In the early 1990s, roughly 30 percent of prostate cancer patients in the United States were treated by surgery, 30 percent by radiation, and 20 percent by watchful waiting. (Most of the rest were treated with a combination of therapies.) In Europe, by contrast, watchful waiting constitutes the standard treatment for asymptomatic prostate cancer.
The popularity of surgery in this country has grown tremendously in recent years. A study of Medicare patients’ records found that the number of men nationwide receiving radical prostatectomy by 1990 was six times greater than the number recorded for 1984, and the increase was seen in all age groups, from the youngest (that is, age 65) to men in their eighties. Recent statistics, however, indicate that since 1993, the rate of prostatectomies has been dropping.
What is a radical prostatectomy?
A radical prostatectomy is surgery to remove the entire prostate gland and regional lymph nodes after a diagnosis of prostate cancer is made. Radical prostatectomy is one of many options for the treatment of prostate cancer. You should discuss all options with your physician.
Radical prostatectomy can be done via an incision made in the abdomen (radical retropubic prostatectomy) or in the perineum, the area between the scrotum and the anus (radical perineal prostatectomy). Alternatively, it may be done with laparoscopy (laparoscopic radical prostatectomy). Laparoscopy is a technique is which surgery is performed by making small incisions and passing specially designed telescopes and instruments into the body.
Laparoscopic radical prostatectomy is a new technique, which may result in less discomfort and earlier return to work. Whether or not it results in the same level of cancer cure and preservation of urinary continence and sexual function is unknown at this time.
In addition to removing the prostate gland, the lymph nodes in the area of the prostate may be removed either before or during the same operation. This is done in order to determine if there has been spread of the prostate cancer to the lymph nodes. This procedure is called pelvic lymph node dissection.. The risk of having cancer in the lymph nodes can be estimated and only men with a moderate or high risk of pelvic lymph node metastases need to undergo pelvic lymph node dissection. This includes men with PSA values in excess of 15 ng/ml or high-grade cancers.
Referred to by many as robotic surgery for prostate cancer or robotic prostatectomy, da Vinci® Prostatectomy is more accurately a robot-assisted, minimally invasive surgery that is quickly becoming the preferred treatment for removal of the prostate following early diagnosis of prostate cancer. In fact, studies suggest that da Vinci Prostatectomy may be the most effective, least invasive prostate surgery performed today.
Though any diagnosis of cancer can be traumatic, the good news is that if your doctor recommends prostate surgery, the cancer was probably caught early. And, with da Vinci Prostatectomy, the likelihood of a complete recovery from prostate cancer without long-term side effects is, for most patients, better than it has ever been.
da Vinci Prostatectomy is performed with the assistance of the da Vinci Surgical System – the latest evolution in robotics technology. The da Vinci Surgical System enables surgeons to operate with unmatched precision and control using only a few small incisions. Recent studies suggest that da Vinci Prostatectomy may offer improved cancer control and a faster return to potency and continence. da Vinci Prostatectomy also offers these potential benefits:
An operation called radical prostatectomy completely removes the prostate and nearby tissues. A radical prostatectomy is further described in terms of the incisions used by the surgeon to reach the gland. In a retropubic prostatectomy, the prostate is reached through an incision in the lower abdomen; in a perineal prostatectomy, the approach is through the perineum, the space between the scrotum and the anus. In radical “Conservative management (watchful waiting) of localized prostatic cancer is difficult for the physician to advise and the patient to accept, in part because both public and physician education (in the United States) have been focused on early diagnosis and cure and because of the powerful emotional impact provided by cancer mortality.” -Willet Whitmore, M.D., Emeritus Memorial Sloan-Kettering Cancer Center, New York prostatectomy, the surgeon excises the entire prostate gland, along with both seminal vesicles, both ampullae (the enlarged lower sections of the vas deferens), and other surrounding tissues. The section of urethra that runs through the prostate is cut away (and with it some of the sphincter muscle that controls the flow of urine).
Pelvic lymph node dissection is done routinely as part of a retropubic prostatectomy; with a perineal prostatectomy, lymph node dissection requires a separate incision.
Radical prostatectomy is a complicated and demanding procedure that typically requires general anesthesia and takes 2 to 4 hours. Patients stay in the hospital for about 3 days, and need to wear a tube to drain urine (catheter) for 10 days to 3 weeks. About 5 to 10 percent of patients experience surgery-related complications such as bleeding, infection, or cardiopulmonary problems. There is a small risk of death from surgery; it is less for men who are young and healthy than men who are older and frail.
Prostatectomy also carries the risk of serious long-term problems, notably urinary incontinence, stool incontinence, and sexual impotence. (The procedure also makes it very unlikely for a man to father children, since little ejaculate is produced without the prostate.) About 70% of men report that their penus has shortened, usually by an inch or 2 cm.
Most men experience urinary incontinence following surgery. Many continue to have intermittent problems with dribbling caused by coughing or exertion. A few men permanently lose all urinary control. Some men can be helped with an artificial urinary sphincter, surgically implanted, or with injections of collagen to narrow the bladder opening.
Infrequently men may develop stool or fecal incontinence after radical prostatectomy. Fecal incontinence is the loss of normal muscle control of the bowels. Muscle damage can occur during rectal surgery. Stool incontinence may also be caused by a reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urgent need to have a bowel movement. Surgery or radiation injury can scar and stiffen the rectum.
At one time, prostatectomy almost invariably resulted in sexual impotence. Today, the risk of impotence may be reduced by nerve-sparing surgery. This technique carefully avoids cutting or stretching two bundles of nerves and blood vessels that run closely along the surface of the prostate gland and are needed for an erection.
However, nerve-sparing surgery is not possible for everyone. Sometimes the cancer is too large or is located too close to the nerves. Even with nerve-sparing surgery, many men-especially older men-become impotent. Most men will lose a degree of sexual function. (If a man has trouble with erections prior to treatment, nerve-sparing surgery is probably not indicated.) Depending on age, extent of disease, and type of surgery, the chances of impotence vary widely-somewhere between 20 and 90 percent.
What happens to Prostate Cancer Patients
Half were between ages 65 and 70 years old at the time of prostatectomy, half were age 70 or older.
Two-thirds reported problems with urinary incontinence.
Nearly one-third used something like absorbent pads to cope with wetness.
About 60 percent were unable to have an erection firm enough for intercourse-even though almost all of them said that they had been able to have erections to at least some extent before surgery.
And one-fifth needed treatment to relieve urinary complications caused by scar tissue in the urethra. In the hands of the most experienced surgeons-and for younger men-some of these complications may be less common.