A surgical approach to treating
prostate cancer will remove all or part of the prostate. Typically, men with
early-stage disease or cancer that’s confined to the prostate will undergo
radical prostatectomy—removal of the entire prostate gland, plus some surrounding
tissue. Other surgical procedures may be performed on men with advanced or
recurrent disease.
In the
most common type of prostatectomy—radical
retropubic prostatectomy—an incision is made in the abdomen and the
prostate is removed from behind the pubic bone. The surgeon then stitches the
urethra directly to the bladder so urine is able to flow.
Because it typically takes a few
days for the body to get used to this new setup, the surgeon will insert a
catheter, or tube, into the bladder. Urine will flow automatically out of the
bladder, down the urethra, and into a collection bag without the need for
conscious control of the sphincter. The catheter is usually kept in place for
about a week to 10 days.
Another
type of surgery, known as radical
perineal prostatectomy, is performed less frequently these days. In this
procedure, the surgeon makes the incision in the perineum (the space between
the scrotum and the anus) and the prostate is removed from behind.
Who Should
Undergo Radical Prostatectomy?
Men younger than age 75 with limited prostate
cancer who are expected to live at least 10 more years tend to get the most
benefit from radical prostatectomy.
Before performing radical prostatectomy, doctors
first try to establish that the prostate cancer has not spread beyond the
prostate. The statistical risk of spread can be determined from tables
comparing the results of a biopsy and PSA levels. Further testing for
spread, if needed, can include CT scans, bone scans, MRI scans, and ultrasound.
If it appears that the prostate cancer has not
spread, a surgeon (urologist) may first offer other options besides surgery.
These can include radiation therapy, hormone therapy, or simply
observing the prostate cancer over time, since many prostate cancers grow
slowly.
Surgical Techniques
Nerve-Sparing
In a nerve-sparing prostatectomy,
the surgeon cuts to the very edges of the prostate, taking care to spare the
erectile nerves that run alongside the prostate. If the nerves cannot be spared
because the cancer extends beyond the prostate, it might be possible to
surgically attach, or graft, nerves from other parts of the body to the ends of
the cut erectile nerves.
Surgeons won’t know until the
time of the procedure if nerve-sparing is possible; it depends on whether the
cancer is invading the nerves. However, the nerve-sparing procedure offers the
best chance to preserve long-term erectile function.
Laparoscopic
In laparoscopic surgery, very
small incisions are made in the abdomen. The surgeon then inserts narrow
instruments fitted with cameras and/or surgical tools, allowing him or her to
visualize and operate on the internal structures without cutting open the
entire abdomen.
With a robotic interface, the
surgeon maneuvers a robot’s arms, which in turn control the cameras and
instruments. Robotic surgery has become very popular over the past 10 years due
to the smaller incision and shorter post-operative recovery period.
To date, open and laparoscopic
procedures have never been compared head-to-head in terms of cancer control and
side effects. In general, in the hands of a skilled surgeon, these outcomes are
optimized with either approach.
What to Expect After Radical
Prostatectomy
Most men stay in the hospital for one to three days after radical
prostatectomy. A urinary catheter is inserted during the surgery, and some men
may need to wear the catheter home for a few days to a few weeks. Another
catheter inserted through the skin also may need to stay in place for a
few days after returning home.
Pain after radical
prostatectomy can generally be controlled with prescription pain medicines. It
can take weeks or months for urinary and sexual function to return to their
maximum levels.
After radical prostatectomy, regular follow-up is essential to make sure
prostate cancer does not return.
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