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Common Questions

What is the prostate? Where is the prostate?

The prostate is a nonessential, secretory, secondary sexual organ found in all male mammals. Among the secretory products of the prostate is a protein known as prostate-specific antigen (PSA). Females do not have prostates, although tiny secretory organs next to the urethra share some homology to the prostate. These female organs, named for Scottish gynecologist Alexander Skene, also produce PSA. 

Anatomically and pathologically, mammalian secondary sexual organs vary greatly from species to species. For instance, the human has a single prostate attached to paired, nonessential secretory organs known as seminal vesicles. By contrast, the dog has only a prostate. In the opossum, the prostate is composed of a series of small glands around the urethra. By contrast, in the human, the prostate is a single, fused, midline structure wrapped around the urethral segment positioned between the urinary bladder and pelvic floor, as shown in the cartoon. Together, the prostate and seminal vesicles produce the liquid portion of semen and are thought to be required for fertility. The necessity of prostates in fertility is debatable, as in the rat, which has several prostates, surgical excision of the lateral prostates has no meaningful effect on fertility. 

As shown in the cartoon, the human prostate is positioned deep in the pelvis behind the heavy pubic bone and enmeshed in other structures. The position of the prostate complicates surgical access. The pointed prostatic apex is pressed against the very bottom of the pelvic cavity, where it attaches to the urethra. The posterior prostatic surface rests against the rectum. Superiorly, the wide prostatic base rests against the bladder neck. Anteriorly, the prostatic apex is covered by the very vascular dorsal venous plexus of Santorini. Access to the dorsal venous plexus is restricted by paired, tough ligaments on each side connecting the prostate to the undersurface of the thick pubic bone. Anterior to the prostate is a thin fascial layer covered in fat. Behind the prostate and seminal vesicles is the thick Denonvillier's fascia. Resting over all these structures is the bladder, behind which are the ureters. Most laterally are the iliac veins, iliac arteries, and lymph nodes.

 

What illnesses are associated with the prostate?

Prostatitis, an often painful inflammation of the prostate, is fairly common and is seen in relatively young men. Benign growth of the prostate (BPH) increases in incidence as men age. BPH is sometimes associated with frequent urination, weak urinary stream, night-time urination, and other symptoms. Cancer is common in the prostate and also increases in incidence as men age.

 

What is PSA?

PSA is prostate-specific antigen, a protein produced by the cells of the prostate that form the liquid secreted by the prostate during ejaculation. PSA is also produced to lower concentrations in other types of cells in the body. PSA is found in very high concentrations in the ejaculate, but normally only a small portion seems to leak into the bloodstream. The concentration of PSA in the blood provides an estimate of the risk of having prostate cancer, which provides the rationale for measuring PSA in asymptomatic men. For instance, a PSA concentration between 2.5 and 10.0 ng/ml is associated with a probability cancer on a biopsy of approximately 25%. Like any test, PSA must be interpreted in context, as infections, medications, and other factors can cause fluctuations in the blood concentrations. PSA is not a diagnostic test. To diagnose prostate cancer today requires a biopsy.

 

What do we learn from a biopsy?

A biopsy of the prostate is generally done under ultrasound guidance and yields tissue cores, such as the unstained core shown in the photo. After retrieval, cores are fixed, typically in formaldehyde, and then placed into cassettes for embedding in paraffin, slicing, and staining prior to pathological evaluation. The ultrasound image identifies different regions of the prostate and the seminal vesicles, which allows properly distributed and targeted sampling. The tissue cores, representing samples of prostate, are submitted for microscopic evaluation by a pathologist, who looks for cancer, infection, inflammation, drug effect, premalignant lesions, and benign hyperplasia. Because it is a sample, a biopsy is not necessarily a complete and fair representation of a prostate: a positive biopsy shows cancer, but a negative biopsy provides no real assurance that there is no cancer. It is also worth noting that biopsies are open to interpretation by pathologists, whose skills and experience vary. Because so much of the patient's decision depends on correct interpretation of biopsy findings, surgeons work closely with pathologists and very often review the slides directly with them. Patients are routinely asked to provide original biopsy material for review by the surgeon and pathologist or by specialized reference laboratories, such as Bostwick Laboratories in Richmond, Virginia (1-800-214-6628).

