Prostate cancer is the most common form of non-skin cancer in men. While 8 in 10 men will develop prostate cancer – usually later in life – most men won't die from it. The 5-year survival rate for men diagnosed with prostate cancer is above 96%.
If your prostate cancer looks like it won't grow quickly and isn't likely to spread, your doctor will most likely recommend a wait-and-see approach – either with regular monitoring or treating symptoms as they develop.
There are a variety of nonsurgical treatment options for prostate cancer ranging from hormone therapy to external radiation therapy, but in some cases, your doctor may recommend surgical removal of the prostate – an operation called "prostatectomy."
There have been significant advances in prostatectomy since the early days of open surgery. It's now mostly done through a minimally invasive approach called Robotic Assisted Laparoscopic Radical Prostatectomy – or RALRP – with better outcomes and lower risks of side effects like urinary incontinence and erectile dysfunction.
Justin Cox, MD, with The Christ Hospital Physicians – Urology and a member of The Christ Hospital Prostate Cancer Collaborative, answers questions about RALRP and some of the advantages over open surgery.
What is a radical prostatectomy?
Radical prostatectomy is a complex surgical procedure which has long been a mainstay of prostate cancer treatment. The surgery removes the entire prostate gland including the attached seminal vesicles (a gland which helps make and store semen). Lymph nodes located near the prostate may also be removed during the operation depending on each patient's clinical information.
After removing the prostate, the bladder must be re-connected to the urethra (tube that drains urine through the penis) to re-establish continuity of the urinary tract. A catheter is placed at the end of the operation to allow for healing of this connection and must remain in place for around a week for proper healing to occur.
What is Robotic Assisted Laparoscopic Radical Prostatectomy (RALRP)?
The traditional surgical approach to radical prostatectomy was performed by making a large incision either on the lower abdomen or below the scrotum. We can now perform this operation via a minimally invasive approach called robotic-assisted laparoscopic surgery or RALRP.
During a robotic prostatectomy, the surgeon makes 5-6 small keyhole incisions in the abdomen to remove the prostate with great precision. Miniaturized instruments passed through these small incisions are attached to robotic arms, and movements of these arms are controlled by the surgeon sitting at a console near the patient.
One of the instruments is a three-dimensional scope giving the surgeon a magnified view of delicate structures surrounding the prostate gland (such as nerves, blood vessels, and muscles). This allows for optimal preservation of these vital structures. Robotic prostatectomy has become the most common approach to radical prostatectomy, with nearly 90% of these operations performed using this advanced surgical system.
What are the advantages of RALRP?
The design of the robotic surgery system allows for a greater range of motion and more precise movements than the human hand, which is important for preserving those vital structures near the prostate.
There are significant advantages to removing the prostate robotically as compared to the open approach, including less blood loss and pain, shorter hospital stays (usually no more than one night's stay in the hospital), and faster recovery times.
What are the risks of RALRP surgeries?
The risks are similar to those of any surgical procedure, including bleeding, infection at the surgical sites, and adjacent tissue/organ damage. However, recent studies have revealed fewer complications such as blood clots, urinary tract infections, and development of internal scar tissue compared to open surgery.
What are the common side effects?
The two most common side effects of radical prostatectomy that most guys want to know about are urinary incontinence (leakage of urine) and erectile dysfunction (ED).
Leakage of urine can range from mild to severe but generally improves over time. The most common type of incontinence is called stress incontinence. This occurs because the muscle that squeezes the urethra to keep urine in the bladder has been weakened or injured. As a result, urine may leak out when you cough, laugh, sneeze, exercise, lift heavy objects, or stand from a sitting position.
ED, or impotence, is the inability to achieve an erection for sexual activity. This can result from injury to nerves or blood vessels that supply blood to the penis, but often is intensified by pre-existing medical conditions in the patient. Return of erectile function is based on the patient's age, pre-operative sexual function, and the ability to preserve the nerves during surgery. During surgery, a nerve-sparing approach can be utilized to improve the success of erectile function unless cancer is suspected in the nerve tissue. Your surgeon will determine if nerve-sparing is possible.
How are side effects managed?
There are ways to manage these side effects after prostate surgery, although it is important to remember that these side effects generally improve over time.
Kegels are pelvic floor exercises that help reduce urine leakage from stress incontinence. I encourage patients to begin these exercises prior to surgery and resume these exercises once the catheter is removed. With time and consistency in performing these exercises, you will see improvement in just weeks, although full recovery usually takes several months. Pelvic floor physical therapists are also available to help with recovery of your muscle control if necessary.
Regaining erectile function is possible but takes time. Managing ED could include the use of oral medications, penile injections, use of a vacuum assisted device, prosthesis or implant. Well-established protocols for penile rehabilitation have been established and are recommended for all patients interested in recovery of sexual function.
What happens after surgery?
After surgery, a pathologist will examine the prostate (and lymph nodes if also removed) under the microscope to determine a final grade and stage. These results are used to determine if further treatment could be needed.
Patients are expected to follow up at regular intervals for symptom-monitoring and PSA blood tests. The PSA is the easiest method to monitor for cancer recurrence. At these appointments, being open about any symptoms or side effects helps your doctor find the best treatment to make you comfortable.
Survivorship is an important part of your cancer care. Our cancer survivorship team will help guide you through life after treatment. At your survivorship appointment, a nurse practitioner will review an individualized care plan with diagnosis information, treatment summary, recommended follow up, any late effects of treatment, and preventative care recommendations. Your survivorship team does not replace your surgeon, but rather provides an extra layer of support.
Is prostate surgery right for me?
Being well informed about all treatment options before deciding about your cancer care is highly encouraged. Patients with questions about current treatment plans or those interested in a second opinion will benefit from The Christ Hospital's Prostate Cancer Collaborative.
During this specialized appointment, the patient and family member or caretaker meets with three prostate cancer specialists – a physician from urology, radiation oncology and medical oncology, along with our nurse navigator. The team will review your medical records ahead of time and will answer any questions, address concerns, discuss your diagnosis, and provide treatment options and recommendations.
Second Opinion Clinics are held on the second Monday of each month. To schedule an appointment, please call our prostate cancer nurse navigator, Amber Michael, at 513-585-3138 or email firstname.lastname@example.org