Radical prostatectomy for prostate cancer
The removal of the prostate is particularly useful for localized prostate cancer without clinically apparent metastases into consideration. There are various surgical techniques, with preservation of erectile nerves.The radical prostatectomy (RPE, complete removal of the prostate) is a treatment with curative (healing) intention. Because she has to completely remove the target the tumor in healthy subjects. It should therefore be used primarily for tumors that can very likely be completely removed, ie, with tumor-free resection margins. Other objectives are, urinary continence and - in appropriate patients - to get the ability to have erections.
In deciding for or against the RPE help PSA value, Gleason score , targeted biopsies and special tables (nomograms). It is also important to know that the clinical, ie determined by studies TNM stage (see the growth and spread , eg cT2b cN0 M0) may be underestimated both above. The pathologic stage (eg pT2b pN0 M0) can only be determined by examination of the removed tissue during an operation. First to the uses of the RPE:
Surgery for localized prostate cancer
The RPE is a way for primary treatment of clinically (ie determined by tests) localized prostate cancer in patients in all risk groups (see the discussion of these groups, treatment planning ).The prostate is to be completely removed to obtain urinary continence and erectile function.The goal is tumor-free surgical margins, because this increases the chances of a cure, if still have seed off no malignant cells, so if no micrometastases are present.In the RPE, the effectiveness has so far as the only method in comparison to the wait-watchingbe detected (English watchful waiting): In patients without metastases (T1b-T2 N0 M0), one with a PSA level of less than 50ng/ml and life expectancy of at least 10 years, it lowers the incidence of disease progression and mortality from prostate cancer significantly. About Here, the patient should be informed.
Surgery in locally advanced prostate cancer
The RPE is a way for primary treatment of clinically locally advanced prostate cancer (T3-4 N0 M0). Patients with such a tumor should be previously informed about the advantages and disadvantages, both the RPE with lymphadenectomy as well as a radiation therapy (possibly with an additional, temporary hormone therapy .) Patients with a T3 tumor and the desire for a RPE should be advised that the risk for positive (tumored) cut edges, a progression of the disease and therefore necessary actions (eg, hormone therapy, radiation) are higher than in a localized tumor.Operation with lymph node involvement
Basically always lymph nodes should be removed for histological (histological) examination at an increased risk for an infestation. Only if this is not possible, one should assess the risk based on the findings or nomograms. In histologically proven lymph node involvement are the hormone therapy for local treatment, the RPE and the radiation available for systemic (general) treatment. A reliable comparison of the methods, either alone or in combination, is not possible due to the current data situation. The decision must be made on an individual (see also below at lymphadenectomy ). An already clinically detectable lymph node involvement (cN1) proves on histological examination usually as pronounced, so that an RPE usually excretes.Access routes in the operation
The prostate is located deep in the pelvis, below the bladder and above the pelvic floor (see also Anatomy of the prostate ). It is surgically accessible in two ways: either from below, through a skin incision in the perineum (perineal, therefore perineal RPE, PRPE called) or from above, from the belly. In the second case there are again several ways:About a vertical incision on the lower abdomen above the pubic bone (pubic bone) and then, without opening the peritoneum in front of the bladder and behind the pubic bone (retropubic, so open retropubic or RPE RPE, RRPE called). Or through several small incisions in the lower abdomen (usually 5), on the endoscope and other instruments are inserted ("keyhole surgery" minimally invasive surgery), either through the abdomen (laparoscopic RPE, LRPE) or outside of the peritoneum (the peritoneum, so endoscopic extraperitoneal RPE, EERPE called). Both endoscopic procedures are also possible with the support of the robot.
The open retropubic radical prostatectomy performed (RRPE) is the best-studied technique in which all other methods must be measured. Each has its own advantages and possible disadvantages, so the choice must be made individually. In experienced hands all seem to have the same overall good. However there is little comparative studies and for the newer, especially the endoscopic and robotic assisted procedures still no long-term results (more on the access paths and robot systems, see Minimally invasive radical prostatectomy for prostate cancer, and"robot" operation for prostate cancer ).
