Radical prostatectomy

A radical prostatectomy is one option to treat prostate cancer, involving surgery to remove the whole of the prostate gland.

Laparoscopic radical prostatectomy (LRP) is a keyhole operation performed through several small cuts in the stomach during which the whole of the prostate, the tumour within it, and the seminal vesicles, the small organs used to store sperm, are removed. Following this procedure, the bladder is joined back to the urethra (water pipe).

It is also sometimes necessary to remove some lymph glands - the small pieces of tissue found all over the body whose role is to filter tissue fluid, or lymph, to monitor for infection. Your specialist will decide whether to remove lymph glands if they think there is any chance cancerous cells have spread to them. The removal of lymph glands won’t leave you at a disadvantage since you have hundreds of others all over the body to make up for the small number that you lose.

The prostate is a small gland located below the bladder, and wrapped around the urethra (water pipe). It manufactures some of the semen in the male body, and probably has a significant role in making a man fertile. As men age, the prostate gets larger which can make urinating difficult. The symptoms of prostate cancer may also include difficulty in urination or high levels of prostate-specific antigen (PSA) in the bloodstream.

In an LRP, 4-6 small incisions of 1-1.5cm are made in the patient’s stomach. The abdominal wall is punctured and the abdominal cavity is expanded with carbon dioxide gas. Long, thin tools are placed inside the cuts, and a thin tube containing a video camera (a laparoscope) is inserted in one of the cuts so the surgeon can see the prostate gland. The surgeon is guided in the operation to remove the prostate and seminal vesicles by a magnified image on a computer monitor. Following this, the bladder is reconnected to the urethra (water pipe) – a process known as an anastomosis.

An LRP is suitable for patients who have early stage prostate cancer, in which it is believed the cancer hasn’t spread to other parts of the body.

The traditional procedure to remove the prostate is an open prostatectomy through a single cut in the lower abdomen (in some hospitals this remains the only option). Other options to treat prostate cancer include brachytherapy – a kind of radiotherapy where radioactive pellets or wires are inserted into the tumour – and exposing the tumour to external beam radiation.

A laparoscopic radical prostatectomy is less invasive than the traditional open prostatectomy, which involves a 4-6 inch cut in the lower abdomen below the belly button. Men recover more quickly than with the open technique, typically spending just one day in hospital compared to three, and getting back to normal activities more quickly.

An LRP offers better cancer control, with less residual tumour and need for radiotherapy to suppress secondary tumour formation, less blood loss and less post-operative pain, with the small incisions normally resulting in the need for only simple analgesics such as paracetamol and diclofenac. It also carries a lower risk of complications and of long-term side effects, such as urinary incontinence and a loss of erections, than the open procedure.

You will be admitted on the day of the operation. You will previously have had blood tests, heart tracing and chest X-rays in preparation for your surgery. You will meet with the anaesthetist to discuss options for pain relief, and your surgeon who will talk to you again about the operation and offer you the chance to ask questions. Before going to the operating theatre, you will be given some stockings to wear, to reduce the chance of deep vein thrombosis (blood clots) developing during the operation.

You may have several tubes in place following an LRP:

  • A catheter which usually stays in for 7-10 days, but sometimes remains in place for up to 3 weeks
  • A drip in your arm to provide you with extra fluids
  • In some cases, a drain into the operation site

You can eat and drink as soon as you have fully recovered from the anaesthetic. You will be encouraged to get out of bed and walk around on the morning after the operation.

Returning home is permitted when you are eating, drinking and walking around without problems, which in most cases will be the day after surgery.

Pain is not usually a problem after keyhole surgery such as an LRP – most men just need tablet painkillers such as paracetamol and diclofenac. In some cases a PCA (patient controlled analgesia) system – a small device attached to the drip in your arm, allowing you to control the amount of painkilling drugs you receive – is needed for the first day after an LRP.

To close the wound, your surgeon will use dissolvable stitches and glue, so there are no stitches to remove. You may experience some discomfort from the wound for several weeks after surgery – if this happens, use simple painkillers (eg paracetamol or ibuprofen) as needed.

So long as you are careful with the wound, you can bath and shower as normal. It is safe to get the wound wet within a few days of the operation, but do avoid using scented soaps, creams and talc around the wound or catheter.

If your catheter becomes blocked or falls out, don’t allow anyone else to insert a new one or flush it out. Contact the Circle hospital where your LRP was performed and we will arrange for you to come in to sort the problem out.

While you should be back to most normal activities within a week or two of the operation, you should avoid intensive exercise, heavy lifting or straining for four weeks.

