Surgery

A radical prostatectomy is the surgery most often recommended for the treatment of prostate cancer. This surgical procedure involves the complete removal (excision) of the prostate gland and surrounding tissues, the seminal vesicles, and a portion of the urethra. It is an operation intended to cure men whose cancer has not spread outside the prostate gland (Stage T1 or Stage T2), but it is sometimes also recommended to men whose cancer has invaded the area immediately surrounding the prostate (Stage T3). However, the complete removal of the prostate is not usually undertaken if a man's cancer has spread to the lymph nodes or if there are distant metastases. Basically, this surgery in a localized treatment in that it removes cancerous tissue from a particular area. Systemic treatments, such as chemotherapy or hormone therapy that treat cancer throughout the body, are used when the cancer is no longer confined in a particular location. Surgery, a local treatment, may be used alone or in combination with systemic treatments or other local treatments, such as radiation, to treat prostate cancer.

The radical prostatectomy is usually performed through an incision in the abdomen (radical retropubic prostatectomy), but it can be performed through an incision in the area called the perineum (radical perineal prostatectomy). Let's explore each of these basic procedures in detail before considering nerve-sparing surgery or laparoscopic surgery. (For a comparison of the outcomes of various types of prostate cancer surgery, see the article “Open, Laparoscopic, or Robotic Surgery for Prostate Cancer.”)

RADICAL RETROPUBIC PROSTATECTOMY
In a radical retropubic prostatectomy, the surgeon makes an incision that runs along the midline of the body from just under the navel to just above the public bone. Sometimes, the surgeon will remove the lymph nodes surrounding the prostate and have these checked for cancer before proceeding with the prostatectomy. (This procedure is called a pelvic lymphadenectomy.) If the lymph nodes are cancer free, then the surgeon continues, removing the prostate, the seminal vesicles, and the portion of the urethra that runs through the prostate. After this, the surgeon reconnects the urethra to the bladder, and inserts a catheter to enable the repaired area to heal.



RADICAL PERINEAL PROSTATECTOMY
This surgery is similar to radical retropublic prostatectomy except that the surgical incision is made in the area between the scrotum and the anus. Perineal prostatectomy is less used in Canada because this approach gives a worse view of a patient's bladder and other significant anatomical features. However, this type of surgery makes sense in certain circumstances, for example, if a patient has extensive scar tissue from past abdominal surgeries.



NERVE-SPARING SURGERY
Nerve-sparing techniques used with retropubic prostatectomy can enable surgeons to identify and preserve the nerves surrounding the prostate, nerves that are involved in achieving erections. These nerves, called cavernous nerves, are in two neurovascular bundles (bundles of nerves and veins) that run along the rectum, pass along the prostate and the urinary sphincter, and make their way into the penis. A nerve-sparing prostatectomy involves cutting very close to the prostate in order to preserve the cavernous nerves, so the risk is that cancer cells remain behind. Obviously, many men with prostate cancer are not candidates for this type of surgery, even if their cancer is confined to the prostate. If a man's cancer is too close to these nerve bundles to allow for nerve-sparing techniques, he may wish to consult his surgeon about the possibility of a nerve graft.



WHAT TO EXPECT

During the weeks before a prostatectomy, you may be asked to undergo some pre-operative tests or procedures, such as blood work, an electrocardiogram, and a chest x-ray. Sometimes, you are asked to consider donating one or two pints of your own blood to be used if necessary during your surgery. Your doctor may also recommend that you begin Kegel exercises to improve the strength of your pelvic muscles and a program of moderate exercise to help improve your general health and stamina.

Before surgery, you will be admitted to the hospital. Sometimes this happens the day of your surgery or the day before. You may be given a laxative or enema to clean out your bowels, and you will be required to refrain from eating or drinking for about eight hours before the operation.

During surgery, you can expect to be anaesthetized, and you will lie flat on your back or with your legs up in stirrups. The operation itself takes from 2 to 4 hours, approximately. You will have a catheter inserted through your penis during this operation. The catheter will allow urine to drain from your bladder until the new connection between your bladder and your urethra is healed.

After surgery, you will experience some pain, especially at the incision site. Pain medication can usually control pain or discomfort well. You might also experience some discomfort from bladder spasms, which are caused by the catheter irritating the wall of the bladder. You will probably stay in hospital for about two to five days after your surgery. During this time, it will be important for you to follow your medical team's advice about post-operative exercise, diet, and methods of caring for your incision.

At home, you will continue the recovery process. Your catheter will probably be removed a few weeks after your return, and you will be asked to refrain from heavy lifting or vigorous exercise until you recover. The average recovery time is between 4 and 6 weeks, although incontinence (loss of bladder control) may continue after this time. Most men have recovered fully at about 3 to 6 months after the surgery. (See complications and side effects for more information.)

POSSIBLE BENEFITS AND SIDE EFFECTS
Please note that benefits, complications, and side effects are possibilities not actualities. Complications are very unusual events that can result during or because of surgery. Side effects occur as a result of surgery as well, but these can persist and can range from common to rare.

Also note that, if a radical prostatectomy has been recommended by your physician, it is that medical professional's opinion that the potential benefits outweigh the possible side effects. The most obvious benefit, of course, is that radical prostatectomy offers the possibility of a cure for early-stage prostate cancer.

