Radical prostatectomy surgery: What to expect

I'm Dr. Robert Nam, I'm one of the urologic
oncologists, a surgical oncologist that specializes in
prostate cancer surgery. We do about 200 prostate cancer surgeries
at Sunnybrook, and we have one of the largest volumes within the Toronto
area. Prostate cancer is the most common male cancer
and it's actually the third leading cause of death among males who have cancer.

Men should be checked once they turn age 50.
That's with a blood test called PSA which they can get through their family doctor.
If there's a family member that has been affected with prostate cancer
they should be checked earlier, once they turn age 40.
Unfortunately, PSA is not the best test to look for prostate cancer
anymore. The best way to evaluate
a person's risk for having prostate cancer is to do what's
called a prostate cancer risk assessment using a risk calculator.
It's available online at prostaterisk dot ca at
our Sunnybrook website, where with a physician's help, they can
determine their risk for having prostate cancer and it encorporates many factors
not only PSA. If you are, unfortunately
diagnosed with prostate cancer, the first thing to do is not panic.
Prostate cancer is a slow growing disease when you compare it with
other cancers. You have a lot of time to think about your options
and what to do. You really have to discuss it with
your physician, do a lot of due dilligence and research what
option might be best for you. Prostate cancer takes 10 to 15
years for it to grow and spread, so just taking a few weeks
or months to really think it over is very important.
There are three treatment options for patients with prostate cancer that is contained within
the prostate gland. The first is, perhaps you don't need to anything
and that's what we call watchful waiting. There are many forms of
prostate cancer that don't progress or cause death
and many patients die with the disease and not from the disease.
But, unfortunately there are a large proportion of patients that do
have aggressive forms of prostate cancer, and the two best treatments
for that are either complete removal, called radical prostatectomy,
or radiation therapy that delivers
high energy to the prostate gland and cancer to kill it.
So over the next minutes I'd like to walk through what's involved
in a radical prostatectomy and what patients and
physicians do during this part of your treatment.
Radical prostatectomy is the complete surgical removal of the prostate
gland and that involves an incision with the patient asleep.
There are many ways of taking out the prostate gland, whether it's through
conventional open surgery, robotic surgery or laproscopic surgery
but the end result is the same, and that is the complete removal of
the prostate gland. And the the intent of that is to
completely cure the patient from their prostate cancer. A common question I
get is, what can I do to prepare for the surgery? Nothing.
Don't try and drastically reduce weight. Don't try and
take on a new lifestyle. You have to maintain what you're doing
and then if you do have some issues with your
lifestyle and diet, we can address at a later time on a safe
and long term basis. So when patient schedule their surgery,
they have to come one more time to the hospital to to pre-admission
clinic where they are fully examined by the anesthetists and
the care team to counsel them, evalulate
their medical condition to make sure they will
be fit to have an operation. One the day of their surgery, they come to the hospital
to the surgical unit where they are
processed and prepared for surgery. They get
checked in, nurses start an intravenous, they administer
pain control medications and some antibiotics
to prevent any future complications from the surgery. And then once
it's their time to have the procedure they are brought up to
the operation room at Sunnybrook where they are met with the operation room
team, the anesthetist, the nurses
and the surgeon and we then proceed with surgery.
Sometimes, patients are offered what's called a
spinal anesthetic, where they insert the needle in the lower part of their
back which provides a very effective type of anesthesia
to the prostate gland, which minimizes pain
and after the spinal anesthetic they are still
placed after sleep with medication. Sometimes
in other situations, patients are given what's called a general anesthetic
where a breathing tube is inserted and
allows the surgeon to do the procedure. The incision
is made from the pubic bone in the middle and it will
extend up close to the bellybutton. It will be a
what we call mid-line incision. So during the surgery,
the majority of patient undergo what's called a nerve-sparing radical prostatectomy
it is very important to men, of course, to spare the
nerves that the erections for their
penis. And the nerves run very close to the penis and we are
very meticulous in sparing the nerves while effectively
removing the prostate and treating their cancer. The surgery itself
takes about 2 hours to do. It's an overnight stay in the hospital
and they just go home the following day. They go home with a catheter
that connects the bladder to the urethra, which is a tube
where patients urinate through. And that catheter
helps promote healing. And that needs to stay in anywhere from
7 to 14 days after their surgery. After that,
it's removed in the clinic and then patients are catheter free
and on the road to recovery. At that time,
we have the results of their surgery, where we can review the exact
results. Whether the cancer has escaped the prostate gland
or whether the cancer is at the edge, called the margins,
and can determine then if they need additional treatments after the surgery.