The end of the operation
In a typical retropubic RPE (RRPE) are first removed under general anesthetic or "spinal anesthesia" after the skin incision on the lower abdomen lymph nodes near the prostate and immediately histological (histological) to a cancer infestation examined (frozen section). Then you cut through the urethra between the prostate apex (apex) and pelvic floor, prostate lays around freely (if necessary with preservation of neurovascular bundles. Cf. nerve sparing ), by separating the two vas deferens, solves the two seminal vesicles from her bed and cuts finally the last link above the prostate at the bladder neck through.So therefore a block of prostate along with the therein urethra, internal sphincter, seminal vesicles and vas deferens-end pieces will be removed. Then sutured to the urethra over an indwelling catheter inserted to the bladder neck, optionally removes more lymph nodes (sulymphadenectomy ), puts a wound drains and closes the incision.
The procedure for the other techniques thereof slightly differs. The removed tissue is examined histologically but in any case, from which the postoperative tumor classification (type and malignancy, such as Gleason score, to see Classification ) and the pathological TNM stage (see the growth and spread ) result. The latter is due to tumor-free resection margins R0 (margin zero) added, otherwise an R1, R2 or R +, which means an incomplete tumor removal.
RPE takes about 2 to about 3 hours, lymphadenectomy. In the recovery room then already infusions to cover the fluid requirement and pain medications are given. Sometimes you spend the first night under observation in intensive care, but often a transfer to the normal ward on the same day is possible. Drinking is usually already allowed on the day of surgery, a slow food intake occurs when the bowel is working again. On the day after surgery, you can usually stand up with the help of the nursing staff.
The wound drains are removed after 3-5 days, then the earliest dismissal is possible (after open surgery is usually after 7-12, otherwise after 5-8 days). The anastomosis (new compound) the urethra after 5-10 days by means of X-ray contrast imaging or TRUS be checked (transrectal ultrasound). It is dense, the indwelling catheter can be removed. In the first days after the urine from flowing may still uncontrolled. A conservation without physical exertion until about six weeks after the operation supports the healing and helps to avoid late complications (see also Rehabilitation ).
Normally, the PSA level decreases in the first few weeks after surgery in the (separately for each measurement method) defined zero range. If this is not the case, it speaks for remaining residual tumor or metastases, so that further treatment may be advisable (see below relapsed). The latter is true also for a subsequent rise in PSA after an initial drop in the zero area (see below relapsed ).
Nerve sparing
Draw directly on the prostatic capsule along and mostly summarized in two rear-side bundles lying blood vessels and nerves to the prostate and partly also to the penis. Among these nerve fibers are (Nervi erigentes), for the erection (stiffening member, potency) provide.The nerve-sparing surgical technique in the RPE is named after its describer also Walsh method. Its goal is to get these two neurovascular bundles, or even just on the unaffected side in order to avoid a subsequent disturbance of an erection (erectile dysfunction, sucomplications ). However, the bundles are difficult to separate from the prostate, and it is known that prostate cancer preferentially along the capsule by breaking vessels and nerves spreading, also from the prostate out.
The patient should be informed about the possibility of a nerve-sparing RPE. Based on the findings (eg, location of the tumor, PSA level, Gleason score) is weighed, what the risk of positive surgical margins (ie, for an incomplete removal of the tumor), the uni-or bilateral nerve sparing holds in this particular case. At high risk should be advised to avoid the nerve sparing.However, the patient should decide what level of risk he wants to take over for a nerve-sparing surgery (see the discussion of this topic, nerve sparing during radical prostatectomy ).