Benefits

• This surgery is a one-time procedure.
• As the whole prostate is removed, it potentially removes all cancer cells.
• The operation has a long history of use, and many surgeons and medical centres specialize in the technique.
• Follow-up procedures are well established, and the results of the surgery are relatively easy to monitor through PSA testing.
• If cancer is left behind, other localized treatments, such as radiation, are available.
• Many specialists believe that the radical prostatectomy offers the best chance of long-term survival for a man with localized prostate cancer.

Complications

• There is a risk that blood loss during surgery will necessitate a transfusion, although modern surgical techniques have minimized blood loss.
• As with any major surgery, there is a small risk of surgically related death, either from the procedure itself or from the anaesthetic. This risk is greater for older men who have other medical conditions.
• Other rare but possible complications include infection (either of the incision or the urinary tracts), excessive bleeding, and a narrowing of the urethra caused by scar tissue. This last complication is more common than the first two and occurs in about 10 percent of patients. The problem is usually easily dealt with by putting an instrument up the urethra and cutting away the scar tissue.

Side Effects

Infertility
After a radical prostatectomy, a man is no longer able to father a child through sexual intercourse. Although orgasms are possible, ejaculations will be dry-they will have no ejaculate. Sperm is still produced, but it can no longer be released. Men who desire to father children after a prostatectomy might consider contributing to a sperm bank before this operation.

Incontinence
Urinary incontinence, or a loss of bladder control, is a common problem experienced by men immediately after a radical prostatectomy. For most men, incontinence is temporary, occurring after the removal of the catheter and improving over the next few months. Control of urination is usually completely re-established about 3 to 6 months after surgery. However, about 10 % of men will continue to have stress incontinence, which means that urine leaks when they sneeze or cough or otherwise exert themselves. A very small percentage of men will remain totally incontinent after this surgery and may decide to have another operation to implant an artificial device to establish urinary control.

Men can prepare physically and psychologically for incontinence. They can start doing Kegel exercises in the weeks prior to surgery and after their catheter is removed. (These exercises strengthen the pelvic muscles.) Also, men should purchase and have on hand absorbent pads to wear after their catheter is removed.

A very small percentage of men will remain totally incontinent after this surgery and may decide to have another operation to implant an artificial device to establish urinary control. (See the article "A Device to Restore Urinary Continence after Prostate Cancer Treatment," by Doug Scott.)

Erectile Dysfunction
Immediately after a radical prostatectomy, men are unable to achieve erections, even with nerve-sparing surgery, and erectile function usually takes longer to recover than control of the bladder. Erectile dysfunction, then, is the most common long-term side effect of surgery for prostate cancer. Recovery depends on the extent of a man's surgery and on whether both, one, or none of the cavernous nerve bundles has been cut. If both have been cut, a man is not likely to have spontaneous erections. Estimates vary greatly regarding the percentage of men who are able to achieve spontaneous erections after a nerve-sparing radical prostatectomy. This variation occurs because other factors affect the possibility of a man achieving spontaneous erections, factors such as age, general health, and sexual functioning previous to the operation. Some estimate at 30 to 40 per cent the chance of having spontaneous erections after surgery that spares one nerve bundle and indicate that this goes up to between 50 to 70 percent if both nerve bundles are spared. A workable erection is occasionally possible in about 4 months after surgery, but 6 months to a year is a more usual recovery time. Sometimes, it takes as long as two years before the spared nerves recover and erectile function is restored. (Read about expert Dr. Mulhall’s research on "Erectile Function and Prostate Surgery.")

There are many new and developing therapies available now to assist men experiencing erectile dysfunction, and you should discuss these with your surgeon, urologist, and other experts. What will work for you depends upon many factors, including the details of your surgery. Viagra and similar drugs, for example, are usually only effective in patients who have had a nerve-sparing prostatectomy.

Note: It is important to realize that prostate cancer, if left untreated, can cause both erectile dysfunction and incontinence, as well as death.

Related information: "Radical prostatectomy versus watchful waiting in early prostate cancer," CPCN Linda A. Johnson, "Prostate surgery better for those under 65," CPCN reprint of a May 11, 2005 newswire story. Dr. Victor Mak, "Coping with complications after a radical prostatectomy or radiation," CPCN (Newmarket Chapter) Dr. Sidney B. Radomski, "Don't suffer in silence with your erectile dysfunction and incontinence," CPCN (Newmarket Chapter), Dr. Andrew Mathews, "Coping with the impact of prostate cancer," CPCN (Newmarket Chapter) "Medical plans coverage for Viagra," CPCN "Dr. Serge Carrier Talks on Sexual Dysfunctions," Montreal West Island Prostate Cancer Support Group Newsletter, April 2006, 5. CPCN Joe Fiorito, "'No Big Deal'-A play about what men don't talk about," CPCN reprint of an National Post article Canadian Prostate Health Council, Radical Prostatectomy: A Patient Guide Dr. S. Larry Goldenberg and Dr. Michael A. Pether, "Surgery Works: Radical prostatectomy is the tried and true cure for most early-stage cases," Our Voice (Special Issue), 8-9, EDHelp: The Canadian Erectile Difficulties Resource Centre, Different expertise, Different treatment: Do urologists and radiation oncologists tend to recommend the treatment that they themselves deliver? CPCN, July 2008.