Surgical Removal
Surgical Removal of the Prostate (Prostatectomy)
Surgical removal of the prostate for prostate cancer, often referred to as a total or radical prostatectomy, has the best chance for a long-term cure. Surgical removal of the prostate can only fail if the cancer was already outside the confines of the prostate prior to its removal. Unfortunately, we cannot be absolutely sure that the cancer is confined to the prostate prior to any treatment. However, surgical removal of the entire prostate gland leaves no potentially cancerous tissue behind in the prostate itself, which can occur with radiation treatment. In addition, surgical removal of the prostate can be followed by external beam radiation therapy, when necessary, in patients with more extensive disease.
The two major concerns men have undergoing surgical removal of the prostate are urine leakage (incontinence) and erectile dysfunction (ED) following surgery. These side effects were common occurrences in years past and unfortunately still are, but rarely in the hands of an experienced surgeon.
Serious urinary incontinence is generally rare today in the hands of an experienced prostate cancer surgeon. However, all patients will experience varying degrees of urine leakage for a temporary period lasting from a few weeks to a few months. You will need to keep a small pad in your shorts as a safety until you feel secure with urine control.
Erectile function can be preserved in the majority of patients today by using the nerve sparing approach to prostatectomy devised by Patrick Walsh, M.D. Success of the nerve sparing approach will be dependent on your age, how good your erections are prior to surgery and how good your surgeon is at performing the operation.
Standard Open Total Prostatectomy under Regional Anesthetic
In a standard nerve sparing total prostatectomy you can expect to be in the hospital 2-3 days, although increasingly men have been going home in one day. I use an epidural anesthetic during surgery and for the first 24 hours. This generally makes it a pain free procedure and is the safest form of anesthesia for this type of surgery. It is extremely rare that you would need a blood transfusion. You will be eating the first day after surgery and out of bed walking. You will be discharged home with a catheter in your bladder to drain the urine to a small bag on your leg. The catheter will remain in for only 7 days. Once the catheter is removed you will be driving and return to most light activities or even a desk job within a short time.
Laparoscopic and Robotic Approaches
The term laparoscopic surgery refers to performing an operation with long instruments placed into the abdomen through small holes and visually monitoring 
the surgery with a TV camera also placed into the abdomen through another small hole. Laparoscopic surgery was popularized for removal of the gall bladder, a procedure ideally suited for this approach. In subsequent years the laparoscopic approach has been tried on increasingly more difficult surgical procedures with varying degrees of success. A laparoscopic prostatectomy is an extremely demanding procedure with a steep learning curve, requiring many hundreds of procedures to gain competence. Laparoscopic surgery can be compared to trying to build a ship within a bottle. In the end, a laparoscopic approach benefits primarily from a cosmetic standpoint. In a traditional open prostatectomy a single short midline incision below the belly button approximately 5 inches long is made. No muscles are cut. Laparoscopy is performed through 4 half inch incisions in the lower abdomen and one two inch incision at the belly button to remove the prostate gland at the end of the procedure. A disadvantage of a laparoscopic approach for prostatectomy is the greatly increased length of time to perform the procedure. Even for an experienced laparoscopic surgeon, it will take at least twice as long as a standard open prostatectomy performed by an experienced surgeon. In addition, a laparoscopic prostatectomy demands that the patient be under a general anesthetic for that time, often about 3-5 hours, increasing the risk of anesthetic problems or complications. A standard open prostatectomy lasts 1 to 2 hours under a simpler epidural anesthetic.
The DaVinci Robotic system is the newest advance in laparoscopic surgery. Its advantage is to supposedly ease the learning curve for laparoscopic surgery by having robotic assistance in controlling the long unwieldy instruments. It is truly a technologic marvel yet still has all of the disadvantages of long operating time under a general anesthetic and also requires full paralysis during surgery. Even minor movements by the patient under anesthesia could result in one of the rigid robotic arms perforating or damaging organs adjacent to the prostate. The robotic controls are across the room from the patient and are very different than anything surgeons are used to. It is advised that proficiency will require a few hundred cases to learn. In addition, the robotic system is highly technical and costly with many expensive disposable elements. It is still not clear whether this added expense, technology and time will add any patient advantage or be just another surgical fad that will lose acceptance when more details of the approach are well known. After having taken the training and assisted in cases on the robot, I am still not convinced of any advantage.
Recent peer reviewed scientific studies are increasingly showing that robotic prostatectomy is not living up to the marketing claims put out by the company which manufactures the equipment. Dr. William Catalona and Dr. Herbert Lapor, both well respected academicians specializing in prostate cancer surgery, have recently published reviews which have been posted previously on this web site (click the links above) concluding that robotic surgery may even be compromising the complete removal of the cancer.