High-grade tumours of low volume may be effectively managed by surgery in a moderate proportion of men. A radical prostatectomy may be indicated for men with low and intermediate risk localised prostate cancer and a life-expectancy greater than ten years.31
It is generally offered to younger, fitter men because the risk of incontinence with this procedure increases with age.47 With the possible exception of a transurethral resection of the prostate in men who are unable to void after androgen deprivation therapy, surgery is not recommended in the management of men with advanced prostate cancer.53
A large observational study of mortality outcomes concluded:54
- The majority of men with clinically localised prostate cancer might benefit more from surgery than radiotherapy, whereas radiotherapy might be preferable in men with metastatic disease.
- Younger men and those with fewer comorbidities who have intermediate or high risk localised prostate cancer might have a greater benefit from surgery.
Radical prostatectomy involves removal of the entire prostate gland between the urethra and bladder, and resection of both seminal vesicles, along with sufficient surrounding tissue to obtain a negative margin. The procedure is often accompanied by bilateral pelvic lymph node dissection.31 The operation may be performed using one of four techniques:39
- a retropubic incision
- a perineal incision
- a laparoscopic technique
- a robotic-assisted technique.
The desired outcomes of radical prostatectomy are to control cancer, and, depending on tumour characteristics and the man's pre-existing sexual function, to preserve urinary and sexual function. Pathological assessment of the prostate gland and usually the obturator lymph nodes occur post-surgery.39
The retropubic approach is most commonly used because it provides access to the regional lymph nodes in the pelvis. This allows sampling of the nodes and removal of the prostate using a single incision where required. The decision to perform a pelvic lymph node dissection and the extent of such dissection depends on the probability of nodal metastases.40
Minimally invasive techniques, such as laparoscopic radical prostatectomy (LRP) and robotic-assisted surgery, have been developed. The LRP technique has shown improved outcomes for pain, length of hospitalisation and blood loss during surgery, but is not as widely available due to the specialised skills required to undertake the procedure.25, 40
Similarly, while the robotic-assisted technique requires advanced training and the cost of the equipment limits its use, it has reported benefits. It is becoming widely used in the USA and Europe.31 It is associated with less blood loss and transfusion rates compared with radical retropubic prostatectomy. Evidence is indeterminate regarding benefits related to urinary continence and erectile function.31
Immediate post-operative considerations include:55
- wound drainage
- paralytic ileus
- anastomotic leak
- urinary output
- catheter blockages
- haematuria (which may persist for several weeks).
People affected by prostate cancer require education and support to help reduce anxiety and manage any problems that may arise after surgery.55, 56 The estimated risks of complications associated with radical prostatectomy include:57
Less than 15%
Up to 10%
up to 70%
Urinary incontinence and impotence are of significant concern for men following prostatectomy. Incontinence will usually improve with time but there are exercises men can do to help improve the recovery process.58 Men should be encouraged to perform pelvic floor muscle exercises early in the recovery to help improve level of continence.55, 56
PSA levels continue to be monitored in the post-operative period, and may be a source of concern for some men.40 A rise in PSA post-surgery may indicate the need for further treatment.40 There is some evidence that adjuvant radiotherapy may reduce mortality in men whose PSA levels are elevated or continue to rise even after prostatectomy.59 Adjuvant radiotherapy may also be offered to men whose surgery revealed seminal vesicle invasion, extracapsular extension, and/or which did not achieve clear margins.40
A recent study found that nearly half of men felt mentally and physically worse after undergoing prostatectomy.60 A combined psychological and physical counseling program before and after surgery has been proposed to improve postoperative health related quality of life, potency and continence.60
Access the Guidelines on Prostate Cancer (2015)31 and outline the indications, advantages and disadvantages of the following surgical approaches in regard to patient outcomes and side effects:
- open radical prostatectomy
- laparoscopic radical prostatectomy
- robotic-assisted laparoscopic radical prostatectomy.
Identify the immediate post-operative complications associated with radical prostatectomy.
Ted’s story 5: Post-operative
Describe the role of the following health care professionals in pre- and post-operative care:
- urology / surgical nurse (non-cancer specialist)
- continence nurse
Outline the components of a pre-operative assessment prior to radical prostatectomy.
Outline the immediate post-operative observations following radical prostatectomy, including timing of these observations, and the rationale for conducting these observations.
Summarise current evidence-based interventions to prevent and manage the following post-prostatectomy complications:
- urinary catheter dysfunction and discomfort
- wound infection
Outline key components of a discharge plan for a man following prostatectomy.