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Prostate cancer
Description
An in-depth report on the causes, diagnosis, treatment, and prevention of prostate cancer.
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 incision can be made in one of the following regions:
- Retropubicly (through the abdomen and under the pubic bone, exposing the entire surface of the prostate).
- Through the perineum (the skin between the scrotum and the anus).
The gland and other structures are then removed. The operation lasts 2 to 4 hours. Advanced surgical techniques such as minilaparotomy and laparoscopy are being developed for radical prostatectomy. These techniques use smaller incisions, are less invasive, and may cause fewer complications.
Nerve-Sparing Techniques. Surgical procedures have been refined over the years, and many operations for localized low-grade prostate cancer now 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. The ability for sexual intercourse recovers in about a third of patients at 3 years and nearly 60% at 5 years after surgery. (Rates vary depending on certain factors, such as the patient's age -- the younger the better.) In cases where the tumor is bulky and undifferentiated, nerve-sparing techniques may not be appropriate.
Convalescence. Patients remain hospitalized for up to 2 weeks. A temporary catheter used to pass urine is kept in place when the patient is sent home and usually removed about 3 weeks after the operation. The convalescent period at home is about a month. In general, younger patients with early-stage cancers recover fastest and experience the fewest side effects.
Complications from Radical Prostatectomy
Complication rates vary after radical prostatectomy and usually depend on the age of the patient and the experience of the surgeon and medical center. In one center, they ranged from 4% in men in their 40s to 14% in men over age 70. Complication rates are 10 times higher in patients who have prostatectomy because of cancer recurrence after radiation treatment.
Complications include the usual risks of any surgery such as blood clots, heart problems, infection, and bleeding. Complications specific to radical prostatectomy, (incontinence, impotence, and contracture of the bladder neck), are discussed below. The mortality rate is very low, about 0.4%.
Quality of life usually improves shortly after surgery, and recovery from certain complications, such as incontinence and sexual function, can continue to occur even over years.
Urinary Incontinence. Urinary incontinence is a common complication and a more distressing side effect of surgery for most men than sexual dysfunction. 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. Major medical centers report that continence returns within about 18 months for nearly all men younger than age 70 and in the great majority of men older than 70. The average time for return of continence in one center was just 1.5 months.
A number of approaches may help prevent or treat incontinence:
- Nerve-sparing techniques can help prevent incontinence, although even in experienced centers, 8% of patients will have some postoperative incontinence, and this rate is much higher (up to 50%) in many community medical centers.
- A procedure called endopelvic anterior urethral stitch (EAUS) used with prostatectomy appears to reduce urinary incontinence. In one small study, 75% of selected patients recovered continence in a month. The procedure requires a simple stitch at the front of the urethra.
- Kegel exercises, contracting and relaxing the muscles used to shut off the urinary stream, strengthen the muscles on the pelvic floor and are reported to be very beneficial for many men.
If incontinence persists beyond a year, patients may require drug therapy or surgery. Collagen injections into the urethra, bladder neck suspension surgery, or a urinary sphincter implant may be helpful for men who have chronic incontinence. (In one study men had better results with the sphincter implant.) [For more information, see In-Depth Report #50: Urinary incontinence.]
Impotence. Studies suggest that about 40% of men have problems with erection after the procedure. In one study, however, more than 70% said they would have the procedure again. There were few differences in erectile function among all ethnic groups.
Nerve-sparing procedures are proving to be helpful in reducing impotence as well as incontinence. Other techniques may improve sexual function after the procedure. For example, some doctors are investigating methods for sparing the vessels that carry seminal fluid in the prostate. In one preliminary study, when this approach combined with nerve sparing techniques it was more effective at preserving erectile function than the nerve sparing approach alone.
Impotence Rates by Procedure |
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Type of Procedure |
Sexual Impairment Rate |
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Bilateral nerve-sparing procedure |
56% |
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Unilateral nerve-sparing procedure |
59% |
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Non-nerve sparing procedure |
66% |
Sildenafil (Viagra) may help restore potency on average in about a third of patients, but some men may do better than others. In one study, for example, 80% of younger men who were potent before surgery and had bilateral nerve sparing procedures responded to the drug. (Only 40% responded with only unilateral procedure.) Sildenafil is unlikely to be effective for men who had unilateral or no nerve sparing procedures. In those who respond, sildenafil may provide a benefit for years. Sildenafil may take 9 months or longer to become effective. Men who take it may benefit from alprostadil injections started right after surgery to preserve elasticity and help prevent scarring.
