Definition:
Radical prostatectomy involves the removal of prostate blockage and seminal vesicles with subsequent bladder anastomosis with the urethral stump.
The intervention is usually preceded by a pelvic lymphectomy, i.e. the removal of lymph nodes that drain the lymph from the prostate gland.
Indications:
The selection of the patient depends on the clinical stage, life expectancy and psychophysical conditions.
It is generally considered to be a candidate for radical prostatectomy surgery, with healing intent, a patient with clinically localized prostate cancer, with a life expectancy of at least 10 years and under satisfactory general conditions.
The purpose of the surgery is to surgically remove the entire tumor, allowing the healing of the patient. However, it should be reminded that, unfortunately, histologic analysis of the part removed in a high percentage of cases, more than 40%, the tumor is found not confined to the prostate or has positive section margins. In such cases, complementary therapy such as radiotherapy or hormone pressure may be needed.
Complications:
Radical prostatectomy is considered a major surgery and as such is not without complications.
The perioperative mortality rate, i.e. occurring in the thirty days after surgery, varies from 1 to 4.6%; while operating mortality is less than 0.5%.
The complications of radical prostatectomy surgery can be divided into three groups: 1) intraoperative, 2) early postoperative (up to 30 days after surgery), 3) late postoperative (after thirty days after Surgical intervention).
Overall, the frequency of such complications varies from 7.5 to 18.5%;
1) Among the first, it is worth remembering intraoperative haemorrhage occurring in less than 10% of cases with a blood loss that does not exceed 1,200 / 1,500 ml on average.
Rectal wall puncture is reported in the 0.1 / 0.2% of the cases; whereas urethral lesions have a variable incidence of 0.1 to 4.7%. Rectal puncture if minimal is repaired in the course of the same intervention; if the rectal lesion is more conspicuous and the only repair is not sufficient guarantees, it is customary to pack a temporary colostomy to allow for a safer healing. Ureteral lesions usually require a bladder ureter reimplantation.
2) Early postoperative complications include 0.7-2.6% thromboembolic complications, cardiovascular 1-4%, wound infections 0.9-1.3%, lymphorrhea or lymphocele 0, 6-2%.
The stenosis of the bladder-urethral anastomosis is reported in a percentage ranging between 0.6 and 32% of the cases and is usually treatable by endoscopy.
3) Among the late complications, mention should be made of urinary incontinence and sexual impotence.
As for the issue of urinary incontinence, the anatomical approach described by Walsh to radical prostatectomy has allowed to reduce the incidence of postoperative urinary incontinence. In the case of radical prostatectomy, the incidence of total incontinence varies from 0 to 12.5% of cases.
Recovery of spontaneous sexual power is conditioned upon the choice of a technique (nerve sparing) applicable only in some cases (low-grade, monolateral tumor in a patient younger than 70), which maintains the sexual power in 50-70% of cases. However, the availability of medications and other surgical instruments allows patients to have an active sexual life even in cases where it is not possible to preserve sexual power.
Radical prostatectomy, preceded by lymphadenectomy, lasts about 2 hours and 30 minutes and is performed in an ordinary hospitalization with a 5 to 14 day stay.
Convalescence:
The convalescence for this type of surgery is about 20-30 days
Checks:
The first check is carried out at 30 days distance with a PSA determination, a urine examination and an urine culture; while subsequent checks, randomly variable, will be planned on average 6 months after the first visit.
Technical Description:
The intervention is performed through a median incision from the navel to the pubic symphysis; once gone beyond muscular plane, first a staging pelvic lymphadenectomy is performed, then the radical prostatectomy whose phases can be summarized in the following points:
- Section of pubo-prostatic ligaments
- Section of the dorsal venous complex
- Division of the urethra
- Mobilization of prostate of the seminal vesicles and section of deferential vessels
- Section of the prostate-vesicular junction
- Reconstruction of the vesical neck
- Bladder-urethral anastomosis.
ALTERNATIVE STRATEGIES
The therapeutic alternatives available today for prostate cancer tumors are essentially two: radical prostatectomy and radiotherapy, the latter being in the form of external irradiation or brachytherapy.
RADIOTHERAPY
External radiotherapy of localized prostate cancer patients provides survival results very similar to those obtained with radical surgical therapy.
It may be reserved for patients over 70 years of age or in general non-optimal conditions. Compared to radical prostatectomy, radiotherapy would be characterized by a higher rate (30-40% more) of biochemical progression (i.e. an increase in PSA some time after treatment). Conventional radiotherapy also has complications that are reported in the table and compared with those of surgery:
- Cardiovascular complications (1-4%)
- Thromboembolism (0.7-2.6%)
- Rectal lesions (0.1-0.3%)
- Impotence (20-90%)
- Urethral stenoses (0.6-32%)
- Total Incontinence (0-12.5%)
- Perioperative Mortality (1-4.6%)
- Acute gastroenteritis or urinary tract complications (3-67%)
- Chronic complications requiring repeated hospitalization or surgery (1-2%)
- Anorexia complications (2-23%)
- Impotence (40-67%)
- Urethral stenoses (3-17%)
- Incontinence (1-3%)
- Mortality (0.2-0.5)
The duration of treatment is approximately 8 weeks, with 5 sessions per week.
BRACHYTHERAPY
Brachytherapy consists in planting semi-radioactive within the prostate gland under the ultrasound control that can determine prostate cancer necrosis.
It is indicated in the treatment of initial prostate cancer and, with respect to radical prostatectomy and radiation therapy, presents less risk of incontinence and impotence.
It is a new method and as such, it has not yet been possible to compare efficacy over conventional therapies and quantify complications.
After surgery, the patient remains in observation for approximately 24 hours and is resigned with the catheter that will be permanently removed after 3-4 days.
Patient Obstructed: In the case of intra-vesical obstruction by tumor-associated prostate hypertrophy (a very frequent occurrence after age of 60), radiotherapy could significantly deteriorate the patient’s obstructive disorders until endoscopic destructive surgical intervention is required.