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Laparoscopic radical prostatectomy for prostate cancer

Posted Mar 28 2012 11:01am

This article describes a modern treatment for prostateA gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., laparoscopicA keyhole surgical procedure. (keyhole) radical prostatectomyThe surgical removal of the entire prostate gland.. This will be of help to any man suffering from organ-confined prostate cancer looking for a new treatment option.

Anatomy of the prostate gland and its surrounding structures

Laparoscopic radical prostatectomy, also known as keyhole prostatectomy, is a minimally invasive operation performed by a Urological Surgeon to treat, and cure, prostate cancer. It is performed under general anaestheticAny agent that reduces or abolishes sensation, affecting the whole body. and involves removing the entire prostate glandAn organ with the ability to make and secrete certain fluids., seminal vesicles A pair of pouch-like glands situated on each side of the bladder in males. These produce the components of semen. , and sometimes the lymphA watery or milky bodily fluid containing lymphocytes, proteins and fats. Lymph accumulates outside the blood vessels in the intercellular spaces of the body tiisues and is collected by the vessels of the lymphatic system. glands within the pelvisThe bony basin formed by the hip bones and the lower vertebrae of the spine; also refers to the lower part of the abdomen.. The bladderThe organ that stores urine. is then re-attached to the urethraThe tube that carries urine from the bladder, and in men also carries semen during ejaculation. with sutures. 

Laparoscopic radical prostatectomy is endorsed by the National Institute for Health and Clinical Excellence (NICE).

Laparoscopic radical prostatectomy can only be performed on prostate-confined prostate cancer and as such, an MRIAn abbreviation for magnetic resonance imaging, a technique for imaging the body that uses electromagnetic waves and a strong magnetic field. scan of the prostate will be taken, sometimes along with a prostate biopsyThe removal of a small sample of cells or tissue so that it may be examined under a microscope. The term may also refer to the tissue sample itself., to establish if the patient has organ-confined disease or not. A modern type of MRI known as a diffusion weighted MRI can show up small cancers that may not have been found during the biopsy and these can therefore help to plan surgery in finer detail.

MRI scan showing the left and right femoral heads (hips) on either side of the prostate gland. The prostate shows multifocal prostate cancer seen in the dark grey areas

The prostate is analysed by a pathologistA specialist in the study of disease processes. giving a precise understanding of the amount and type of cancer removed, and whether any additional treatments such as prostatic bed radiotherapyThe treatment of disease using radiation. will be required.

In low risk disease, a decision can be made to spare the nervesBundles of fibres that carry information in the form of electrical impulses. in an attempt to preserve potency, although in a high risk disease a wide local excisionThe removal of a piece of tissue or an organ from the body. will normally be performed.

  • Less complications both during, and after, the operation e.g. damage to adjacent structures such as bowelA common name for the large and/or small intestines. and major bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. vessels.
  • Better cancer control with less residual tumourAn abnormal swelling. and need for adjuvant radiotherapy following surgery.
  • Shorter hospital stay; most patients are discharged after one or two nights in hospital.
  • Less blood loss; blood transfusions are very rare and occur in less than 1% of patients.
  • Less post-operative pain and a quicker return to normal activities. The smaller incisions, no larger than 2–3cm, result in less pain and only simple analgesicsAnother term for painkillers. such as paracetamol and diclofenac are needed following surgery. It is very rare to require morphine-based analgesia resulting in fewer side effects such as drowsiness and constipationa common condition where stools are not passed as frequently as normal.

Laparoscopic radical prostatectomy is a minimally invasive operation for localised prostate cancer, the daVinci is a robotic tool used by the surgeon to perform this operation. The outcomes are equivocal in terms of cancer and functional outcomes such as continence and potency.

The laparoscopic radical prostatectomy operation is for localised prostate cancer, other options such as brachytherapyA type of radiotherapy where radioactive pellets or wires are inserted into the tumour. or external beam radiationEnergy in the form of waves or particles, including radio waves, X-rays and gamma rays. exist. There are pros and cons to each of the treatments and a discussion between the patient and their consultant should occur to decide which way to go, this is a complex decision with many different options.

  • An infectionInvasion by organisms that may be harmful, for example bacteria or parasites. of the wound, chest or urinary tractThe channels that carry urine from the kidneys to the outside of the body.. Antibiotics are given during the operation but not afterwards as these can lead to side effects, drug resistantA microbe, such as a type of bacteria, that is able to resist the effects of antibiotics or other drugs. strains of virusesMicrobes that are only able to multiply within living cells., and to minimise side effects, resistanceThe ability of a microbe, such as a type of bacteria, to resist the effects of antibiotics or other drugs. and problems such as Clostridium difficile which can occur when the bacteriaA group of organisms too small to be seen with the naked eye, which are usually made up of just a single cell. in the gut are wiped out due to antibioticsMedication to treat infections caused by microbes (organisms that can't be seen with the naked eye), such as bacteria. and can lead to diarrhoeaWhen bowel evacuation happens more often than usual, or where the faeces are abnormally liquid. and intestinalrelating to the intestines, the digestive tract between the stomach and the anus disease.
  • Bleeding, during or after the operation. Laparoscopic procedures lead to much less bleeding however, due to better vision and the use of state of the art vascularRelating to blood vessels. sealants.
  • Thrombosis in the form of Deep Vein Thrombosis (DVTAn abbreviation for deep vein thrombosis: the obstruction of one of the deep veins, often in the calf, by a blood clot.) or pulmonary embolismObstruction of the pulmonary artery by a blood clot.. To reduce this risk, patients self-administer anti-thrombotic agents with a needle for 40 days after the procedure.

