Part of the “Enhancing Prostate Cancer Care” MOOC

Catherine HolbornSenior Lecturer in Radiotherapy & Oncology

Sheffield Hallam University

Aim of the presentation

To provide an overview of the key aspects of surgery in the radical treatment of localised and locally advanced prostate cancer

This supplements the information already provided on the overall management of prostate cancer and the role of the main radical treatment options (surgery and radiotherapy)

Radical ProstatectomyAim is to eradicate the cancer, preserve urinary

continence and if possible, erectile functionInvolves removal of the entire prostate gland and

resection of the seminal vesicles, plus a margin of surrounding tissue sufficient to achieve a negative margin

The pelvic lymph nodes will also be removed for high risk localised and locally advanced prostate cancer, and also possibly for intermediate risk localised prostate cancer

ConsiderationsFor men with localised prostate cancer, surgery is a treatment

option alongside radiotherapyA number of factors may influence their final decisionSide effects are covered in a separate presentationWhat else may be a consideration?

General health and suitability for surgery/general anaestheticThe psychological aspect of having the cancer removed from the bodySuccess can be gauged early as the PSA levels should fall very quickly

to negligible levelsThe prostate can be examined after surgery to more thoroughly assess

grade/extra-capsular extensionLess burden i.e. time spent attending hospital

Negative resection marginThis is when the resected margin of surrounding tissue (especially

the outer edge) is clear from any cancer cells, when examined under a microscope

If cancer cells are seen, there is a chance that some may also remain in the body. Especially if these extend to the outer edge of the margin of tissue resected (a ‘positive’ resection margin)

These can re-populate and signs of biochemical disease progression (rising PSA levels) may eventually occur. If left untreated, this may ultimately cause the man to develop clinical symptoms, indicative of more advanced disease

A decision must be made as to whether further treatment (post-operative radiotherapy) is given immediately after surgery (‘adjuvant’ to), or in a ‘salvage’ setting (when biochemical progression occurs)

Surgical expertiseAn important factor , regardless of what surgical method

is usedIt can influence the ability to achieve a negative resection

margin (if this is possible given the clinical and pathological features of the cancer)

It can also influence the ability to spare the neuro-vascular bundle (again, if this is possible) and in turn, help to preserve erectile function

The Neuro-Vascular Bundle (NVB) The NVB runs in the posterior-lateral grooves between

the prostate and rectum. This is close to the peripheral zone were most prostate cancers arise and it is important to widely dissect around this area as a means of achieving a negative resection margin

Removal of the NVB is responsible for the occurrence of erectile dysfunction

Nerve sparing surgery (of one or both bundles) and careful excision around this area is possible but usually only for low risk, low volume cancers, maybe intermediate risk cancers

Traditional surgical methodsThe traditional method uses an ‘open’ incisionThis may be a ‘retropubic’ incision (via the abdomen) or a

‘perineal’ incision (via the area between the scrotum and the anus)

Perineal incision provides better access to the prostate and is associated with less blood loss; but is potentially more limiting in the amount of tissue that can be removed e.g. for larger glands/extra capsular spread and it is suggested that positive surgical margins may be more frequent with this approach as a result. It also doesn’t allow for the removal of lymph nodes if this is needed.

Laparoscopic (key hole) method Less invasive5 or 6 small openings are used (as opposed to one large

one)This may be done by hand or robot assistedKey advantages are; a quicker procedure, less time spent

as an in-patient, less surgical complications e.g. blood loss and the need for a blood transfusion

Robotic prostatectomy is increasingly being used, instead of the aforementioned traditional methods

Recent evidenceA recently published systematic literature review

demonstrated that Robotic Prostatectomy was more favourable compared to open surgery and conventional laparoscopy, in terms of peri and intra operative complications and adverse events; and at least as equivalent to these in terms of positive margin rates

ReferenceTewari A, Sooriakumuran P, Block DA, Sehsadri-Kreaden U, gerbert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparospcopic and robotic prostatectomy. European Urology. 2012. 62; pp.1-15

Post-op careDuring surgery, the prostate is detached from the bladder and

the urethra. After careful excision, the bladder is then attached to the end of the urethra, to re-create the urinary tract and a temporary catheter is inserted to bridge this connection.

This enables the urine to drain freely as the wound/stitches heal and prevents any build up of pressure being placed on these.

It remains in position for approximately 2 weeks (can be as little as 3-4 days) and is usually removed in an outpatient setting. The man is allowed to leave once they have passed water normally. Whilst the catheter is in place, information about how to care for the catheter, to prevent infection, is important.

The man is usually discharged from hospital up to a week post-op (could be much less with a robotic prostatectomy).