Introduction to surgery
Surgery is an option for most stages and grades of prostate cancer, including localised and locally-advanced prostate cancer. It involves removing the prostate entirely in a procedure known as a ‘radical prostatectomy’. Instinctively, many patients want to have the cancer removed from their body and surgery provides this solution for them. It is a major operation lasting 2-4 hours conducted under general anaesthetic, and patients need to be fit enough for this.
There are two types of radical prostatectomy that you should know about.
- Open surgery (also known as radical retropubic surgery) is where a single large incision is made in your stomach and the surgeon operates through that one incision.
- Keyhole (laparoscopic and robotic) surgery (also known as minimally-invasive) is where several small incisions are made in your lower abdomen and the abdomen is inflated with carbon dioxide gas. A camera, light source and instruments are then inserted through hollow tubes called ‘ports’ to allow the surgeon to operate with a brightly illuminated and magnified view of the prostate and surrounding structures.
There are about 10,000 operations using both techniques performed each year in the UK, with open and keyhole surgery split between approximately 20% and 80% respectively. The advantages of keyhole surgery over open surgery are:
- less blood loss during the operation and a lower risk of blood transfusion;
- a lower complication rate;
- a shorter recovery time;
- cancer control, continence and potency may be superior.
Watch Professor Eden explain why prostate cancer surgery can be a good option for patients
You have probably also heard about ‘robotic’ surgery. This is where the surgeon uses a surgical robot (called the ‘da Vinci’) to help perform your operation. The surgeon is fully in control at all times – it is not automated like a robot on a car production line, but serves to enhance the surgeon’s capabilities. The robotic hands allow for scaled and tremor-free movements, a wider range of movement than is possible with the human hand and greater visibility for the surgeon into the patient’s abdomen during the operation thanks to magnification and a 3D view. There is some evidence that robotic prostatectomy delivers better patient outcomes than other forms of prostate surgery in terms of cancer control, continence and potency but this has not been proven in a randomised controlled trial. However, in our experience many patients want the robot used as it is seen to be at the cutting-edge of surgery. In the United States for instance, up to 90% of radical prostatectomies are now performed using the da Vinci system. For more information, see our da Vinci page.
Regardless of what technique you choose, the main difference between surgery and other treatments is that the outcome of your treatment is highly dependent on the skill and experience of your surgeon. It’s all concentrated in the hands of one person, so it’s vital you are happy with their results on previous patients and competence.
A radical prostatectomy is a complex operation that requires several weeks of recovery as your body heals, and patients must be fit enough to undergo it. It is conducted under general anaesthetic, so the patient is asleep for the entire duration. Six small incisions are made in the lower abdomen, and carbon dioxide is pumped in to allow the surgeon more room to operate. Cameras are inserted to give the surgeon a clear view of the prostate as he operates, removing the prostate from the nerves and arteries that surround it.
Most patients will need to have the pelvic lymph nodes removed as well. These are structures that filter infection and cancer from the fluid returning from the tissues into the circulation. You have several hundred of these structures in your body and if some are removed then the fluid simply finds another channel to flow through to return to the circulation. It is useful for them to be removed and analysed to determine the true extent of your cancer (known as ‘completing the staging’), but the main reason for their removal is that it increases the probability of a full cure.
The lymph nodes and lymphatic system around the pelvis
Once the prostate has been freed it is placed intact into an impermeable plastic bag inside your abdomen to be retrieved at the end of the procedure. This is done so the cancerous cells do not touch healthy tissue. The two structures either side of it (the bladder and the urethra) are then connected using stitches and a catheter (a soft plastic tube) is inserted in the urethra and through the join. This is left in place for 2 weeks until the join has healed. All internal and external stitches dissolve after a few weeks.
