Surgery for prostate cancer

Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the gland (stage T1 or T2 cancers).

The main type of surgery for prostate cancer is known as a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in different ways.

Open approaches to radical prostatectomy

In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long incision to remove the prostate and nearby tissues. This is sometimes referred to as an open approach.

Radical retropubic prostatectomy

For this operation, the surgeon makes a skin incision in your lower abdomen, from the belly button down to the pubic bone. You will be either under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery.

If there is a reasonable chance the cancer may have spread to the lymph nodes (based on your PSA level, DRE, and biopsy results), the surgeon may remove lymph nodes from around the prostate at this time. The nodes are usually sent to the pathology lab to see if they have cancer cells (it takes a few days to get results), but in some cases the nodes may be looked at right away. If this is done during surgery and any of the nodes have cancer cells, which means the cancer has spread, the surgeon may not continue with the surgery. This is because it is unlikely that the cancer can be cured with surgery, and removing the prostate could still lead to serious side effects.

When removing the prostate, the surgeon will pay close attention to the 2 tiny bundles of nerves that run on either side of the prostate. These nerves control erections. If you are able to have erections before surgery, the surgeon will try not to injure these nerves (known as a nerve-sparing approach). If the cancer is growing into or very close to the nerves the surgeon will need to remove them. If they are both removed, you will be unable to have spontaneous erections. This means that you will need help (such as medicines or pumps) to have erections. If the nerves on one side are removed, you still have a chance of keeping your ability to have erections, but the chance is lower than if neither were removed. If neither nerve bundle is removed you may be able to function normally. Usually it takes at least a few months to a year after surgery to have an erection because the nerves have been handled during the operation and won't work properly for a while.

After the surgery, while you are still under anesthesia, a catheter will be put in your penis to help drain your bladder. The catheter usually stays in place for 1 to 2 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.

You will probably stay in the hospital for a few days after the surgery and be limited in your activities for about 3 to 5 weeks. The possible side effects of prostatectomy are described below.

Radical perineal prostatectomy

In this operation, the surgeon makes the incision in the skin between the anus and scrotum (the perineum), as shown in the picture above. This approach is used less often because the nerves cannot easily be spared and lymph nodes can't be removed. But it is often a shorter operation and might be an option if you don't want the nerve-sparing procedure and you don't require lymph node removal. It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic approach if done correctly. The perineal operation usually takes less time than the retropubic operation, and may result in less pain and an easier recovery afterward.

After the surgery, while you are still under anesthesia, a catheter will be put in your penis to help drain your bladder. The catheter usually stays in place for 1 to 2 weeks while you are healing. You will be able to urinate on your own after the catheter is removed.

You will probably stay in the hospital for a few days after the surgery and be limited in your activities for about 3 to 5 weeks. The possible side effects of prostatectomy are described below.

Laparoscopic approaches to radical prostatectomy

Laparoscopic approaches use several smaller incisions and special surgical tools to remove the prostate. This can be done with the surgeon either holding the tools directly, or using a control panel to precisely move robotic arms that hold the tools.

Laparoscopic radical prostatectomy

For a laparoscopic radical prostatectomy (LRP), the surgeon makes several small incisions, through which special long instruments are inserted to remove the prostate. One of the instruments has a small video camera on the end, which lets the surgeon see inside the abdomen.

Laparoscopic prostatectomy has some advantages over the usual open radical prostatectomy, including less blood loss and pain, shorter hospital stays (usually no more than a day), and faster recovery times (although the catheter will be needed for about the same amount of time).

LRP has been used in the United States since 1999 and is done both in community and university centers. In experienced hands, LRP appears to be as good as open radical prostatectomy, although we do not yet have long-term results from procedures done in the United States.

Early studies report that the rates of side effects from LRP seem to be about the same as for open prostatectomy. (These side effects are described below.) Recovery of bladder control may be slightly delayed with this approach. A nerve-sparing approach is possible with LRP, increasing the chance of normal erections after the operation.

Robotic-assisted laparoscopic radical prostatectomy

A newer approach is to do the laparoscopic surgery remotely using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic radical prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to perform the operation through several small incisions in the patient's abdomen.

Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient.

In terms of the side effects men are most concerned about, such as urinary problems or erectile dysfunction (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy.

For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon's experience, commitment, and skill.

If you are thinking about treatment with either type of LRP, it's important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.

Possible risks and side effects of radical prostatectomy (including LRP)

There are possible risks and side effects with any type of surgery for prostate cancer.

Surgical risks

The risks with any type of radical prostatectomy are much like those with any major surgery, including risks from anesthesia. Among the most serious, there is a small risk of heart attack, stroke, blood clots in the legs that may travel to your lungs, and infection at the incision site.

If lymph nodes are removed, a collection of lymph fluid (called a lymphocele) can form and may need to be drained.

Because there are many blood vessels near the prostate gland, another risk is bleeding during and after the surgery. You may need blood transfusions, which carry their own small risk. Rarely, part of the intestine might be cut during surgery, which could lead to infections in the abdomen and might require more surgery to correct. Injuries to the intestines are more common with laparoscopic and robotic surgeries than with the open approach.

In extremely rare cases, people die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team.

Side effects

The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). It should be noted that these side effects can also occur with other forms of treatment for prostate cancer, although they are described here in more detail.

