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Once the prostate, seminal vesicles and pelvic lymph nodes (if sampled) are dissected and removed they are sent, in their entirety, to our genitourinary pathology team. There they evaluate the prostate to determine the final Gleason grade. The Gleason grading system is based upon the growth pattern and aggressiveness of the prostate cancer cells. They will also determine how much of the prostate gland is involved with cancer and whether the margins of the prostate are involved. The pathologists will determine whether the cancer has started to migrate outside the capsule. This is called extra-prostatic extension. If pelvic lymph nodes are sampled, the pathologists will determine whether they contain cancer cells. This process can take up to 2 weeks and provides us with important prognostic information.
Laparoscopy is a surgical approach to abdominal surgery where, instead of making a large incision and placing the surgeon's hands inside the patient, we make several small incisions of about one centimeter each. Then we place a camera and long thin instruments through these incisions, and we use the instruments to perform the operation. We perform prostate surgery and remove the entire prostate and adjacent lymph nodes with these minimally invasive instruments.
Advancement in minimally invasive technology has allowed patients to benefit from less invasive surgery for prostate cancer, thus allowing excellent cure rates while diminishing potential complications such as blood loss, protracted pain, infection, transfusions and longer hospitalization. The superior visualization and instrument control of robotic surgery is the reason for these advantages. Patients should understand, however, that a high level of surgical skill and experience are required to obtain these advantages. In expert hands, even patients with high grade cancer benefit from robotic surgery.
Patients who have undergone extensive abdominal surgery previously may not be a good candidate for robotic or laparoscopic surgery. This is also the case for some patients who have been treated for prostate cancer with external beam radiation or brachytherapy and require salvage prostatectomy. Adhesions (scar tissue) can make surgery very difficult and increase the risks of bleeding, damage surrounding organs and increase surgical time. An experienced laparoscopic surgeon can make this decision.
Laparoscopic or robotic prostatectomy is a minimally invasive approach to the traditional, "open" prostatectomy. In the past, prostatectomy had always been accomplished through open surgery, making a 5-8 inch incision in the lower abdomen. Laparoscopic and robotic surgery use small, one-centimeter abdominal incisions and laparoscopic tools to operate. In straight laparoscopy the surgeon is standing at the bedside manipulating the instruments directly. In robotic surgery the surgeon is seated at a console. Robotic surgery gives the surgeon superior 3-D visualization of prostate anatomy and more precise instrumentation to perform the meticulous dissection necessary for high quality prostatectomy.
You will return to our urology office one week after surgery to have your catheter removed and to discuss urinary and sexual function moving forward as well as your pathology results. Your next scheduled visit will be three months after your surgery and we ask that you have your PSA drawn 1 week prior to this visit. The PSA becomes extremely specific and sensitive to prostate cancer after a prostatectomy and will be closely followed for the rest of your life. Typically, we see you at three-month intervals with a PSA for the first year. If your PSA remains undetectable or <0.1 or 0.00 and you are comfortable, you may continue follow up with your primary care physician or urologist after the first year. We ask that you have your PSA drawn every six months the second year and annually thereafter, if it remains undetectable. If your PSA should ever elevate to 0.2 after prostatectomy we ask that you come back and see us immediately. Patients with more aggressive disease may be followed for a longer period of time with more frequent PSAs. This is a discussion you will have with your surgeon.
The seminal vesicles are removed as cancer can invade these organs, which lie adjacent to the prostate. In patients with more aggressive disease a pelvic lymph node dissection will be performed. The pelvic lymph nodes are often the first place prostate cancer will go once it is outside the prostate. Sampling of these nodes is a standard approach for assessing regional lymph node status, and will provide important prognostic information.
BIDMC stands apart particularly because of our personalized approach to prostate cancer. Patients are cared for by a team of doctors and nurses, not just a surgeon. Our team meets weekly to discuss important patient issues and therefore patients really do benefit from that team approach. Furthermore, we treat patients like we would want our family to be treated; with respect, kindness, and patience. Having this diagnosis can be extremely stressful and every patient is different. We take pride in the fact that we get to know our patients as people, because understanding these differences can impact the decisions we make and advice we give. We therefore spend as much time as is needed with each patient and their loved ones to answer every question. We want our patients to be well informed and comfortable with the treatment they have chosen. Regarding surgical advances, we are able to offer the most recent advances in minimally invasive surgery as well as advanced techniques in nerve-sparing radical prostatectomy, performed by fellowship-trained experts in prostate surgery. In addition to world class training and experience with robotic surgery, our team is available 24-7 before and after surgery for your support by phone or email.