Surgery for Prostate Cancer
Surgery is a frequent choice to try to cure prostate cancer when there is no evidence that the cancer has spread beyond the prostate. When surgery is performed on the prostate for cancer, it is called a “radical” prostatectomy, which simply means removal of all prostate tissue with surrounding soft tissue to ensure all cancer is removed to the best of our ability. This includes the seminal vesicles as well as the urethra that passes through the prostate. There are three possible approaches to the removal of the prostate:
- Traditional open radical prostatectomy
- Laparoscopic radical prostatectomy
- Robotic-Assisted radical prostatectomy
In the open prostatectomy, the incision made below the belly button, and this surgery can be utilized for patients with all clinical stages of localized disease. In a laparoscopic prostatectomy, several smaller incisions are made and use long surgical tools to remove the prostate after the abdomen is insufflated with gas to create working space. With the newest and most precise technology, the DaVinci surgical robot, smaller incisions are also made in the abdomen, but a control panel to precisely operate with robotic arms is used, which holds the instruments in the abdomen. This approach affords more dexterity, and improves several aspects of the recovery, although cancer outcomes compared to open prostatectomy are very similar.
For both types of procedures, you will either be under general anesthesia, and the surgery will also entail removal of lymph nodes, known as a standard pelvic lymph node dissection. The extent of the nodal dissection will be determined based on your pre-operative risk based on your individualized prostate cancer specific characteristics. All tissue is examined microscopically by expert uro-pathologists. You will wake up with a catheter which will drain the bladder as the urinary tract heals, and this thin, flexible tube will usually stay in place for 10-14 days. You will be able to urinate on your own after the catheter is removed. The usual length of stay for patients in the hospital is one day for robotic procedures, and 2 days for traditional procedures.
Although most often used for non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH), a TURP or transurethral resection of the prostate is occasionally used in prostate cancer cases to relieve obstruction, or as an adjunct to radiation therapy in men with large prostates which are too big for successful radiation. During this operation, the inner part of the prostate gland is removed endoscopically, through the urethra. There are several tools to do this, but in cancer cases, a traditional minimally invasive method is used. Spinal anesthesia or general anesthesia is used. The operation takes an hour on average and requires one night in the hospital during which the bladder will be irrigated overnight with warm saline. It remains in place for 24-48 hours. You will be back to normal activity in 2 weeks, during which your healing will result in occasional blood in the urine which will stop.
Risks of Prostate Surgery:
- Reactions to anesthesia
- Bleeding
- Blood clots in the legs or lungs
- Damage to nearby organs
- Infections at the surgery site.
During a prostatectomy, although very rare, these specific acute side effects may occur:
- Bowel injury requiring repair and drainage
- Lymphatic fluid collections requiring drainage
- Cardiac or other major complications based on your pre-op risk factors
When the acute risks of surgery decrease, the possible side effects of radical prostatectomy are urinary incontinence (being unable to control urination) and erectile dysfunction, which can be defined as problems achieving or maintaining an erection for sex.
Urinary Incontinence:
After surgery, you might have difficulty in controlling your urine leading to accidents and dribbling. After surgery, normal bladder control usually returns within several weeks or months, and can be helped with aggressive pelvic physiotherapy, some medications, and patience to allow your body to recover. Rarely, reconstructive options such as slings or artificial sphincters may be needed. Although it is difficult to predict who will recover quickly and who will take time, older men and those who have postoperative complications while in hospital, or have problems with blockage of urine after surgery tend to have more incontinence problems. Incontinence can be treated and the small risk should not prevent men from benefiting from surgical approaches to prostate cancer.
Erectile Dysfunction:
Erections are controlled by 2 tiny bundles of nerves that run on either side of the prostate, from your spine to your penis, carrying electrical impulses that help blood move to the penis for creation of an erection. If your erections are normal preoperatively, there is a good chance that after surgery, you will be able to engage in normal sexual intercourse after a rehabilitation period. Before surgery, Dr Feifer will plan the surgical approach and define his ability to save nerves based on where the cancer is located, what the clinical stage is, and what the prior sexual performance is as well.
During the surgery, the surgeon will try not to injure these nerves, which is known as a nerve-sparing approach. But if the cancer is growing into or very close to the nerves, the cancer outcome is more important and the nerves, often on one side, will be partially removed with the cancer. If both nerves are removed completely, you won’t be able to have spontaneous erections, but will still be able to have erections with some help.
In general, your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were involved with cancer. Most men can expect some decrease in the ability to have an erection, but the younger and healthier you are, the more likely you will regain pre-surgical form. A wide range of impotency rates have been reported in the medical literature, but each man’s situation is different, so Dr. Feifer will discuss your specific risks with you when you discuss surgical options to deal with your prostate cancer. Surgeons who do many radical prostatectomies, as Dr. Feifer does, tend to report lower impotence rates than doctors who do the surgery less often. This has to do with physician experience in nerve sparing.
When you regain the ability to have erections after surgery, it often returns slowly, from a few months up to 2 years. This does not mean that you will wait that long to engage in intimate activity. During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use oral medications or other forms of therapy to attempt to speed up the healing process, and to enhance your quality of life in the process. Dr. Feifer believes in early penile rehabilitation, and the program used for this end will be discussed with you in detail, and may include: Phosphodiesterase-5 such as Viagra or Cialis, a self injected medication called “Triple Mix”, which can be injected painlessly into the base of the penis 5 to 10 minutes before intercourse, vacuum devices, and penile implants if other methods don’t help.
While the surgery may affect your ability to have an erection, it will not affect your ability to experience sexual pleasure, to have an orgasm, and will not affect your interest in sexual activity. You will have a change in ejaculation at orgasm because the glands that made most of the fluid for semen (the seminal vesicles and prostate) are removed during surgery. The pathways used by sperm to travel to the penis are not present any longer as well, so it will not be possible to impregnate your partner via natural means any longer. Patients wishing to have children will have to do so via assisted reproductive technology, which is highly effective. Some men do sperm banking as an extra precaution. Also, a possible side effect of surgery is a small decrease in penis length, likely due to a shortening of the urethra when a portion of it is removed along with the prostate.
One last possible very rare complication of the procedure is a collection of fluid in the genital region and lower extremities called lymphedema. Although this is rare, lymphedema is highly treatable with physical therapy, although it may become chronic.
TREATMENTS & CONDITIONS
Benign Prostate Gland Enlargement (BPH)
Benign prostatic hyperplasia (BPH), also called prostate gland enlargement, is a common age associated condition. An
Surgery, Medical Management of BPH
When BPH needs to be treated, the first thing that is trying is a modification of lifestyle factors. There may be food
Erectile Dysfunction
Erectile Dysfunction (ED) is a medical condition where a man is unable to achieve and maintain an erection that allows for satisfactory sexual function. This can show up
Male Voiding Dysfunction
The lower urinary tract in the male includes the bladder, prostate and urethra, which allows for storage and timely expulsion of urine. Voiding dysfunction describes a condition
