Less invasive surgery for prostate cancer

The radical prostatectomy is an operation designed to cure prostate cancer by removing the entire gland. Introduced by Dr. Hugh Young in 1905, it is the oldest treatment for prostate cancer. But it has changed for the better over the years. In the 1940s, urologists developed the retropubic approach; in the 1980s, Dr. Patrick Walsh pioneered the nerve-sparing operation; and in the 1990s, medical teams devised better methods of postoperative care. It was a century of progress, and in this century, minimally invasive techniques are raising hope that prostate surgery may become easier still.

The reclusive prostate
A surgical cure of prostate cancer depends on removing all the malignant cells. To do this, the operation removes the entire prostate gland along with the seminal vesicles and surrounding tissues. It’s not easy, for the prostate lies deep in the body. Wedged between the rectum and bladder and wrapped around the urethra, it is surrounded by important structures that are vulnerable to injury, including the nerves and blood vessels that control erections.

The open prostatectomy
The traditional or open operation requires an incision that is large enough to allow the surgeon and his assistant to get their hands on the prostate. They can approach it from either of two directions. The older, perineal prostatectomy uses an incision in the area between the anus and the scrotum. But most doctors now favor the retropubic technique, which uses an incision in the lower abdomen. It has the advantage of allowing the surgeons to inspect the pelvic lymph nodes and to biopsy any that seem abnormal before operating on the prostate itself. If the lymph nodes appear normal, the surgeons will carefully separate the prostate and seminal vesicles from the surrounding tissues. To remove the gland, they will have to cut through the urethra, the tube that carries urine from the bladder, but they repair it once the prostate has been removed. All the tissue is sent to the pathology laboratory for evaluation. If the cancer is present only in the prostate, the operation itself has the potential to cure, but if the tumor has already passed through the capsule surrounding the gland, additional treatment may be recommended.

The nerve-sparing prostatectomy, an important variation, is designed to protect and preserve the fine network of blood vessels and nerves on both sides of the prostate. If the nerves are not damaged, there is a greater chance that the patient will retain his potency, but the operation requires special skill.

Most radical prostatectomies are performed under general anesthesia. In experienced hands the operation is quite safe, with a mortality rate below 1% in most centers. After spending 3_–4 hours in the operating room, the average patient will spend 2–4 days in the hospital. He will then need several weeks to recuperate at home, and he will have to urinate through a Foley catheter for 1–3 weeks while his urethra heals.

Minimally invasive surgery
Minimally invasive operations are designed to accomplish exactly the same goals as their traditional open counterparts. The difference is access. Surgeons use several small incisions, usually about a half inch in length, to enter the body. Because they can’t put their hands through such small openings, they use tiny instruments to repair damaged tissues or remove diseased organs (see figure). If all goes well, minimally invasive operations achieve the usual therapeutic goals with fewer complications, less postoperative pain, shorter hospital stays, and faster recoveries.

The first minimally invasive procedure to achieve widespread acceptance was the laparoscopic cholecystectomy (gallbladder removal). Many other successful operations have followed. The technology that made it all possible was the development of miniature video cameras that produce high-quality images, allowing the assistant to have the same view as the surgeon. The assistant can hold the camera with one hand and use his other hand to help the surgeon, who has both hands free to manipulate his instruments while he watches his progress on a video screen.

Surgeons perform the operation with tiny instruments introduced through the surgical scope while they watch their work on a video screen that shows images obtained through the viewing scope.

Comparisons count
The success of a minimally invasive procedure depends on its ability to perform better than the standard open operation. In the case of uncomplicated gallbladder removal, laparoscopic surgery is the winner: Patients go home sooner and recover faster. But surgeons require special training and hospitals need special equipment, so the anticipated lower costs have not materialized. And when the gallbladder is severely inflamed or there are other problems, the open operation may still be necessary.

In the case of hernia surgery, the laparoscopic and traditional operations both have advantages (see Harvard Men’s Health Watch, November 2002). Open surgery can be performed under local anesthesia, allowing the patient to go home after the operation is completed. Laparoscopic surgery, however, requires doctors to inflate the patient’s abdomen with carbon dioxide gas at the start of the operation. That’s painful, and it requires general anesthesia. Because of the additional equipment and training, laparoscopic hernia repair is more expensive than open surgery, but patients have less pain, and they recover faster.

