What is a radical prostatectomyAre there different types

Cliff's comment:

It has been 10 years since my radical prostatectomy, and I feel great. I am doing all of the things that I had done before the surgery and more. So far, my PSA has remained unde-tectable, and it is very reassuring to hear this at my urology clinic visits.

Radical prostatectomy is the surgical procedure whereby the entire prostate is removed, as well as the seminal vesicles, the section of the urethra that passes through the prostate, the ends of the vas deferens, and a portion of the bladder neck. After the prostate and surrounding structures are removed, the bladder is then reattached to the remaining urethra. A catheter, which is a hollow tube, is placed through the penis into the bladder before the stitches that attach the bladder to the urethra are tied down. The catheter allows urine to drain while the bladder and urethra heal together. In open radical prostatectomy a small drain is often placed through the skin of the abdomen into the pelvis. This drain allows for drainage of lymph and urine that may occur during the first few days after the surgery. This drain is removed when the fluid output decreases. At the time of radical prostatectomy, depending on the approach used, the pelvic lymph nodes, which are a common location of prostate cancer metastases, may also be removed (see

Radical prostatectomy is the surgical whereby the entire prostate is removed, as well as the seminal vesicles, the section of the urethra that passes through the prostate, the ends ofthe vas deferens, and a portion ofthe bladder neck.

Catheter

A hollow tube that allows for fluid drainage from or injection into an area.

Question 12). A radical prostatectomy may be performed via three different approaches. A common form is the open retropubic approach, in which an incision is made that extends from the umbilicus (belly button) to the symphysis pubis (pubic bone) (Figure 9). The radical prostatectomy may also be performed laparoscopically through several small incisions made in various locations in the abdomen (Figure 11), or through a perineal approach, with the incision being made in the area between the scrotum and the anus (Figure 10). More recently, the radical prostatectomy may be performed with the use of a robot, robotic-assisted radical prostatectomy, which has quickly become the most popular technique for radical prostatectomy.

Radical prostatectomy differs from a transurethral resection of the prostate (TURP) and an open suprapubic prostatectomy in that the entire prostate is removed in a radical prostatectomy. Therefore, unlike TURP and open suprapubic prostatectomy, the PSA should decrease to an undetectable level within a month or so after the procedure if no prostate cancer cells are present.

The decision as to what approach will be used for a radical prostatectomy depends on your urologist's preference and skills, your body characteristics, and whether a pelvic lymph node dissection is planned.

An advantage of the retropubic approach is that it allows for easy access to the pelvic lymph nodes so that a pelvic lymph node dissection can be performed easily at the same time. In addition, the blood vessels and nerves that control your potency are visualized easily. A disadvantage of this procedure is the abdominal incision, which may lead to a longer recovery time and increased discomfort and a higher blood loss compared to laparo-scopic and robotic-assisted radical prostatectomy.

The perineal prostatectomy does not involve an abdominal incision, is reported to be less uncomfortable and the recovery period shorter. The perineal approach allows for good visualization of the outlet of the bladder and the urethra for sewing the two together; however, the nerves that control potency are not seen as easily as with the retropubic approach. Another disadvantage of this procedure is that it does not allow for removal of the pelvic lymph nodes through the perineal incision and would require an additional incision for the pelvic lymph node dissection. This procedure is best suited for overweight men, for whom the retropubic approach is more difficult.

Laparoscopic radical prostatectomy is a procedure that has the advantages of the retropubic approach but, because there are several small abdominal incisions as opposed to the longer midline incision, the discomfort is less and the recovery is quicker with this approach. The disadvantage of this procedure is that it is relatively new and requires a urologist with advanced skills in laparoscopy. It may take longer to perform than an open radical retropubic prostatectomy. The outcomes of laparoscopic prostatectomy, such as urinary incontinence, erectile function, and positive margin rates are similar to open surgery. Robotic-assisted radical prostatectomy has surpassed laparoscopic radical prostatectomy in terms of the number of procedures being performed.

Robotic-assisted prostatectomy is the newest form of minimally invasive surgery for prostate cancer. The procedure is performed using a three-armed robot. The robot is controlled by the surgeon, who sits at a specialized desk and controls movement of the robot's arms. Advantages of robotic-assisted prostatectomy are its ease of use compared to laparoscopy and the surgery

Perineal prostatectomy

Removal of the entire prostate, seminal vesicles, and part of the vas deferens through an incision made in the perineum.

Laparoscopic radical prostatectomy

Removal of the entire I prostate, seminal vesicles, and part of the vas deferens via the laparoscope.

The perineal prostatectomy does not involve an abdominal incision, is reported to be less uncomfortable and the recovery period shorter.

Laparoscopy

Surgery performed through small incisions with visualization provided by a small fiberoptic instrument and fine instruments that fit through the small incisions.

Positive margin

The presence of cancer cells at the cut edge of tissue removed during surgery. A positive margin indicates that there may be cancer cells remaining in the body.

Robotic-assisted radical prostatectomy

A radical prostatectomy performed with the assistance of a robot.

Laparoscopic

Performed with a laparoscope.

Nerve-sparing prostatectomy

Form of radical prostatectomy whereby an attempt is made to spare the nerves involved in erectile function.