After analysis of prostatic tissue, the pathologist issues a written report of his findings. At a minimum, a prostate biopsy report must indicate the number and length of cores examined, the prostatic region from which the cores were taken, and the pathological assessment. In the case of cancer, the report should indicate the specific grade and proportion of the tissue involved. Many laboratories supplement their reports with selected images of  the most troubling component of the tissue. In the report shown in the photo, one sees the minimal elements of a biopsy report plus a photograph of a focus of cancer from the prostatic left base. Also reported are benign tissue, atrophy, inflammation, atypical small acinar proliferation (ASAP), and high-grade prostatic intra-epithelial neoplasia (PIN). In a biopsy without cancer, the observation of ASAP and/or PIN may have implications for future cancer diagnosis, for which reason biopsy reports should routinely cite their presence. Another feature, one not seen in this example, that should routinely be reported is peri-neural invasion (PNI), a feature seen in some cancers and which has implications regarding cancer stage.

 

I have been diagnosed with prostate cancer. Is it something I did?

No. Certain behaviors, which in theory can be altered, appear to be associated with cancer risk: sunbathing and skin cancer, smoking and lung cancer, and others. However, no clear link has been established between behavior and prostate cancer. While theories about behavior and prostate cancer abound, not much has been nailed down as fact. In our search for behavioral modifications that can help reduce cancer risk, dietary behavior has been examined. Among the most interesting nutrients is the mineral selenium. A number of years ago, Dr. Krongrad and his colleagues published a study in the Journal of the American Medical Association (Clark LC, Combs GF Jr, Turnbull BW, Slate EH, Chalker DK, Chow J, Davis SL, Glover RA, Graham, GF, Gross EG, Krongrad A, Lesher JL Jr, Park K, Sanders BB Jr, Smith CL, Taylor JR, for the Nutritional Prevention of Cancer Study Group: Effects of selenium supplementation for cancer prevention in patients with carcinoma of the skin. A randomized controlled trial. JAMA 276:1957-1963, 1996) that demonstrated for the first time a reduced incidence of prostate cancer in men supplemented with selenium. Certain limitations in the study design require that the study now be repeated for confirmation. In any event, there is no proof that for most men selenium deficiency is a relevant problem. Furthermore, there is no proof that, once diagnosed with prostate cancer, selenium supplementation is useful. Overall, we have no obvious behavioral tools with which to prevent prostate cancer and no reason to believe that a man's specific behavior promoted the development of prostate cancer.

 

What is cancer grade? What is cancer stage?

All prostate cancers are minimally described by two characteristics: grade and stage. While grade and stage are correlated, they are independent ways of assessing the potential behavior of a cancer. Grade is a description of the cancer cells as they appear under a microscope and is assigned by a pathologist; the most common form of prostate cancer grading is the Gleason grading system. Stage is a description of the extent of growth of a cancer and is assessed by various means, such as physical examination and bone scans. Prostate cancer is staged commonly with the TNM system. T represents the size of the primary tumor in the prostate. N represents the involvement of lymph nodes. M represents metastasis to distant sites, e.g. bones.

 

How does the Gleason grading system work?

Prostate cancer is composed of cells of varying shapes. Dr. Donald Gleason characterized prostate cancer cell shape and described categories, which provide some assessment of risk of cancer stage (how extensive the cancer is) and survival. The Gleason score is a sum of the two most prevalent patterns detected by the pathologist and ranges from 2, the least aggressive, to 10, the most aggressive.

 

What is a radical prostatectomy?

The radical prostatectomy is the complete surgical excision of the prostate, seminal vesicles, tips of the vas deferens, and, depending on oncological considerations, surrounding fat, nerves, and blood vessels. The radical prostatectomy is a standard first-line treatment for prostate cancer.

 

What are the chances that I will not die of prostate cancer if I have radical prostatectomy?

Prognosis depends on the severity of the prostate cancer and of competing illnesses. A great deal of information about the cancer and prognosis is gotten from the pathological inspection of the prostate after the radical prostatectomy. Such information permits a more detailed assessment of prognosis than information available from pre-surgical data. The reason that post-operative data are more informative is that clinical (pre-operative) staging and grading are not always precise and can lead to misleading assessments of prognosis. With pathological data in hand, one can make general assessments of prognosis. According to estimates that Dr. Krongrad and his colleagues published in the Journal of the American Medical Association (Krongrad A, Lai H, Lai S: Survival after radical prostatectomy. JAMA 278:44-46, 1997), prognosis depends strongly on age, grade, and stage. These published estimates, thought to be the most generalizable estimates of survival after radical prostatectomy, permit relatively fine assessments. As one example, a 60-year old man whose specimen shows a moderate-grade, organ-confined cancer has a 97% chance of being alive or dying of other causes in the first 10 years after his radical prostatectomy.

