The “anatomical approach” to radical retropubic prostatectomy, designed to spare the nerve bundles on both sides of the prostate and better control bleeding during surgery, was developed by Patrick Walsh, MD (see right) of the Brady Urological Institute at Johns Hopkins Hospital in Baltimore, Maryland, in the early 1980s. It rapidly became the “standard” surgical procedure for removal of the prostate (“radical prostatectomy”).
Procedures described as minimally invasive or laparoscopic radical prostatectomy (which have become increasingly common since about 2001) are modifications of Walsh’s technique, refined through the use of a less surgically invasive process.
The following points are critical to understanding what will happen during and immediately after any “open” radical retropubic prostatectomy:
- The procedure is carried out in a hospital under general, spinal, or epidural anesthesia.
- Your surgeon will make an incision in the lower part of your abdomen, in between your navel and the base of your penis. He (or she) will carry out the operation through this incision.
- The operation will include the removal of the entire prostate, the associated seminal vesicles, and (often but not always) some of the pelvic lymph nodes to see whether cancer has spread into these nodes.
- After removal of the relevant organs, the surgeon will reconnect your urethra to your bladder so that urinary function is restored.
- All patients will initially require a urinary catheter (a tube that runs up through your penis into your bladder). The primary reason for catheterization is not to manage continence; rather, it is to ensure healing of the connection between the bladder and the urethra in the proper anatomical position.
This operation may take anything from about 90 minutes to 3 hours depending on things like prostate shape and size, need for lymph node removal, obesity, and other factors such as previous surgery (e.g., a transurethral resection of the prostate or TURP) and the skill of the surgeon.
There is normally a relatively brief period for recovery and observation in the hospital (1-3 days) and then an extended recovery period of a week or two at home, which is typical of any invasive surgical procedure that requires a deep incision through the abdomen.
It would be foolish for us to waste our time describing a technique which Dr. Walsh and others have described so perfectly. We therefore refer the interested reader to the following sources:
- The detailed description of the procedure (prepared by Dr. Walsh and his colleagues) that is available on the Brady Urological Institute web site. Please appreciate that this description was prepared for the education of other surgeons.
- The original video material (also prepared by Dr. Walsh and colleagues) that can be viewed on line, also developed for a surgical audience.
Since the original development of this procedure, others have introduced modifications which they believe improve the operation. However, these modifications are all dependent on the skills of the individual surgeon, and no two radical prostatectomy operations are ever exactly alike!
Walsh’s original approach to preservation of the neurovascular bundles is now known as the “apical” approach. A slightly simpler technique was first described by Ruckle and Zincke and is generally known as the “lateral” approach. This lateral approach has, over the years, been further modified by Scardino and colleagues (initially at Baylor College of Medicine in Houston, Texas and more recently at Memorial Sloan-Kettering Cancer Center in New York) and by Klein and colleagues (at the Cleveland Clinic in Cleveland, Ohio).
From the patient’s point of view, these technical details of the surgery are not of great significance. It is the outcome that is of importance.
Who Is an Appropriate Patient for This Procedure?
Any patient who is believed to have early stage (localized) prostate cancer, i.e., prostate cancer that is confined within the prostate, is theoretically an appropriate candidate for open radical retropubic prostatectomy. Such patients would normally have clinical stage T1N0M0 or T2N0M0 prostate cancer.
The Results You Can Reasonably Expect?
On the basis of their experience of several thousand patients treated by open radical retropubic prostatectomy at the Mayo Clinic between 1987 and 1995, Gavamian and Zincke report the following outcomes:
- Among patients with clinical stage T1aN0M0 (comprising 1.5 percent of all prostate cancers believed to be organ-confined at the start of surgery), 88 percent were shown to be actually organ-confined at pathologic examination of the prostate post surgery.
- Among patients with clinical stage T1bN0M0 (comprising 5.6 percent of all prostate cancers believed to be organ-confined at the start of surgery), 68 percent were shown to be actually organ-confined at pathologic examination of the prostate post surgery. In other words, there is a significant risk of under-staging of clinical stage T1b disease.
- Among patients with clinical stage T1cN0M0 (comprising 45 percent of all prostate cancers believed to be organ-confined at the start of surgery), 76 percent were shown to be actually organ-confined at pathologic examination of the prostate post surgery.
- Among patients with clinical stage T2N0M0 (also comprising 45 percent of all prostate cancers believed to be organ-confined at the start of surgery), 71 percent of T2a patients and 54 percent of T2b,c patients were shown to be actually organ-confined at pathologic examination of the prostate post surgery.
- For patients with clinical stage T1c disease at the start of surgery, 7-year survival and 7-year survival free of PSA recurrence were 96 percent and 73 percent, respectively (and prostate cancer-specific survival was 99.9 percent).
- For patients with clinical stage T2a disease at the start of surgery, 7-year survival and 7-year survival free of PSA recurrence were 92 percent and 75 percent, respectively (and 7-year prostate cancer-specific survival was 98.6 percent).
- Finally, for patients with clinical stage T2b,c disease at the start of surgery, 7-year survival and 7-year survival free of PSA recurrence were 89 percent and 66 percent, respectively (and 7-year prostate cancer-specific survival was 97.6 percent).
Series from other institutions with a high degree of experience are comparable. For purposes of comparison, the 15-year data published by Walsh and his colleagues from Johns Hopkins in 2001 and based on 2,404 patients showed the following:
- Overall 5-, 10-, and 15-year recurrence-free survival rates were 84, 74, and 66 percent, respectively.
- Overall metastasis-free survival rates at 5, 10, and 15 years were 96, 90, and 82 percent, respectively.
