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Prostate cancer - Surgery

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of prostate cancer.

Surgery:

In men whose cancer is confined to the prostate, surgical resection (radical prostatectomy) offers the potential for cure. Cure rates from initial surgery in men with localized cancer are about 90%, depending on tumor stage, tumor grade, PSA levels, and overall health of the patient. Research suggests that surgery provides long-term cancer control. Most patients can consider themselves disease-free if their PSA levels remain undetectable 10 years after surgery.

Radical Prostatectomy

Radical prostatectomy is the surgical removal of the entire prostate gland along with the seminal vesicles (the vessels that carry semen) and surrounding tissue. The surgeon may also remove the pelvic lymph nodes. The incision can be made in one of the following regions:

Retropubically (through the abdomen and under the pubic bone, exposing the entire surface of the prostate). This is the approach used most often.
Through the perineum (the skin between the scrotum and the anus). The perineal approach causes less bleeding and has a shorter recovery time, but it makes it more difficult to preserve nerves and remove lymph nodes. This approach is now rare.

The gland and other structures are then removed. The operation lasts 2 - 4 hours.

Laparoscopic Prostatectomy. Less invasive surgical techniques using laparoscopy have been developed for radical prostatectomy. These techniques use smaller incisions and allow faster recovery, but they require special surgical training. Laparoscopic surgery may also be done using a robotic system, which involves the surgeon directing a robotic arm through a computer monitor. Not every hospital can do robotic-assisted laparoscopic prostatectomy and these procedures are difficult to perform.

Prostatectomy - series
Click the icon to see an illustrated series detailing prostatectomy surgery.

Nerve-Sparing Techniques. In the retropubic approach, the surgeon will attempt to spare the nerves that control erection:

A bilateral nerve-sparing procedure saves the nerves on both sides of the sex organs.
A unilateral procedure saves nerves on only one side.

Nerve-sparing techniques can improve quality of life, by decreasing the occurrence of incontinence and erectile dysfunction. In cases where the tumor lies too closely to the nerve, nerve-sparing techniques may not be possible.

Convalescence. Patients remain hospitalized for about 3 days after an open procedure or 2 days after less invasive procedure. Full recovery at home takes about 3 - 5 weeks. A temporary catheter used to pass urine is kept in place when the patient is sent home and is usually removed about 3 weeks after the open operation or 1 week after their robotic procedure. In general, younger patients with early-stage cancers recover fastest and experience the fewest side effects.

Complications from Radical Prostatectomy

The main complications from radical prostatectomy are urinary incontinence and erectile dysfunction. Other complications include the usual risks of any surgery, such as blood clots, heart problems, infection, and bleeding.

Urinary Incontinence. Urinary incontinence is a common complication. When the urinary catheter is first removed following surgery, nearly all patients lack control of urinary function and will leak urine for at least a few days and sometimes for months. Normal urinary function usually returns within about 18 months. A percentage of men will continue to have small amounts of leakage with heavier exertion or possibly sexual activity.

Click the icon to see an image of catheterization.

If incontinence persists beyond a year, patients may require drug therapy or surgery. [For more information, see In-Depth Report #50: Urinary incontinence.]

Erectile Dysfunction. Erectile dysfunction after radical prostatectomy is caused by nerves that were damaged or removed during the surgery. Virtually all men will have problems with erectile dysfunction after surgery. It can take up to one to two years to recover erectile function after surgery. Because seminal glands are removed along with the prostate gland during surgery, men who regain sexual function will not produce semen during orgasm (“dry ejaculation”).

With the use of effective nerve-sparing techniques, men who were sexually active before surgery and are involved in an ongoing relationship seem to have a better chance of returned sexual function. Drugs such as sildenafil (Viagra) may help some men regain erectile function. Use of these drugs three times a week accompanied by sexual stimulation is now commonly recommended. Other treatments for erectile dysfunction (alprostadil injections, vaccum devices, penile implants) may also be options. [For more information, see In-Depth Report #15: Erectile dysfunction.]

Resources

www.cancer.gov -- National Cancer Institute
www.cancer.org -- American Cancer Society
www.asco.org -- American Society of Clinical Oncology
www.cancer.net/portal/site/patient -- Cancer.Net
www.prostatecancerfoundation.org -- Prostate Cancer Foundation
www.urologyhealth.org -- Urology Health
www.nccn.org -- National Comprehensive Cancer Network
www.cdc.gov/cancer/prostate -- CDC Cancer Prevention and Control
www.psa-rising.com -- PSA Rising: Prostate Cancer Survivor Info
www.ustoo.org -- Us Too! Prostate Cancer Education and Support
www.cancer.gov/clinicaltrials -- Find clinical trials
www.zerocancer.org -- Zero -- The Project to End Prostate Cancer

References

Agency for Healthcare Research and Quality. Comparative effectiveness of therapies for clinically localized prostate cancer: executive summary no. 13. AHRQ Pub. No. 08-EHC010-1. February 2008.