You won’t be able to drive again until you’re confident you can make an emergency stop – usually at least two weeks after the operation. Check with your car insurance company before you start driving again.

When you have your catheter in position, you should drink more than normal – 2-3 litres a day – to help prevent urinary infections and to flush out any bleeding. You might find caffeinated drink, alcohol and fizzy drinks aggravate the bladder so are best avoided (the odd glass of wine or beer will do no harm). Cranberry juice reduces the risk of urinary infections.

One or two weeks after the operation, you will go back to hospital for the removal of your catheter. You will be shown how to use pads, the pathology results from the operation will be reviewed with you and you will be taught how to perform pelvic floor exercises. You can return home the same day.

Mild discomfort, numbness or tightness around the scars is normal – this could last for months but will disappear with time. It is also normal to feel tired and lacking in energy after the operation. This can often be the last side-effect to disappear fully.

Most men regain their urinary continence quickly. It is important to keep doing pelvic floor exercises. Talk to your Nurse Specialist or Consultant if continence continues to be a problem.

It is normal for most men who have undergone an LRP to be impotent for some time after their operation. This can be overcome with a tablet, injection or vacuum pump. You should then be able to continue your sex life, although the sensation of orgasm may feel different and you will be unable to ejaculate.

Following your operation, we will see you in the outpatient clinic to monitor your PSA levels and check your progress. When we are confident your PSA level is stable, and you’ve had no ongoing problems for the previous three or six months, we will discharge you to your GP. Most men in this situation will need regular PSA tests for the rest of their lives.

Common side effects include:

  • The majority of patients will experience some leakage of urine after surgery, but this lessens over time, and most men regain control of their urination within a time frame of up to one year. Doing regular pelvic floor exercises speeds up the process. Around one in 30 men will be left with some degree of permanent leakage, but this is usually minor and can be managed effectively with pads. The greater risk is with an open prostatectomy. Around one patient in 100 will have severe leakage and may need further surgery to correct this.
  • When the prostate is removed, the nerves which cause erections are very often damaged since they run close to the prostate. In most cases, a “nerve-sparing” keyhole operation can be performed as part of an LRP, by carefully dissecting the nerves away from the prostate before its removal. This is not possible in all men, as sometimes retaining the nerves can risk leaving part of the cancer behind. Your doctors can give you some idea about whether they will be able to preserve the nerves or not before surgery, but the final decision is made during the operation.
  • Blood loss is a frequent problem during an LRP, and a blood transfusion is sometimes necessary after surgery.

Less common side effects:

  • In around one man in 50 who has an LRP, scar tissue can form at the join where the bladder is sewn back on to the urethra, called the bladder neck. This causes a blockage to the flow of urine called a bladder neck stricture, and usually requires a small additional operation done through a telescope to put right.

    This problem can sometimes recur after the corrective surgery. If this happens, your doctors may teach you a technique called “intermittent self-catheterisation”, which entails putting a small tube up the urethra (water pipe) several times each week to stop scar tissue from developing.
  • Shortening of the penis. Some men notice their penis is shorter after the operation. The reasons for this are unclear – it may be due to the surgery itself or possibly because of lack of erections afterwards. The shortening is typically not severe and sometimes improves over time.
  • Around 3 in every 100 men who have had an LRP will develop a hernia (a lump on the groin) within a year of the surgery, requiring another small operation to remove it.

Rare side effects:

  • Rectal injury. The prostate is close to the rectum, which in rare circumstances may be damaged during LRP surgery. If this happens, it can usually be repaired during the operation, but there may be a need to form a temporary colostomy bag to allow the injury to heal.
  • Risks from lymph node dissection. In cases where men having an LRP also have their lymph nodes removed, this can result in a build-up of fluid in the groin. This may be uncomfortable and require a small operation to drain the fluid. In rare circumstances, removing lymph nodes can damage the obdurator nerve which controls some of the hip muscles, leading to some leg weakness.
  • Damage to the ureter tube (which carries urine from the kidney to the bladder). This occurs in fewer than one in every 100 men having an LRP, and can be repaired during the operation if it is spotted straight away. If the injury is only recognised after surgery, a second operation may be needed to fix it.
  • A side-effect caused by the stress of surgery or the anaesthetic, such as a deep vein thrombosis (a blood clot in the leg), which breaks off and travels to the lung. This can make you seriously unwell and cause long-term health problems. Other examples of LRP side-effects, which occur very rarely, include stroke, heart attack and serious infection.

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