Surgery for prostate cancer is a common treatment choice for men who are in good overall health and who have early stage prostate cancer. This would include men whose prostate cancer is localized to the prostate (stage T1 or T2 cancers) or to the prostate and seminal vesicles (stage T3 cancer). These men stand to achieve the highest rates of cure from prostate cancer surgery, making the risk-benefit ratio of undergoing a surgical procedure a reasonable one.
Radical prostatectomy is the term used to describe surgical removal of the prostate and nearby tissue. There are two main surgical approaches used in radical prostatectomy: the open approach and the laparoscopic approach.
Open Approach to Radical Prostatectomy
The two open approaches used for removing the prostate gland involve making large incisions in either the lower abdomen or perineal region (the area between the scrotum and anus) while the patient is under general anesthesia.
These procedures are being performed less frequently because the recovery time, length of hospital stay, and blood loss associated with them are greater than for the newer laparoscopic approaches. This open approach to radical prostatectomy remains the preferred option, however, for men with very large prostates.
- Radical Retropubic Prostatectomy: In this procedure, the surgeon makes an incision from just below the navel to just above the pubic bone. He or she will remove the prostate as well as nearby lymph nodes to see if the cancer has spread to the lymph nodes. In some instances, a pathologist will examine the lymph nodes immediately to determine the presence or absence of cancer involvement as the surgeon may opt not to proceed with removal of the prostate if the cancer is more advanced than it was originally thought to be. In many instances, though, it will take several days to obtain the pathology report for the lymph nodes. A nerve-sparing technique, developed in an attempt to spare the nerves controlling bladder and erectile function, can be used in this type of prostatectomy to try to minimize the side effects of urinary incontinence and erectile dysfunction (ED).
- Radical Perineal Prostatectomy: This surgery involves removing the prostate through an incision between the scrotum and anus. Because lymph nodes cannot be biopsied and the nerve-sparing technique cannot be employed in this type of prostatectomy, it is typically only performed in men for whom a retropubic approach is contraindicated.
Laparoscopic Approach to Radical Prostatectomy
Beginning in 1999, surgeons in the U.S. began performing radical prostatectomies from a laparoscopic approach. This involves making several small incisions in the lower abdomen and using special surgical instruments including a laparoscope, a long thin instrument with a camera and light on the tip. Smaller incisions and less manipulation of nearby tissue result in a generally easier recovery than in an open approach, although their cancer cure rates are essentially identical.
There are two types of laparoscopic radical prostatectomies (LRP):
- Traditional Laparoscopic Radical Prostatectomy: Traditional LRP involves the surgeon directly manipulating the laparoscope and other surgical instruments to remove the prostate and lymph nodes. The nerve-sparing technique can be performed in LRP.
- Robotic-Assisted Laparoscopic Radical Prostatectomy: This procedure is a recent development in radical prostatectomy surgery. Using a robotic interface, the surgeon controls robotic arms that perform the surgery through the small incisions instead of the surgeon directly maneuvering the surgical tools.
Despite the differences in recovery time, hospital length of stay, and blood loss between an open and laparoscopic approach to radical prostatectomy, the incidence of side effects appears to be the same for both. The most common side effects of radical prostatectomy impacting a man’s quality of life are:
- Urinary incontinence: Inability to control urinary flow can occur because of trauma or damage to the nerves involved in urination. The most common type of incontinence suffered by men after radical prostatectomy is stress incontinence in which men leak urine during activities that put “stress” on the muscular sphincter that keeps urine in the bladder. These activities can range from sneezing or coughing to exercising. Other men experience urge incontinence in which the need to urinate is sudden and urgent, or overflow incontinence in which they have difficulty emptying their bladder and may leak urine without having the sensation of needing to urinate. The good news is that incontinence issues typically resolve with less than 5 percent of men experiencing any permanent problems.
- Erectile dysfunction: The majority of men who undergo a radical prostatectomy experience some difficulty in achieving an erection after their surgery, which is thought to be mediated by injury to the nerves involved in erectile function. In many men, erectile function gradually returns to pre-operative status, especially in those who had a nerve-sparing approach performed, although it may take as long as two years. The use of medications, particularly phosphodiesterase-5 inhibitors (PDE-5), can significantly help many men regain erectile function following prostate surgery.