What about sex?

Some men find it difficult to have an erection after a prostate cancer radical prostatectomy. The nerves and blood vessels (neurovascular bundles) that control erection are located on either side of the prostate. Sometimes one or both of these nerves and vessels can be preserved during surgery (nerve-sparing radical prostatectomy), thereby maintaining the ability to have a normal erection. However, depending on your age, your pre-operative ability to obtain and maintain an erection, and the extent of the cancer, natural erections may not return. In some cases, the neurovascular bundles need to be removed because cancer may extend close to them.

Therefore, complete cancer excision may not be possible without removing them. Please feel free to discuss any concerns with your physician, who will provide information about alternative ways to manage impotence such as Viagra, Cialis or Levitra, penile injections, vacuum pumps, and, rarely, penile implants, Since the prostate has been removed, there will be no ejaculate (semen) released. Whether or not you are able to obtain an erection, you should still be able to have an orgasm (climax) with stimulation to the penis.

It is important to realize that one can continue to be sexually active despite even extensive prostate cancer treatment. Be open-minded, seek treatment for impotence if it occurs and realize that sexual gratification can be achieved (for you and your partner) in many ways.

Is there anything else I should know?

Swelling of the penis and scrotum occurs commonly after radical prostatectomy. This is temporary and should resolve within 4 to 7 days. Swelling of the feet or legs is uncommon and your doctor should be notified if this occurs.

What is the pathology report and how do I interpret it?

Once the prostate gland and lymph nodes are removed, a pathologist will coat the prostate with ink and fix all the tissues in substances, which will preserve the architecture of the tissues and allow the pathologist to detect the extent of the cancer using the microscope. The prostate gland is coated with ink to allow the pathologists to determine how close any cancer comes to the edge of the prostate. There are at least 3 features, which are important in the pathology report: cancer grade, cancer stage, and margin status.

Cancer grade Cancer grade refers to how malignant cancer cells look through the microscope. Most often grades are assessed using the Gleason grading system named after the pathologist who developed it. Gleason grade is a numerical value given to prostate cancers that quantitates tumor grade. Grades are assigned to the most common pattern of cancer as well as the second most common. Grades for each pattern range from 1 to 5. A grade of 1 denotes a cancer that closely resembles benign or normal tissue. A grade of 5 is assigned to cancers that appear aggressive and differ significantly from benign tissue.

Therefore 2 grades are given: a primary and secondary grade. When added together, a total sum or Gleason sum is obtained. This sum can range from 2 to 10. Two through 6 representing low-grade cancers and 7 through 10 representing high-grade cancers.

Cancers with both primary and secondary grades of 1 to 3 (sums of 2 to 6) tend to have a better outcome, lower chance of recurrence, compared to cancers of higher grades. Cancers with grades of 4 and 5 (sum of 7 to 10), tend to have a higher chance of recurrence. A word of caution about Gleason sum 7 cancers (3/4 or 4/3). Gleason grade 3/4 cancers are associated with a lower risk of recurrence compared to grade 4/3 cancers.

Cancer stage is a measure that defines the extent of a tumor. T2 cancers are those completely confined to the prostate. T3 cancers are those that have gone beyond the prostate, either through the capsule of the prostate, T3a, or into the seminal vesicles, T3b. T4 cancers re very rare and include those which have invaded nearby organs such as the bladder. Patients with T3 cancers are at an increased risk of cancer recurrence compared to those with T2 cancers.

Margins It is the goal of surgery to remove all the cancer. A positive margin means that the pathologist notices that cancer cells are at the very edge of the prostate touching the ink that was applied during initial processing of the prostate gland. The pathologist will note the number and location of any positive margins. Those patients with positive surgical margins are at an increased risk of cancer recurrence. Patients with more than one positive margin are more likely to have cancer recur compared to those with a single positive margin.
Patients with an extensive positive margin (large area where the cancer is in contact with the edge of the prostate) are more likely to have recurrence of their cancer compared to those with a very small area (focal positive margins) where the cancer just touches the edge.
It is important to note that most patients with positive margins are cured. Depending on the number and extent of margins your physician may recommend post-operative radiation to decrease the risk of recurrence.