Dissect

The surgical removal of tissue.

tends to be quicker as compared to laparoscopy. In addition, the arms of the robot have movements similar to a human arm/hand/wrist, but the tremors that may be present with human movements are controlled. A disadvantage of the robot is the expense of the robot, so not all hospitals can afford to purchase one. The outcomes with the robot are similar to those of laparoscopic and open radical prostatectomy; however, long-term outcomes are limited for the robot and are limited for laparoscopy (Figure 12).

What is a nerve-sparing radical prostatectomy?

The nerves responsible for erectile function run along each side of the prostate and along each side of the urethra before passing out of the pelvis into the penis. These nerves travel along with blood vessels, and the group is called the neurovascular bundle, which lies outside of the prostate capsule. These nerves are not responsible for control of urine, only erectile function. During a nervesparing prostatectomy, the urologist attempts to dissect the neurovascular bundle from the prostate and the urethra. The surgeon may perform a bilateral nervesparing radical prostatectomy, in which the neurovascu-lar bundle on each side is spared, or a unilateral nervesparing prostatectomy, in which one neurovascular bundle is removed with the prostate. The decision of whether or not to perform a nerve-sparing radical prostatectomy depends on many issues, one of which is your erectile function. If you already have erectile dysfunction, then sparing the nerves is not an issue. Other considerations include the amount of tumor present in your biopsy specimen, the location of the tumor (whether it is in both sides of the prostate), and the Gleason score. Remember that a radical prostatectomy is a cancer operation, and the goal of the procedure is to try to remove all of the cancer. Therefore, if you are at high risk for having cancer at the edge of the prostate, it is better to remove the neurovascular bundle(s) and surrounding tissue on that side in hopes of removing all of the cancer. A bilateral nerve-sparing radical prostatectomy does not guarantee that you will have normal erectile function after the surgery. You should consider this fact and decide before surgery how much of an impact postoperative erectile dysfunction would have on your life.

What is the success rate of radical prostatectomy?

In general, more than 70% of properly selected patients (i.e., men who are believed to have prostate cancer that is clinically confined to the prostate) remain free of tumor for more than 7 to 10 years. If one has a T2 tumor, the probability of remaining free from PSA elevation can be as high as 90% if there were no positive margins. However, it is hard to predict before surgery who is the best candidate for surgery because 30 to 40% of patients are diagnosed with a higher stage or grade of cancer when the surgical specimen is reviewed by the pathologist. Positive surgical margins are found in 14 to 41% of men undergoing radical prostatectomy, and in those men with positive margins, there is an almost 50% chance that the PSA will increase within 5 years after surgery. This varies with the amount of tumor at the margin and the location of the positive margin. Your urologist would discuss whether additional therapy is indicated if the margin is positive. Men with negative margins have only an 18% chance of the PSA rising at 5 years after surgery. Initially after surgery, you will have your PSA level checked every 3 months. Depending on the lab that your physician uses, a PSA level < 0.1 ng/mL or a PSA level < .02 ng/mL may be reported as undetectable. The numbers vary because the sensitivity in PSA testing varies from lab to lab. If the PSA remains undetectable after 1 year, then your urologist may order PSA testing every 6 months for about 1 year, after

Sensitivity

The probability that a diagnostic test can correctly identify the presence of a particular disease.

which you will continue with yearly PSA tests. Depending on your pathology report and your urologist's preference, you may also have a digital rectal examination at the time of your PSA.

Cliff's comment:

The first PSA test after surgery is the most suspenseful. Even though your urologist may tell you that your pathology specimen from surgery looks good and that there are no cancer cells at the the edges of the tissue, you are still anxious to hear what the PSA is. You want it to be undetectable—want it to indicate that the cancer has been caught and removed. You get your blood drawn and then you wait to meet with your urologist or for the phone call regarding your results. I remember how happy I felt when I got my first PSA report after the surgery. Now, 21/2 years later, I am still slightly anxious when I have my PSA drawn, although as each year goes by the anxiety is decreasing. With each good PSA result, I start to believe that they've gotten it all. I can technically say that I am cured, but each year that goes by that I am healthy and the PSA remains undetectable is another year enjoyed and another closer to that goal.

Who is a candidate for radical prostatectomy?

The ideal candidate for a radical prostatectomy is a man who is believed to have prostate cancer that is confined to the prostate gland, is healthy enough to withstand the general anesthesia and the surgical procedure, and is expected to live for at least an additional 7 to 10 years so that he will benefit from the surgery. It is difficult to determine who really has organ-confined disease, which is cancer that is apparently confined to the prostate. Tables may help estimate the risks of having tumor outside of the prostate, but these are only part of the decision making process. Approximately 20 to 60% of men undergoing radical prostatectomy have a higher stage of prostate cancer when the pathologist reviews the surgical specimen.

Just because you are a candidate for a radical prostatectomy does not mean that this is the best form of treatment for you. You must look carefully at your lifestyle, the risks of the surgery, and what is most important to you regarding your quality of life before making a decision. If, for example, the possibility of urinary incontinence would be devastating to you, then maybe surgery is not the best therapy for you. On the other hand, if the idea of leaving your prostate in place will constantly worry you, then perhaps surgery is best for you.

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