Laparoscopic radical prostatectomy being performed with a robotic camera holding arm and a High Definition screen

  • Urinary incontinenceThe involuntary passage of urine or faeces.. All men will suffer unintentional leakage of urine when the catheterA tube used either to drain fluid from the body or to introduce fluid into the body. is removed one week after the operation and pads are necessary. Patients are taught to perform pelvicRelating to the pelvis. floor to help regain continence; this can take days, weeks or months depending on the patient. In the long term, keyhole prostate surgery gives improved continence outcomes compared to traditional open surgery.
  • Erectile dysfunction. Depending on the amount and type of cancer it may be possible to attempt to protect or spare nerves and blood vessels that are involved in erections however this does not guarantee future erections and recovery can take up to two years. Men who have existing erectile problems will see a further decline and are the most difficult to treat. Men wishing to return to potency after the operation are encouraged to engage in penile rehabilitationThe treatment of a person with an illness or disability to improve their function and health.. This may involve the use of daily tablets such as tadafil or sildenafil citrate and penile vacuum pumps.
  • Bladder neck contracture; a narrowing of the connection between the bladder and urethra due to excessive scar tissueA type of connective tissue that forms after a wound heals., this can lead to symptoms such as incontinence. The connection between the bladder and urethra will occasionally need to be released under anaesthetic as a day case.
  • Rectal injury. This is a rare (<1%) but serious complication and may require a temporary colostomySurgery that involves bringing part of the large intestine through the abdominal wall, through an opening called a stoma. Faeces are collected by a bag worn over the hole..

There has been quite a change in this area in recent years. Traditionally, a cut-off at 70 years for surgery used to be applied but not any more. A patient's physiological age rather than chronological age is considered. We live in an age of 'pateint choice' and most surgeons would not deny a fit 75 year old who wanted surgery. Minimally invisive surgery is much better tolerated than traditional open surgery in the older man and length of stay and recovery is comparable with younger men (this is not the case with open surgery).

Patients are encouraged to eat and drink normally on the night of the operation and most patients will be discharged one or two nights after the operation with a catheter to be removed after a week. Some abdominalRelating to the abdomen, which is the region of the body between the chest and the pelvis. bloating is expected and bowels will typically open after 2–3 days. Drinking plenty of water (two to three pints a day) is essential to ensure a good urine output and prevent catheter blockages.

Any activity more than light walking i.e. driving, lifting and gardening, should be avoided for two to three weeks after the operation to prevent damage to internal healing.

The oncological result is monitored using PSAAn abbreviation for prostate-specific antigen, an enzyme that is produced by the prostate. High levels are present in the blood when the prostate gland is enlarged or inflamed. tests, with the first test taken at 4–6 weeks after the surgery.

Mr G, a fit and well 56 year old, was getting up at night to urinate and went to see his GP. He thought it was related to late nights at work and stressRelating to injury or concern. but was seeking reassurance. After a thorough review from his GP his PSA level was found to be high at 8.5µg/L (a normal level is below 3.0µg/L).
He was reviewed urologically and by this time his urinary symptoms had improved. A palpable nodule was felt during a rectalRelating to the rectum, the lowest part of the bowel leading to the anus. examination and a prostate biopsy was undertaken.

MRI staging was undertaken and prostate-confined disease was confirmed. Due to having intermediate risk disease, cancer treatment was recommended as opposed to active surveillance. Mr G was then seen in a joint consultation by a surgical urologistA specialist in the treatment of diseases of the urinary tract, the channels that carry urine from the kidneys to the outside of the body. and a radiation oncologistA specialist in the treatment of cancer. to decide on his treatment; either a laparoscopic radical prostatectomy or radical radiotherapy and two years of hormoneA substance produced by a gland in one part of the body and carried by the blood to the organs or tissues where it has an effect. ablation therapy (medical castration).

Mr G discussed his options with his family and GP and decided to take the surgical route. The multidisciplinaryRelating to a group of healthcare professionals with different areas of specialisation. team had recommended surgery due to the age of Mr G as surgery is usually recommended to the younger, fitter patients.

After admission, the operation proceeded uneventfully and he was discharged home the following day with a catheter. The pain was very minimal requiring only simple analgesia. After the catheter was removed he was incontinent for the first three weeks requiring pad changes every 3–4 hours but by week four he was in full control, only leaking when lifting or stooping. By week four he was back playing golf and was able to work from home after just one week. Six months following surgery his disease is in remissionThe lessening or disappearance of the symptoms or signs of a disease. with an un-recordable PSA. He has full control of his bladder but can only achieve a partial erection with an oral phosphodiesterase inhibitor but things are slowly improving. Full potency recovery is possible over the next 18 months.

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