 

Will I need treatment after the radical prostatectomy?

The indications for additional treatment are unclear and not based in rigorous scientific study. However, contemporary standards include the use of radiation, hormones, and/or chemotherapy after radical prostatectomy in some cases. Generally speaking, the decisions to use additional treatments after radical prostatectomy are based on observations made by the pathologist of the surgical specimen. Decisions for immediate additional therapy are made in the minority of radical prostatectomy cases.

 

What is an LRP?

The LRP is a minimally invasive radical prostatectomy.

 

How is LRP different from open radical prostatectomy?

The complete and original LRP technical manual was published in 1999 by Drs. Bertrand Guillonneau, Arnon Krongrad, and Guy Vallancien and is posted on this site. In summary, the LRP and open radical prostatectomy both physically remove the entire prostate and then attach the urethra directly to the bladder. In excision and reconstruction, therefore, the LRP and open radical prostatectomy are the same. However, the LRP and open radical prostatectomy differ technically in gaining physical access to the deep pelvis and generating views of the operative field.

In contrast to open radical prostatectomy, the LRP does not require an abdominal incision and relies instead on tiny entry sites, most of which are no longer than five millimeters. In the cartoon, a typical operative field is represented, in which a surgeon, assistant, and voice-controlled robotic arm work through five entry sites for the introduction of surgical instruments. A laparoscope is introduced in the subumbilical site and is used to guide the operation. The surgeon and assistant each use the other four sites for the introduction of instruments. In contrast to open radical prostatectomy, the LRP makes no use of heavy retractors and does not require that the abdominal wall be parted and stretched for the duration of the operation.

Like cystoscopic, neurosurgical, and other operations, laparoscopic surgery takes advantage of modern optics. The LRP, a specific form of laparoscopic surgery, applies a scope that provides uniform lighting everywhere, including the far reaches of the narrow male pelvis. The scope used in LRP transmits dynamic, magnified images to a monitor that can be simultaneously viewed by everyone involved in the proceedings: surgeon, assistant, scrub nurse, circulating nurse, anesthesiologist, visitors, and students. As such, the LRP provides everyone present more precise and identical views of the a operative action, which promotes greater control of the anatomy and excellent coordination among team members. In the photo, one sees a typical image transmitted by a laparoscope, an image that would be visible to anyone in the operating room. In this example, the surgeon is placing a suture around the dorsal venous complex of Santorini, deep under the pubic bone. At this stage, the assistant is poised to retract the prostate, seen as a pink, fat-covered ball at the bottom. One can appreciate that even in this confined, bone-covered, potentially bloody space the laparoscope offers a magnified, well illuminated, and beautifully presented view.

In making use of good lighting, modern optics, magnification, single operative views, and finer instruments, LRP is a relatively bloodless, controlled, coordinated, and elegant operation.

 

Does LRP remove the whole prostate?

Yes. LRP removes the prostate, seminal vesicles, ends of the vas deferens, and, depending on oncological considerations, nerve bundles and/or lymph nodes. In the photo, a single specimen consisting of the prostate, seminal vesicles, and vas deferens has been placed in a plastic sac for extraction through a subumbilical incision; a pelvic drainage tube has been positioned and is visible in the background. Patients are often amazed that such specimens can be extracted through the incisions used. Yet the extraction, in which a rubbery object slips through an elastic portal, mechanically resembles the extraction of a baby through a vagina. It takes some coaxing and the occasional extension, but specimen extraction is simple and straightforward.

 

What are the benefits of LRP?

Due to numerous technical features, LRP is associated with very low blood loss, typically in the range of 100 to 200 milliliters. By contrast, the conventional radical prostatectomy is typically associated with a blood loss approaching one liter. Reductions in blood loss may reduce the chance of transfusion, intra-operative blood pressure fluctuations, and risks of post-operative complications such as heart attack. Because it is performed through very small incisions, the LRP is associated with very little surgical pain. Most patients recover without narcotic medication, which reduces side effects such as lethargy, constipation, and dizziness. The reduction of pain also permits most patients to get on their feet within hours of surgery and to leave the hospital in approximately 16 hours. Some patients have been back to work within 48 hours of surgery. While we don't endorse it, one of our patients actually drove himself home from the hospital the morning after surgery, suggesting a level of comfort unimaginable with conventional radical prostatectomy.

 

Why is there less blood loss with LRP?