After the operation
After the operation, you will wake up in hospital and spend 2-3 days there resting. You will have a catheter inserted into your penis to allow urine to drain from your bladder, which will be in place for 2 weeks. You could expect to drive after 7-10 days and be doing 90% of what you were doing physically before the operation by 3 weeks after surgery. You will be seen again as an outpatient 4 weeks after surgery to discuss the pathology lab report on your prostate and lymph nodes and your progress. You will then have your PSA checked every three months for the first year after surgery, every 6 months for the next 4 years and once a year thereafter.
Read a patient’s experience
Dan Zeller is the US blogger behind Dan’s Journey, a journal he started back in 2010 that chronicles his experience of prostate cancer. Dan eventually chose surgery, and he shares his reasoning with us below.
“It was actually a DRE that got the ball rolling for me. I went to the doctor to have an aching hip checked out, and she noted that it had been a while (3 years) since we last checked my prostate. She did a DRE, felt a mass, ordered the PSA, and when it came back at 5.0, sent me off to the urologist for a biopsy.
The urologist took 20 tissue samples (high, if you ask me), and 11 came back positive with cancer. I was 52 years old when I was diagnosed, and I am notoriously known for researching before making a decision – even if it’s something as simple as a television.
One of the best resources that I came across to educate me about my options was “Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer.” While I did explore other options, it became clear to me that surgery would be my best choice.
My thought process was that, by having surgery first, I would have radiation and hormone therapies available as salvage treatments if the cancer remained after the surgery. If I had had radiation first, the surgery would no longer be an option, and I would have one less “tool” available to beat the cancer. And, at the age of 52, I wanted as many options available to me as Plan B, Plan C, Plan D… It was that simple.”
Potency and continence
Removing the prostate is a delicate operation that requires it to be disconnected from the surrounding rectum, bladder, nerves (that control erections), veins and the urethra. While rare, damage to these areas is possible during surgery. Men in particular worry about impotence after surgery (being unable to get an erection), so I want to address this here.
Impotence is caused by damage to one or more of the two nerve ‘bundles’ that surround the prostate. In some cases, the cancer may have spread to the nerves or very close to them and so they must be removed as well to ensure the cancer is cured. But if they don’t have to be removed, then it comes down to the surgeon’s skill in handling the nerves during the operation, which as known as ‘nerve sparing’.
Prostate nerve bundle
In other words, if your nerves are not cancerous, then impotence can be avoided. The same goes for damage to your bladder, urethra and rectum. It can all be avoided in experienced hands.
Because of this, when selecting a surgeon (as is your right to do so, including in the NHS) be sure to find out how many operations they do each year, as it has been shown that patients who choose a high-volume surgeon (someone performing 100 or more operations in a year) are likely to have a better outcome in cancer control, continence and potency than if they choose a low-volume surgeon. The national average in the UK for 2014 was 31 cases per surgeon per year.
At Santis, we are able to offer nerve sparing to around 80% of our patients, and 87% of our patients who had normal erections before surgery and who had both nerves preserved continued to do so after surgery. So the fear of impotence, while understandable, is not borne out by real patient results.
- Certainty – following the operation, your prostate is removed and sent for analysis to determine the final stage and grade of the cancer. Some patients find that their final stage and grade are actually better or (more frequently) worse than predicted by the biopsy, allowing for an accurate estimation of prognosis.
- A target PSA – your PSA also falls to zero as the prostate is removed, allowing your urologist to definitively and conclusively inform you of your outcome each time you have a blood test. With radiotherapy there is no target PSA so the outcome remains unclear, often for many years.
- Avoiding radiotherapy-induced bladder and rectal cancers – although it must be stressed that while the risk is very low, it can happen to radiotherapy patients.
- Backup options – if surgery cannot control the disease, then you still have the backup options of radiotherapy and hormone therapy in reserve should you need to use them after surgery.
- You will no longer be able to ejaculate – your prostate produces seminal fluid and as your prostate is removed entirely, this will no longer be produced. Remember that you can still achieve orgasms and often erections too, so most patients do continue to have a fulfilling sex life.
- There is the risk of impotence, incontinence and bowel problems caused by surgery, although as explained above these can be minimised with an experienced surgeon.