Prostate Surgery

Men’s Guide to Surgery for Prostate Cancer

According to the National Institutes of Health (NIH), about one in six to seven men will be subject to a diagnosis of prostate cancer at some point in their life.

Most of them will have surgery to treat their cancer.

Several types of prostate cancer surgery are available, but any man considering a surgical option should have first had his condition evaluated independently to access the need for surgery.

Being Diagnosed with Prostate Cancer

About the most devastating news for a man is a diagnosis of prostate cancer.

On receiving such a diagnosis, many men suspend their intelligence and become mindless robotic followers of the medical protocols.

Most men scheduled to have their prostates removed are unaware that the surgery may have little positive effect on their lifespan and a significant negative effect on both sexual ability and quality of life.

This is especially true for localized (confined to the gland) prostate cancer.

Every man for whom surgery is recommended should get opinions from several doctors or organizations that have no investment in the outcome.

An organization that provides expert professional advice to men with prostate cancer is the Prostate Cancer Research Institute (https://pcri.org/).

They provide a free hot-line for patients and caregivers to help them intelligently navigate the maze of options.

Surgical removal of the prostate is considered major surgery, and, as such, it has a significant risk of complications.

In addition, all prostate surgery carries with it the likelihood of severe long-term side effects, particularly in the area of sexual performance and continence.

In many cases, especially with older men, the risks of surgery may be considerably greater than disease progression.

A 2012 study in the New England Journal of Medicine found that adverse events within thirty days after surgery occurred in 21.4 percent of men, including one death. 1


For more information on the function and purpose of the prostate gland, click here.


Types of Prostate Surgery

Today, the most common surgery for prostate cancer is a radical prostatectomy. There are several variations of this surgery that involve the approach and implementation.

However, its primary purpose, regardless of how it is performed, is surgical removal of the entire prostate gland.

Depending on the extent of disease, other tissue, glands, and nerves around the prostate, including the seminal vesicles may also be removed.

In articles about prostate surgery, a procedure known as a trans-urethral resection of the prostate (TURP) is often discussed. In this procedure, the surgeon inserts a thin instrument known as a resectoscope into the urethra.

The instrument contains at minimum, a light, viewing lens, and some kind of device for removing tissue, either by cutting, heat or the use of a laser.

This type of surgery is typically used to treat benign prostate hyperplasia (BPH). It does not remove the entire prostate, is not used for prostate cancer, and is not further discussed here.

Radical Prostatectomy

There are three main types of radical prostatectomy. While the purpose of each of these procedures is the same, they differ in approach as well as side effects and risks:

Retropubic prostatectomy – This procedure is performed via an incision in the wall of the lower abdomen from about the navel (belly button) to just above the penis.

The surgeon removes the prostate and the lymph nodes through the incision for pathological examination. This procedure allows for a nerve-sparing approach.

Perineal prostatectomy – This surgical approach is through the perineum or the area between the scrotum and the anus. It allows for a nerve-sparing approach but does not allow lymph node removal, which, if necessary, must be done through a second small incision.

Laparoscopic prostatectomy – This procedure uses several small incisions (typically about 1 cm or ½ inch).

Through these small incisions, the surgeon inserts lighted, viewing devices, cameras, and other tools.

One of the small incisions is extended slightly to allow for the prostate and lymph nodes to be removed. This procedure allows for a nerve-sparing technique.

Robotic Laparoscopic prostatectomy – This is essentially a laparoscopic prostatectomy done with the aid of a robotic surgical device, such as a “da Vinci” surgical system where the surgeon sits at a console, manipulating robotic tools through the small laparoscopic incisions.

The use of robotic surgical tools generally requires the surgeon to have participated in many hours of training and practice with the robot. This procedure allows for a nerve-sparing technique and lymph node removal.

Recent studies have shown that either of the laparoscopic procedures, when performed by an experienced surgeon, have similar efficacy to open radical prostatectomy surgery.

A primary advantage of laparoscopic procedures is that recovery time is significantly reduced, and there is less bleeding and postoperative pain.

Also, and since the incisions for a laparoscopic procedure are smaller, the common surgical risks (see below) are somewhat lower.

Benefits and Risks of Surgery

Like all major surgery, a radical prostatectomy carries potential risks.

Surgical risks include a reaction to anesthesia, serious bleeding, unwanted or accidental damage to nearby organs, surgical infections, blood clots, and improper healing at the surgical site.

Radical prostatectomy has been shown to be an effective method to treat low-risk prostate cancer that has not spread beyond the outside of the prostate or broken through the fibro-muscular band that surrounds most of the prostate (prostatic capsule).

The procedure is also used for higher-risk disease in the hope of a definitive cure. For low-risk prostate cancer, the five-year survival rate is nearly 100 percent.

During the surgery, a catheter is inserted into the bladder to allow for the draining of urine. The catheter remains in place for one to two weeks after surgery.

Urine produced during the healing period drains into an external collection bag.

