An brief overview of the Radical Prostatectomy as a radical treatment option for prostate cancer

1. Part of the “Enhancing Prostate Cancer Care” MOOC
Catherine Holborn
Senior Lecturer in Radiotherapy & Oncology
Sheffield Hallam University

2. Aim of the presentation
To provide an overview of the key aspects of
surgery in the radical treatment of localised and
locally advanced prostate cancer
This supplements the information already
provided on the overall management of prostate
cancer and the role of the main radical treatment
options (surgery and radiotherapy)

3. Radical Prostatectomy
Aim is to eradicate the cancer, preserve urinary
continence and if possible, erectile function
Involves removal of the entire prostate gland and
resection of the seminal vesicles, plus a margin of
surrounding tissue sufficient to achieve a negative margin
The pelvic lymph nodes will also be removed for high risk
localised and locally advanced prostate cancer, and also
possibly for intermediate risk localised prostate cancer

4. Considerations
For men with localised prostate cancer, surgery is a
treatment option alongside radiotherapy
A number of factors may influence their final decision
Side effects are covered in a separate presentation
What else may be a consideration?
General health and suitability for surgery/general anaesthetic
The psychological aspect of having the cancer removed from the
body
Success can be gauged early as the PSA levels should fall very
quickly to negligible levels
The prostate can be examined after surgery to more thoroughly
assess grade/extra-capsular extension
Less burden i.e. time spent attending hospital

5. Negative resection margin
This is when the resected margin of surrounding tissue (especially
the outer edge) is clear from any cancer cells, when examined under
a microscope
If cancer cells are seen, there is a chance that some may also remain
in the body. Especially if these extend to the outer edge of the
margin of tissue resected (a ‘positive’ resection margin)
These can re-populate and signs of biochemical disease progression
(rising PSA levels) may eventually occur. If left untreated, this may
ultimately cause the man to develop clinical symptoms, indicative of
more advanced disease
A decision must be made as to whether further treatment (post-operative
radiotherapy) is given immediately after surgery
(‘adjuvant’ to), or in a ‘salvage’ setting (when biochemical
progression occurs)

6. Surgical expertise
An important factor , regardless of what surgical method
is used
It can influence the ability to achieve a negative resection
margin (if this is possible given the clinical and
pathological features of the cancer)
It can also influence the ability to spare the neuro-vascular
bundle (again, if this is possible) and in turn, help
to preserve erectile function

7. The Neuro-Vascular Bundle (NVB)
The NVB runs in the posterior-lateral grooves between
the prostate and rectum. This is close to the peripheral
zone were most prostate cancers arise and it is
important to widely dissect around this area as a means
of achieving a negative resection margin
Removal of the NVB is responsible for the occurrence of
erectile dysfunction
Nerve sparing surgery (of one or both bundles) and
careful excision around this area is possible but usually
only for low risk, low volume cancers, maybe
intermediate risk cancers

8. Traditional surgical methods
The traditional method uses an ‘open’ incision
This may be a ‘retropubic’ incision (via the abdomen) or a
‘perineal’ incision (via the area between the scrotum and
the anus)
Perineal incision provides better access to the prostate
and is associated with less blood loss; but is potentially
more limiting in the amount of tissue that can be
removed e.g. for larger glands/extra capsular spread and
it is suggested that positive surgical margins may be more
frequent with this approach as a result. It also doesn’t
allow for the removal of lymph nodes if this is needed.

9. Laparoscopic (key hole)
method
Less invasive
5 or 6 small openings are used (as opposed to one large
one)
This may be done by hand or robot assisted
Key advantages are; a quicker procedure, less time spent
as an in-patient, less surgical complications e.g. blood
loss and the need for a blood transfusion
Robotic prostatectomy is increasingly being used, instead
of the aforementioned traditional methods

10. Recent evidence
A recently published systematic literature review
demonstrated that Robotic Prostatectomy was more
favourable compared to open surgery and conventional
laparoscopy, in terms of peri and intra operative
complications and adverse events; and at least as equivalent
to these in terms of positive margin rates
 Reference
Tewari A, Sooriakumuran P, Block DA, Sehsadri-Kreaden U, gerbert AE, Wiklund P.
Positive surgical margin and perioperative complication rates of primary surgical
treatments for prostate cancer: a systematic review and meta-analysis comparing
retropubic, laparospcopic and robotic prostatectomy. European Urology. 2012. 62;
pp.1-15

11. Post-op care
During surgery, the prostate is detached from the bladder and
the urethra. After careful excision, the bladder is then
attached to the end of the urethra, to re-create the urinary
tract and a temporary catheter is inserted to bridge this
connection.
This enables the urine to drain freely as the wound/stitches
heal and prevents any build up of pressure being placed on
these.
It remains in position for approximately 2 weeks (can be as
little as 3-4 days) and is usually removed in an outpatient
setting. The man is allowed to leave once they have passed
water normally. Whilst the catheter is in place, information
about how to care for the catheter, to prevent infection, is
important.
The man is usually discharged from hospital up to a week post-op
(could be much less with a robotic prostatectomy).