Radical prostatectomy involves removal of the prostate, seminal vesicles and, in many cases, the pelvic lymph nodes.
The entire prostate is removed because cancer may arise at multiple locations within the gland. Cancer may spread to the seminal vesicles, which are small glands attached to the prostate that contribute fluid to the semen. Cancer may also spread to the lymph nodes, which are small structures throughout the body that help defend against infection.
The operation is performed under general anaesthesia and usually takes about two to three hours. The robotic procedure is performed through six small incisions, one for the camera and the remainder for the surgical instruments. The open procedure is performed through a single midline incision below the belly button.
In localised prostate cancer this operation is used with the goal of cancer cure. In high-risk or advanced disease, radical prostatectomy can be used in combination with radiotherapy and androgen deprivation therapy (an approach called multimodality therapy) to maximise cancer control and delay time to disease progression.
Dr Pras Sivam remains the only Melbourne Urologist to have trained in cancer surgery at New York’s prestigious Memorial Sloan-Kettering Cancer Centre. His unique approach to robotic prostatectomy combines elements of both the traditional “anterior” and newer “posterior” techniques. As a result, his patients recover continence earlier whilst maintaining excellent cancer control.
In a recent audit of outcomes, we found that 39% of patients achieved continence (0 pads or 1 security pad) within 2 weeks of surgery, and 65 % within 2 months. Few studies have looked at continence this early after surgery, however one large systematic review reported 3-month continence rates ranging from 25% to 90% (1).
Furthermore, we achieved superior cancer control rates with a positive margin rate of 0% for organ-confined cancer (stage pT2) and 17% for locally-advanced cancer (stage pT3). For comparison, in one large systematic review, the average positive margin rate was 9% for pT2 cancers (range: 4–23%) and 37% for pT3 cancers (range: 29–50%) (2).
(1) Ficarra et al. European Urology, Volume 62 Issue 3, September 2012, Pages 405-417.
(2) Novara et al. European Urology, Volume 62 Issue 3, September 2012, Pages 382-404.
Click here for a quick summary video outlining the steps of robotic radical prostatectomy. Note that this video contains actual surgical techniques and viewer discretion is advised.
Before Your Surgery
Certain medications increase the risk of bleeding and need to be stopped prior to surgery. You should tell your surgeon about all prescription medicines, over the counter medicines, vitamins, and herbal supplements that you are taking. Some patients, such as those with artificial heart valves or high blood clotting risk, will need to take blood-thinning injections whilst coming off their tablet medications.
You will see a pelvic floor physiotherapist to learn pelvic floor muscle exercises prior to surgery, in order to increase the likelihood of early return of urinary continence. Continue to perform these exercises after your surgery, but not while your catheter is in place.
You will no longer be able to ejaculate after this operation. If your plans include fathering a child then you should consider sperm banking before your surgery.
After Your Surgery
When you wake from anaesthesia you will have a catheter draining the bladder via the penis. You may also have a drain tube in your abdomen. You will have dressings over the incisions in your abdomen, and a drip in your arm.
The drain tube and drip are usually removed the following day. You will go home with the catheter in place and return in 7-10 days for it to be removed. The catheter will be attached to a leg bag hidden discreetly under your trousers. Further instruction on how to manage the catheter will be given by the nursing staff. Supplies will be provided by the hospital for the management of your catheter at home.
Some men experience bladder spasms while the catheter is in. These feel like sudden cramping pains in the lower abdomen and penis, and may be associated with an urge to urinate. A small amount of leakage around the catheter may occur at the same time.
You should expect some minor discomfort in the area of your incisions. This is usually managed with tablet painkillers, which you will continue to take once you go home. While you are taking painkillers it is recommended to also take stool softeners (eg. coloxyl and senna) to prevent constipation.
You may develop swelling and bruising of the scrotum and penis. This usually gets better in about one to two weeks. You can help reduce the swelling by keeping your scrotum elevated on a rolled towel while lying down. It also helps to wear briefs instead of boxers.
You will be expected to get out of bed on the evening of your surgery and start walking. This will help minimize the risk of blood clots in the legs. You should aim to go for a walk every two hours.
After a robotic procedure most patients should be able to go home the following day. Patients who have an open operation usually require an additional night in hospital.
The dressings on your wounds can stay in place until your review appointment. If the dressings fall off and the wounds are clean and dry there is no need to replace them. Steri-Strips (adhesive tape) on your incisions can be removed after 7 days. You may shower any time once you are home, but you must not take a bath until the catheter is removed.
Continue to take painkillers as required. If you need to take strong painkillers containing codeine, remember to also take stool softeners to avoid constipation. Do not use an enema or suppository for at least six weeks after your surgery.
Resuming Normal Activities
No driving for a minimum of 2 weeks after the operation. Avoid heavy lifting, bending, stretching, or straining activities like mowing the lawn for up to 4 weeks after your surgery. You may resume walking or light exercise immediately after your procedure. Ask your surgeon when to recommence blood-thinning medications. You will probably be able to return to work 2 weeks after your surgery. You may be comfortable with desk or office work once your catheter has been removed.
