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Radical prostatectomy


Medical editor Bjørn Brennhovd
Urologist
Oslo University Hospital
Norway

General

A radical prostatectomy is, in addition to high-dose radiation therapy, the only internationally recognized curative treatment option for localized prostate cancer.

During the procedure, the prostate and seminal vesicles (or parts) are removed. The neck of the bladder is anastomosized directly to the urethra. A nerve sparing technique is attempted to conserve erectile function.  

Radical surgery is preferred for patients having at least 10 years expected survival time and organ-localized cancer. Patients with locally advanced cancer are increasingly considered. In such cases, supplementary treatment is often likely.

The surgery can be performed as open surgery or as robot-assisted laparoscopic surgery. There is no difference in side-effects or postoperative complications between these methods. 

At Oslo University Hospital, all radical prostatectomies are performed by robot-assistance. This tendency is also consistent with the rest of Norway, western Europe, and the US. 

Advantages of robot-assisted laparoscopic surgery compared to surgery:

  • Shorter reconvalescence
  • Less blood loss
  • Less scars
  • Less postoperative pain
  • Shorter sick-leave period 

Indications

  • Localized prostate cancer

  • Locally advanced prostate cancer

Goal

 

  • Cure the disease

Equipment

  • Laparoscopy
  • Robot instruments
  • Urological robot forceps
  • 0° optic
  • Suction/rinse

Preparation

  • Thrombosis prophylaxis
  • Foley catheter
  • Trendelenburgs position

Implementation

  • During the operation, the patient lies in the supine position and extreme Trendelenburg position.
  • Five trocar ports are made. The abdominal cavity is inflated.
  • The robot is docked.
  • The peritoneum is opened around the bladder.
  • Lymph nodes are removed if necessary as described under lymph node dissection.
  • Open the endopelvic fascia and divide the puroprostatic ligaments.
  • Incise the neck of the bladder down to the deferens ducts which are divided.
  • Dissect both seminal vesicles which are pulled up.
  • Denonvilliers' fascia is incised and a layer between the rectum and prostate is reached.  
  • Divide side ligaments to the prostate using a nerve-sparing technique if possible.
  • Split the urethra close to the prostate and place in a plastic bag.
  • Anastomosize between the bladder and the urethral stump.
  • Test anastomosis by instilling saltwater into the bladder.
  • The prostate is removed via the umbilical opening.

Follow-up

Observations

  • Bleeding
  • Anastomotic dehiscence
  • Urinary tract infection  
  • Deep venous thrombosis/lung embolism

The patient will have the Foley catheter in place for 14 days. He will be trained to clean the catheter and use a leg before returning home. The patient should also be informed about erection and continence training. After a robot-assisted radical prostatectomy, the patient is usually discharged on the second postoperative day.

The Foley catheter is removed after 10 days and a urine sample is collected for bacterial testing

The pathology report may take 2-3 weeks. This histological examination is very resource-demanding for a pathology laboratory.

The patient have a follow-up examination with an urologist 6 weeks postoperatively.

 


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