prostatectomy

Generality

Radical prostatectomy is the surgical operation of total removal of the prostate, a gland that secretes a fundamental component of the seminal fluid.

Radical retropubic prostatectomy.

Image taken from: trialx.com

Performed with a traditional surgery or laparoscopy, this operation is the treatment of choice for prostate cancer treatment.

The prostatectomy is performed under general anesthesia, therefore, to minimize the risk of complications, the patient must follow the letter to some pre-operative recommendations.

Once the operation is complete, the following are generally expected: a 2-4 day hospitalization, the use of bladder catheters for at least three weeks and some radiotherapy sessions.

To promptly notice any recurrences, it is advisable that the person operated undergoes periodic checks.

Prostate: outline of anatomy and functions

The prostate is a gland located just below the bladder, in front of the rectum. It resembles, in shape and size, a chestnut.

The urethra runs through the prostate, or the duct that carries urine and seminal fluid outside at the time of orgasm.

Around the prostate, muscles called sphincters take place, the contraction of which makes urine exit momentarily impossible, while it favors the expulsion of sperm ( ejaculation ).

FUNCTIONS

The prostate (or prostate gland ) secretes a particular liquid called prostatic fluid, which, mixing with other secretions (for example the liquid produced by the seminal vesicles) and with spermatozoa, constitutes the seminal fluid (or sperm ).

Prostatic fluid is vitally important for spermatozoa originating from the testicles, because it guarantees their nourishment, protection (when and if they are inside the vagina) and increased motility.

What is that?

Radical prostatectomy is the surgical intervention aimed at the total removal of the prostate and, if necessary, of some tissues surrounding the latter.

When you run

Radical prostatectomy is the treatment of choice for the treatment of prostate tumors at an early stage, in which the neoplastic mass is small and has not yet affected the neighboring organs (except the lymph nodes).

For prostate tumors at an advanced stage - which have spread metastases to the bladder and to other organs located elsewhere - no surgical operation is generally foreseen, as it is now considered to be ineffective. One of the conditions, which can induce a surgeon to perform radical prostatectomy also an advanced prostatic neoplasm, is the presence of an obstruction in the urinary tract; obstruction due to compression of the tumor mass to damage of the urethra.

However, it should be emphasized that usually in these situations it is preferable to remove only part of the prostate, putting into practice a particular partial prostatectomy called transurethral resection .

PROSTATE CANCER

Prostate cancer, or prostate cancer, is the most common male cancer. Consider, in fact, that in Italy alone the cases of prostate cancer are around 42800 a year.

The risk of getting prostate cancer increases with age: in particular, starting from the age of 50, the danger of developing a prostatic neoplasm becomes ever higher.

The triggering causes are unclear, although researchers have identified some predisposing conditions, such as obesity, a family history of prostate or breast cancer, the recurrence of prostate inflammation ( prostatitis ) and - as was anticipated - the 'old age.

The two most widely used diagnostic tests for the identification of prostate cancer are: digital rectal exploration and the determination of the blood level (ie in the blood) of the prostate specific antigen ( PSA ).

Signs and symptoms of prostate cancer

• Difficulty urinating
• Frequent stimulation to urinate, especially at night
• Difficulty maintaining a constant flow of urine
• Pain and burning during urination
• Blood in urine and sperm
• Erectile dysfunction
• Painful ejaculation
• Discomfort in the pelvic area
• Fatigue, loss of appetite and general malaise
• Pain in the back, hips and pelvis
• NOTE: many of these symptoms are also typical of benign prostatic hyperplasia, an enlargement of the prostate that does NOT depend on the proliferation of neoplastic cells.

risks

Like any surgical operation, radical prostatectomy can involve the following complications:

• Internal bleeding
• Infections
• Formation of blood clots in the veins ( deep vein thrombosis )
• Stroke or heart attack during the operation
• Allergic reaction to anesthetic drugs or sedatives used during surgery

Furthermore, since the prostate is surrounded by different nerve endings and organs, and because it is crossed by the urethra, there is a real risk of:

• Erection problems . When removing the prostate gland, the surgeon may inadvertently or by necessity related to the procedure, the nerves that pass by; these nerves control the erection, therefore their injury reduces the erectile capacity of the operated individual.
• Urinary incontinence . During radical prostatectomy, the urethra is momentarily cut off at one point. Its reconnection to the bladder, at the end of the operation, may not be perfect (at least in the early stages following the surgery) and cause urine leakage.
• Damage to the rectum . They are due to surgical equipment and the proximity between prostate and rectum.

