Frequently Asked Questions

Radical Prostatectomy

Q: What other treatments should we consider?

A: The only other treatment I would recommend considering is Radical Prostatectomy.

Q: What is a Radical Prostatectomy?

A: Radical Prostatectomy is a major surgical procedure performed under general anesthesia in a hospital operating room where the urologist removes the prostate gland and the seminal vesicles (an organ attached to the top of the prostate). There are several methods to perform Radical Prostatectomy, but all do basically the same thing. The prostate is dissected along with the seminal vesicles away from the bladder and off the rectum. The urethra tube is cut across, both at the top of the prostate where the tube joins the bladder, and also at the bottom of the prostate. The bladder is then pulled down into the man’s pelvis and sewn to the lower part of the urethra located below where the prostate used to be. Depending on the extent of the cancer, the surgeon will try to preserve the sex nerves. The pelvic lymph nodes may also be removed. The surgery takes approximately two hours to perform, but may take longer, depending on the skill of the urologist. Additionally, depending on the skill of the surgeon, a man wears a urinary catheter one week or more after the procedure.

Q: What are the techniques for performing a Radical Prostatectomy?

A: One technique is the retropubic (open) Radical Prostatectomy where a surgeon makes an incision in a man’s lower abdomen and begins his dissection of the prostate. Another method is a laparoscopic Radical Prostatectomy where the urologist makes four ½-inch incisions in a man’s lower abdomen. Then, the urologist inserts tubes through which he or she manually removes the prostate. The robotic Radical Prostatectomy is also a laparoscopic radical procedure, but the instruments are remotely controlled by a device called the da Vinci robot.

Q: If you cut out the entire prostate, why would you not be cured with Radical Prostatectomy?

A: Because of microscopic capsule penetration, and/or spread of cancer (metastases) elsewhere in a man’s body, which is not detectable at the time of surgery. A study from the Southwest Oncology Group documented that the most common reason for men with advanced cancer not to be cured with Radical Prostatectomy is because microscopic penetration cancer cells were left behind.

Q: What is the most common location for microscopic capsule penetration that causes cancer cells to be left behind after surgery?

A: Microscopic capsule penetration can occur at any location around the prostate and result in Radical Prostatectomy failure. However, the most common location for cell leakage is at the bottom of the prostate (the apex). It is common for prostate cancer to be located at the bottom of the prostate: 67% of men on biopsy have cancer at the bottom of the prostate. However, there is no capsule to contain prostate cancer at the apex which means that prostate cancer can easily leak out of the prostate in this area. Although cancer cells can be left at any location, leaving cancer cells behind at the apex is the most common reason for surgery to fail in curing men with prostate cancer. Despite this problem, it is remarkable that highly experienced surgeons can successfully dissect the apical area and cure many men with microscopic capsule penetration.

Q: If I had a Radical Prostatectomy and the pathologists found no microscopic capsule penetration, would this guarantee cure?

A: No. Even if the pathologist, based upon examination of the whole prostate under the microscope, reports that all the cancer is contained inside the prostate and no microscopic capsule penetration is present, 14% of men still are not cured and have regrowth of prostate cancer within 10 years of surgery. Evidently, microscopic capsule penetration can be missed or cancer can spread by other means such as small veins.

Q: How often do men leak after Radical Prostatectomy?

A: Urinary leakage (incontinence) is defined as men wearing one or more pads per day, and it varies with the skill of the surgeon. With highly experienced surgeons, the chance of urinary leakage has been reported from 8-17%. The incontinence rate is the same regardless of Radical Prostatectomy technique – open, laparoscopic or robotic.

Q: I understand that more men are choosing the robotic Radical Prostatectomy technique over the other two methods. Is there any advantage to the robotic method?

A: The cure and complication rates (urine incontinence and loss of sex function) are the same for all techniques. The only documented advantage to the robotic technique is that men are discharged from the hospital within one to two days after the robotic, as compared to four to seven days with the open method. There is also less blood loss and a lower transfusion rate with the robotic technique, but a significant loss of blood is very low with any method of Radical Prostatectomy if an experienced surgeon performs the procedure.

Q: Based on tables you have shared, the cure rate for Radical Prostatectomy is 68% at 15 years. Correct?

A: No, that is the cure rate when surgery is performed at Johns Hopkins. Those urologists are better surgeons than most urologists. Also, that is the overall cure rate for men treated many years ago. Surgical techniques have improved since then so that their results will be better. Medical studies have shown that cure and complication rates vary a lot between surgeons. So, you have to ask the urologist who might operate on you for his chance of your having zero PSA 15 years later with your Gleason 4+3 cancer.

Q: I have been told that if you are not cured with Radical Prostatectomy (have microscopic capsule penetration); you can be treated with irradiation. Is this correct?

A: That is correct. Men can receive beam irradiation after Radical Prostatectomy, which helps some men who are not cured with surgery. However, men are then receiving two full treatments with a risk of more complications – urinary incontinence and loss of sexual function. If there is a risk of microscopic capsule penetration, it might be better to consider ProstRcision.