Anatomic radical prostatectomy, or open surgery, is the most commonly performed surgical procedure for treatment of localized prostate cancer. A less invasive option, laparoscopic radical prostatectomy has its basis in traditional open surgery, with less blood loss and better cosmetic results.
Laparoscopic instruments improve visualization, enabling precise dissection of the prostate and neurovascular structures. Additionally, laparoscopic suturing techniques allow for a meticulous connection of bladder to urethra following removal of the prostate. This offers the potential for less scarring of the urethra following surgery. Figure 1 displays the anatomy of the prostate, bladder, and neurovascular bundles.
Minimally invasive surgery is part of BIDMC’s multidisciplinary approach to prostate cancer. To learn about the comprehensive treatment options available through our Prostate Care Center, please click here.
Laparoscopic prostatectomy is performed using a camera and thin, specialized instruments placed in the abdomen through three tiny (half inch) and one small (2 inch) incisions.1 In comparison, open surgery requires a 5-8 inch incision. (see figure 2a and 2b)
While a robotic arm steadies the camera, producing a magnified view, the surgeon performs maneuvers using highly specialized laparoscopic instruments. First, the seminal vesicles are dissected free from surrounding blood vessels and nerves. Next, the prostate is carefully dissected from its bed. To ensure maximum cancer control, great care is taken to determine whether the tumor has grown outside the prostate. Your surgeon does this through preoperative tests as well as tactile and visual cues during the procedure.
If no growth is detected, the surgeon can spare at least one neurovascular bundle (nerves that control erection) in the vast majority of patients. Both neurovascular bundles can be spared at least 80% of the time in appropriate candidates, optimizing the likelihood of return of erectile function. (video 1 and video 2)
In some cases, your surgeon may perform a sampling from the pelvic lymph nodes to evaluate for spread of the cancer. The bladder is then sutured back to the urethra using laparoscopic techniques inside the pelvis. (video 3) Finally, the catheter and pelvic drain are placed and incisions closed with absorbable sutures. The procedure typically lasts 3-5 hours depending on body size, prostate size and amount of inflammation surrounding the prostate.
Advantages over open surgery
- Significantly less blood loss
- Better cosmetic result
- Quicker return to normal activity
- Improved visualization of surgical field
Results
The success of surgery for prostate cancer is measured in three key ways: cancer cure, preservation of urinary continence and preservation of sexual function. We have found that early cancer control as well as continence and sexual function following laparoscopic radical prostatectomy are similar to open surgery.2-4
Cancer control
Laparoscopic prostatectomy has been performed in this country for under ten years, so analysis of long-term cure rates is difficult. However, studies have shown that during an early period of follow-up, cancer control using the laparoscopic procedure is similar to open surgery.2
Continence (urinary control)
Many patients have temporary incontinence following either open or laparoscopic prostatectomy. Recovery of continence occurs gradually after either approach, and the majority of patients return to baseline urinary function in 6-8 months; continued improvement occurs for up to 24 months.4,7 At least 90% of patients are considered “dry” one year following surgery. However, some may choose to wear a “safety pad” to catch occasional dripping of urine during coughing, sneezing or heavy activity.
Sexual function
The return of sexual function is based on many factors, including age, preoperative function, having an active sexual partner and degree of nerve sparing. We have found that patients who were potent preoperatively and undergo bilateral nerve sparing have a 50% to 80% likelihood of regaining potency by 12-24 months. 3,4,8
Age plays an important role
At least 75% of men under 60 years of age can expect recovery of potency, while only 50% over 60 years can.3,9
Blood loss
Average blood loss is 200cc during laparoscopic prostatectomy compared with at least 800cc during open surgery. Blood transfusions are extremely rare.
What to expect after surgery
Hospital stay
Patients typically are discharged the first or second day after laparoscopic prostatectomy.
Diet
Patients resume normal eating as they recover in the first day after surgery or soon thereafter.
Postoperative pain
Pain is managed immediately with an intravenous patient controlled analgesia pump, which is removed and replaced with pills the day after surgery. Minor aches that continue for 1-2 weeks following surgery are treated with over-the-counter acetaminophen or ibuprofen. Occasionally, patients experience bladder spasms due to irritation from the urinary catheter. This is controlled with oral medication.
Pelvic drain
A small drain placed in the pelvis after surgery is usually removed the first or second day after surgery.
Urinary catheter
The urinary catheter is left in place for 1 week to allow for complete healing of the bladder-urethral connection. Your surgeon will remove this in the office.
Recovery
Overall physical recovery (not including urinary and sexual function) averages 4 weeks, slightly shorter than after open surgery.6
Follow-up
After removal of the catheter, follow-up is every 4 months for the first 2 years to evaluate prostate specific antigen (PSA) results and discuss the recovery of continence and sexual function. Appointments can easily be conducted over the phone for those living outside the Boston area, including international patients.
References
1. Sanda MG, Wagner AA, and Su LM. “Nerve-sparing open and laparoscopic radical prostatectomy.” In: Baker RJ and Fischer JE, editors, Mastery of Surgery. Lippincott Williams & Wilkins, in press 2006
2. Sulman A, Su LM, Trock BJ, Wagner AA, Mettee L, Pavlovich CP. “Laparoscopic radical prostatectomy: interim analysis of oncologic outcomes following a four-year experience.” Abstract from American Urologic Association Annual Meeting, Atlanta 2006
3. Wagner AA, Link RE, Sullivan W, Pavlovich CP, Su LM. “The use of a validated quality of life questionnaire to assess sexual function following laparoscopic radical prostatectomy.” International Journal of Impotence Research, 2006:18:69-76
4. Wagner AA, Link RE, Sulman A, Sullivan W, Pavlovich CP, Su LM. “Functional outcomes and quality of life following laparoscopic radical prostatectomy: prospective analysis over a four-year experience.” American Urologic Association Annual Meeting, Atlanta 2006
5. Dash A, Dunn RL, Resh J, Wei JT, Montie J, Sanda MG. “Patient, surgeon and treatment characteristics associated with homologous blood transfusion requirement during radical retropubic prostatectomy: multivariate nomogram to assist patient counseling.” Urology, 2004: 64: 117-22
6. Bhayani SB, Pavlovich CP, Hsu TS, Sullivan W, Su LM. “Prospective comparison of short-term convalescence: laparoscopic radical prostatectomy versus open radical retropubic prostatectomy.” Urology, 2003: 61:612-616
7. Kielb S, Dunn RL, Rashid MG, Murray S, Sanda MG, Montie JE, Wei JT. “Assessment of early continence recovery after radical prostatectomy: patient reported symptoms and impairment.” The Journal of Urology, 2001: 166: 958-61
8. Hollenbeck BK, Dunn RL, Wei JT, Montie JE, Sanda MG. “Determinants of long-term sexual health outcome after radical prostatectomy measured by a validated instrument.” The Journal of Urology, 2003: 169:1453-57
9. Rogers CR, Link RE, Su LM, Wagner AA, Pavlovich CP. “Do younger men have better health related quality of life after laparoscopic radical prostatectomy?” The Journal of Urology, 2006 in press
