Radical prostatectomy includes the removal of the prostate and seminal vesicles. If performed via the retropubic approach (abdominal incision), the pelvic lymph nodes are also removed. If performed by the perineal approach (the space between the anus and scrotum), a separate procedure must be performed to remove the pelvic lymph nodes. Most surgeons ask the patient to bank his own blood prior to surgery for administration during the procedure. The operative time is approximately 2 to 3 hours. Typically, the patient will remain hospitalized for three to seven days and will use a urethral catheter for 10 to 21 days. The vast majority of men will have temporary incontinence following removal of the catheter for several weeks and up to several months.
Even with the Walsh modifications, complications associated with the radical prostatectomy procedure have limited its acceptance. The two most-feared complications are urinary incontinence and erectile impotency. The American College of Surgeons performed a 1990 survey of 2122 patients treated by radical prostatectomy that were representatives of the national patterns of care. This survey noted urinary control in 81%, complete urinary incontinence in 4%, stress incontinence in 15% and maintenance of erectile potency in 28%.
Since Hugh Hampton Young’s original report in 1905, radical prostatectomy has been considered the definitive treatment for localized prostate cancer. Radical prostatectomy is the gold standard for treatment efficacy against which other modalities must be measured. Traditionally, radical prostatectomy has been performed with curative intent in patients with clinically localized prostate cancer (clinical stages A and B or T1-2).
Unfortunately, approximately 55% of men with clinically localized prostate cancer actually have extraprostatic tumors, based on examination of the radical prostatectomy specimen. Additionally, about 15% of radical prostatectomy specimens have tumors so small that they are considered unlikely to cause death during the expected lifetime of the patient. These small volume tumors are called “clinically insignificant tumors”. If 55% of radical prostatectomy specimens have extraprostatic disease and 15% have clinically insignificant tumors, only 30% of patients have surgery that is clearly beneficial on a histopathological basis. Thus, in a majority of patients, radical prostatectomy is primarily a surgical debulking procedure and, secondarily, a curative procedure. Studies of untreated patients with serial PSA values have demonstrated that prostate cancer has a relatively long doubling time and, theoretically, debulking the primary tumor may provide a therapeutic benefit.
A recent study from the Mayo Clinic showed that even in a relatively fast doubling time of two years, a tumor of 0.25 cc (a residual cancer volume that can be achieved following radical prostatectomy) should not significantly impact longevity over a 12-year period.
Results of surgery may be described in terms of patient survival. “Overall survival” reports deaths due to prostate cancer as well as other non-cancer related deaths. In an older group of men, non-cancer deaths may be substantial. “Cause-specific survival” has been used to reduce the impact of age, medical condition and other risk factors. It reports the death rate due only to prostate cancer and excludes other causes.
If all radical prostatectomy series originating in 1950 or later that have 15 year overall survival data are considered together, the overall survival at 5, 10 and 15 years is 92%, 74%, and 58%, respectively. This approximates the expected survival in an age-matched control population. A report from the Mayo Clinic of 472 men over a period of 10 years and 166 men over a period of 15 years following surgery, shows a 10-and 15-year cause-specific survival of 90% and 82%, respectively.
Radical prostatectomy has also been used to treat patients with extraprostatic disease by administering hormonal therapy prior to surgery. Preoperative hormonal therapy was used to make the prostate smaller or reduce the incidence of cancer outside of the prostate. Scott reported using oral estrogens before radical prostatectomy in 1964. More recently Labrie randomized 161 patients to radical prostatectomy, half received combination hormonal therapy (flutamide and lupron) before surgery and the other half did not. The patients treated with combination hormonal therapy had a lower incidence of positive margins than the surgery only group (8% versus 34%, respectively). Additionally, more patients in the combination hormonal therapy group had organ-confined tumors when the pathologist examined the radical prostatectomy specimen (78% versus 49%, respectively).
At the Mayo Clinic 1035 patients with pathologic stage C (T3) disease have been treated with radical prostatectomy; some also received hormonal therapy or radiotherapy. The overall survival at 10 and 15 years was 68% and 46%, respectively. The cause-specific survival at 10 and 15 years was 81% and 66%, respectively.
Recent developments in the field of surgical robotics have ushered in a new era of minimally invasive surgery that now challenges conventional open surgery. Currently available telemanipulation devices allow the performance of complex surgical tasks with dexterity and minimal fatigue due to their ergonomic design, expanded degree of movements, tremor filtering, and 3-D stereoscopic visualization. These devices provide an unsurpassable view of the operative field and unrestricted ability to execute any surgical task, Robotic surgery has been embraced by urologists who have applied it to complex surgical procedures such a pyeloplasty, radical cystectomy, donor nephrectomy, and radical prostatectomy.
The goal of treating prostate cancer includes complete eradication of cancer coupled with minimal morbidity and negligible deterioration in the quality of life. In order to meet these goals, the surgeon can use a da Vinci master-slave robot system. The use of the da Vinci can result in excellent oncological and surgical outcomes, cause minimal bleeding, and provide for the procedure to be completed in 90 to 160 minutes. The patient satisfaction has been tremendous. Not only do both patients and families appreciate the cosmetic benefits, but also hospitalization has been significantly reduced. Most patients can revert back to their normal lifestyle in less than two weeks.
Robotic Versus Laparoscopic Prostatectomy
In laparoscopy, the surgeon uses long instruments through small openings and maneuvers them with direct hand contact. Robotic systems use even more delicate instruments that possess two additional degrees of movement excursion (for a total of six, as with a human hand). Comfortably seated at the robot console, the surgeon can maneuver the instruments via a computer interface.
Laparoscopic radical prostatectomy is associated with a steep learning curve. Even in the hands of expert surgeons, laparoscopic radical prostatectomy requires extensive learning, approximately 40 cases are needed to master this technique. In contrast, the learning of robotic prostatectomy seems to be more intuitive and less demanding.
A comparison of 10 robotic prostatectomies with 10 laparoscopic prostatectomies, all performed by the same surgeon, who is an experienced upper urinary tract laparoscopist produced these results. Despite the fact that the surgeon had a large amount of experience with the laparoscopic procedures, the mean time was on average 145 minutes less for robotics than for laparoscopic prostatectomy. The estimated blood loss was comparable, and there were two conversions in each group, but no major complications occurred.
Robotic prostatectomy is a safe, effective and reproducible technique for removing the prostate. In most patients, it can be performed within one and a half to two hours with minimal blood loss and few complications. The procedure incorporates principles of both laparoscopic and open radical prostatectomy. The patients enjoy benefits of surgical treatment in the setting of less invasion, minimal pain, limited blood loss and early functional and overall recovery. The early results show similar cancer control outcomes.