Radical Prostatectomy is a surgical operation which is meant to remove the entire prostate gland along with some tissue surrounding it. This procedure is commonly performed for removal of prostate cancer. Radical prostatectomy operation can either be performed by open surgery or may be done using laparoscopic surgery involving small incisions. Laparoscopic prostatectomy surgery can either be done through the traditional method by hand or like now some surgeons are applying guiding robotic arms which hold the surgical tools. This newly developed technique is known as Robot-Assisted Prostatectomy.
What is Prostatectomy?
Prostatectomy basically is a surgical procedure which is designed for partial or complete removal of prostate gland. It is normally performed as a treatment procedure for benign prostatic hyperplasia or prostate cancer. Common surgical approach for prostatectomy includes making a surgical incision for approach & removing the entire prostate gland or part of it. This goal may be accomplished through two methods, the suprapubic or retropubic incision within the lower abdomen or a perineum incision which is made through the skin between rectum & scrotum. It is quite often necessary to undergo a prostate biopsy before taking up prostatectomy surgery.
What is a Prostate Gland?
Prostate gland is just about the size of a walnut & surrounds the neck of bladder & urethra in men. Urethra is the tube which carries urine from bladder through penis. Prostate is part muscular & part glandular with ducts that open into the prostatic portion of urethra. Basically made up of three lobes, prostate has a central lobe & two others on each side. Working as part of the male reproductive system, primary function of the prostate gland is to secrete a slightly alkaline fluid which forms part of the seminal fluid carrying sperms from the testicles. The muscular portion of prostate gland helps propel prostatic fluid during the male orgasm in addition to sperms which travel into the urethra. Semen subsequently jet through the tip of penis during ejaculation. However, researchers still do not know all the functions of prostate gland. Nevertheless, prostate gland plays a significant role in both, urinary & sexual functions. It is commonly found that prostate glands enlarge as men age & are more likely to cause some type of prostate problem during their lifetime. Many common problems associated with prostate gland occur in men of all ages; however, most do not require radical prostatectomy.
Problems Associated with Prostate Gland
- BPH or Benign Prostatic Hyperplasia – This is basically an age related enlargement of prostate gland which is not malignant. One of the most common noncancerous problems of the prostate gland, BPH occurs in most men by the time they reach 60 years of age. BPH signs & symptoms include a weak, slow or interrupted urinary stream, urgency with dribbling or leaking & frequent urination which is mostly at night time. Although BPH is noncancerous, signs & symptoms are most often quite similar to those of prostate cancer.
- Prostatism – This problem involves decrease in urinary force which is due to obstruction of flow through prostate gland. However, the most common cause of prostatism is BPH itself.
- Prostatitis – it is infection or inflammation of the prostate gland which is characterized by pain, discomfort, frequent or infrequent urge to urinate along with fever sometimes.
- Prostatalgia – Also called Prostatodynia, this involves pain within the prostate gland. Prostatalgia is frequently a symptom of prostatitis.
- Prostate Cancer – Cancer of prostate is a very common & serious health concern nowadays. It is also one of the most common cancers found among men older than 50 years of age & the third leading cause of death from cancers.
Types of Prostatectomy Treatments
There are many different ways of removing prostate gland when it is diseased with cancer. Prostatectomy methods include the following.
- Radical Prostatectomy or RP is a procedure for surgical removal of prostate gland with either a perineal or retropubic approach. Radical prostatectomy basically involves removing the entire prostate gland. Nerve-sparing surgical removal is an associate procedure where it is important to preserve as much function as it is possible.
- Transurethral Resection of prostate gland or TURP is another procedure which involves removal of part of prostate gland. It is an approach which is performed through penis with help of an endoscope. Endoscope is a small & flexible tube which holds a light & a lens at the end. TURP procedure does not cure prostate cancer but can however remove obstructions while doctors plan for a definitive treatment.
- Laparoscopic Radical Prostatectomy is a surgical procedure which is either done manually or by a robot. This is another method which is suitable for removal of prostate gland.
Methods of Radical Prostatectomy Surgeries
Traditional Open Surgery – Surgeons make a large incision in traditional open surgery so as to reach the prostate gland. This incision is made either in the perineum between anus & scrotum or in the lower belly depending upon the merits of the case. It is called a retropubic approach when incisions are made in the lower belly. Surgeons during this operation also remove the lymph nodes within the area so as to test them for cancer. It is called the perineal approach when incisions are made in the perineum during traditional open radical prostatectomy surgery. However, recovery time after perineal approach may be shorter than with the retropubic approach for surgery. However, in case surgeons want to remove lymph nodes for testing, they will need to make a separate incision along with the perineal approach. Surgeons may not remove lymph nodes at times when lymph nodes are understood to be free of cancer based upon the results of PSA test & grade of cancer.
