Open Prostatectomy for Prostate Cancer
Open prostatectomy is a traditional “open” surgical procedure, which means the surgeon accesses the prostate gland through a standard surgical incision. For most patients, the incision is 4 to 5 inches long.
In contrast, a robotic prostatectomy performed with laparoscopic instruments requires several smaller incisions.
The open procedure’s longer incision results in a slightly longer recovery time. While the average recovery time following robotic prostatectomy is 4-1/2 weeks, recovery following open prostatectomy is about 6 weeks.
Less Time Under Anesthesia with Open Prostatectomy
An open prostatectomy, however, is a much shorter surgery than the robotic procedure, which means patients spend less time under anesthesia. Length of anesthesia for an open prostatectomy is 2 to 3 hours, compared to 4 to 7 hours for a robotic prostatectomy.
In several measures, there is no demonstrated difference between open and robotic prostatectomy. The risk of blood transfusion for an open prostatectomy is less than 1 percent, and fewer than 1 percent of patients have wound complications. Post-operative pain on the morning following surgery is typically 2 on a 10-point scale. The patient’s length of stay in the hospital is 1½ to 2 days. Approximately 85 percent of patients regain excellent urinary control, and three-quarters retain sexual potency.
While all precautions are taken to reduce the likelihood of complications, no surgical treatment is completely without risk. Potential complications of open and robotic prostatectomies include infection, bleeding requiring blood transfusion, urinary incontinence, erectile dysfunction and injury to adjacent organs.
Advantages of Open Prostatectomy
No therapy is right for every patient. Choosing the best surgical option is a matter of balancing the patient’s individual situation with the advantages and disadvantages of each approach. Open prostatectomy offers several advantages that can be important to certain patients.
While the robotic surgery system provides excellent visualization of the surgical site, it does not allow the surgeon to touch the prostate gland and surrounding structures. For some prostate cases, however, tactile input can be an important part of surgical decision making. During surgery, the firmness of various tissues can provide valuable information on the presence of cancer and how far the cancer has spread. This input can contribute to the surgeon’s decision about which tissues need to be taken out and which can remain. This could potentially enable a surgeon to preserve the nerves for sexual function in cases where they might otherwise be removed.
One question that has not yet been resolved is how open prostatectomy and robotic prostatectomy compare with regard to successful cancer treatment. Most data sources show no difference in cure rates between the two procedures. However, a recent study of Medicare patients examined how likely patients are to receive additional therapy following each of the two surgeries. According to the study, 9 percent of open prostatectomy patients and 27 percent of robotic prostatectomy patients eventually received additional treatment aimed at controlling cancer. More follow-up studies are required to determine if cancer control rates are comparable for robotic prostatectomy and open prostatectomy.
Lower Risk of Bladder Neck Contracture
When the prostate gland is removed (in either an open or a robotic prostatectomy), the urinary tract must be put back together by sewing the urethra (the tube through which urine passes out the body) to the bladder. As this junction heals, it tends to narrow, which can lead to significant problems urinating. This condition is called bladder neck contracture (BNC). According to the medical literature, as many as 1 in 5 men develop BNC following prostate surgery. William A. See, MD, Medical College of Wisconsin urologic surgeon, has pioneered a new technique for urinary tract reconstruction called intussuscepted vesico-urethral anastomosis (IVUA).
Based on data from hundreds of surgeries at Froedtert & the Medical College, this technique appears to reduce significantly the risk of developing BNC. For well-selected patients, the risk is approximately 1 in 400. IVUA can be performed in an open prostatectomy, but at this time it cannot be performed robotically.
No Risk of Abdominal Complications
In a robotic prostatectomy, the prostate area is accessed through the abdominal cavity. During an open prostatectomy, the surgical path is entirely outside the abdomen, eliminating the potential for injury to the abdominal contents. Any surgical complications would be confined entirely to the pelvis.
Open prostatectomy takes place under general anesthesia with the patient positioned on his back at an incline.
The surgeon makes a single incision approximately 4 to 5 inches long. For the most part, the critical structures in and around the prostate can be readily seen. If magnification is required, the surgeon can use a simple devise called a surgical loupe to enhance his or her view.
Once the prostate area is exposed, the surgeon detaches the prostate gland from the urinary bladder and the urethra. The goal is to remove tissue in a way that eliminates the cancer but minimizes damage to critical surrounding structure — the muscles that control urinary continence and the nerve that enables erectile function.
Once the prostate is removed, the resected end of the urethra is attached to the neck of the bladder (see above for information about the IVUA technique). A Foley catheter is left in place to enable urine to drain during the healing process. The patient is then taken to the Post-Anesthesia Care Unit where he awakes from anesthesia.
What to Expect After Surgery
Following surgery, most men spend one to two days in the hospital. Patients typically receive intravenous (IV) pain medication during their first day after surgery (post-op), then transition to oral pain medications by the second day. Once pain is under control and bowel function has begun to return, the patient is ready for discharge.
After discharge, patients are able to walk. The only restriction is to avoid anything that causes strenuous physical exertion to the lower abdomen. Patients may shower, but they should avoid bathing or swimming.
About 10 to 12 days following surgery, the patient returns to Froedtert & the Medical College of Wisconsin for a cystogram (an X-ray of the bladder). If the bladder has healed adequately, the patient’s urinary catheter is removed.
Most patients can return to work approximately 3 to 4 weeks after surgery, provided it does not include anything physically strenuous. Heavy lifting should be avoided for about 6 weeks following the surgery.
Following a prostatectomy, the removed tissue is sent to a pathologist for careful evaluation. The surgeon reviews the pathology report with the patient during the first post-op visit.
Based on the pathology results, the patient may need additional treatment such as drug or radiation therapy. Patients have the opportunity to discuss suggested treatment alternatives with a full range of physician experts. Most patients require long-term monitoring of the PSA level to help detect any return of cancer. The first PSA test occurs 3 months after surgery. Subsequent tests take place every 6 months for a minimum of 5 years.
In addition, patients have regular follow-up appointments with the surgeon for several months after surgery. One of the goals of follow-up care is to help reestablish urinary continence and sexual function. The Prostate and Urologic Cancer Program provides patients with a range of therapies and resources to help them achieve these goals.