Goals for Robotic Surgery for Prostate Cancer
The fundamental goals after treatment are the same regardless of whether the operation is done with an open or laparoscopic approach. These goals are, first, to cure the patient (i.e., the prostate cancer is removed completely) and, secondly, to help the patient maintain urinary control (or continence, the absence of urinary leakage), and erectile function. But there are definite advantages to a robotic laparasopic prostatectomy.
We gauged a patient’s cure after prostate cancer treatment based on their post treatment PSA level, and in the case of surgical removal of the prostate, the pathologic findings when the prostate is evaluated after surgery. After the prostate is removed, we want to see the follow-up PSA six weeks after treatment to be undetectable. It is important that the PSA continue to be checked at three months post-op and then after every six months for five years to assure that the patient is cured.
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Other Pathological Evaluations
The prostate and seminal vesicles, and lymph nodes if necessary, are also evaluated by the pathologist post-operatively and the volume of tumor, grade of tumor and “margin status” are evaluated. Thereafter, we are able to advise the patient, based on these characteristics, of their likelihood of cure versus the possibility of needing some secondary treatment. We want to see “negative surgical margins” which means that the prostate tumor has been removed completely.
In some cases the prostate tumor can grow in such a way that it approaches the margin of the prostate and therefore is difficult for the Pathologist to determine whether the contour of the tumor is to the edge of the specimen removed or if the presence of cancer at the specimen edge may indicate some residual tumor. That is why it is very important to have a long term follow-up in all cases to assess for any of evidence of disease or occurrence.
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The second goal after prostate cancer treatment is urinary control or continence. As stated above, a catheter is used for about one week after prostate cancer removal following a laparoscopic/robotic prostatectomy and after the bladder neck and urethra have healed, the catheter is removed. It is common for patients to have a small amount of urinate leakage for 2 to 6 weeks requiring wearing a small pad in the underwear.
The amount of leakage can be variable in some situations however in the vast majority of patients, the amount of leakage progressively improves after the first three weeks after a prostatectomy so there is a very small or minimally bothersome amount within a few months. A handful of patients do continue to have leakage beyond six months and even smaller number have leakage that go on for up to one year after prostatectomy. At this point, we frequently offer other interventions to remedy the leakage in this very small number of patients. Normally, 94% of patients are leakage free at one year following prostate cancer removal and at least 40-60% of patients are free of leakage at 6-9 weeks of treatment.
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Maintaining Erectile Function
The third goal after treatment for prostate cancer is erectile function. Of course, treatment for prostate cancer does not improve a patient’s erections and in fact many patients do have at least a temporary decline in their erectile ability after prostate cancer treatment.
The change in erections after treatment for prostate cancer is different among the patients treated with radiation therapy compared to those treated surgically. After nerve sparing surgical removal of the prostate there is an immediate decline in the quality of erections in most patients and thereafter in the recovery of function over the next 3-6 months.
The recovery of erectile function after prostate cancer surgery is primarily dependent upon the ability to preserve the erectile nerves. These nerves are part of “the neurovascular bundle” that is located adjacent to the prostate on both the right and left sides behind the gland (ie between the prostate and rectum). After radiation therapy, there is typically no immediate change in the quality of erections after treatment.
Over the next 18 to 24 months after radiation, there is a decline in erectile function in many cases. Forty to 60% of patients who do not need some medical therapy for erectile dysfunction (such as Viagra, Cialis or Levitra) will need such treatment after radiation therapy. But these medications are typically effective among these patients. In some cases, men may want more potent treatment for erectile dysfunction than oral medications in which case intraurethral suppositories, a vacuum device, or penile injections may be very effective so that the patients may continue to be sexually active after treatment for prostate cancer.
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