Catheter Removal and Trial of Void
- An appointment will be made for your catheter removal and wound check about 7- 10 days after your operation.
- If, after going home, you find that you are unable to pass urine comfortably, please call the practice.
- Expect to have a degree of urinary leakage when the catheter is removed. In most cases you will need to wear a number of pads throughout the day for several weeks. The number of pads you need to use will reduce with time.
- We ask that you recommence your pelvic floor exercises once the catheter has been removed. Performing pelvic floor exercises before and after the operation will reduce the time to recovery of urinary control.
- Most men (65%) will be dry within two months of the operation, but some may take up to one year to achieve continence.
- Between 5% and 10% of men will still require more than a single security pad after twelve months.
- A number of management options exist for men with persistent leakage after twelve months.
- You may experiment with erections and sex at any time after the catheter is removed.
- It usually takes months for erectile function to recover. In the weeks following surgery most men are unable to achieve erections sufficient for intercourse, even with the use of medications like Viagra and Cialis.
- Not every man will be able to recover erectile function, even with a nerve-sparing procedure.
- Be aware that you do not need an erection to climax. You will not ejaculate as the prostate gland, which is responsible for the production of seminal fluid, has been removed. However, you will still be able to achieve a pleasurable sensation (climax).
- If erections do not return there are numerous treatments available. Please discuss management of erectile function with your Doctor.
- You should consider penile rehabilitation to help maximize recovery. This may commence the moment the catheter is removed.
Penile rehabilitation therapy
- Penile rehabilitation therapy involves taking medications to increase blood flow to the penis. The goal is to minimize the duration of reduced oxygen that occurs from not having erections, thereby reducing the risk of erectile tissue scarring.
- You may start penile rehabilitation as soon as the catheter is removed.
- Start by taking one regular maintenance dose of medication per night:
- Sildenail (Viagra) 25 mg, or
- Vardenail (Levitra) 10 mg, or
- Tadalail (Cialis) 5mg
- Try to take a challenge dose once per week on an empty stomach. This is either 100mg sildenafil, 20 mg of vardenafil or 20mg of tadalafil.
- Try to become aroused from intimate contact with your partner or self-stimulation.
- Make a record of your response to discuss with your doctor at your follow-up visit.
Specific Risks and Side Effects
- Infertility as a result of vasectomy, which is an integral component of surgery.
- Lack of ejaculation due to removal of the prostate and seminal vesicles, the organs that produce the seminal fluid.
- Reduction in penile length.
- Altered sensation of orgasm.
- Impotence can occur even after nerve-sparing prostatectomy. It’s occurrence depends upon the age of the patient, their preoperative erectile function and whether or not they are suitable for nerve-sparing surgery. Almost all men will be unable to achieve an erection immediately after prostatectomy, however those who will eventually recover tend to start seeing improvement within four to six months.
- Transient urinary incontinence is normal after this operation. Most men will be completely dry within three months of the operation, but some may take up to one year to achieve continence. Five to ten per cent of men may have persistent urinary incontinence twelve months after radical prostatectomy, defined as requiring more than just a security pad to remain dry. These men may require additional treatments or procedures to regain continence.
- Bleeding requiring a blood transfusion is more common after open rather than robotic prostatectomy.
- Bladder neck contracture refers to scarring that occurs at the surgical join between bladder and urethra. It occurs more often after open (rather than robotic) surgery, and may require a telescopic operation to incise the scar.
- Lymphocele, a collection of lymphatic fluid that occurs after lymph node dissection, occurs in less than ten per cent of cases. It may occasionally cause pain or become infected, in which case a minor drainage procedure may be required.
- Anastomotic leak refers to leakage of urine from the join between the urethra and bladder. This rarely occurs, and if it does all that is usually required is keeping the catheter and drains in a little longer.
- The ureter, the pipe draining urine from the kidney to the bladder, may very infrequently be injured during this operation. If this occurs it may require repair or stenting of the ureter.
- Injury to major nerves around the prostate, causing weakness or altered sensation in the leg, is very rare.
- Rectal injury is very rare and tends to occur in situations where there has been prior major surgery or radiation to the rectum.
- Anaesthetic complications, such as heart attack or stroke.
- Infection, for example of the urinary tract, chest, or other sites.
- Clots forming in the legs (DVT), which may then pass to the lungs.
- Allergic reactions to drugs, antiseptics, or wound dressings.
- The risk of death relates to the patient’s general health and the complexity of the surgery, and may arise due to either anaesthetic or surgical complications.
When to contact your surgeon
- If you experience fevers, sweats, shakes, nausea or vomiting after you go home, or if you feel generally unwell.
- If your catheter stops draining for more than two hours. DO NOT allow anyone other than your treating surgeon to adjust or remove your catheter. Inappropriate manipulation of the catheter may dislodge the connection between bladder and urethra and require further surgery.
- If you see heavy blood or clots in your catheter tubing.
- If you are unable to pass urine at all after removal of the catheter.