Prostate Cancer
Surgery
There is no doubt about it. Surgery is an invasive
procedure. There is evidence that surgery for prostate
cancer is rampant in the United States with an increase of 60%
between 1984 and 1990. Contrast this with the Watchful
Waiting approach used in Europe for the same stage prostate
cancer.
Recent studies, however, do show a decrease in the
number of men having radical prostatectomy
procedures.
While the medical community would like to see more incidence of
the Watchful Waiting approach, patients find the approach too
stressful.
Let’s discuss the actual surgical
procedure. It is called a radical
prostatectomy and is the complete removal of
the prostate as well as tissue nearby. The
procedure can be further described by the incision used to
accomplish the procedure. These incisions are:
- Retropubic prostatectomy. The prostate is reached
via an incision in the lower abdomen.
- Perineal prostatectomy. The prostate is reached
via an incision in the perineum which is the space between
the scrotum and the anus.
Radical prostatectomy consists of removing the entire
prostate gland, the seminal vesicles, both of the ampullae (the
enlarged lower sections of the two vas deferens which are the
tubes that carry sperm from the testicles to the actual
prostate gland) and the other surrounding tissue. The
portion of the urethra that travels through the prostate is cut
away as well as the bladder neck and some of the sphincter
muscle that controls urine flow.
Dissection of the pelvic lymph node is routine with a
retropubic prostatectomy but with a perineal prostatectomy the
dissection requires a separate incision.
A radical prostatectomy is a serious, complicated,
demanding procedure. The surgery itself will
take anywhere from 2 to 4 hours. The patient will remain
in the hospital for approximately 3 days. He will require
a catheter (tube to drain urine) for about 10 days to 2
weeks. There is a small percentage (5 to 10%) of surgical
related problems like bleeding or infection. The risk of
death from the surgery is very minimal and much less for
younger men as opposed to older men who may be frail.
Post surgical, long term problems associated with prostatectomy
range from sexual impotence, stool incontinence and urinary
incontinence. It is highly unlikely that a man will
father children after the procedure. The reason is that
without the prostate, very little ejaculate is produced.
It is common for the majority of men to experience incontinence
after surgery and have occasional dribbling when coughing or
exerting themselves. A few will lose all urinary
permanently. Some men are candidates for an
artificial urinary sphincter which is implanted surgically or
narrowing the bladder opening with injections of collagen.
Stool or fecal incontinence (loss of normal
muscle control of the bowels) may affect some men after
their prostatectomy. This is caused by muscle
damage during rectal surgery and stool incontinence is also
caused because of a reduction of the elasticity of the
rectum. What this does is shorten the time period between
the sensation of the stool and the need to have a bowel
movement. The rectum can be scarred and stiffened
by surgery or radiation.
Historically, a prostatectomy always resulted in sexual
impotence. Advances in surgical procedures called
“nerve-sparing surgery” may reduce the risk of
impotence. The nerve sparing technique avoids
cutting the two bundles of nerves and vessels that run along
the surface of the prostate gland that are needed for an
erection.
Unfortunately, this procedure is not viable for everyone, if
the cancer is too large or if it is located too close to the
nerves. Under these circumstances, even with
this technique many men (especially older men) will become
impotent.
The fact is that most men will lose a degree of sexual
function and if a man has a problem with erections
before treatment, the nerve-sparing surgery is not
indicated.
The chances of impotence run the gamut from 20 to 90% depending
on age, stage of the disease and the type of surgery.
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