The portion of the urethra that passes through the prostate is removed with the prostate. The catheter allows the reconnected ends of the urethra time to heal and usually stays in place for one to two weeks.

Recovery from the surgery usually requires a hospital stay of a couple of days and varies with the procedure and overall health of the patient.

Most activities, especially strenuous ones, are limited for several weeks. Laparoscopic procedures require shorter hospital stays and less healing time.

Nerve Sparing Surgery

The prostate is surrounded by two small nerve bundles that, among other purposes, regulate blood flow in and out of the penis to produce an erection. The penis is essentially a plumbing device.

When a man becomes sexually aroused, the nerves signal two large blood vessels on each side of the penis to begin filling with blood.

These vessels, (corpus cavernosum), and another running down the center of the penis (corpus spongiosum), when filled with blood, cause the penis to be hard and erect.

A nerve sparing surgery is where the surgeon tries to preserve one or both of the small nerve bundles surrounding the prostate, thereby preserving erectile function.

If the surgery is successful, the patient may spontaneously recover function for unassisted erections.

This typically takes from several months to about two years. However, if the nerves are damaged, either during surgery or due to cancer, spontaneous erectile function may never return.

Nerve-sparing surgery may not be possible if cancer has already invaded the nerve bundles.

Studies have found that virtually 100 percent of men will have erectile dysfunction immediately after prostate surgery.

After one year, about 75 percent of men that had a non-nerve-sparing procedure was totally impotent.

Nerve-sparing surgery reduces the number of men experiencing impotence after one year by about 9 percent, clearly still leaving the vast majority impotent. Many of these men, regardless of the procedure, will remain impotent for life.

Nerve-sparing surgery is not foolproof. It can improve the potential for regaining spontaneous erectile function, but it does not eliminate the risk of lifetime impotence due to surgery. Physicians that treat neuro-genic nerve problems might provide relief in this area. 2


For more information on the side effects of prostate surgery, click here.


Immediate Side Effects of Prostate Cancer Surgery

Prostate surgery has several immediate side effects.

  • Sexual function, as well as urinary continence, are typically non-existent immediately after surgery and for a period of time thereafter.

  • The penis and scrotum may encounter temporary swelling that will self-resolve within a few days to a week.

  • The catheter placed in the bladder during surgery is usually removed within a week or two, but urinary dribbling, incontinence, and blood in the urine are common afterward.

    The leakage may be significant for a couple of months, requiring the use of a diaper or pad, but most men regain an acceptable degree of control within a few months.

    If the problem persists for longer, some men might need follow-up surgery to correct long-term (over one year) incontinence.

  • In some cases, erectile dysfunction is total for the period immediately following the surgery.

    This means there are no erections at all, no night-time or early morning erections and no amount of stimulation will cause an erection.

    While the surgery does not physically affect desire for sex (libido), and libido may still be high, but the physical, sexual ability is compromised.

  • Men that have had nerve-sparing surgery have a slightly better outcome than those who did not.

The prostate is the source of a considerable part of a man’s seminal fluids, but removing the prostate does not mean a man will not have an ejaculation. There are other glands that contribute to semen formation.

What we DO have is a reduction of lubrication and ejaculation volume, but not total removal of fluids and ejaculation.

For some men, this is a source of distress, but it actually has only a minor effect on function or sensation.

Long-Term Side Effects of Prostate Cancer Surgery

Penile rehabilitation using various drugs or devices is often presented as a “sure-fire” way to eliminate long-term surgical problems like erectile dysfunction.

Most men that have surgery can regain some degree of sexual function with the use of various oral or injected drugs, mechanical devices, and active penile rehabilitation, no matter how serious their erectile dysfunction is.

However, using them successfully is highly dependent on the motivation of the man.

Rehabilitation From Surgery-Induced Erectile Dysfunction

Erectile dysfunction, for most men, is the most serious and debilitating side effect of prostate surgery.

There are several methods used to recover from erectile dysfunction after prostatectomy.

Men that have had a nerve-sparing technique tend to recover faster and more completely, although the percentage difference in recovery between them is small.

However, to have a chance of recovery, the subject must be patient and inclined to try various techniques.

A motivated man should always be able to find a way to have a satisfactory sexual life. Below are several methods that a man might try:

PDE-5 inhibitors

One of the primary rehabilitation techniques is the daily use of PDE-5 inhibitors (Viagra, Cialis, Levitra, etc.) immediately after surgery.

Initially, they may have little effect, but as time progresses and nerve function recovers, patients increasingly respond to them. Not all patients respond, though.

If there is no reasonable erectile response within a year of the initialization of the drug, there probably will never be one.

Considering the amount of time that usually passes between surgery and failure of the PDE-5 inhibitor drugs, some men lose motivation and cease rehabilitation.

Vacuum Erection Devices

These devices, also known as penis pumps or VED′s, are useful for men that cannot get a usable erection regardless of the source of their dysfunction. Used daily, one can help with penile rehabilitation after surgery.