Given a choice, most doctors and patients would choose laparoscopic over open gallbladder surgery, but for hernia repairs the verdict is mixed. How do they feel about the rival approaches to prostate surgery?

The laparoscopic prostatectomy
The operation was pioneered in Europe. In some hospitals, particularly in France and Germany, it has become the favored operation. It is finding its way into American medical centers. But it wasn’t always so successful.

The first laparoscopic radical prostatectomies were performed in 1991, using the retropubic approach. Like other abdominal laparoscopic operations, they required filling the abdomen with gas under general anesthesia. And they succeeded in removing the prostate gland and seminal vesicles, just as in the open operation. Nevertheless, the operation did not take the urological world by storm. The early operations were very slow, taking an average of more than nine hours, and they did not offer any advantages over the standard approach.

Since then, however, the operation has improved greatly. The reason is experience. The open operation is difficult and delicate in its own right, and it’s important to have an experienced urologist (see HMHW, February 2003). The laparoscopic prostatectomy requires even more training. The learning curve is steep, but urologists with 40–60 operations under their belts are now reporting results quite comparable to those of standard surgery. With an experienced team, the laparoscopic surgery is nearly as fast as the open operation and requires fewer blood transfusions, produces less pain, and allows a quicker recovery. The complication rates are similar, and surgeons can perform nerve-sparing operations with either approach.

A 2003 report shows the importance of experience. Doctors in Germany compared their open operations with their first laparoscopic operations and their most recent ones. The three groups, each with 219 patients, were virtually identical in the patients’ ages and in the severity of the cancers. Table 3 summarizes the results.

Other experienced centers have confirmed these findings: In the best hands, laparoscopic operations require fewer transfusions, produce less pain, and allow a faster recovery. And the risk of major complications such as urinary leakage, erectile dysfunction, and rectal injury also seems similar, though the wide range of reported complications makes them difficult to compare.

Even if laparoscopic surgery is easier on the patient, however, that doesn’t necessarily mean it’s better. The goal, after all, is not just to get men through the operation but to cure their cancers.

Some early results raised concern: Pathologists were more likely to find cancer cells at the edges of the surgical specimens from laparoscopic than open procedures. But in other comparisons the results are similar. The rate of early relapses, as measured by rising PSA levels after surgery, also seem similar, but it will take years to learn if long-term survival rates show any difference.

Laparoscopic prostatectomy is a work in progress, but as this story is evolving, an even newer procedure is attracting attention.

Laparoscopic surgery by robots
This operation is still done by a person, but instead of holding the instruments in his hands, the surgeon manipulates a machine that performs the surgery using special instruments and techniques. Despite its name, the machine is not a true robot but an extension of the surgeon.

Technology makes it possible. In this case it’s the DaVinci Surgical System, which allows three-dimensional video visualization, a wide range of motion, and 360-degree maneuverability of the instruments. These pencil-sized tools have tiny “wrists” that can imitate the movement of the surgeon’s hand and wrist at the remote control console. Special computer software translates large human movements into precise, tremor-free micromovements.

It’s another wrinkle in laparoscopic surgery, and several centers in the United States and Europe have reported good results. But if laparoscopic prostatectomy is a work in progress, robotic surgery is a technique that’s just beginning to make progress, and it’s too early to say how it will fit into the spectrum of surgical options.

Choices, choices
It gets more confusing all the time. It can be hard enough for a man just diagnosed with prostate cancer to pick a hospital and choose a surgeon. Now he has to decide which surgical approach is right for him. In the end, though, it depends on the surgeon. Skill and experience are mandatory. If that expertise includes at least 60 laparoscopic radical prostatectomies, a man should discuss the advantages and limitations of open and laparoscopic surgery with doctors who understand both, then decide for himself.

Because laparoscopy is not available everywhere in the United States, many men won’t have the luxury of a choice. But every man with early prostate cancer will still have to make more fundamental and difficult choices among surgery, external beam radiation, brachytherapy using radioactive “seeds,” a combination of radiation and androgen deprivation, and watchful waiting. Those are decisions to be made by patients and their families, not computers and robots.