The reduction in blood loss reflects the improved view of the operative field, especially behind the pubic bone, home of the venous plexus of Santorini. The improvement in view comes from using a lens that tracks directly into the operative field where the remote human eye has a hard time going. The LRP provides also magnification and bright illumination. Overall, this improved view permits a more precise and gentle dissection, which means better control of potential sources of bleeding. Furthermore, the CO2 pressure probably compresses some of the smaller veins, which themselves are low-pressure systems.

 

Who is a candidate for LRP?

Anyone diagnosed with localized prostate cancer may benefit from LRP. However, the decision to have a prostate cancer treated surgically revolves around numerous considerations, most importantly the severity of the prostate cancer and the severity of other illnesses. The following variables enter into preoperative evaluation: age, pre-biopsy PSA, biopsy findings, previous prostate cancer treatments, height and weight, other illnesses, smoking history, previous surgery, and current medications. LRP can be done for men of all sizes and shapes. One of our recent patients weighed 330 pounds; he was out for dinner at his favorite restaurant in three days, was fully continent in ten days, and is cancer free. LRP can be done in men who have had other operations: appendectomy, laparoscopic hernia repair, repair of abdominal trauma, transurethral prostatectomy (TURP), and others. In this intraoperative photo, the TUR defect in the prostate can be recognized as a hole at the base of the prostate; the vas deferens has been grasped before transection, while the seminal vesicle is partly visible behind the vascular pedicle.

 

Does LRP Require General Anesthesia?

Yes. LRP is a major operation and would be unbearable without anesthesia. During an LRP, the operating table is positioned such that the patient's head is lower than his feet. Also, the patient's abdomen is filled with CO2 to a pressure of 15 mm Hg. Under such conditions, a sedated patient cannot breathe on his own. For these reasons, LRP requires general anesthesia with full intubation.

 

Does prostate size matter?

LRP delivers a prostate whole, so in theory a prostate may be so big that it requires a very large incision to remove it. As a practical matter, prostate size is not much of an issue. We routinely remove prostates ranging from 10 to 100 ccs in size.

 

Can lymph nodes be removed with LRP?

Yes. Lymph nodes, to which prostate cancer may spread, can be removed during an LRP. However, lymph node removal is of little use in most cases of prostate cancer detected in the modern, PSA-driven era. Furthermore, lymph node removal carries risks less likely with just LRP: injury of the very large iliac vein, laceration of the obturator nerve, and formation of lymph collections in the pelvis. The decision to remove lymph nodes depends on an individual risk-benefit analysis that today almost always favors not removing them.

In the photo, one can see the pelvic anatomy after lymph nodes have been removed. A window has been opened in the peritoneum. Exposed through the window is the arc of the pubic bone. Seen below that is the obdurator nerve, a whitish thin line. Running vertically on the right are the blue-colored external iliac vein and the pink external iliac artery. The lymph nodes were originally positioned over the bone, left of the vein, above the nerve.

 

What are the risks of LRP?

LRP is major surgery, done under general anesthesia and carrying the general risks of any major operation: heart attack, stroke, and death. LRP is also associated with the risks of infertility, injury, impotence, and incontinence.

 

Can the neurovascular bundles be preserved?

Yes. The neurovascular bundles whose preservation is associated with the likelihood of maintaining erections can be preserved. Nerve preservation does not guarantee satisfactory erections after surgery. In the photo, the right neurovascular bundle can be seen coursing alongside the seminal vesicle and the prostate, which has been slightly rotated to the left. The prostatic capsule, free of the bundle and surrounding fat, appears shiny and smooth.

 

Does it make sense to preserve the neurovascular bundles?

Not in all cases does it make sense to preserve the neurovascular bundles. The issue here relates to the physical proximity of the bundles to areas of malignancy, which can microscopically extend beyond the prostate and into the bundles. Furthermore, in men with poor erectile function, there is no known value to nerve preservation, which requires more effort and operative time. As with lymph nodes, the decision to preserve one or both neurovascular bundle depends on an individual analysis of baseline function, the importance of maintaining erections, and the risks of leaving cancer behind.

 

What determines the likelihood of maintaining erections after surgery?

Erectile function depends on numerous physical and psychological factors. Thus, the likelihood of preserving erections after surgery depends on many factors, including preoperative function. Many patients have diminished erectile function or no erectile function before surgery and are at highest risk of losing erections with prostate surgery. Patients with satisfactory erections before surgery often have risk factors that can interfere with function after prostate surgery, including hypertension, diabetes, obesity, atherosclerosis, history of smoking, anxiety, and others.

