A radical prostatectomy remains the gold standard for management of localised prostate cancer in Australia and the world.
Why would I choose a radical prostatectomy to treat my prostate cancer?
Radical prostatectomy offers excellent long term local control of prostate cancer. Removal of prostate will also improve any associated symptoms from bladder outflow obstruction, such as a slow stream or straining to pass urine.
A radical prostatectomy also offers patients the option of excision of the pelvic lymph nodes which does offer prognostic information for long term outcome and possibly a small therapeutic benefit. Radical prostatectomy also avoids the potential complications of radiation therapy, which has been associated with increased irritability of the bowel and bladder compared with prostate surgery.
What about the problems with incontinence and impotence after prostate cancer surgery?
The use of a prostate blood test (PSA) for screening of prostate cancer has resulted in a massive stage shift to early curable, low volume prostate cancers. These cancers are usually localised within the prostate. Therefore the surgeon can spare the nerves around the prostate that supply your erections, without increasing the risk of leaving behind cancerous cells which can sometimes spread outside the prostate. Dissecting the nerves off the prostate gland will increase the chance of a patient recovering erectile function / erections in the future. There is a far greater chance of recovery of sexual function following a radical prostatectomy in 2013, compared with 2003 and certainly compared with 1993. This is due to improved surgical techniques over the last 30 years and also the shift towards towards lower volume prostate cancer where the nerves can safely be preserved without risking cure from prostate cancer.
There is increasing data to show that nerve sparing techniques also improve the chance of a patient recovering his urinary continence. The risk of wearing a pad in 2013 is much less than 20 years ago, due to improved surgical techniques. When a patient is operated on by an experienced urological surgeon, using modern surgical techniques, the risk of significant incontinence requiring a pad would be expected to be 5% or less.
What are the advantages of robotic surgical technique over a standard open radical prostatectomy procedure?
A robotic surgical technique is key hole surgery using technology which improves the ability of the surgeon to perform laparoscopic techniques due to a greater degree of movement of the robotic instruments. The robotic assisted laparoscopic approach offers an excellent view to the prostate and has been associated with less blood loss and less risk of wound complications compared to an open surgical technique. There does appear to be an earlier discharge from hospital and an earlier return to work with robotic surgery.
Robotic surgical techniques have become very popular over the last 5 years in Australia and in from 2013 in Queensland, four out of every 5 private patients who undergo a radical prostatectomy have had the procedure performed by a robotic assisted laparoscopic approach.
Is there any functional advantage in a robotic prostatectomy compared with open techniques?
The long held belief is that your surgeon is the most important determinate of functional outcome following a radical prostatectomy procedure. A very experienced surgeon using the latest surgical techniques offers the best chance of recovery of erections, recovery of continence, and “cure” from a prostate cancer (negative surgical resection margins).
Whether there is a functional difference between open and robotic assisted laparoscopic surgery will only be answered by randomised prospective clinical trials. The Royal Brisbane Hospital in one of the few centers in the world to commence a randomised trial of robotic verses open surgery for prostate cancer. The RBWH trial of open vs robotic radical prostatectomy commenced in 2010 and it is anticipated that the results of this trial will be known by the end of 2014.
A recent meta-analysis of the results of non-randomised studies of open vs robotic surgery has recently been published. The results suggest that that robotic surgery improves the recovery of erectile function and also improves the recovery of urinary continence compared to open surgical techniques.