Radical Prostatectomy &,,,, Lymph Node Dissection
When prostate cancer is estimated that is located inside the organ then the surgical management of the disease is called radical prostatectomy with lymph node dissection. This is the surgical removal of the whole prostate, the seminal vesicles, and the surrounding tissue and of the lymph nodes and the suturing of the bladder to the urethra.
When a considerable amount of aggressive prostate cancer is diagnosed in both lobes of the gland, then it seems that is a good choice that provides a high rate of cure for the patient.
Advantages of this operation
- After the histological report we can really state with accuracy the stage and the grade of the disease (extension and aggressiveness).
- If it appears that the cancer was organ confined then we could start talking about high rate chances of cure.
- As usually elderly males have some degree of blockage of the urine outflow this also gets fixed with this operation.
- Usually the PSA levels drop very low post-op so, we can always follow-up the evolution with blood samples.
There are several points of technique mainly aiming to preserve early continence and sexual function if necessary, the author prefers:
- In case of open retropubic approach the: Christian Barré – Philippe Chauveau as it provides early removal of the catheter and continence with excellent rates of erectile preservation if nerve sparing is performed.
- In case of laparoscopic robotically assisted approach the: extraperitoneal King’s College technique (by Philippe C.R. Grange) (link: Kings Hospital Pioneers) that is a laparoscopic variation of the previous one. It comes in two variations: traditional 4 port laparoscopy (left) and single port (right) (kings journal ).
The benefits of the laparoscopic approach over the open one are:
- Excellent functional results, we do not only remove the gland and the lymph nodes but we also can guarantee excellent and early recovery of continence and of the erections. Laparoscopy gives the surgeon the opportunity to have the visual field at a magnification of 10-15 times which is much more than the traditional eye-loop systems used in open surgery. The delicate tissues such as the external sphincter, nerve fibres, the rectum, that are responsible for continence, erections, etc can be recognized and spared.
- The anastomosis between the urethra and the bladder is performed under direct visual control and this also contributes to the early restoration of continence.
- The “surgical trauma” delivered to the tissues is much less than open surgery.
- Less post-op pain.
- Shorter hospitalization time and less hospitalization cost.
- Quick recovery and short convalescence time, the patient can go back to his normal life-style before the removal of the catheter.
- Less blood loss and decreased possibility of getting a transfusion.
- Better aesthetic result as especially the single port approach is virtually scar-less as the incision is performed through the belly button.
They are performed with the robotically guided camera arm Freehand™ of Prosurgics® that was developed at King’s College Hospital and gives the same benefits of bigger and more costly systems when combined with experience in laparoscopy.
The benefits are exactly the same as above plus the fact that they contain the cost within a very reasonable threshold. The instruments are less expensive than other robotic systems as they are not necessary due to the personal experience built over the last years. Mastering of these techniques help the author to easily overwhelm what for others is considered a “limitation of laparoscopy” (lack of 3D vision, rigid instruments).
Complications of this operation
The complications of open or laparoscopic robotically guided radical prostatectomy are: skin wound complications, infection, trauma to adjacent organs (ureter, ureteric orifice, rectum, vessels, obturator nerve, etc), bleeding, incontinence, impotence, leak of urine from the anastomosis, deep vein thrombosis and also lymphocele in case of extensive lymph node dissection.
The main care is to prevent any non desirable incident regarding the catheter such as pulling it away. As the anastomosis of the urethra to the bladder is healing around this tube we have to reassure that it will stay clean and in place.
At the same time, the patient will be instructed to perform pelvic floor exercises in order to re-train the sphincters and gain early continence once the catheter will be removed. This helps the sphincter to continue functioning and recover soon after the operation which will contribute to the quality of life post-op.
Also, further instructions will be given for re-training of the erectile structures no matter if nerve sparing was performed or not. This will contribute significantly to gain potency once the catheter will be removed. Although we tend to perform nerve sparing operations if indicated, we cannot predict how long it will take to have again spontaneous erections. Further consultations might be necessary in order to assist the patient to gain potency and orgasm.
Once the catheter is removed, the first appointment is in 1 month with a PSA measurement and in order to have a physical examination and discuss the histology report and have a precise plan for the future. Usually, this is PSA measurements and repeated physical examinations. It is rare to need further adjuvant treatment such as local radiotherapy but it might be necessary in selected cases. The follow-up plan might also require some extra investigations.