One surgical approach to treating prostate cancer is to remove the entire prostate and seminal vesicles. Other surgical procedures may be performed on men with advanced or recurrent disease, such as removal of Lymph Nodes, which are the initial landing spots for the spread of prostate cancer.
The most common type of Prostatectomy is robotic radical prostatectomy, which requires small incisions to be made in the abdomen by the surgeon. With a robotic interface, the surgeon then controls the robot’s arms, which in turn control the cameras and instruments. Robotic surgery has become very popular over the past 10 years due to the smaller incision and shorter post-operative recovery period (typically 1-2 days).
Although robotic surgery creates much smaller incisions than classical open surgery, there is still a large surgery occurring inside the body. For this reason there is an important healing process that must occur post-operatively. After the usual 1 to 2 night stay in the hospital, patients typically go home with some form of catheter to help drain urine for 7-10 days. The initial weeks to months after surgery it is expected and common to have incontinence or leakage of urine and you will need to wear diapers or pads, but this generally improves significantly over the first year following surgery. During the first ~2 months after surgery exercise, golf, and most physical activities are prohibited while the abdominal muscles heal from the incisions.
Other therapies that can be given in conjunction with surgery:
- Hormone therapy: This is rarely used with surgery today, and if your surgeon recommends you start hormone therapy you should inquire the purpose. Multiple clinical trials have been performed that have largely not demonstrated a benefit of using hormone therapy with surgery. One exception is in men with lymph node positive disease.
- Adjuvant radiation therapy: For men with high risk prostate cancer (PSA >20, grade 4 or 5, or T3 disease) have a high probability that their cancer has penetrated through the prostate capsule (also called stage T3 disease) and more frequently have positive margins after surgery (tumor extended all the way up to the edge of what was removed). In men with either T3 disease or positive margins the AUA, ASTRO, and ASCO recommend that these men be offered adjuvant radiation therapy (radiation soon after surgery). This is because 3 large trials showed that men recurred twice as often after surgery alone compared to those who received surgery with adjuvant radiation therapy. Unfortunately, despite national guidelines, the majority of men with these adverse features after surgery are not referred to a radiation oncologist to discuss adjuvant radiation therapy. You should take charge of your care and ask your Urologist to setup a consultation with a radiation oncologist to see if adjuvant radiation therapy is necessary. As always, a balance of cure and quality of life must be had to avoid under or overtreatment. Some radiation oncologists may prefer to closely observe you despite having these risk factors to allow more time to heal after surgery.
In a nerve-sparing prostatectomy, the surgeon cuts to the very edges of the prostate, taking care to spare the erectile nerves that run alongside the prostate. Sometimes the nerves cannot be spared because the cancer extends beyond the prostate requiring a more extensive resection.
Surgeons won’t know until the time of the procedure if nerve-sparing is possible; it depends on whether the cancer is invading the nerves. However, the nerve-sparing procedure offers the best chance to preserve long-term erectile function.
The Importance of Surgical Skill
Prostatectomy, like many surgical procedures, is very delicate work, and the difference between a good surgeon and a great surgeon can affect outcomes.
When choosing a surgeon, at a minimum, ensure that he or she is someone in whom you have confidence and trust, and someone who has enough experience to not only perform the operation, but also to make an informed clinical judgment and change course if necessary. As many studies have shown, surgeons who are at the top percentiles of prostatectomies performed have the best outcomes.
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