Radical prostatectomy involves the removal of the entire prostate gland. Depending on the type of surgical approach, we distinguish between standard treatment and minimally invasive methods – i.e. removal of prostate cancer either by laparoscopic or robotic surgery. The surgery is most often performed on patients who are in good biological condition and have no other serious diseases. This operation can significantly change the quality of life of the patient. Incontinence or urinary retention disorder can occur in 10-20% of patients after this operation. Radical prostatectomy can also have an impact on sexual life in the form of erectile dysfunction (present in varying degrees up to 70-80%) *. Patients must be followed up regularly and continuously after surgery, as the disease may return after several years.
Standard surgery is rarely performed anymore. This is due to the trend towards minimally invasive approaches. An open prostatectomy is performed by an incision through the abdomen or the perineum. The patient is most often admitted the day before surgery. The operation is always performed under general anaesthesia and takes about 90-120 minutes. An approximately ten-centimetre incision is made in the midline of the lower abdomen and in certain cases the lymph nodes in the pelvic area are also removed during the procedure. At the end of the procedure, a urinary catheter is inserted into the bladder through the urethra and removed in 7-14 days. The patient is monitored in the intensive care unit after the procedure and transferred to a standard ward once his condition has stabilised. If the patient’s condition and their background allow for it, the hospitalization can be terminated after a few days and home-care will follow.
Before the removal of the urethral catheter, an X-ray check of the tightness of the urethral connection to the bladder may be performed during which the existing catheter is filled with a contrast agent. If the contrast medium does not leak outside the bladder, the catheter can be removed, otherwise it is left in place for a few days. The patient is then followed up in a specialist urological or oncological outpatient clinic.
For approximately 4 to 6 weeks after the operation, it is recommended not to lift heavy objects, engage in straining physical activity (e.g. sports, gym, gardening, etc.) and ride a bicycle. Medical leave tends to last the same but that depends mostly on the severity of the physical work the patient is doing. Until the surgical wound has fully healed and the stitches have been removed, it is advised to only take showers and swimming in a swimming pool is not recommended.
Laparoscopic surgery is one of the two minimally invasive methods in which instruments are inserted through small incisions into the abdominal cavity to remove the prostate and possibly lymph nodes, to the same extent as in open surgery. The pre-surgery directions, surgery time and post-surgery care with hospitalization are also the same. Better cosmetic result is an advantage of the laparoscopic approach as well as sometimes shorter hospitalisation and recovery time. The urethra is usually removed on the 8th day post-surgery, the removal of sutures and other controls are performed in the same way as in open surgery.
This is also a minimally invasive approach where robotic instruments are introduced into the patient from several tiny punctures which perfectly transmit all the movements of the surgeon’s hands, with multiple magnification and 3D imaging. With these instruments, it is possible to precisely yet radically remove the tumour-affected tissue – the prostate, seminal vesicles and sometimes even the pelvic nodes – while maximally sparing the surrounding tissues of the bladder and urethra, the muscles that allow urine to be retained, and the nerves and blood vessels necessary for erection. The urethra is usually removed on the 8th day post-surgery, the removal of sutures and other controls are performed in the same way as in open surgery.
Complications after all surgical procedures are divided into early (during or immediately after surgery) and late (during follow-up or long lasting).
Both complications are caused by a damage of the nerves and blood vessels that run along the prostate gland that can be severed or damaged during surgery by ligation or a thermal process (coagulation).
Up to 15% of patients have to use some form of incontinence aid after surgery, usually pads, nappies, but also urinal condom or a penis clamp. Medications for incontinence are not yet available but spasmolytics can relieve urine leakage by reducing involuntary bladder contractions and increasing bladder capacity. Urinary leakage can also be reduced during recovery and is expected to improve during up to 24 months after surgery. **
Erectile dysfunction treatment should be started as soon as possible; a drug form may be prescribed but it achieves only limited effectiveness. Much more effective is the application of an erectile stimulant directly into the erectile bodies with a thin needle – the patient learns the application at the clinic and then performs it himself. As a last resort, a prosthesis can be implanted in place of the erectile bodies to allow the penis to become erect. Erectile dysfunction can also be corrected during the first two years of surgery. ***
The most important indicator of cancer persistence or recurrence is prostate-specific antigen (PSA). Therefore, the common method is to monitor PSA levels. PSA is expected to be undetectable within six weeks after a successful radical prostatectomy. If this is not the case or if the PSA increases gradually during follow-up, additional radiation to the site after surgery (radiation therapy) or systemic treatment with hormonal agents is most often initiated. Follow-up should also include a digital rectal examination to detect any localised recurrence of the disease.
*https://www.linkos.cz/pacient-a-rodina/onkologicke-diagnozy/zhoubne-nadory-muzskeho-pohlavniho-ustroji-c60-c62/o-nadorech-prostaty/
**/***https://www.cus.cz/pro-pacienty/diagnozy/karcinom-prostaty/
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