Surgery for Prostate Cancer

Surgery is an invasive procedure. There is evidence that surgery for prostate cancer is rampant in the United States with an increase of 60% between 1984 and 1990. Contrast this with the Watchful Waiting approach used in Europe for the same stage prostate cancer. Recent studies, however, do show a decrease in the number of men having radical prostatectomy procedures.

While the medical community would like to see more incidence of the Watchful Waiting approach, patients find the approach too stressful.

Lets discuss the actual surgical procedure. It is called a radical prostatectomy and is the complete removal of the prostate as well as tissue nearby. The procedure can be further described by the incision used to accomplish the procedure. These incisions are:

    Retropubic prostatectomy. The prostate is reached via an incision in the lower abdomen;
    Perineal prostatectomy. The prostate is reached via an incision in the perineum which is the space between the scrotum and the anus.

Radical prostatectomy consists of removing the entire prostate gland, the seminal vesicles, both of the ampullae (the enlarged lower sections of the two vas deferens which are the tubes that carry sperm from the testicles to the actual prostate gland) and the other surrounding tissue. The portion of the urethra that travels through the prostate is cut away as well as the bladder neck and some of the sphincter muscle that controls urine flow.

Dissection of the pelvic lymph node is routine with a retropubic prostatectomy but with a perineal prostatectomy the dissection requires a separate incision.

A radical prostatectomy is a serious, complicated, demanding procedure. The surgery itself will take anywhere from 2 to 4 hours. The patient will remain in the hospital for approximately 3 days. He will require a catheter (tube to drain urine) for about 10 days to 2 weeks. There is a small percentage (5 to 10%) of surgical related problems like bleeding or infection. The risk of death from the surgery is very minimal and much less for younger men as opposed to older men who may be frail.

Post surgical, long term problems associated with prostatectomy range from sexual impotence, stool incontinence and urinary incontinence. It is highly unlikely that a man will father children after the procedure. The reason is that without the prostate, very little ejaculate is produced.

It is common for the majority of men to experience incontinence after surgery and have occasional dribbling when coughing or exerting themselves. A few will lose all urinary permanently. Some men are candidates for an artificial urinary sphincter which is implanted surgically or narrowing the bladder opening with injections of collagen.

Stool or fecal incontinence (loss of normal muscle control of the bowels) may affect some men after their prostatectomy. This is caused by muscle damage during rectal surgery and stool incontinence is also caused because of a reduction of the elasticity of the rectum. What this does is shorten the time period between the sensation of the stool and the need to have a bowel movement. The rectum can be scarred and stiffened by surgery or radiation.

Historically, a prostatectomy always resulted in sexual impotence. Advances in surgical procedures called “nerve-sparing surgery” may reduce the risk of impotence. The nerve sparing technique avoids cutting the two bundles of nerves and vessels that run along the surface of the prostate gland that are needed for an erection.
Unfortunately, this procedure is not viable for everyone, if the cancer is too large or if it is located too close to the nerves. Under these circumstances, even with this technique many men (especially older men) will become impotent.

The fact is that most men will lose a degree of sexual function and if a man has a problem with erections before treatment, the nerve-sparing surgery is not indicated.
The chances of impotence run the gamut from 20 to 90% depending on age, stage of the disease and the type of surgery.