Urinary incontinence: You may develop urinary incontinence, which means you are not able to control your urine or have leakage or dribbling. There are different degrees of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well. There are 3 major types of incontinence:

• Stress incontinence is the most common type of incontinence after prostate surgery. Men with stress incontinence leak urine when they cough, laugh, sneeze, or exercise. It is usually caused by problems with the muscular valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments may damage the muscles that form this valve or the nerves that keep the muscles working.
• Men with overflow incontinence cannot empty the bladder well. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.
• Men with urge incontinence have a sudden need to go to the bathroom and pass urine. This problem occurs when the bladder becomes too sensitive to stretching as it fills with urine.

Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence.

After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs gradually, in stages.

Doctors can't predict for sure how any man will be affected after surgery. In general older men tend to have more incontinence problems than younger men.

Most large cancer centers, where prostate surgery is done more often and surgeons have more experience, report fewer problems with incontinence.

Incontinence can be treated. Even if your incontinence cannot completely be corrected, it can still be helped. You can learn how to manage and live with incontinence. See our document called Managing Incontinence for Men With Cancer to learn more about this side effect and what can be done about it.

Impotence (erectile dysfunction): This means you cannot get an erection sufficient for sexual penetration. The nerves that allow men to get erections may be damaged or removed by radical prostatectomy. Other treatments (besides surgery) may also damage these nerves or the blood vessels that supply blood to the penis to cause an erection.

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 cut. Everyone can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability.

A wide range of impotency rates have been reported in the medical literature, from as low as about 1 in 4 men under age 60 to as high as about 3 in 4 men over age 70. Doctors who perform many nerve-sparing radical prostatectomies tend to report lower impotence rates than doctors who do the surgery less often.

Each man's situation is different, so the best way to get an idea of your chances for recovering erections is to ask your doctor about his or her success rates and what the outcome is likely to be in your particular case.

If your ability to have erections does return after surgery, it often occurs slowly. In fact, it can take up to 2 years. During the first several months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments.

If potency remains after surgery, the sensation of orgasm should continue to be pleasurable, but there is no ejaculation of semen – the orgasm is "dry." This is because during the prostatectomy, the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed, and the pathways used by sperm (the vas deferens) were cut.

Most doctors feel that regaining potency is helped along by attempting to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time. Be sure to talk to your doctor about your situation.

Several options may help you if you have erectile dysfunction:

• Phosphodiesterase inhibitors such as sildenafil (Viagra^®), vardenafil (Levitra^®), and tadalafil (Cialis^®) are pills that can promote erections. These drugs will not work if both nerves that control erections have been damaged or removed. The most common side effects are headache, flushing (skin becomes red and feels warm), upset stomach, light sensitivity, and runny or stuffy nose. Rarely, these drugs can cause vision problems, possibly even blindness. Nitrates, which are drugs used to treat heart disease, can interact with these drugs to cause very low blood pressure, which can be dangerous. Some other drugs may also cause problems, so be sure your doctor knows which medicines you are taking.
• Alprostadil is a man-made version of prostaglandin E1, a substance naturally made in the body that can produce erections. It can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or placed into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You may have side effects, such as pain, dizziness, and prolonged erection, but they are usually minimal.
• Vacuum devices are another option that may create an erection. These mechanical pumps are placed around the entire penis to produce an erection. The erection is maintained after the pump is removed by a strong rubber band placed at the base of the penis. The band is removed by cutting it off when intercourse is done.
• Penile implants might restore your ability to have erections if other methods do not help. An operation is needed to put them in place. There are several types of penile implants, including those using silicone rods or inflatable devices.

For more detailed information on coping with erection problems and other sexuality issues, see our documentSexuality for the Man With Cancer.

Changes in orgasm: In some men, orgasm becomes less intense or goes away completely. A few men report pain with orgasm. Even if you have problems with impotence, you may still be able to have an orgasm.

Loss of fertility: Radical prostatectomy cuts the connection between the testicles (where sperm are produced) and the urethra. Your testicles will still produce sperm, but it can't get out as a part of the ejaculate. This means that a man can no longer father a child by natural means. Often, this is not an issue, as men with prostate cancer tend to be older. But if it is a concern for you, you might want to ask your doctor about "banking" your sperm before the operation.

Lymphedema: A rare but possible complication of removing many of the lymph nodes around the prostate is a condition called lymphedema. Lymph nodes normally provide a way for fluid to return from all areas of the body to the heart. When nodes are removed, fluid may collect in the legs or genital region over time, causing swelling and pain. Lymphedema can usually be treated with physical therapy, although it may not go away completely.

Change in penis length: A possible effect of surgery is a small decrease in penis length. This is probably due to a shortening of the urethra when a portion of it is removed along with the prostate.

Inguinal hernia: A prostatectomy increases a man's chances of developing an inguinal (groin) hernia in the future.

Transurethral resection of the prostate (TURP)

This operation is more commonly used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). A TURP is not used to try to cure prostate cancer, but it is sometimes used in men with advanced prostate cancer to help relieve symptoms, such as urination problems.

During this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra (the tube through which urine exits the bladder). The skin is not cut with this surgery. An instrument called a resectoscope is passed through the end of the penis into the urethra to the level of the prostate. Once it is in place, either electricity is passed through a wire to heat it or a laser is used to cut or vaporize the tissue. Spinal anesthesia (which numbs the lower half of your body) or general anesthesia (where you are asleep) is used.

The operation usually takes about an hour. After surgery, a catheter is inserted through the penis into the bladder. It remains in place for about a day to help urine drain while the prostate heals. You can usually leave the hospital after 1 to 2 days and return to normal activities in 1 to 2 weeks.

You will probably have some blood in your urine after surgery. Other possible side effects from TURP include infection and any risks that come with the type of anesthesia that was used.