Men's Health Matters
Baltimore's Dr. Edward Leventhal gives you advice on how men can live healthier lives.Treating Prostate Cancer - Radical Prostatectomy
Today’s discussion regarding prostate cancer will address surgical removal of the prostate. Other treatment options will be addressed at a later date. Radical prostatectomy implies removal of the prostate and seminal vesicles with reattachment of the bladder to the urethra. It can be performed in multiple fashions including open retropubic (abdominal incision), perineal (subscrotal incision), laparoscopic and robotic fashion.
The procedure in one form or another has been present in urology for decades. It would be unfitting to speak of radical prostatectomy without mentioning Dr. Patrick Walsh of Johns Hopkins Medical Center who was one of the pioneers in the advancement of the procedure. He, along with some other notable urologists, turned the procedure from what was a bloody surgery with a very high complication rate into a technically sound procedure with good to excellent results in terms of complications and efficacy.
The last five to ten years has seen the introduction and incorporation of laparoscopy and robotic prostatectomy into the surgical options to treat the disease of prostate cancer. There have been a number of studies performed which show that there is no real difference between the methods of surgical extirpation in terms of complication rate and results. There is no question that laparoscopic or robotic prostatectomy has a longer “learning cure” for the surgeon and in general takes much longer to perform.
A detailed review comparing the robotic procedure to the open procedure was recently performed by Dr. Herber Lepor who trained under Dr. Walsh at JHU and is the current Chairman of Urology at New York University. I have met Dr. Lepor and have had the opportunity to watch him perform radical prostatectomy. As a surgeon who has performed the procedure many times it was a real treat watching Dr. Lepor operate. He is technically outstanding and truly an “artist” as a surgeon. He makes the argument that as a minimally invasive procedure, his version of the radical prostatectomy is in truth less invasive than the robotic procedure and to be honest his arguments are sound. The important point to remember is that you want a surgeon who has done a large number of radical prostatectomies and it is not inappropriate to ask your prospective surgeon how many he or she has done in total or on a yearly basis.
The procedure is performed as an inpatient in the hospital. Most men are discharged from the hospital before the third postoperative day. Significant blood loss is common and many men “bank” their own blood in case of the need for a transfusion. It is uncommon with today’s procedure to need to get transfusions from other donors. After discharge from the hospital most if not all men will need to wear an indwelling foley catheter to drain the urine from the bladder while the anastomosis (the connection of the urethra to the bladder) heals. Catheterization times are dependent upon the surgeon and typically average 10 - 14 days. Most men return to work a few weeks after surgery.
The big worry of most patients regarding radical prostatectomy is what I call the big “I’s” of impotence and incontinence. Most sources report that even after a prostatectomy designed to spare the nerves responsible for erection a large number of men will have difficulty with erection. The percentages reported are dependent upon who is asking the question and how it is phrased. It is fair to assume that if you have excellent erectile function, are less than 60 years of age, and get a nerve sparing procedure by a skilled surgeon you will have a very good likelihood of maintaining your ability to get an erection sufficient for completion of penetrative intercourse. If you have marginal erections, are over 60, have medical issues like hypertension, hypercholesterolemia or diabetes it is fair to assume that radical prostatectomy will make things worse to the point that you will need either oral medications or penile injection therapy to augment and sustain your erectile function.
Incontinence is much less common than erectile issues after radical prostatectomy, but for most men it is much more troublesome. It is hard to predict who will have major continence issues after surgery and for most men the worst of it is an occasional loss of urine with sneezing or swinging a golf club. But for some men (less than 10% in most studies) profound incontinence is a serious potential complication of radical prostatectomy. It is cited by most of my patients who have no interest in surgery as their main concern and while profound incontinence that truly limits lifestyle is uncommon, for the guy that gets it after his surgery it can really cause problems. The good news is that there are good secondary surgical procedures available to treat the problem, but the problem itself is enough to put many men off of extirpative surgery to treat prostate cancer.
The take home message is straightforward. Radical prostatectomy done through any number of avenues is a valid and successful treatment for prostate cancer. If you are the type of guy who says, “Doc, get it out of me!!!” then radical prostatectomy is for you. Understand that as a major surgical procedure there are a number of significant risks and potential complications. Ask your surgeon how many he or she has done and it is totally appropriate to ask them about their complication rates and success rates. The most important factor is to be sure that no matter what treatment you have selected, you are comfortable with the person performing the procedure and the type of procedure performed. I tell every patient that this is their cancer and not mine. So they better be darned sure that they have researched their options and have selected the treatment that makes the most sense in their particular case.
Football aside. What a relief to have a quarterback in Baltimore that can win a game. The win against the Chargers was huge for the Ravens. To go across to the left coast and beat a team that many had pegged for the Superbowl and to do so in their home opener says a lot about our team. While there are questions on the defense, it’s great to watch our team go 2 - 0. Now the Browns come to town and we need to take care of business. It wasn’t so long ago that we would play down to the level of our competition. Somehow, I don’t think Coach Harbaugh will let that happen. Go Ravens!!! Beat the Browns! 3 - 0. Ho… Ho… Ho….
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