American Urological Association. Prostate-specific antigen best practice statement: 2009 update. April 2009.

Andriole GL, Crawford ED, Grubb RL 3rd, Buys SS, Chia D, Church TR, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009 Mar 26;360(13):1310-9. Epub 2009 Mar 18.

Babaian RJ, Donnelly B, Bahn D, Baust JG, Dineen M, Ellis D, et al. Best practice statement on cryosurgery for the treatment of localized prostate cancer. J Urol. 2008 Nov;180(5):1993-2004. Epub 2008 Sep 25.

D'Amico AV, Chen MH, Renshaw AA, Loffredo M, Kantoff PW. Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. JAMA. 2008 Jan 23;299(3):289-95.

Gaziano JM, Glynn RJ, Christen WG, Kurth T, Belanger C, MacFadyen J, et al. Vitamins E and C in the prevention of prostate and total cancer in men: the Physicians' Health Study II randomized controlled trial. JAMA. 2009 Jan 7;301(1):52-62. Epub 2008 Dec 9.

Keating NL, O'Malley AJ, Smith MR. Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol. 2006 Sep 20;24(27):4448-56.

Kramer BS, Hagerty KL, Justman S, Somerfield MR, Albertsen PC, Blot WJ, et al. Use of 5-alpha-reductase inhibitors for prostate cancer chemoprevention: American Society of Clinical Oncology/American Urological Association 2008 Clinical Practice Guideline. J Clin Oncol. 2009 Mar 20;27(9):1502-16. Epub 2009 Feb 24.

Lawson KA, Wright ME, Subar A, Mouw T, Hollenbeck A, Schatzkin A, et al. Multivitamin use and risk of prostate cancer in the National Institutes of Health-AARP Diet and Health Study. J Natl Cancer Inst. 2007 May 16;99(10):754-64.

Lim LS, Sherin K; ACPM Prevention Practice Committee. Screening for prostate cancer in U.S. men ACPM position statement on preventive practice. Am J Prev Med. 2008 Feb;34(2):164-70.

Lin K, Lipsitz R, Miller T, Janakiraman S; U.S. Preventive Services Task Force. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Aug 5;149(3):192-9.

Lippman SM, Klein EA, Goodman PJ, Lucia MS, Thompson IM, Ford LG, et al. Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). JAMA. 2009 Jan 7;301(1):39-51. Epub 2008 Dec 9.

Litwin MS, Gore JL, Kwan L, Brandeis JM, Lee SP, Withers HR, et al. Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer. Cancer. 2007 Jun 1;109(11):2239-47.

Loblaw DA, Virgo KS, Nam R, Somerfield MR, Ben-Josef E, Mendelson DS, et al. Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol. 2007 Apr 20;25(12):1596-605. Epub 2007 Apr 2.

Lu-Yao GL, Albertsen PC, Moore DF, Shih W, Lin Y, DiPaola RS, et al. Survival following primary androgen deprivation therapy among men with localized prostate cancer. JAMA. 2008 Jul 9;300(2):173-81.

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: prostate cancer. V.2.2009.

Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008 Mar 20;358(12):1250-61.

Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009 Mar 26;360(13):1320-8. Epub 2009 Mar 18.

Shelley M, Wilt TJ, Coles B, Mason MD. Cryotherapy for localised prostate cancer. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005010.

Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2009 Jan-Feb;59(1):27-41.

Thompson I, Thrasher JB, Aus G, Burnett AL, Canby-Hagino ED, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007 Jun;177(6):2106-31.

U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Aug 5;149(3):185-91.

Van Patten CL, de Boer JG, Tomlinson Guns ES. Diet and dietary supplement intervention trials for the prevention of prostate cancer recurrence: a review of the randomized controlled trial evidence. J Urol. 2008 Dec;180(6):2314-21; discussion 2721-2. Epub 2008 Oct 18.

Walsh PC, DeWeese TL, Eisenberger MA. Clinical practice. Localized prostate cancer. N Engl J Med. 2007 Dec 27;357(26):2696-705.

Walter LC, Bertenthal D, Lindquist K, Konety BR. PSA screening among elderly men with limited life expectancies. JAMA. 2006 Nov 15;296(19):2336-42.

Wilt TJ, MacDonald R, Hagerty K, Schellhammer P, Kramer BS.Five-alpha-reductase inhibitors for prostate cancer prevention. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD007091.

Wilt TJ, MacDonald R, Rutks I, Shamliyan TA, Taylor BC, Kane RL. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med. 2008 Mar 18;148(6):435-48. Epub 2008 Feb 4.

Reviewed last on: 8/5/2009
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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