Lymphadenectomy
The lymphadenectomy (lymph node dissection) is the best method to detect an infestation, however, involves additional risks. Before RPE is to clarify whether and to what extent (limited, as standard or extended), it should take place.Patients with localized prostate cancer should be advised about the risk of lymph node metastasis and the pros and cons of lymphadenectomy. In a tumor with a low risk of progression (PSA less than 10ng/ml and cT1c and Gleason score to 6) can be omitted lymphadenectomy. If they performed at least 10 lymph nodes should be removed. The more extensive it is done, the more likely an infestation is to prove, so that thus estimate the prognosis better and possibly a supportive treatment (see below adjuvant therapy can) initiate early. The fact that an extended lymphadenectomy without adjuvant therapy provides a survival advantage for patients with or without lymph node involvement, is not proven. However, there is evidence of increase in survival with no further progression of the disease.
Patients with locally advanced prostate cancer have a higher risk of lymph node metastasis than patients with a localized tumor. To date there is no evidence that lymphadenectomy with them a positive effect on disease progression. So it only seems to offer a chance for cure, if more than one lymph node is infected. But it forms the basis for the decision on adjuvant therapy (see below). Before the RPE patients should have an extended lymphadenectomy is recommended with a cT3 tumor.
A lymphadenectomy is possible for all RPE procedure. In the perineal RPE but it requires a second access or is previously performed endoscopically in a separate procedure.
Sentinel lymph node: this is injected the day before the RPE a radiolabeled substance in the prostate, which is transported in the lymph nodes. Can be achieved during the operation, the so-called sentinel lymph node (sentinel node, Eng. Sentinel lymph node, SLN) by means of a measuring device (gamma probe) detect and remove, so those who usually first affects the tumor, but in everyone else lie. Whether after an extended lymphadenectomy is performed depends on the risk of an infection and / or the result of the frozen section. Provided that the sentinel node as tumor-free lymph node metastases in other are very unlikely. By prior prostate surgery or hormone therapy and cancer in extensive infestations, the method may fail and is in the robot-assisted RPE currently not possible.
Complications of surgery
As with any major surgery there can be complications in the RPE. The operation method affects the nature and frequency only slightly, a long experience of the surgeon and ever finer techniques they can, however, be rare. Therefore, the RPE should be carried out only under the supervision of an experienced surgeon. Perioperative (occurring during and immediately after surgery) complications can be difficult, but this is rarely the case. This also applies to the long-term complications, most of which the new connection (anastomosis) of the urethra (leakage or narrowing due to scar) or the lymph vessels affect (eg after lymph node dissection formation of a lymphocele = local accumulation of tissue fluid). Exceptions are:Urinary Incontinence: After the RPE, the outer sphincter must prevent the involuntary loss of urine usually alone. If this is damaged or overloaded, followed by a stress urinary incontinence, which means the loss of urine at a greater or lesser impact (through coughing, laughing, sports). This affects about one in ten patients one year after RPE (the numbers range from 3% to 49%, depending on the strictness of the criteria and the subjective or objective assessment).Leaving the tips of the seminal vesicles and the nerve sparing (see above) can improve the continence rate. A possible urinary incontinence can be treated with various methods (eg, pelvic floor exercises, medication, Templates, Surgery), the implantation of an artificial sphincter is only in 1% of cases necessary (see more about rehabilitation and urinary incontinence ).
Erectile Dysfunction: The erection (stiffening member) is disturbed by an RPE of almost all men. However, it recovers especially in men often again who were potent before surgery and with bilateral nerve sparing (see above) were operated: A good half can perform sexual intercourse without tools again, one can add those on PDE-5 inhibitors appeal , there are up to 90%. Overall, up to 30% of men after more relaxing operation and up to 80% of men after surgery without nerve sparing erectile dysfunction. For treatment are numerous methods available, the transplantation of nerves as a replacement of a remote neurovascular bundle is still the subject of studies (see more about rehabilitation and erectile dysfunction ).