Different Approaches for Radical Prostatectomy
There are several approaches to radical prostatectomy which are mentioned below.
- Radical Prostatectomy with Retropubic (Suprapubic) Approach – This is one of the most common surgical approaches which is used by doctors specializing in diseases & surgery of the urinary tract. Surgeons will also remove lymph nodes from around prostate gland in addition to removing prostate gland in case they have reason to believe that cancer has also spread to the lymph nodes. Finding cancer within lymph nodes helps them make sure that cancer indeed has spread beyond the prostate gland. This surgery will be discontinued in such a case as it will not be able to adequately treat cancer at this stage. Additional treatments will be required in such a scenario. Retropubic approach also has a smaller & hidden incision for improved cosmetic effect while it can avoid major muscle groups at the same time. This also makes it less painful & requires lesser time for recovery.
- Nerve Sparing Prostatectomy Approach – It may not be possible to maintain structure or nerve function when prostate cancer is tangled with the nerves. Therefore, sometimes nerves are required to be cut in order to remove cancerous tissue. When both sides of nerves are removed or cut men will not be able to have erections any more. Although there are interventions which can restore erectile dysfunction, this will not improve itself over time without treatment. When only one side of the bundle of nerves is removed or cut, men may experience less erectile function as some function will still be intact. When neither nerve bundles are disturbed during surgery erectile function may remain normal as before. However, quite often it takes months after surgery to find out whether full recovery is possible. This is generally because nerves handled during surgery may not be able to properly function for a while after nerve-sparing prostatectomy surgery.
- Laparoscopic Radical Prostatectomy – Surgeons during this surgical procedure make several small cuts through which they insert thin & long surgical tools. They will then insert a thin tube with a video camera called laparoscope inside a cut which will eventually help them see the operation site during the procedure.
- Robotic-Assisted Laparoscopic Radical Prostatectomy – This surgical operation is done through small incisions made in the belly along with robotic arms which effectively translate surgeon’s hand motions into finer & perfectly precise action. However, this type of surgical intervention requires surgeons who are specially trained for the job.
- Radical Prostatectomy with Perineal Approach – Although used less frequently used than retropubic approach, since radical perineal prostatectomy cannot spare nerves nor can lymph nodes be removed through this surgical technique. However, the positive aspect is that it takes lesser time & therefore may be an ideal option if nerve-sparing approach is not required. Perineal approach is also appropriate when removal of lymph nodes is not required. It may also be utilized in case other medical conditions rule out possibility of using the retropubic approach.
Main purpose of either laparoscopic or open radical prostatectomy surgery is to remove all cancer in & around the prostate gland. This can at times mean removing prostate gland & the tissue surrounding it, including set of nerves connected to penis which affect ability of men to have erections. Moreover, some prostate tumors can also be removed using the nerve-sparing surgical technique. However, this requires careful cutting around the nerves so as to leave them intact. Nerve-sparing prostatectomy surgery is basically meant to preserve capability of men to have erections.
Why Undergo Radical Prostatectomy?
Main purpose of radical prostatectomy is to remove the entire prostate cancer. This procedure is utilized when cancerous cells are believed to be confined to the prostate gland. Prostate gland, along with some surrounding tissue including seminal vesicles, is removed through surgical intervention during this procedure. Seminal vesicles basically are two sacs secreting semen & which are connected to vas deferens. Vas deferens is a tube which runs through testicles.
Some other less common reasons for undergoing radical prostatectomy surgery include the following.
- Inability to empty bladder completely
- Recurrent bleeding from prostate gland
- Prostate enlargement with bladder stones
- Extremely slow urination
- Hydronephrosis – increased pressure on kidneys & ureters from urinary retention
- Various other reasons for which doctors recommend radical prostatectomy
Preparing for Radical Prostatectomy Surgery
There are some things radical prostatectomy surgery patients are expected to do before the procedure including the following.
- Doctors will invariably explain the procedure to radical prostatectomy patients & ask them if they have any questions regarding the surgical procedure.
- Patients will be asked to sign a consent form which gives the surgeon permission to undertake the procedure. Patients should read the form carefully & ask questions if something is unclear.
- Surgeons may perform a physical examination so as to ensure that patients are in good health before undergoing surgery. Apart from checking the complete medical history they may additionally ask patients to undergo blood tests & other diagnostic tests.
