Prostate Cancer - Surgery

Prostate Surgery

Prostatectomy (surgical prostate removal) is the most common treatment for prostate cancer. Innovative surgical techniques have provided more options for men who desire complete cancer control with minimal impact on quality of life.

There are two types of "open" prostatectomy:

Retropubic:An incision is made between the navel and pubic bone. The surgeon removes the prostate and any affected lymph nodes and then sews the urethra and bladder back together. Retropubic prostatectomy provides the best chance of sparing the urethra to preserve urinary continence, as well as the neurovascular bundles responsible for erection. The procedure takes 2.5 to 3 hours if nerves are not spared; 3.5 to 4 hours if nerves are spared. It is the most common type of prostatectomy.

Perineal:The incision is made between the scrotum and rectum, and the prostate is approached from the bottom. Perineal surgery is less invasive than retropubic, with a faster recovery time and fewer days on a catheter, but it is seldom used today and few surgeons are trained on this approach. Perineal prostatectomies are best for low-grade and/or early stage tumors with no lymph node involvement, or for very obese patients.

Nerve-Sparing Surgery
Nerve-sparing surgery is performed during a prostatectomy in order to preserve the two neurovascular bundles next to the prostate that are responsible for erections. Before 1980, these nerves were routinely taken to make sure all cancer cells were removed, but the unfortunate result was sexual impotence.

Today, surgical and diagnostic advances have allowed M. D. Anderson surgeons to spare one or both nerves in about 75% of prostatectomies, giving the patient a better chance of retaining sexual function. If both nerves are spared (bilateral), the patient has an 80% chance of maintaining sexual potency; if one nerve is spared (unilateral), the potency rate is about 30%.

The decision for nerve-sparing surgery is largely up to the patient, but controlling the cancer is the surgeon's primary goal. The best candidates for nerve-sparing surgery are men with:

• Localized tumors
• A PSA level of 10 or less
• A Gleason score of 6 to 7 or less
• No prior use of erectile dysfunction (ED) drugs

Nerve-sparing is not recommended for men with large tumors or high-grade disease, or for those who have pre-existing erectile dysfunction unrelated to cancer treatment.

Sural Nerve Graft
This surgery is generally performed on patients who are not eligible for nerve-sparing, but had normal erections before surgery. The sural nerve, which is located in the calf, is removed and then used to replace either one or both of the nerve bundles alongside the prostate.

Sural nerve graft was developed in the late 1990s and is still considered experimental. Its role in preserving sexual function has diminished as nerve-sparing techniques have improved. However, for young, potent men with locally advanced disease, this may be an option. M. D. Anderson performs about 30-40 sural nerve grafts a year.

An M. D. Anderson study of 30 sural nerve graft patients indicates that 50% can achieve erection when both nerves are replaced. A clinical trial that combines sural nerve graft with unilateral nerve-sparing surgery hopes to achieve the same outcome as bilateral nerve-sparing.

Laparoscopic Radical Prostatectomy (LRP)
Minimally invasive surgery is quickly becoming an alternative to standard "open" surgery for treating prostate cancer. A laparoscopic radical prostatectomy (LRP) involves the use of a laparoscope, which is a thin tube with a tiny camera. An incision less than an inch long is made at the navel and the laparoscope is inserted so that surgeons can view the treatment area on a monitor. Four other tiny incisions are made for miniature surgical instruments that can remove the entire prostate.

Although LRP is more complicated than traditional surgery and may take longer, there are many benefits for the patient:

• Less blood loss during surgery
• Shorter hospital stay
• Decreased recovery time
• Decreased reliance on narcotic pain medications
• Less fluid buildup
• Fewer days with a urinary catheter

Other benefits may include a decreased risk of post-surgery bladder and bowel continence. Outcomes appear to be similar to standard surgery.

The best candidates for LRP are men with low to intermediate grade prostate cancer who have no prior pelvic radiation or surgery. Age is not a factor, but generally, surgery is not offered to men over age 70.

Side effects of prostatectomy:urinary incontinence (stress and total), erectile dysfunction (ED), typical post-operative complications.

Post-Prostatectomy Erectile Dysfunction
While outstanding surgical techniques clearly play a large role in preventing post-prostatectomy ED, early counseling for the patient and his partner about realistic expectations and treatment possibilities is critical.

The ultimate goal in treating prostatectomy-related ED in men who are potent prior to surgery is the return of spontaneous erections sufficient for sexual intercourse. Although this is probably not achievable in every patient, it is possible to predict whether erectile function will be recovered on the basis of certain factors. Men most likely to recover erectile function:

• Are less than 60 years old
• Do not have diabetes, hypertension, coronary artery disease, and/or elevated cholesterol
• Are non-smokers
• Have undergone ideal nerve-sparing surgery
• Had low-stage disease before surgery
• Have a motivated partner

An assessment of a patient's erectile function is essential when counseling patients prior to surgery, so they are appropriately informed of their risk for ED. This is particularly important for men who use phosphodiesterase type 5 inhibitors such as Viagra, Levitra, or Cialis, which place them at risk of worsening ED after surgery. Using a validated questionnaire such as the International Index of Erectile Function (IIEF) may help determine the severity of the patient's preoperative ED during the initial patient assessment.

Post-Prostatectomy Penile Rehabilitation
Treatment to restore erectile function should be a part of every patient's recovery plan following prostatectomy, but early return of erectile function is not always possible. M. D. Anderson physicians are committed to a program of early penile rehabilitation for patients after radical prostatectomy. This includes frequent use of a vacuum erection device and early use of oral therapy. For men who do not recover erections early, physicians may recommend penile injection therapy, as studies have consistently shown that without some intervention, spontaneous erections sufficient for intercourse are unlikely to begin more than one year after surgery.

Current and future studies of post-prostatectomy ED are focusing on improving penile rehabilitation, enhancing nerve regeneration and preserving penile length. In addition, researchers are developing drugs to help protect the nerves spared during prostatectomy, a novel approach that may help prevent post-prostatectomy ED.