Surgical Options for Prostate Cancer


Email Raji.Kooner@svha.org.au or call 02 8382 6980 for a confidential appointment.

With my patients that have prostate cancer who wish to discuss the surgical options I always discuss the three options.

Number one, open surgery, number two, keyhole laparoscopic surgery and number three, keyhole robot assisted surgery.

My fellowship was in prostate cancer and I performed an extensive number of open surgery procedures.

I was very happy with the outcomes and the results but there were some problems with open surgery, there was significant blood loss which was often unpredictable, it was very hard to get access because the prostate is in a deep inaccessible area and it’s sometimes difficult to do an accurate anastomosis1 rejoin.

Sometimes it’s also hard to do a proper nerve sparing procedure because of the blood loss that can occur.2

So the operation is done with an incision, usually in the lower abdomen between the umbilicus or belly button and the pubic bone. 

It usually takes about two to two and a half hours. 

Patients are usually in hospital for seven to 10 days and recovery is variable but usually one to two months, sometimes a bit longer.3

Because of the concerns though and the potential side effects I then started offering laparoscopic surgery or keyhole laparoscopic surgery and this particularly suited me.

I did play a lot of sports and was fortunate to play at a representative level in New South Wales.

Prior to med school I was lucky enough to do that and I think the hand, eye coordination that I had in those sports really helped to transfer these to the operating room with laparoscopy.

With laparoscopy what we do is we make small incisions in the abdomen, we insert instruments into the patient and this is an example of a laparoscopic port that gets inserted and that goes into the patient and subsequently what we do is we put instruments through this and the instruments for example a pair of scissors go through the laparoscopic port and get inserted into the patient.4

We then can open and close the scissors and we move these instruments. 

Now to move the instrument to the left you’ll see on the outside we actually have to move it to the right.

So it’s a bit counterintuitive and the instrument can’t rotate but there is gas pressure in the abdomen which is higher than the vein pressure so there’s less bleeding5, there’s more magnified view and we can get access to a deep inaccessible area.

With regards to laparoscopy I visited numerous centres in the world and I was very fortunate to be personally trained by the pioneers in laparoscopy surgery in the world.

These include Claude Abbou, Bertrand Guillonneau, Professor Valencian, Indupi Gul and Chris Eden. 

They’re world leaders on laparoscopic surgery, three or four of them have actually personally taught me how to laparoscopic surgery. 

I conducted a workshop in Australia and was one of the first surgeons in Australia to do this.

So although I was quite happy with the outcomes of laparoscopic surgery it is quite difficult to do, it takes a substantial amount of time sometime and at the end of the procedure you’re quite tired and the most difficult part, the anastomosis or the join is very difficult to do because the instruments don’t bend.

So for me there were some concerns about laparoscopy.

We had a robot donated or partly donated to us through the cardiothoracic department actually with the donors and fortunately I was chosen to lead the robotic program and I pioneered the use of the robot in Urology.6

Initially it was quite difficult to do and it took a substantial time period but fortunately because I had the experience with laparoscopic surgery it was much easier for me and I had a very short learning curve.

Robot assisted surgery has performed well in multiple studies7, 8, 9 and is significant part of my practice and this is really patient driven. 

So I offer my patients open laparoscopic and robot assisted surgery. 

I describe the pros and cons of all

References

1. Prostatectomy - for cancer - Department of Health, State Government of Victoria - https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/prostatectomy-for-cancer
2. Porcaro, A.B., Tafuri, A., Rizzetto, R. et al. Predictors of complications occurring after open and robot-assisted prostate cancer surgery: a retrospective evaluation of 1062 consecutive patients treated in a tertiary referral high volume center . J Robotic Surg 16, 45–52 (2022). https://doi.org/10.1007/s11701-021-01192-w
3. What to expect after surgery - Cancer Council NSW - https://www.cancercouncil.com.au/prostate-cancer/management-treatment/surgery/what-to-expect-after-surgery
4. Radical Prostatectomy - John Hopkins Medicine - https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/radical-prostatectomy
5. George Kasotakis, Michael Duggan, Yongqing Li et al - Optimal pressure of abdominal gas insufflation for bleeding control in a severe swine splenic injury model - J Surg Res. 2013 Oct;184(2):931-6. doi: 10.1016/j.jss.2013.03.016
6. Man's kidney removed by robot (October 14, 2007) - The Sunday Telegraph - https://www.dailytelegraph.com.au/news/nsw/robot-removes-kidney/news-story/661e98f5b14efdb9ebd83dc54a1aacd8
7. Jianglei Ma, Weidong Xu, Rui Chen, et al - Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies - Int J Surg. 2023 May; 109(5): 1350–1359. - doi: 10.1097/JS9.0000000000000193
8. Mehrdad Alemozaffar, Martin Sanda, Derek Yecies, et al. - Benchmarks for Operative Outcomes of Robotic and Open Radical Prostatectomy: Results from the Health Professionals Follow-up Study - European Urology, Volume 67, Issue 3, 2015, Pages 432-438, ISSN 0302-2838, https://doi.org/10.1016/j.eururo.2014.01.039.
9. Muaddi, Hala; Hafid, Melanie; Choi, Woo Jin; et al - Clinical Outcomes of Robotic Surgery Compared to Conventional Surgical Approaches (Laparoscopic or Open): A Systematic Overview of Reviews. - Annals of Surgery 273(3):p 467-473, March 2021. | DOI: 10.1097/SLA.0000000000003915