Satyendra Persaud MBBS DM(Urol) FCCS Registrar, Department of Urology San Fernando General Hospital, Trinidad and Tobago
Last time we discussed situations where it would be appropriate to observe low risk prostate cancer – this is called active surveillance. This week I wanted to briefly discuss another option for managing prostate cancer which hasn’t spread outside the prostate – radical prostatectomy. I should remind you that in order to determine whether the cancer hasn’t spread, the urologist may request an MRI scan and a special scan of the bones. Not everyone is suitable for surgery and if your cancer is too large, you may be better suited for radiation therapy. Also, if you have other medical issues which may put you at risk during surgery, the urologist may opt for another form of therapy.
What is a radical prostatectomy and how is this done?
This is an operation to remove the prostate. The surgeon removes the prostate and then joins the bladder to the urethra which is the tube through which the urine passes. This is done through a cut in the tummy below the belly button which is usually 3-5 inches long. Increasingly, in the developed world the operation is being done using robots. Use of the robot may result in earlier recovery and slightly better outcomes. However, excellent outcomes are still achieved with open surgery. The open operation typically takes about 2-3 hours and the patient spends 1-2 days in hospital. A urine tube is usually left in place for around 2 weeks to allow healing. Depending on your risk scores, your surgeon may decide to remove your lymph nodes. Your biopsy scores, PSA and rectal exam will determine your risk.
What are the risks of radical prostatectomy?
There are certain risks associated with any major surgery and these include heart and lung complications as well as wound and urinary tract infections. There is also a risk of bleeding and you will be asked to have a few persons donate blood on your behalf prior to surgery. It is not uncommon to have difficulty keeping up the urine in the early phase following the operation. However, this usually resolves with time. Around 1-2% will have severe incontinence and will require further treatment. You should be taught pelvic floor exercises before your surgery and continue these after the procedure as they may help with holding up the urine. A small percentage will develop a narrowing of the area where the bladder was joined to the urethra – this is called a bladder neck contracture. Perhaps the most common issue following prostatectomy is erectile dysfunction (ED) or impotence. Erectile dysfunction occurs because the nerves going to the penis are very close to the prostate and are easily damaged during surgery.
What is a nerve sparing operation?
Given that the nerves controlling erections are so close to the prostate, men undergoing prostatectomy in years gone by had a very high risk of ED following surgery. Modern prostatectomy uses a nerve sparing technique, where the nerves are preserved. However, if during surgery there is doubt about whether the cancer has spread to the nerves are very close to the nerve on a particular side, the surgeon may no e able to perform a nerve sparing technique. If both nerves are spared, most patients will recover erectile function.
What can I do to maximize my chance of having good erectile function following surgery?
Therapy to encourage the return of erections is called penile rehabilitation and is a controversial area as the data coming out of several studies are inconsistent. It is my personal belief that there is solid basic science evidence and some clinical evidence in support of penile rehabilitation. It is therefore my practice to commence therapy as early as two weeks following surgery ie at the time when the urine tube is removed. The patient is encouraged to have erections using medication such as Viagra and these are gradually reduced over time. Recovery of erectile function may take several months.
How will I be followed after surgery?
You should have your PSA (blood test) around 6 weeks following surgery. Ideally this number should be zero as the entire prostate has been removed. If your PSA is zero following surgery and starts to rise OR if the PSA never fell to zero, you will need additional therapy, usually radiation. Also, if the pathologist looks at the prostate under the microscope and realizes that the cancer has spread outside the prostate (even though your pre-op imaging was normal) your urologist may offer you early radiation even if your PSA is zero. This is called adjuvant radiation and the data have shown us that it may improve survival.
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