Surgery Overview

• Retropubic approach: The prostate gland is removed through an incision in the lower abdomen. Recovery time after this surgery may be longer than after perineal surgery. The pelvic lymph nodes may be removed and examined at the time of surgery (pelvic lymph node dissection). Retropubic prostatectomy is the most widely performed treatment for prostate cancer.
• Perineal approach: The prostate gland is removed through an incision between the rectum and base of the penis. The recovery time after this surgery may be shorter. Examination of the pelvic lymph nodes must be done in a separate surgery. In some cases, when the lymph nodes are believed to be free of cancer based on the grade of the cancer and results of the PSA test, the lymph nodes may not be sampled.

• Laparoscopic radical prostatectomy sometimes is used as an alternative to conventional (open) prostatectomy. It involves inserting a lighted viewing instrument (laparoscope) into the pelvic region and allows examination and removal of the prostate without a large abdominal incision. This technique may reduce complications during and after surgery. Laparoscopic prostatectomy is not yet widely available, and because it is a relatively new technique, no results from long-term follow-up after treatment are available.

Each type of surgery may be done as a nerve-sparing or non-nerve-sparing type of procedure.

• Nerve-sparing procedures are used to avoid damaging nerves that run alongside the prostate and control erection.
• Non-nerve-sparing procedures remove the entire prostate, the tissue surrounding it, and the nerves needed to get an erection.

• This operation offers patients with localized prostate cancer a potential cure;
• The indications for surgery remain the same as for Brachytherapy;
• The cure rate of 75% in ten years is noted in patients with a Gleason's Grade of 3 + 3 = 6 or less and a PSA of 10 or less and cancer localized to one lobe of the prostate;

An incision is made in the lower abdomen below the umbilicus and the nerves for erection are moved away from the prostate prior to removal of the prostate. Then the bladder exit is joined to the urethra so that the patient can pass urine normally.

After surgery, the patient may get mild to moderate stress incontinence i.e. there is some leakage of urine in coughing, sneezing or on standing up from a sitting position. A pad may be necessary for absorption of the urine. However, this usually resolves completely with exercises, anticholinergenics and time.

Patients may experience erectile dysfunction initially. This resolves in most cases and more so in younger men i.e. in their 50’s. However, tablets and injections can assist in obtaining a full erection.

There is no ejaculate after surgery since the prostate is removed and so one cannot father a child after surgery. Blood loss is usually well controlled and patients can donate their own blood if they wish.

The advantages of Radical Nerve Sparing Prostatectomy are that patients with a poor urinary flow or unable to pass urine (retention) get a very good relief with this operation. Patients with prostates greater than 60 cc choose this option.

The prostate specific antigen (PSA) drops to 0-2 ng/ml or less within 2 weeks of surgery. The prostate is sent to histology testing which gives an accurate grade and an idea of the extent and possible invasion of the capsule.

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