Early treatments with alprostadil injections may helpful in restoring erectile function in any case. This treatment maintains blood flow in the penis, and some research suggests that impotence after prostate surgery may be due in part to injury to these blood vessels. In one study, men administered injections every other night for 6 months. They then started taking sildenafil (Viagra) 3 months after surgery. At 6 months, 82% of these men achieved penetration compared to only 52% of men who took Viagra only. The vacuum pump may serve a similar purpose as the injections.
[For more details on this condition, see In-Depth Report #15: Erectile dysfunction.]
Even when erectile function is preserved, men may experience other sexual problems:
- Erections may not be as rigid as before the operation
- Orgasm and sexual sensation may be altered
- Patients who retain potency may suffer from retrograde ejaculation, also known as dry ejaculation. During ejaculation, semen travels backward into the bladder, causing infertility.
Fecal Incontinence. Radical prostatectomy can also cause fecal incontinence. The risk may actually be higher in men undergoing nerve-sparing procedures.
Contracture of the Bladder Neck. Another common postsurgical complication is contracture of the bladder neck at the point where it has been stitched to the remainder of the urethra. Contracture usually occurs within the first 3 months after the operation, causing a sharp decrease in urinary stream. The condition can be treated by dilation or surgery on the bladder neck, and rarely recurs.
Pelvic Lymphadenectomy
Pelvic lymphadenectomy is the surgical removal of the pelvic lymph nodes. It is usually performed at the same time as prostatectomy. If the surgeon suspects that cancer has spread beyond the prostate, he will perform the lymphadenectomy as part of the operation. Some surgeons do this procedure as a matter of course when performing prostatectomy, since it has few complications and adds information on the state of the disease. The lymph nodes are removed through an incision in the lower part of the abdomen, using conventional surgery or laparoscopy, a less invasive variation. The nodes are immediately examined. If they show signs of cancer, then metastasis has occurred. In such cases, the operation is usually stopped and the patient is offered radiation or hormone treatments. Experts argue about whether a prostatectomy may still be beneficial. One study found a survival advantage in those who had their prostate removed even when cancer had spread. More research is needed.
Cryosurgery (Cryoablation)
Cryosurgery is an alternative to standard prostatectomy. A 2001 study reported that it was as effective as radiation therapy (and perhaps better than brachytherapy in patients at medium to high risk). Survival in the study exceeded 70%, comparable to radiation therapy and brachytherapy. Among patients with localized prostate cancer, the 5-year disease-free rate approached 80%. The cryosurgical technologies used in the study were not as good as newer ones now available, so these figures even may understate the technique's performance.
The Procedure. The goal of cryosurgery is destruction of the entire prostate gland and possibly surrounding tissue. Steel probes are inserted through the skin between the anus and the rectum and into the prostate. Liquid nitrogen is pumped through the probes to freeze all prostate cells, both healthy and cancerous. For success, cryosurgery requires a uniformly frozen area. The dead cells are absorbed and eliminated by the body. Patients can leave the hospital in 2 to 3 days.
Candidates. Cryosurgery may be considered for patients with:
- Early stage local cancer
- Cancer that has recurred after radiation treatments
- Large primary tumors that the surgeon wishes to reduce
- Possibly tumors that have spread beyond the prostate if they have not yet reached the lymph nodes
Strong indicators of treatment failure include:
- A history of both hormonal and radiation treatments
- Tumor grades 8 and above
- PSA levels of more than 10 ng/mL
Complications. Complications are similar to those of standard prostatectomy, but incontinence rates are much lower. Impotence rates, however, are much higher. Nevertheless, 96% of patients report that they are satisfied with the results. Incontinence and other side effects may be higher in patients who have had previous radiation treatments. Other significant complications include scarring and narrowing of the urethra and fistulas (abnormal passages from internal organs to the skin or between two internal organs).
- Review Date: 7/9/2006
- Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.
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