Studies have shown that rehabilitation may help hasten recovery of sexual function after surgery

A VED device typically consists of a clear plastic tube into which the penis is inserted.

A small battery or manually operated pump creates a vacuum on the penis that pulls blood into the erectile chambers, causing an erection. The erection is released by pressing a small button on the machine.

Thus, it mechanically simulates the natural bodily action that occurs daily with a normal healthy male. The devices produce a near-normal erection and can help prevent penile shrinkage due to atrophy.

In addition, a man with complete erectile dysfunction can use a VED device with a constricting ring at the base of the penis to allow him to have near-normal sex.

Direct Drug Stimulation

During sexual arousal, the body releases several chemicals that increase blood flow (vasodilators) into the erectile chambers of the penis. This causes it to enlarge into an erection.

The release of these chemicals is controlled by the nerve bundles around the prostate that may be damaged or destroyed by prostate surgery.

However, by introducing the chemicals directly into the penis, an erection can be instituted without fully functional nerve bundles.

The primary drug used for this purpose is the vasodilator, Prostaglandin (PGE-1). For most men, PGE-1 will reliably produce an erection when introduced into the corpus cavernosum.

Along with PGE-1, the drugs Papaverine and Phentolamine, also vasodilators, can be used.

The combination of these three drugs is typically mixed together and supplied for injection directly into the corpus cavernosa of the penis. The mixed combination is used by many urologists and called Trimix.

There are several ways to introduce drugs into the penis. The most direct approach is injection therapy. In this process, the drug mix is injected directly into the side of the penis and into the cavernosum.

Another is to insert the drug into the penile urethra and allow it to be in contact with the urethra until it is absorbed through the urethra. (about 10 to 20 minutes).

Introducing the chemical into the urethra for absorption is not as effective as directly injecting it into the penis.

In both cases, the result is that the drugs cause the smooth muscles of the penis to relax, thus allowing increased blood flow into the penis. An erection is produced with a few minutes and can last for 1-2 hours.

The disadvantage of these techniques is that, due to the advanced preparation, they do no contribute to a relaxed, spontaneous atmosphere for sex. But, most men that use this technique become comfortable with it after their initial hesitancy.

Each of these techniques can help men that have nerve damage due to radical prostatectomy.

The drugs do not require functioning nerves to induce an erection. Some men have found that they can use a VED alone or in combination with another method to improve both their performance and satisfaction.

Conclusions

This paper has looked at the various surgical options for treating prostate cancer. Surgery is the most common, but not the only option for treating prostate cancer.

Others include:

  • watchful waiting (active surveillance)

  • radioactive seed implantation (brachytherapy)

  • radiation, freezing cancer cells (cryotherapy or cryosurgery)

  • hormone therapy (androgen deprivation therapy (ADT)

  • chemotherapy, immune boosters (Provenge)

  • bone therapy (bisphosphonates).

The first four treatments above are the most popular alternatives and are used for uncomplicated or low-risk prostate cancer.

The last four are typically used for men who have prostate cancer that has metastasized (spread) beyond the prostate.

Watchful waiting or active surveillance is the most common non-surgical approach.

During this “waiting” period, scheduled blood tests or biopsies monitor the disease for progression. However, if this is all that is done, a critical healing period may be missed.

The “waiting” time can be used to introduce other natural techniques, such as nutrition and herbal remedies, that may halt or reverse the potential for cancer to spread.

Unlike the other treatments listed here, watchful waiting does not have a long list of serious side effects.


For more information on active surveillance, click here.


Any man diagnosed with prostate cancer should be sure to seek information on possible treatments as well as a second opinion from a professional. But do not delay in doing so because some forms of prostate cancer might be more aggressive than others.

Studies have shown that due to the usual slow progression of prostate cancer, time spent evaluating the conditions and treatment options does not interfere significantly with later treatment and overall prognosis.

Side effects from any treatment of prostate cancer can be very debilitating and make a huge impact on life.

The time spent getting second or even third opinions can reward a man with a better quality of life.

Sources

  1. Timothy J. Wilt, M.D., et al, Radical Prostatectomy versus Observation for Localized Prostate Cancer, N Engl J Med 2012; 367:203-213
  2. Anand N. Shridharani, et al, The treatment of erectile dysfunction in patients with neurogenic disease, Transl Androl Urol. 2016 Feb; 5(1): 88–101. 
  3. Yoshifumi Kadono, et al, Changes in penile length after radical prostatectomy: investigation of the underlying anatomical mechanism, BJU International, Feb 2017, Vol 120, No 2, 293-299
  4.  Yu Ko WF, et al, Penile length shortening after radical prostatectomy: men’s responses., Eur J Oncol Nurs. Apr 2010 Vol 14, no 2:160-5.
  5. Young Suk Kwon, et al, Longitudinal recovery patterns of penile length and the underexplored benefit of long-term phosphodiesterase-5 inhibitor use after radical prostatectomy, May 2018, BMC Urol. 2018; 18: 37.

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