Surgical removal of the prostate for both enlargement (BPH) and cancer can be traced back to the early 19th century. A major breakthrough in surgical anatomy came in the late 1970's and early 80's when Dr. Patrick Walsh at the Johns Hopkins School of Medicine was able to better delineate the nerves and blood supply to the gland. The result was a reduction of blood loss during surgery and better preservation of the nerves responsible for sexual function. The most recent technologic advance came in the early 2000's with the advent of minimally invasive robotically assisted prostatectomy, which remains the most commonly utilized approach if surgery is chosen. For the most part, radical prostatectomy is a treatment option across all risk groups. There are essentially 2 major surgical approaches for a radical prostatectomy:
1. Open (Abdominal or perineal)
2. Minimally Invasive (Robotically assisted or Laprsocopic)
The approach recommended by the urologist takes into account the following variables:
1. Experience and preference of the surgeon.
2. Patient anatomy, prostate size and history of prior surgery to the pelvis or abdomen.
3. Concurrent medical illnesses.
4. Pre-operative sexual function, activity level and urinary symptoms.
During the immediate post-operative period, the following are common, regardless of the approach:
1. 1 -- 5 night hospital stay.
2. A catheter in place for 3 -- 14 days to allow for healing.
3. Return to the work force and activity, including exercise, in 4 -- 8 weeks.
Major complications may include:
1. Bleeding require blood transfusion
2. Urinary incontinence
3. Risk of blood clots in the legs and lungs
4. Sexual dysfunction
5. Incisional pain.
6. Injury to nearby organs at the time of surgery, especially the rectum.
7. Narrowing/stricture of the urethra and bladder neck
8. Lymphocoele (as a result of the lymph node dissection, see below)
By removing the prostate, the pathologist is able to determine the extent of tumor, if it has tried to spread beyond the confines of the gland and tumor upgrading, which are cells with higher grade Gleason that were not identified at biopsy. In addition, most surgeons will perform a limited lymph node dissection at the time of surgery to better stage the extent of disease which will give insight to what treatment, if any, will need to be undertaken post operatively. There are times, depending on the pathologic findings at the time of surgery, post-operative radiation therapy may be indicated once the patient recovers from his operation.
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