Prostate Cancer 101
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.
Many surgical urologists use a “cookie cutter” approach to prostate surgery. Thus, any man with a suspicious digital rectal exam (DRE) or abnormal biopsy might be recommended for surgery.
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
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.
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.
A 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 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 the cancer, spontaneous erectile function may never return. Nerve sparing surgery may not be possible if the 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 were 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
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 afterwards. Sometimes these symptoms self-resolve within a few weeks, but in some cases may last far longer.
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 virtually all 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.
A normal man will have several erections during a day that are not sexually motivated. They occur several times during the night and early morning (nocturnal erections) and sometimes at random times during the day. This is the bodies way of maintaining the mechanism of erection. Each time the penis fills with blood, additional oxygen is delivered to the penile and surrounding tissues, maintaining the health of these structures.
When nerves are damaged or traumatized due to surgery, these normal body functions do not occur, leading to some degree of oxygen starvation as well as atrophy (shrinking) of the organ over time.
It is well-known that penile size is affected by radical prostatectomy. A loss of 2 to 3 cm (approx. 1 inch) is typically reported. Some studies say the effect is temporary and normal size may return after about a year, but if no active penile rehabilitation is initiated, the loss may be permanent.3 Men that have had nerve-sparing surgery have a slightly better outcome than those who did not.
While it is possible for a man to have an orgasm without being erect, all men will have an immediate and complete loss of ejaculatory fluid, including initial fluid on arousal, after a radical prostatectomy. The prostate is the source of virtually all lubrication and other fluids released from the penis during arousal and orgasm, and its removal completely eliminates all fluids and ejaculate. 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
Many urological surgeons do not provide an accurate depiction of the side effects of the procedures they perform. Also, websites – often sponsored by clinics and doctors that engage in surgery – also present an inaccurate synopsis of surgical side effects. Penile rehabilitation using various drugs or devices is often presented as a “sure-fire” way to eliminate long-term surgical problems like erectile dysfunction.
While it is true that some men will regain full postoperative potency, the vast majority will not. Many men, after having surgery and discovering the inevitable side effects, are resentful of their doctors for not having fully and accurately enumerated these effects prior to their procedure.
Inaccuracy on the part of the surgeon as well as incomplete information from other sources can often lead to a patient entering surgery with totally unrealistic expectations. The truth is, virtually all pelvic surgery and especially radical prostatectomy leads to complete loss of erectile function for many months and often for life.
For many men, penile size is psychologically related to their manhood. Thus, penile shrinkage hits them especially hard. A small study found that most men react to the loss of length with resignation, but many men are seriously resentful; they were not pre-advised and were unprepared for this common side effect before their surgery.4
Additionally, misinformation or missing information on the part of the patient and his partner can exacerbate the issue. For some men, the loss of erections leads to complete withdrawal from sex after a few unsuccessful tries. While the surgery has little effect on libido, physical inadequacy can bring on a psychological loss of libido.
In reality, virtually all 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. Long-term, consistent use of PDE-5 inhibitors, immediately after surgery was associated with less loss of penile length. 5
• 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 preserve penile length and 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 are often 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 the 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.
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), and 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 metatasized (spread) beyond the prostate.
Watchful waiting or active surveillance is the most common non-surgical approach. However, many urologists seem to approach it as simply a waiting period before the cancer becomes serious enough to spread.
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 the cancer to spread.
Unlike the other treatments listed here, watchful waiting does not have a long list of serious side effects.
Any man diagnosed with prostate cancer should be sure to seek information on possible treatments as well as a second or even a third opinion from a professionals with no ties to the diagnosing clinician. 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.