Note on sexual function: The RPE itself does not affect the touch sensitivity of the skin (eg on the penis), nor the libido ("Lust") or the ability to orgasm. However, this can be experienced differently or psychological reasons disturbed (eg by a depressed mood because of the serious illness). In contrast, the ejaculation is always lost (dry effusion), because the vas deferens no longer open into the urethra, and the main education centers of the seminal fluid, the prostate and seminal vesicles are removed.
Adjuvant therapy
Occasionally, depending on the individual findings before or after the RPE adjuvant (supportive) therapy may be necessary: Adjuvant percutaneous radiotherapy (external radiation by the RPE, see also radiation therapy ), neoadjuvant hormone therapy (before RPE) or adjuvant hormone therapy ( after RPE):Adjuvant percutaneous radiotherapy: This refers to an external radiation (energy dose 60-64Gy) after RPE when the PSA level after surgery in the (separately for each measurement method) defined zero field has fallen (for not so far fallen and again rise in PSA level belowrelapsed ). You should usually begin no later than 4 months after surgery. Patients with a pT3pN0 tumor with positive (tumor-bearing) cut edge should such therapy be offered under information about the benefits and risks as an option. A similar offer should receive patients with a pT3 tumor and negative resection margin, but other risk factors (eg, seminal vesicle invasion), the expected effect is smaller than in a positive cutting edge. Patients with pT2 tumors with positive resection margin can offer it. In all three cases, the alternative to a percutaneous radiotherapy in the investigation are mentioned only at the PSA increase from the defined zero range (salvage radiotherapy, su relapse therapy ).
Neoadjuvant hormone therapy: In patients with clinically localized prostate cancer should not (neoadjuvant) hormonal therapy should be performed in patients with clinically locally advanced tumor before the RPE.
Adjuvant hormone therapy: This refers to hormonal therapy, which is to start soon after an RPE after which the PSA level has dropped in the defined zero range and no signs of illness on the part of the tumor exist. Such treatment is not carried out when, after a RPE localized tumor histologically (histological) was detected. This also applies to a locally advanced tumor without lymph node metastases. In histologically proven lymph node metastases, however, they may be offered.
Relapse therapy
If the PSA level after the RPE is first dropped in the defined zero range, but later again rises to more than 0.2 ng / ml, which must be confirmed by at least two measurements, one speaks of a biochemical recurrence (BCR, laboratory signs a recurrence of the disease). This may be caused by a recurrence of the tumor at the original site (tumor recurrence, "local recurrence") or the growth of metastases (secondary tumors) to lymph nodes or other parts of the body ("systemic relapse").A biopsy to secure a local recurrence after RPE is not required. If is pulled in a patient with a biochemical relapse after RPE topical treatment (see below) into account to make a distinction between a local and a systemic recurrence are sought on the basis of PSA doubling time (PSA DT), the time between the RPE and increase in PSA and Gleason score in distant tissues. The shorter the PSA DT (for example, less than 3 months) and the distance to the operation and the higher the Gleason score (greater than 7), the more likely it is a systemic recurrence, wherein a hormone is eligible. However, the latter is the biochemical recurrence no standard therapy.
For they considered to be local recurrence has the following recommendations: In patients with favorable criteria (eg elderly patients, PSA-DT more than 10 months, PSA rise more than 2 years after RPE, Gleason score less than 8, no infection of the seminal vesicles or lymph nodes), the wait-and behavior an option (see active monitoring ). In patients whose lymph nodes proven not infested or are not assessable (pN0 or NX), an external radiation, called a percutaneous salvage radiotherapy (SRT, energy dose of at least 66Gy) should be offered as an option. You should start as early as possible (even with a PSA of less than 0.5 ng / ml). Are the lymph nodes not affected (pN0) and starts the SRT early, the lymphatic drainage should not be mitbestrahlt. The SRT also serves as an alternative to adjuvant external beam radiotherapy (as adjuvant therapy ).
If the PSA level after the RPE has not fallen into the defined zero range (so-called persistent PSA), treatment can be done as with the aforementioned biochemical recurrence according to the same principles.
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