Finally, based on an analysis of data from nine regions of the United States, Krongrad et al. found that estimates of 10-year disease-specific survival after open radical retropublic prostatectomy ranged from 75 to 97 percent for patients with well-differentiated and moderately differentiated cancers and from 60 to 86 percent for patients with poorly differentiated cancers. In other words, in patients diagnosed early, radical retropubic prostatectomy appears to be associated with very high survival at 10 years. They also found that survival did not vary by geographical region, which suggests that risk assessment and treatment quality is generally uniform across the USA, even if quality varies from surgeon to surgeon or institution to institution.
The clear message to the patient is that truly localized disease can be treated by open radical retropublic prostatectomy with a high degree of confidence that all cancer will be removed if the cancer really is organ-confined at the start of surgery. However, until the operation is completed, the surgeon simply has no way to tell whether the tumor really is organ-confined.
A variety of tools, including the Partin tables, the Han tables, and the Kattan nomograms are available to help doctors and their patients project the likelihood of particular outcomes after radical retropubic prostatectomy, based on based on pre-surgical data (the patient’s PSA, clinical stage, and biopsy-based Gleason score), post-surgical data (the patient’s pathological stage and pathology-based Gleason score), and other factors. These “prognostic tools” are discussed in detail elsewhere.
The Adverse Effects of Treatment
Open radical retropubic prostatectomy comes with a series of common (but usually manageable) short-term side effects, a risk for some significant and problematic long-term side effects, and a risk for some serious short-term risks, as follows:
The common, short-term side effects — Immediately following surgery almost every patient has two short-term problems. He has little to no control over his bladder, and he will have lost the ability to have an erection (even if he has the nerve-sparing procedure).
Assuming that the operation has been successfully carried out, and there are no unexpected complications, a high level of urinary control will start to return within weeks or a couple of months. (It is true that some men are continent immediately but they compose a decidedly small proportion of patients.)
Nearly all men will find that they don’t have quite the same degree of urinary control as they may have had prior to their surgery. Even 5 or 10 years after surgery, many men may worry about minor leakage on sudden movement or when lifting a heavy weight. For most men this is a minor irritation as opposed to a serious problem. On the other hand, men who have had some problems with urination because of prostate enlargement find that radical prostatectomy has “killed two birds with one stone.”
Recovery of erectile function normally takes significantly longer. The neurovascular bundles (even when preserved) are always affected to some degree by the surgical procedure. (You can think of this in terms of them being badly bruised by the procedure.) Some men find that they recover a degree of erectile function within a few weeks. For others it may take 18 months to 2 years. The overall likelihood of recovery of erectile function is dependent on many factors, not just on anatomical preservation of the neurovascular bundles. These factors including age, baseline function, obesity, smoking history, other illnesses (e.g., diabetes, depression, and fatigue), and more. Radical prostatectomy is not an operation designed to improve erectile performance for men! The use of products like sildenafil (Viagra/Pfizer) or taldalifil (Cialis/Lilly) can assist with both the return of erectile function and the quality of performance once function has returned.
A third, less common, but still not unusual side effect can be problems with bowel movements. Some men may have difficulty defecating after surgery, and may need to use stool softeners or other forms of therapy to assist in resolving this problem. Again, this is a relatively short-term issue for the majority of men.
Significant, longer-term problems — For a relatively small percentage of men (particularly in the hands of the most skilled and experienced surgical teams), long-term incontinence and perceived failure to achieve the return of erectile function may become major issues. And if both neurovascular bundles have to be removed, then normal erectile function is very rarely going to return (although it is known to happen). There are ways to address both of these problems, but they require the understanding and the cooperation of both partners. For many men, loss of erectile function can be emotionally and psychologically disturbing and, in combination with the diagnosis of cancer and other life stressors, can lead to clinical depression.
Similarly, some men may never regain a normal level of urinary continence; and we do not understand why this happens. Again, there are ways to manage such problems, sometimes requiring additional surgery or other interventions. However, as with loss of erectile function, loss of bladder control can lead to depression as a consequence of the loss of control over an important, normal function.
The third longer term issue that occurs with some frequency is a slowly (or sometimes rapidly) increasing difficulty with urination. Most commonly this is a result of what is known as a “bladder neck contracture.” When your urethra is reconnected to your bladder, there may be regrowth of tissue as the surgical join recovers. This may result in the new tissue gradually blocking the urethral passage, and making it difficult or impossible to urinate. Various surgical means are available to resolve this problem in the short term and the longer term. For the vast majority of men who experience this problem, it may be temporarily worrisome but is relatively easily solved.
The serious short-term risks — An open radical retropubic prostatectomy is a serious and invasive surgical procedure. As with all such procedures, there are risks related to anesthesia and the normal complications of surgery. In the past, death was considered to be a significant risk associated with this type of surgery. However, today, the number of deaths associated with radical prostatectomy has become vanishingly small except in the most unusual circumstances. (Please understand that it is never zero for any invasive surgical procedure.) The most common problem that can occur is serious blood loss during this operation, requiring one or more blood infusions. Again, this is far less common today than it was even in the later 1980s and early 1990s, but blood infusions may still be required for a small but noticeable number of patients.
Patients should appreciate that this is not, nor is it intended to be, a complete list of every possible risk associated with open radical retropubic prostatectomy. If you decide to work with a surgeon who intends to use this procedure, you should be sure to review these and other risks — infertility, infection, injury to other organs, pain, recurrence — with that surgeon prior to your operation, and you will certainly be asked to sign a relevant consent form prior to surgery.