2-4 weeks after your surgery.
Conclusion
We are at a point in managing prostate cancer where we can give better
advice to patients regarding the ability of surgery to eliminate the
cancer and estimate the chances of incontinence and impotency. Our goal
is to eradicate the cancer with a minimum of adverse effects so that
every man can maintain a high quality of life. Although surgery offers
many benefits, it is not for every man. It is incumbent for each man and
his doctor to work together in order to select the most appropriate
therapy.
References:
• Walsh PC, Lepor H: The role of radical prostatectomy in the
management of prostate cancer. Cancer 60:526, 1987.
• Iversen P, Madsen PO, Corle DK: Radical prostatectomy versus
expectant treatment for early carcinoma of the prostate: twenty-three
year follow-up of a prospective randomized study. Scand J Urol Nephrol
Suppl. 172:65, 1995.
• Gerber GS, Thisted RA, Scardino PT, et al: Results of radical
prostatectomy in men with clinically localized prostate cancer. JAMA
276:615, 1996.
• Stanford JL, Feng Z, Hamilton AS et al. Urinary and sexual function
after radical prostatectomy for clinically localized prostate cancer.
JAMA 283:354, 2000.
• Siegel T, Moul JL, Spevak M, et al: The development of erectile
dysfunction in men treated for prostate cancer, J Urol 165:430, 2001.
• Steinech G, Helgesen F, Adolfsson J, et al: Quality of life after
radical prostatectomy or watchful waiting. N Engl J Med 347:790, 2002.
• Holmberg L, Bill-Axelsen A, Helgesen F, et al: A randomized trial
comparing radical prostatectomy with watchful waiting in early prostate
cancer. N Engl J Med 347:781, 2002.
• Lepor H, Nieder AM, Ferrandino MN:. Intraoperative and postoperative
complications of radical retropubic prostatectomy in a consecutive
series of 1,000 cases. J Urol. 166:1729, 2001.
• Bacon CG, Giovannuci E, Testa M, Kawachi I: The impact of cancer
treatment on quality of life outcomes for patients with localized
prostate cancer. J Urol. 166: 1804, 2001.
 



knowledge is power - growing old is mandatory - growing wise is optional    
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
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