- Patients will be asked to fast for 8 hour prior to undergoing surgery, which is generally after midnight.
- Patients must notify surgeons if they are allergic or sensitive to any medications, iodine, latex, contrast dyes, tape & anesthetic agents, including both local & general anesthesia.
- Patients should notify surgeons of all medications they are taking (including both over-the-counter & prescribed) & herbal supplements.
- It would also be sensible of patients to let surgeons know if they have a history of bleeding disorders or if they are taking any blood-thinning (anticoagulant) medications like aspirin or other such medications which affect the capacity of blood to clot. It may also be necessary for patients to stop taking these medications before undergoing this surgical procedure.
- In case patients smoke, they will have to quit smoking weeks prior to the surgical procedure so as to improve their chances of successful recovery after surgery & to improve overall health.
- Patients may receive a sedative before undergoing the surgical procedure so as to help them relax during surgery.
- Surgeons may also instruct patients to undertake certain specific preparations based upon their medical condition.
Radical Prostatectomy Surgery Procedure
Although radical prostatectomy surgery procedures vary depending upon the patient’s condition & surgeon’s practice, it will invariably require them to stay in the hospital for some time. Retropubic or perineal approach of radical prostatectomy would generally follow the following process.
- Patients will be asked to remove all jewelry & other objects which may interfere with the working of the surgical procedure.
- Patients will also be asked to remove clothing & will instead be given a gown to wear.
- Patients will be asked to empty the bladder fully before commencement of the procedure.
- An IV (intravenous) line will be started on the patient’s hand or arm.
- Excessive hair at the incision site may be clipped off at the start of operation.
- Skin over surgical site will be cleaned with an antiseptic solution.
- An anesthesiologist will continuously monitor breathing, blood pressure, heart rate & oxygen level in blood during the surgical procedure.
- A breathing tube is inserted through throat into lungs & connected to a ventilator once patients are sedated. This will be the breathing apparatus for patients during surgery.
- Surgeons will either choose regional anesthesia or general anesthesia depending upon the merits of the case. Regional anesthesia is medication which is delivered through an epidural so as to numb the area which is to be operated. Patients will receive medication which will help them relax while analgesic medication is provided for relief from pain. Surgeons will however determine which type of anesthesia is most suitable in a particular situation.
- Catheter will be inserted into bladder of the patients so as to drain urine.
Retropubic or Suprapubic Approach Radical Prostatectomy
- Patients will be positioned lying on the back upon the operating table.
- Incision will be made below the belly button (navel) towards the pubic region.
- Surgeons usually perform the lymph node dissection first. Nerve bundles will then be carefully released from prostate gland & urethra, which is a narrow channel through which urine passes, will be identified.
- Seminal vessels will also be removed if required.
- Prostate gland will be finally removed along with some surrounding tissue.
- Drain, which is normally inserted, will be in the lower right area of the incision.
Perineal Approach Radical Prostatectomy
- Patients will be placed in the supine – lying back position in which knees & hips will be fully bent along with legs that are elevated & spread apart with feet resting on straps. Stirrups will also be placed under legs for support.
- An up-side-down U shaped incision is made within the perineal area, i.e. between the anus & scrotum.
- While approaching prostate gland surgeons will try to minimize trauma to nerve bundles within the prostate area.
- Prostate gland & abnormal looking tissue within the surrounding region will now be removed.
- Seminal vesicles, which are a pair of pouch-like glands located on either side of urinary bladder which secrete seminal fluid & promote movement of sperm into urethra, will also be removed in case there is concern about abnormal tissue within the vesicles.
Completion of Procedure for Both Methods
- Incision sites will be sutured on the completion of procedure.
- Dressing or sterile bandage will be applied at the incision site.
- Patients will be transferred from operation table to beds & will be taken to post-anesthesia care area for monitoring.
Radical Prostatectomy Aftercare
Patients are taken to the recovery room so as to be closely monitored following radical prostatectomy surgical procedure. Patients will be connected to monitors that will constantly display their blood pressure, heart beat & other pressure readings including oxygen level & rate of breathing. Patients may also receive pain medication as required during this time by a nurse through a device connected to the intravenous system. Once patients are awake & their condition has stabilized, they may start with consuming liquids. Diet may gradually be advanced to solid foods as their ability to tolerate improves. Drains are normally removed on the day following surgery. Activity of patients will gradually increase as they get out of bed & walk around for long periods of time. Urinary catheter will stay in place upon discharge & will stay in place for about 1 – 3 weeks following radical prostatectomy surgery. Patients will also be instructed as to how they should take care of catheter at home. They will also be instructed about the scheduled follow-up visits with the surgeon.
