PROSTATE CANCER: SURGICAL MANAGEMENT
Prostate cancer is the second most common form of cancer in men, after skin cancer. It is estimated that in the United States (U.S.), there will be more than 238,590 new cases and 29,720 deaths from prostate cancer in 2013. As a man ages, his chance of having prostate cancer increases. However, doctors are making progress in early detection and treatment, and consequently survival rates are improving. From 1991 to 2006, there was a 40 percent decrease in the prostate cancer mortality rate in the U.S. A similar trend is also found in other Westernized countries where early detection and effective treatment are widely practiced.
What happens under normal conditions?
The prostate is part of the male reproductive system. It is about the size of a walnut and weighs about an ounce. The prostate is located below the bladder and in front of the rectum. The prostate goes all the way around a tube called the urethra, which carries urine from the bladder out through the penis. The main job of the prostate is to make fluid for semen. During ejaculation, sperm made in the testicles moves to the urethra. At the same time, fluid from the prostate and seminal vesiclesalso moves into the urethra. This mixture – semen- goes through the urethra and out of the penis.
What is prostate cancer?
Prostate cancer is a malignancy that usually arises in the glands and ducts of the prostate. It occurs when the normal process of cell growth within these structures becomes uncontrolled. This uncontrollable growth results in the development of masses of cancerous cells referred to as a malignant prostate tumor.
As with many cancers, the cause of prostate cancer is unknown, but, like all cancers, both genetic and environmental factors and their interactions are important in the development and progression of the disease. Prostate cancer is more common as men age, in African-American men, and in men with a family history of the disease. Its growth is also affected by male sex hormones (benign and malignant prostate growth are stimulated by male hormones and suppressed by lack of male hormones).
For men in the U.S., the overall lifetime risk of being diagnosed with prostate cancer is 1 in 6. In men who undergo regular prostate cancer screening and are diagnosed with prostate cancer, approximately 80-90 percent will have a tumor confined to the prostate. Prostate cancer that is localized at diagnosis has a very high relative five-year survival rate with appropriate treatment.
What are the symptoms of prostate cancer?
In its early stages, prostate cancer may not cause any symptoms. However, as the cancer grows, the following symptoms may appear: pain in the bones, weight loss, problems with urination(inability, weakened flow, pain, burning, etc.), blood in urine or semen and/or frequent pain or stiffness in the back, hips or upper thighs.
How is prostate cancer diagnosed?
Ideally, prostate cancer should be detected when it is so small that there are no symptoms. Early detection can be achieved by a prostate specific antigen (PSA) test and a digital rectal examination (DRE). A PSA test is a simple blood test used to measure the level of PSA, a protein produced by the prostate gland. During a DRE, the physician gently inserts a lubricated gloved finger into the rectum; it may be uncomfortable but not painful. A biopsy is recommended if either the DRE and/or the PSA are suggestive of cancer (hardness, irregularity, or a mass on the DRE, a steadily rising PSA level or a PSA level that is higher than the median level for the age group). The biopsy procedure uses an ultrasonic probe that is inserted into the rectum and a biopsy needle that is directed into various regions of the prostate gland. This procedure, performed under local anesthesia, is relatively painless and is normally performed in an office setting.
Once prostate cancer has been diagnosed by a prostate biopsy, the physician seeks to determine the extent of the cancer (i.e., the “T” stage) and whether it has already spread to the lymph nodes and/or the bones. The clinical T stage is determined by the DRE and can be divided into the following categories:
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is low grade (Gleason sum of 6 or less) and present in less than 5% of the tissue removed
T1b: Cancer Cancer is found after a simple prostatectomy for presumed benign enlargement but is high grade (Gleason sum of 7 or more) and/or is present in more than 5% of the tissue removed
T1c: Cancer is found by needle biopsy that was done because of PSA abnormalities
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate
T2b: Cancer is found in more than half of only one side (left or right) of the prostate
T2c: Cancer is found in both sides of the prostate
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
T3a: Cancer extends outside the prostate but not to the seminal vesicles
T3b: Cancer has spread to the seminal vesicles
T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis
To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT scan of the pelvis, an MRI of the pelvis, and/or a bone scan.
In addition to clinical staging, the physician seeks to determine the so-called “aggressiveness” of the cancer. This is done by determining the grade of the cancer; that is, how “aggressive” it looks under the microscope.
The most frequently used prostate cancer grading system is the Gleason system. Each area of cancer in the biopsy is assigned a Gleason pattern or grade between 1 and 5. The two most common Gleason grades within a biopsy are added together to give the Gleason “score” which is designated between 2 and 10. A Gleason score of 2-4 designates well-differentiated cancers that tend to be slow growing. Gleason scores of 5, 6, or 3+4 =7 (predominately pattern 3 with a lesser amount of pattern 4) are moderately-differentiated, while Gleason scores of 4+3=7 (mostly pattern 4) to Gleason 10 are called poorly differentiated. The second sign of aggressiveness is the PSA level before biopsy. In general PSA levels less than 10 are associated with a high likelihood of organ-confined disease, levels between 10 and 20 are worrisome for more extensive disease, while levels greater than 20 are worrisome for distant metastases, although cure is still sometimes possible.
What is a radical prostatectomy?
A radical prostatectomy is the removal of the entire prostate, the seminal vesicles, the tissue immediately surrounding them, and some of their associated pelvic lymph nodes.