 

Are venous compression devices used in LRP?

Yes. My patients receive heparin before surgery as a precaution against clots. They also get venous compression devices during surgery, which come off as they become ambulatory.

 



Does LRP require a catheter, drain, dressings, or stitches?

Yes. Like any radical prostatectomy, LRP requires reconstruction of the bladder-urethra connection. A catheter is left in the urethra, connected to a drainage bag, and used to align the healing suture line and drain the bladder. In the immediate post-op period, LRP also requires a drain that goes through the abdominal wall and left in the pelvis behind the pubic bone. The drain assures the collection of blood and urine that may accumulate immediately after surgery and is removes when the output drops, usually the morning after surgery. There are stitches, but these dissolve by themselves and require no special care. The surgical dressings for LRP are five Band-Aid dots used to cover the instrument entry sites. These dressings are generally removed 48 hours after surgery. In the photo, a patient's abdomen is shown as it appeared the day after LRP, after the drain had been removed. An old, diagonal appendectomy scar is seen on the patient's right.

 

Can I bathe after LRP?

Yes. Most patients have showered within 24 hours of surgery.

 

 

What can I expect immediately after LRP?

Patients leave the operating room with an intravenous line, a urethral catheter, and a small rubber drain in their lower abdomen. After recovering from anesthesia, almost all patients start to drink clear liquids. In the first few hours, depending on strength and motivation, most patients get out of bed and stretch their legs. Most have walked around the nurse's station by nightfall and most leave the hospital the next morning. Patients are discharged with a catheter connected to a leg bag, which fits under their pants. Loose clothing and shoes that don't require tying seem easier to handle in the first few hours and days. In the photo, taken the morning after LRP, a patient prepares for discharge and is seen wearing baggy pants that cover his catheter and leg bag.

 

What can I expect after getting home?

The single most common complaint after hospital discharge seems to be sleep deprivation and fatigue. While relative to open surgery the LRP is generally less demanding, the experience is still demanding. Most patients are anxious going into surgery, get little sleep the night before surgery, arrive at the hospital very early on the morning of surgery, and get very little sleep the night after surgery. Accordingly, most patients seem most interested in a good, long nap and a shower after getting home. The other major complaint seems to be a sense of bloating, with clothes fitting very tight. This bloating seems related to the effects of surgery, anesthesia, and bedrest on intestine function and responds well to walking, which helps the patient expel intestinal gas, which helps the patient regain his overall comfort and appetite.

 

What if I live far away? Can I travel after surgery?

Many of our patients come from far away and we can help with numerous logistical issues related to travel, from finding a suitable hotel to arranging medical evaluations pre-operatively. After surgery, we have had patients leaving Miami within 2 days, be it by car to Tampa or plane to Washington. One patient recently flew in and out from Ft. Worth by himself. He had his LRP on a Monday, left the hospital Tuesday, and drove his rental to the airport and caught his flight Wednesday morning.

 

What happens to my medical records and who will take care of me when I get home?

We work with our patients to transmit any and all relevant medical data to their home physicians. For those who chose to stay a while, we provide all followup medical care.

 

Must I return for followup?

We support our patients regardless of where their paths take them. In a practical sense, this means that once a patient has joined the LRP fraternity, we consider him a lifetime member and are always available. In fact, most of our patients, having come to rely on us during a very trying time in their lives, stay in touch and regularly call and email to update us or ask for our help. While we deliver urological care to all our local patients, there is usually no compelling reason for patients from far away to make trips to Miami.

 

How long should the catheter stay in?

There is no real science behind the question of when it's best to remove the catheter. We all grew up with leaving it in for 3 weeks. But experience shows that there is no good reason for this duration. Some surgeons are experimenting with 3 days, with open and laparoscopic techniques, and some have reported complications with early catheter removal.

 

What can I expect after the catheter comes out?

Almost all patients have some incontinence when the catheter comes out. Continence function returns with time and patience here is a real virtue. While recovering continence, it is wise to carefully consider one's fluid intake, as a full bladder is much more likely to leak than an empty bladder. Patients who go out for beers with the guys right after LRP pay the price, as do those devoted to heavy consumption of grapes, watermelon, coffee, and other sources of water and caffeine.

 

What is the long-term followup after LRP?

Depending on the pathologist's report of the LRP specimen, a patient may or may not consider additional cancer treatments. In most cases, but not all, the wise course of action is surveillance: periodic measurement of blood PSA, thought to be the most sensitive indicator of cancer recurrence.

 

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