.Stephan L. Werner, M.D., F.A.C.S.

Radical Prostatectomy, surgery for prostate cancer, is used when there is a reasonable likelihood of curing the disease.  It is used in younger, healthy patients with Stage A, Stage B, and some surgeons believe in some early Stage C prostate cancers.   Surgical treatment also has better results in patients with high grade, (Gleason 8, 9 and 10), than does radiation, Although there are some data suggesting the combination of neoadjuvant therapy, external beam irradiation, brachytherapy , (seeds), and long term hormonal therapy may offer benefit to patients with these ominous high grade tumors.   Surgery is  uncommonly done for patients age 70 and over, as the gain in benefit does not  counterbalance the increased risk.  The operation is usually done through a lower abdominal incision, although some surgeons prefer the perineal approach, where the incision is made between the scrotum and rectum. A small number of surgeons can do radical prostatectomies through a laparoscope, or a surgical robot.

    The operation involves removing the entire prostate, the seminal vesicles, (the  organs that produce seminal fluid and are attached to the prostate), and reconnecting the bladder to the urethra, so that the patient may void normally. The open operations take 2 to 4 hours and require a 3 to 5 day hospital stay.  When the procedures is done through a laparoscope, (belly button surgery), the procedures takes a significantly longer time, but the hospital stay is often reduced to a day or so.  At the present time there are only a few surgeons in the US skilled in this procedure.

   The advantage of surgical treatment is that the cancer is removed from the body.  The disadvantages may include impotence, the inability to get or sustain an erection.  . Other post operative problems may include  incontinence, the inability to control urine after the surgery, (may be temporary or permanent), loss of ejaculation and fertility, and the other complications of surgery.  However, the best long term  cures are seen after surgical treatment for prostate cancer.

    There are two variations major variations in the operation,   nerve-sparing and non nerve sparing.  The nerves that supply the penis for erectile function run along the sides of the prostate.  

    In the standard, non-nerve sparing operation, the surgeon cuts widely around the prostate, including the nerves in the removed portion, thereby getting further out from the prostate and cancer, improving the chances of removing all the cancer.  In the nerve sparing operation, the surgeon, in an attempt to preserve natural potency, cuts much closer to the prostate.  A few surgeons around the country are replacing the native nerves with nerve grafts from the foot, with some improvement in post operative erectile function

    Even with the nerve sparing operation, potency is frequently decreased.  The  preservation of erection is better in younger, healthier patients with good potency before surgery.  Preservation of potency  decreases with increasing age and associated conditions such as diabetes or hhypertension. Erectile ability may take up to two years to achieve maximal improvement.  Frequent stimulation plus long term use of Viagra may be helpful in improving erection.

    Fortunately, post operative erections can  frequently be restored with drugs like Viagra or PGE-1 after either form of radical prostatectomy.  Some patients will need a penile implant.

    Incontinence, or loss of urinary control is another problem seen sometimes after radical prostatectomy.  It is common immediately after surgery, and although usually temporary, and frequently mild, it may  take months or years to resolve, and in  a few patients be a persistent problem. Exercises, rehabilitative services and occasionally surgery to control incontinence are sometimes required.

Post operative care Most patients are out of bed the day of surgery or the day after.  Diet is progressed as the patient can tolerate it.  Pain is controllable with medication and is usually not severe.  Most patients go home on the third to fifth postoperative day.  They can walk about and climb some stairs, but should not do any lifting or carrying for at least 4 weeks, and no heavy exercise for 6 weeks after the operation.

Positive Margins    Sometimes the pathology after the operation reveals that cancer is present at the limit of the surgery,  suggesting that microscopic cancer has been left in.  This is less likely to happen with the standard radical prostatectomy, (30-35%), than with the nerve sparing surgery, ( 45-49%), as the margin of resection is further out with the standard operation.  Positive margins may have significant effects on prognosis. (More)

Recurrence

   An advantage of surgical therapy is that if the cancer recurs in the surgical site, radiation therapy can then be given in a second attempt at cure.    While surgery after failed radiation therapy, (salvage prostatectomy.), can be done, it is difficult surgery because of the scarring due to radiation, and has a high complication rate.  (More)

Long Term Follow-up after Surgery   (next)

Rev: 04/03

Stephan  Werner, M.D., F.A.C.S.

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Rev:03/08