Radical Prostatectomy

Radical prostatectomy is an operation performed to remove the entire prostate and is only done for cancer which is thought not to have spread beyond the prostate ('organ-confined'). It should not be confused with transurethral (performed through the penis through a telescope) prostatectomy or TURP, which removes only the inner 2/3 of the prostate and is performed for a prostate obstructing the flow of urine from the bladder.

Dealing with a diagnosis of organ-confined prostate cancer
Although it is upsetting to be diagnosed as having cancer, prostate cancer is a slow-growing cancer and you are fortunate in having had it diagnosed at a potentially-curable stage. You now need to choose one of the three treatment options available. This is a very important decision and you should take as much time as you think you need to do make it. Your doctor will help you make the right choice for you but cannot make this decision for you. You might also find the contacts listed below helpful.

Why do anything?

It is true that more men die with prostate cancer than because of it. In fact, approximately 75% of men aged 80 years have cancerous cells in their prostate. However, most of these cancers are tiny and will never lead to any problems. On the other hand, the average size of prostate cancers detected by the PSA (prostate specific antigen) blood test is 50x larger and needs to be regarded in a different light.

Although prostate cancer is slow-growing it is ultimately lethal. In blunt terms, if your life-expectancy is greater than 10 years (i.e. if you are younger than 75 years) then you stand to benefit from active treatment. If you are older than 75 years, especially if your tumour is of low grade, then watchful waiting is likely to be the best choice.

What is the relevance of the grade of tumour?

The tumour is graded using the Gleason 'system', which assigns a number from 2-10, depending on the microscopic appearance of the cancer cells. This appearance predicts the aggressiveness of the cancer. The higher the score, the more aggressive the tumour.

Aggressiveness	Gleason Score	Surgery	Radiotherapy	Watchful Waiting
Low	2 - 4	94%	90%	93%
Moderate	5 - 7	87%	76%	77%
High	8 - 10	67%	53%	45%

Methods

This can be delivered either from outside the body ('external beam' radiotherapy) as an outpatient or by inserting radioactive pellets into the prostate under a general anaesthetic (brachytherapy). A combination is sometimes used. Both forms leave the prostate and its cancer where they are and try to eliminate the cancer by damaging it with radioactivity. This radioactivity also damages surrounding structures (chiefly the bowel, the bladder and the back passage), which leads to symptoms in the short-term and can lead to symptoms in the long term as well. Radiotherapy can also lead to impotence and, rarely, incontinence. Brachytherapy has been developed in order to reduce the damage to surrounding structures. The experience with this technique is limited world-wide, especially as far as the long-term results (> 10 years) are concerned.

Results

The risk of still having cancer present in the prostate 3 years after external beam radiotherapy is 25-33%, depending on the tumour size. Two large studies from the USA have recently demonstrated a lower success rate for brachytherapy compared to surgery. The design of these studies was not optimal and we await the results of better-designed studies to determine precisely how brachytherapy compares with surgery.

Surgery

The operation

Radical prostatectomy involves removing the entire prostate and the seminal vesicles. Key-hole (laparoscopic) radical prostatectomy is more comfortable for the patient, allows greater precision, carries a lower risk of blood transfusion than conventional surgery and has been our preferred technique since March 2000. Over 2000 cases have been done worldwide. The results to date demonstrate that the laparoscopic surgery is as effective as the traditional operation. We typically perform 2-4 laparoscopic radical prostatectomies each week and have the largest experience of this procedure in the UK.

The operation is complex and takes approximately 2-3 hours to perform. Patients are allowed to drink freely on the day following surgery and to eat on the day after. Patients are ready for discharge with their catheter in after 2-3 days and are re-admitted for 24 hours for catheter removal on the 10th day.

Radical prostatectomy step 1	Radical prostatectomy step 2
Radical prostatectomy step 3

Incontinence

You will most likely not be dry when your catheter is removed. Urinary control recovers quickest in younger patients and is usually noticeably improved by 6 weeks, but you may not be fully dry until 3-6 months. Five percent of patients have long-term urinary incontinence. Patients who have not regained satisfactory urinary control by one year following surgery will be offered insertion of an artificial sphincter. This entails another smaller operation but has a very high success rate.

Impotence

The other chief potential complication of surgery is impotence. This is because the nerves that allow erections travel on either side of the prostate on their way to the penis from the main nerve supply (pelvic plexus) in the pelvis. Although an attempt is made to preserve them if they do not seem to be involved by the cancer at the time of surgery, scarring of the nerves following surgery can interfere with their function. If the nerves seem to be affected by the cancer, they will be removed with the prostate. The risk of impotence following surgery rises with increasing age of the patient and the extent of the cancer. I cannot, therefore, give you a single success rate which is meaningful. Since my range is 0-100% it would be reasonable to use 50% as a guideline. Patients who regain their potency can do so up to 2 years following surgery. In the meanwhile, Viagra tablets are used as a first-line treatment and have a success rate of 50%. If they do not work erections can be achieved using a pellet inserted just inside the urethra (the tube you pass water through) or an injection into the side of the penis. It is important to appreciate that all impotent patients can have their potency restored somehow.

Cure

Surgery is only offered to patients in whom there is an expectation of cure, based on the pre-operative tests (PSA, Gleason grade, rectal examination and transrectal ultrasound). Patients with a PSA >10 mcg/l will have a bone scan and body (computerised tomography (CT) or magnetic resonance imaging (MRI)) scan to exclude spread beyond the prostate to the bones and lymph glands, respectively. MRI and CT scans are not accurate enough to assess spread of the prostate cancer through the capsule of the prostate. Fifteen percent of patients will have a positive surgical margin, which means that tumour extends up to the cut edge of the prostate. This is perhaps not surprising because 70% of prostate cancers arise in the outer part of the prostate. It does not indicate a failure to cure, although this is a possibility. All patients, regardless of whether they have positive surgical margin, are followed up with regular PSA tests for at least 15 years following surgery.

Other benefits

Surgery also corrects obstruction to the drainage of urine from the bladder caused by enlargement of the prostate. It additionally allows PSA to be used to monitor the success of the treatment. Following radiotherapy it can take up to 18 months for the PSA to reach its lowest level.

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