Preparation

Radical prostatectomy is a surgical procedure that involves general anesthesia . Therefore, before its execution, the individual must be subjected to the following clinical controls:

• Accurate physical examination
• Complete blood analysis
• Electrocardiogram
• Evaluation of clinical history (diseases suffered in the past, possible allergies to anesthetic drugs, medicines taken at the time of checks, etc.).

If there are no contraindications of any kind, the operating surgeon (or a member of his staff) will explain the methods of intervention, the possible risks, the pre- and post-operative recommendations and, finally, the recovery times.

The main pre- and post-operative recommendations:

• Before radical prostatectomy, suspend any treatment based on antiplatelet agents (aspirin), anticoagulants (warfarin) and anti-inflammatory drugs (NSAIDs), because these drugs, by reducing the coagulation capacity of the blood, predispose to serious blood loss.
• On the day of the procedure, appear at full fast since at least the previous evening.
• After the surgery, be assisted by a trusted person .

Procedure

Radical prostatectomy can be performed with a traditional surgery (or " open-air ") or with a laparoscopic surgery (or laparoscopic operation ).

Figure: main stages of radical prostatectomy. It can be seen that the urethra is reattached to the bladder after prostate removal. Image taken from: urologygroupvirginia.com

TRADITIONAL RADICAL PROSTATECTOMY

"Open-air" radical prostatectomy involves the execution of a single large skin incision, either at the level of the lower abdomen or at the level of the perineum (ie between scrotum and anus).

If the surgeon opts to affect the lower abdomen, we talk about a retropubic approach or radical retropubic prostatectomy ; if instead it opts to affect the perineum, it is called perineal approach or perineal radical prostatectomy .

From the opening following the incision, the surgeon cuts the prostate and extracts it; then reconnects what remains of the urethra to the bladder and closes the opening on the abdomen (or perineum) with stitches.

If the abdominal lymph nodes have been affected by the tumor (or there is only the suspicion that they are), they too are appropriately removed, but with another abdominal incision.

PSA and lymph node removal

The choice to remove the lymph nodes adjacent to the prostate depends on the progression stage of prostate cancer. However, sometimes the stage of tumor progression is difficult to establish and surgeons rely on the measurement of PSA blood levels. If this measure is particularly high, the lymph nodes are eliminated.

LAPAROSCOPIC RADICAL PROSTATECTOMY

Image taken from: cancer.org

During laparoscopic radical prostatectomy, the surgeon makes small incisions of about one centimeter on the lower abdomen; through these incisions, he introduces the surgical instrumentation to orient himself inside the abdomen ( laparoscope ) and to sever the prostate (scalpel). Once the prostate is extracted, re-attach the remaining urethra to the bladder and stitch up the small incisions.

Radical prostatectomy performed in robotic laparoscopy

Radical prostatectomy interventions can also be performed in robotic laparoscopy .

During robotic laparoscopy, performing a patient operation is a kind of robot, guided by the surgeon. This operational approach guarantees great precision and further reduces the invasiveness of the laparoscopic intervention.

It is practiced especially in the case of relatively young patients, suffering from small prostatic tumors.

Post-operative phase

At the conclusion of the intervention, a hospitalization of 2-4 days is foreseen, during which the operating surgeon and the hospital staff monitor, step by step, the patient's condition.

For at least three weeks, the operated person must resort to bladder catheterization to eliminate urine. Therefore, a qualified member of the medical staff will teach him how to do this independently.

RADIOTHERAPY

It is quite frequent that, after a radical prostatectomy, the surgeon prescribes radiotherapy sessions for the patient. This would have the purpose of eliminating any tumor cells that the surgeon might not have removed, due to the difficult location.

ACTIVE SURVEILLANCE

All prostate cancer operated patients must undergo periodic precautionary checks, which serve to identify recurrences in good time (principle of active surveillance ).

These checks consist of:

• Physical examination
• PSA measurement
• Digital rectal exploration
• Tissue biopsy

Results

The results of a radical prostatectomy depend on several factors, including:

• Age of the patient
• State of health of the patient before surgery
• Tumor severity

Removal of small tumors, confined to the prostate, is almost always successful.

ERECTILE PROBLEMS AND URINARY INCONTINENCE

In about half of operated men, erectile problems are temporary and resolve within a few months (from a minimum of 3 to a maximum of 12). For the other half, they are definitive or in any case only partially resolve.

With regard to urinary incontinence, on the other hand, more than half of patients report urine leakage. However, in a fair number of cases, there is a significant improvement in the condition over time. On waiting times, doctors state that recovery from urinary incontinence could occur up to a year after radical prostatectomy.