Recovery at Home Following Radical Prostatectomy Surgery
It will be very important to keep the surgical site clean & dry, once patients have reached home. While surgeons will provide patients with specific bathing instructions, surgical staples or sutures will be removed only during the follow up visit of the patient in case they were not removed earlier before leaving hospital. Surgical incision site may however be sore or tender for several days following radical prostatectomy surgery. Patients may take pain relievers for soreness as recommended by the surgeon. Radical prostatectomy patients should not drive until the doctors permit them to do so. Other restrictions of various other activities may also apply & they should therefore check with the doctors. Once catheter is removed, patients may have leaking of urine for some time & the length of time for which this occurs can vary from one patient to another. However, surgeons will provide them with suggestions for improving control on bladder. Patients & the physician will assess any side effects & work towards improving erectile dysfunction problems over the next few months. It would be sensible of patients to notify the surgeons if they face any of the following symptoms following radical prostatectomy surgery. Doctors may be able to give them some additional or alternative instructions which will depend upon the particular situation of each case.
- Chills and/or Fever
- Swelling, Redness or Bleeding or Additional Drainage from Incision Site
- Increase in Pain around Incision Site
- Inability to have proper Bowel Movement
- Inability to Urinate after Removal of Catheter
Risks Associated with Radical Prostatectomy Procedure
Certain complications can occur with radical prostatectomy as with all other surgical procedures. Possible complications resulting from radical prostatectomy surgery of both perineal & retropubic approaches include the following.
- Urinary Incontinence – This involves involuntary & uncontrollable leaking of urine which may improve over time. It may sometimes last even up to a year following radical prostatectomy surgery. This symptom quite often worsens among patients over 70 years of age when this surgery is performed.
- Urinary Dribbling or Leakage – At its worst immediately after surgery, this symptom will usually improve over time.
- Erectile Dysfunction – Recovery of sexual function usually takes about two years of time to complete following radical prostatectomy surgery. Nerve-sparing prostatectomy surgery however lessens chances of impotence but does not guarantee erectile dysfunction.
- Lymphedema – This is a condition where fluid accumulates in soft tissues & thereby results in swelling. Lymphedema can be caused by obstruction, inflammation or removal of lymph nodes during radical prostatectomy surgery. Even though this complication is rare, fluids may accumulate in genital region or legs over time if lymph nodes were removed during the surgical procedure. Swelling & pain may often result in such a condition but physical therapy is generally helpful for treating effects of lymphedema.
- Sterlity – Radical prostatectomy disrupts the connection between urethra & testicles & therefore causes retrograde ejaculation. This will eventually result in men being unable to provide sperms which are required for biological children. Although men may have orgasms without any ejaculate, thereby resulting in ‘dry’ orgasms.
- Change in Length of Penis – Very small percentage of radical prostatectomy are found to result in decrease of length of penis among patients.
Risks Associated with Anesthesia & Radical Prostatectomy Surgery
- Reactions to anesthesia & medications
- Difficulty in breathing
A specific risk which is associated with retropubic approach is potential for rectal injury which can eventually cause fecal urgency or incontinence. There may also be some other risks which will depend upon specific medical conditions of the patients undergoing radical prostatectomy. Patients should therefore make sure to discuss all concerns with surgeons prior to undergoing radical prostatectomy procedure.
Affordable Laparoscopic & Open Radical Prostatectomy Surgery in India
Any type of radical prostatectomy surgery for prostate cancer is a major operation which requires patients to be fit enough for surgical intervention. This may at times not be suitable for patients who are having other health problems like heart disease. It is also a difficult proposition for patients who are over 75 years of age or overweight, since they are most likely to have problems during & after radical prostatectomy surgery. The good news is that, although cost of surgical procedures around the world are steadily rising beyond the reach of common man, India is a delightful aberrance providing high quality yet low cost surgical procedures including oncology treatments like laparoscopic & open radical prostatectomy surgery for men from all around the world. IndianMedTrip is a globally reputed medical tourism company based in South Asia which is associated with the top surgeons & best accredited hospital facilities in the country offering a wide spectrum of affordable healthcare solutions to international patients. IndianMedTrip services begin with the first phone call & go on to assist obtaining medical visa, a warm reception at airport on arrival, convenient travel along with comfortable accommodation, scheduling appointments with doctors & treatment procedures without any waiting period, follow up appointments, exotic recuperative vacationing options & a successful farewell.