Prostate cancer > Treatment options for prostate cancer that has not spread beyond the gland
Radical prostatectomy
A radical prostatectomy is a surgical procedure in which the prostate, seminal vesicles and a sample of some nearby lymph nodes are removed. It is a technically difficult operation and, as a result, is usually carried out only in certain hospitals by surgeons with particular expertise and experience. Because it is a fairly major operation, and pelvic surgery (whether open or laparoscopic) always carries certain risks, a radical prostatectomy is most suitable for otherwise healthy, younger men (generally those under 70) whose cancer appears not to have spread to the distant lymph nodes or bones.
The open operation is carried out under a general anaesthetic, and usually takes 1–3 hours; you should expect to stay in hospital for 4–7 days. An 8–10 cm lateral or vertical cut will be made through your abdomen above the pubic bone (or less commonly through the perineum), and your prostate and seminal vesicles will be removed. Samples from the lymph nodes nearest to your prostate will also be taken to check whether the cancer has spread. The so–called cavernous nerves, which lie close to the prostate and are important for achieving an erection, will be identified and the surgeon will take particular care not to disturb them (this may not be possible if the cancer has spread very close to the nerves); this is called a nerve–sparing approach. A catheter will be inserted into the penis so that urination can continue while the join (technically called the anastomosis) between the bladder and urethra heals. The catheter will usually have to stay in place for up to a fortnight (so you will often have to keep it for a week or so after you go home). The scar from the operation heals quite quickly and after a few months will be almost invisible.
| In a radical prostatectomy, the entire prostate and seminal vesicles are removed through an incision in the abdomen. Sometimes nearby lymph glands are also removed. The urethra is joined to the bladder and a catheter is inserted to drain urine. |
You will need to take it easy when you return home from hospital; the usual period of convalescence is 6–8 weeks, but you may still feel tired even after this time. Avoid lifting heavy objects for several months. Some guidelines as to what you should and should not do after the operation are shown in the table below.
| After a radical prostatectomy |
| Returning to work |
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| Driving |
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| Sexual activity |
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| Drinking |
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| Exercise |
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Laparoscopic and robotic radical prostatectomy A recent technological development has enabled the prostate to be removed using telescopes and 4–6 small incisions (‘minimally invasive surgery’). The advantages of this technique include reduced blood loss and a quicker recovery time, but the disadvantages are a longer operating time and the difficulty in training surgeons to perform what is a technically very demanding procedure. After puncturing the abdominal wall, the abdominal cavity is distended with gas (carbon dioxide) and the operation performed by the surgeon who is guided by the magnified image on a television monitor.
The very latest development is the use of the da Vinci robot to assist with the laparoscopic operation. This device, which costs around £1.5 million, allows three-dimensional visualization at 10 times magnification and very precise control of movement, which may reduce blood loss and enable better preservation of the nerve bundles that are important for erections. The American surgeons who originally developed the technique recently reported that more than 80% of their patients were able to have satisfactory intercourse some months after surgery. At the time of writing, there are over 250 robots in action in the USA, but only a handful in the UK, though this number is likely to increase as results seem good.
| The Da Vinci robot enables very precise control of movement, which can help to preserve the nerves that lie close to the prostate and are important for sexual function. |
PSA level after surgery After the operation, your PSA level will be checked every 3 months for at least a year. It should drop to about 0.2 ng/mL soon after the operation and then gradually reduce further, ideally to below 0.1 ng/L, but this will depend to some extent on the laboratory that analyses the sample; some laboratories have machines that only measure PSA as low as 0.5 ng/L, whereas others have machines that can measure as low as 0.1 or even 0.01 ng/mL.
If your PSA starts to rise because the cancer has not been completely removed (remember that almost all prostate cancer cells manufacture and secrete PSA), you will usually need further treatment.
When further treatment is needed In between one-tenth to one-third of all men who undergo radical prostatectomy, the cancer will be found to have spread to the margin of the prostate once the pathology report is available. This finding is particularly likely in men whose PSA level is above 10 ng/mL. As a consequence, the operation will sometimes not be 100% successful in these men as the cancer has not been wholly removed from the body. If this is the case for you, your doctor may recommend a 'mop-up' course of radiotherapy or some long-term drug therapy with anti-androgens.
Possible side effects and risks after radical prostatectomy A radical prostatectomy, even using the latest laparoscopic and robotic technology, is major surgery and, as such, has side effects that you should consider when deciding whether this is the appropriate course of action for you. For men who may have wanted children, infertility from the surgery needs to be talked through thoroughly with their doctor and partner. Sperm banking is one option that could be considered.
Some men also experience a degree of temporary urinary incontinence after the operation. For most, incontinence is mild – a leakage of a small amount of urine on, for example, coughing. A very small proportion of men have severe incontinence requiring further treatment, but very few have a permanent problem, other than having to wear a small pad for security.
Impotence (difficulty achieving an erection) is another side effect and affects many men who have undergone a radical prostatectomy. The risk is reduced where a surgeon uses a nerve-sparing approach but, even so, potency cannot be guaranteed. Although impotence can usually be treated quite effectively, the surgeon should discuss this with you in detail before surgery, and you should discuss it with your partner. Recent evidence suggests that early active rehabilitation using Viagra (sildenafil) or similar agents, such as Levitra (vardenafil), can help to restore sexual function after surgery.
Internal scarring from the operation is a further potential complication. If your urine flow deteriorates after surgery, it may mean that you will have to undergo dilatation (stretching) of the join between the bladder and urethra; this is usually curative, but sometimes has to be repeated. Some patients will require a period of self-catheterization to ensure that the join between the bladder neck and the urethra remains wide open as it heals.
On the positive side, for men who have BPH as well as prostate cancer, radical prostatectomy can potentially offer a 'double cure' as the prostate, the source of the BPH symptoms, is removed.
The risks associated with radical prostatectomy are those that are generally associated with major surgery – blood loss or blood clots, an adverse reaction to the general anaesthetic and infection.
Your chance of experiencing side effects and the likely success of the operation are governed largely by the expertise of your urologist. If you are offered this operation, you should ask your urologist a number of questions.
| Questions for your urologist |
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