While early prostate cancer is considered a highly treatable cancer, it often involves the surgical removal of the prostate, which is a male reproductive gland that stores a component of semen. Even though prostatectomy, as this operation is known, is usually successful, it has traditionally had a serious impact on men's lives. Because the prostate surrounds the urethra, incontinence following surgery is a concern and some men experience erectile dysfunction, though this is a less common side effect today because the nerves that control erection are carefully spared.
Traditionally, the gland is removed during open surgery, a fairly safe procedure that has typical surgical risks and a somewhat painful and long recovery period. But a new surgical approach to prostate removal called laparoscopy is making the surgery easier on men. In this procedure, a surgeon makes a number of small incisions, rather than one large one, and inserts into one incision a camera called a laparoscope that provides a magnified image of the area. This minimally invasive surgery was once used primary for tubal ligation and gallbladder surgery and is now available in select medical centers to people with prostate cancer. Studies show that laparoscopic prostatectomy offers patients less bleeding, less pain and a quicker recovery, allowing men to get back to normal activities sooner. Below, Jihad Kaouk, MD, a staff member of the Urological Institute at The Cleveland Clinic, discusses the benefits of this surgical technique in treating prostate cancer.
How has prostate cancer surgery traditionally been performed?
The standard way to remove the prostate has been the open surgery; the procedure is called a radical prostatectomy. In open surgery, the incision is in the midline, below the belly button to the pubic bone. The prostate sits between the bladder and the urethra, and the surgery is designed to remove the prostate completely with the seminal vesicle (that's a gland adjacent to it). One has to be very careful because continence is an issue so we make sure the bladder is stitched to the urethra so that urine can still flow out. And we are also careful about the nerves responsible for erections, so that's another very delicate area.
What is laparoscopic surgery?
Laparoscopic surgery is also known as "keyhole" surgery. It's doing the surgery through small incisions, which are each about one centimeter long. We use at least three incisions: one for the camera and two for the surgeon's instruments. We use CO2 gas to inflate the belly of the patient to create a space in order to do the surgery, and we use a scope that has a camera at its tip and a powerful light source so that we have a good image. We look at a TV monitor while doing the surgery, which gives us a very detailed picture of the anatomy and what we are doing.
Does the type of surgery affect cancer recurrence or survival?
This was studied thoroughly and laparoscopy is as effective as open surgery in controlling prostate cancer, so there is no difference.
Is there less blood loss with laparoscopic surgery?
Blood loss is minimal when you perform laparoscopic surgery compared to open. And there are several reasons for that. One of them is that the magnification and the image you get is so precise that you can avoid blood vessels. The second is that the gas we use to inflate the abdomen of the patient puts pressure on small vessels and prevents bleeding.
Are there any disadvantages of not being hands-on, so to speak?
The idea of not having tactile feedback during laparoscopy is not very accurate. There is some tactile feedback from feeling the tip of your instruments because you can feel pressure or resistance when you're dissecting tissue. Also, you have visual feedback. When you're looking at the magnified image, you can see how much pressure you're putting on the tissue. Also, the magnified image gives us a lot of details that you may not see in open surgery. And you always have the option to zoom out and check the whole field.
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How do the recovery times for people going through open surgery and laparoscopic surgery compare?
In terms of hospital stay, I would say it's comparable. Usually the laparoscopy patients stay overnight. With open surgery, it may be one or two days. As for the returning back to normal activities, it's much faster in laparoscopy. I would say the patient would be back to work after laparoscopic surgery within two to three weeks, and that's mainly because the catheter that drains the bladder is removed very early in laparoscopy compared to open surgery. In laparoscopic surgery, we remove the catheter three to five days after surgery, while in open surgery it takes two to three weeks.
In open surgery, you can only aim at stitching the bladder and the urethra together after the prostate is removed because it is a difficult area to see well. In laparascopy, with the magnified image, we can see clearly where we are putting the sutures. As a result, you can put in very precise stitches in a water-tight manner, so that you don't need the tissue to heal completely before you remove the catheter.
Are the rates of continence and erectile function the same between the different surgeries?
We know that 98 percent of patients have as good control of urine after laparoscopic surgery as before surgery. This is as good as the best open surgical results reported. Because potency is very hard to study, it will take us maybe a few more years to investigate whether erectile function after is less affected by laparoscopy than by open surgery.
Is the pain you might experience with each type of surgery different?
The first day after surgery is painful, so one should not think that with small laparoscopic incisions there is no pain. It is a major surgery, after all. But after the first day, recovery is very fast.
After open surgery, patients require more pain killers. That's why they may stay one or two days in the hospital, and that's part of the reason why the recovery and going back to work may be extended for three weeks to one month.
What is the criteria in deciding who is a candidate for laparoscopic surgery?
In general, patients who are candidates for open surgery are candidates for laparoscopic surgery, too. We are now accepting patients who we didn't accept earlier in our experience, such as patients who are morbidly obese or patients who have in the past had multiple abdominal surgeries. Now we can easily and effectively perform laparoscopy for them as well. In fact, we are seeing more morbid obesitye patients being referred to laparoscopy from open surgery, because in these patients, the prostate is so deep in the pelvis that you may not be able to reach it in open surgery. With the laparoscope, you can really go deep in the pelvis.
How does a patient make an informed decision about surgery?
You should go to an experienced surgeon who knows how to do the surgery well. If you are considering open surgery with someone who is more experienced doing it open, I think that's the way to go. So, bottom line, you should look for a surgeon who has a lot of experience and does this surgery frequently.
Also, some people like to go a conservative, standard way and say, "I would like to do the open surgery that has been done for the last 30 years." And some people say, "I'm convinced that science is evolving, and we have new methods that provide better advantages to the patient, so I choose laparoscopy." It depends on the personality of the patient.