At Sunnybrook, we have done a lot of research
in trying to minimize a patient's pain from this procedure, from
the very beginning to the very end.
the very beginning to the very end and when they come in
to the hospital for the surgery, they're given various medications and
suppositories to help prevent future pain and spasms
that patients get, or can get, from the catheter.
During the procedure and afterwards, our pain control team is very effective
in managing this, and many patients don't even need to go on pain medication
after the operation.
Once the catheter is out, it takes
about 2 weeks to get about 80 to 90 percent urinary
control. It will take another 2 months to get to 95 to
99 percent. It can take up to a year to get to perfection.
Some patients experience what's called stress urinary incontinence
where they laugh and experience a little drop of urine.
About 4 weeks after the catheter is removed, I encourage
patients then to engage in sexual activity. And this is where they have to
start taking the Viagras, Levitras, Cialis, all the
pills you see on the commercial, as we need to go into what's called a penile
rehabilitation phase, where they really try and engage
in sexual activity. It's very important to focus on this and
to continue this so that the blood flow
to the penis is re-established. Although we want patients to start
on these types of medications, the goal at the end is for them to
spontaneously have erections and enjoy having a productive
sex life with their partners. It can take up to
1 to 2 years for this happen, but that's the goal.
Even if the medications or erections, unfortunately don't work after
a nerve sparing procedure, don't lose hope. We have many effective
non-invasive, and sometimes invasive ways, of
being able to achieve erections for men.
The advantages of
the surgery over the radiation is that you get your
results immediately. Once the prostate gland is removed, the pathologist
can then examine it closely under the microscope and determine whether
the cancer is more aggressive than we anticipated.
Also, they can tell us whether the cancer was confined
and maybe not as aggressive, where they have the best chances for cure.
Another advantage from that is that then we determine whether they
need additional treatments.
That would include radiation treatments afterward,
and maybe some medical treatment called hormone
therapy.
The disadvantage of the surgery is that the erections
do take a hit, even after a nerve sparing procedure.
With our best efforts to spare the nerves, the erections aren't as perfect as
they were before the operation. Another potential disadvantage
is that they can experience urinary leakage, what we call incontinence.
This is where men require pads because they leak urine.
However, the chances of that happening are very low, and in fact
Only 1 percent of men who undergo this procedure
have problems with urinary incontinence.
Although the majority of patients
are generally fit when they have this surgery, Sumnybrook takes on
the most challenging types of patients who are the sickest
but need the treatment to cure their prostate cancer.
We have these medical resources to take on
what we've referred to as complex radical prostatectomy
patients who have serious medical conditions and very serious cancers that
other surgeons may not want to tackle because they may not be able
to fully provide them with the effective cancer surgery
that they need. At Sunnybrook, we have the expertise to carry on
just that. Over the last 20 years, the procedure itself has
continued to evolve. Although the principles of complete eradication
of the cancer remain the same, the method to preserve nerves
and urinary control
have dramatically improved. As well, the methods to minimizing
blood loss have also improved. No person should really
require a blood transfusion from this procedure in 2011.
This procedure is one of the most
effective ways we have to control prostate cancer. It's a time
honoured tradition in eradicating patients with this
disease. It's a very safe procedure with very, very
minimal side effects in terms of their medical condition. Yes,
we have to address the recovery from their erections and
urinary control, but these methods are also very effective. Overall,
patients are very satisfied after having this surgery
especially knowing the cancer is out and knowing
what the precise results are from their surgery.
For more information, visit, sunnybrook.ca