Because prostate cancer may be scattered throughout the prostate gland in an unpredictable way, the entire prostate must be removed so that cancer cells are not left behind. The pelvic lymph nodes are small oval or round bodies located along blood vessels and filter lymphatic fluid. When prostate cancer begins to grow and spread, the pelvic lymph nodes are one of the first locations (typically prostate cancer spreads to the soft tissues surrounding the prostate capsule, then to the seminal vesicles, then to the lymph nodes and then to the bones and other organs of the body). There are many other lymph nodes, so the body will not be compromised by the removal of these few lymph nodes.
When is surgery the best treatment for prostate cancer?
In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation and have a 10-year or more life expectancy from other medical conditions. Life expectancy is assessed by both patient age and health.
What are some risk factors associated with prostate cancer surgery?
Like any surgery, radical prostatectomy carries some risk of complications. Some complications may appear early, while others appear later, if at all. The type of prostatectomy you choose (retropubic-also known as “open surgery”, perineal, laparoscopic or robotic) can determine the risk for complications such as blood loss, infection, incontinence and sexual dysfunction. It can also determine the length of your hospital stay and overall recovery.
While some men experience the following symptoms they are very rare: surgical injury to adjacent structures, such as the rectum and ureter (tube that drains urine from the kidney to the bladder) is uncommon. Infection in the incision or urinary tract is also rare. Deep venous thrombosis (blood clots in the leg veins or pelvic veins) and pulmonary embolism (blood clot that goes to the lung) occur in approximately 1-2 percent of patients after radical prostatectomy.
As with all operations, there may be complications of radical prostatectomy; some occurring early and some late. Bleeding can occur in any major operation. Some surgeons recommend that patients donate their blood before surgery or receive a blood-stimulating hormone (Epogen, EPO) to boost blood count and reduce the risk of needing a blood transfusion from an anonymous donor.
Long-term complications after surgery may include urinary incontinence (urine leakage) and erectile dysfunction (impotence). Short-term incontinence after radical prostatectomy is common. Many men will require a protective pad for several weeks to months after surgery. Fortunately, most men will ultimately recover urinary control. Long-term (after 1 year) incontinence is rare with occurrence in less than 5-10 percent of all surgical cases. However, when it does occur, there are procedures that can solve the problem.
Erections occur because of stimulation through the nerves that run adjacent to the prostate and send signals to dilate the blood vessels in the penis, allowing it to fill with blood and become rigid. The two nerve bundles responsible for erection run only a few millimeters away from the area where prostate cancer most commonly arises. Although preserving these nerves at the time of surgery is usually possible, it is not always optimal. The less tissue removed around the prostate, the greater the chance that cancer cells will remain behind. Since the primary goal of the operation is to remove all of the cancer, one or both of these nerves sometimes has to be completely or partially sacrificed. Unless both nerves are sacrificed, the chance of recovering erectile function exists, but recovery may be slow.
The average time until recovery of erections sufficient for intercourse is 4 to 24 months, but in some men it takes longer. Erections usually improve with time, lasting anywhere from 2-3 years or more after the operation, because some of the traumatized nerve fibers recover slower. Even if both nerves are spared, most men find their erections are less rigid and durable than before surgery. Younger men recover sooner, and those with stronger erections before the operation have a better chance of recovery than if the erections were weak preoperatively.
Postoperative erectile dysfunction can also be treated by oral medication (Viagra, Cialis, etc.), vacuum pumps, urethral suppositories (MUSE), or penile injections (Tri-Mix or Bi-Mix, etc.). Also, surgical implantation of a penile prosthesis is an option for men who do not wish to use these less invasive measures or in whom they are not effective.
What are the different types of prostate cancer surgery?
Retro pubic prostatectomy: During this procedure, the surgeon makes an incision through the lowerabdomen that is about 4 inches in length. The surgeon removes the prostate, surrounding tissue and pelvic lymph nodes (if necessary).
Perineal prostatectomy: In this approach, the surgeon removes the prostate through an incision in the skin between the scrotum and the anus. Nerve-sparing is more difficult to achieve, and this approach may be less efficient if the lymph nodes need to be removed or examined before the prostate is removed.
Laparoscopic prostatectomy:This minimally-invasive surgery that uses six 1-inch incisions, with one being slightly larger in order to extract the prostate gland from the abdomen. Surgical instruments, including a camera, are inserted through the incisions to perform the surgery.
Laparoscopic surgery is less traumatic because of the smaller incisions and may result in less pain, less scarring and a faster recovery. However, it can be technically challenging during complex operations due to the instrumentation used.
Robotic-assisted laparoscopic prostatectomy: The latest advancement in minimally invasive surgery to remove prostate cancer involves use of a robotic platform. Through small incisions, surgeons operate using a robotic platform with #D-HD vision and miniaturized wristed instruments. Robotic prostatectomy enables surgeons to operate with enhanced visions, precision and control. This is important when it comes to removing the cancer and also preserving urinary and erectile function.
What can be expected after surgical treatment?
At the time of surgery, after the prostate has been removed, the urinary tract is reconstructed by reattaching the bladder to the urethra with sutures. A urinary catheter is passed through the urethra into the bladder to drain the urine while the new connection between the bladder and urethra (called the “anastomosis”) heals. The catheter will remain in place for 1-2 weeks after the surgery. The catheter is removed on a return visit to the surgeon’s clinic, and the patient begins exercises (called Kegel exercises) to strengthen the urinary control valve. Urinary control (continence) can be immediate but usually takes several weeks to months to recover.
One or two suction drains are left beside the bladder, deep in the pelvic cavity, and brought out through the lower abdomen to drain any fluid that might accumulate in the surgical wound. They help to decrease the risk of infection and pressure from fluid in the operated area. The drains are usually removed before you are discharged from the hospital.
While in the hospital, you begin physical recovery. After the operation you will be in the Post-Anesthesia Care Unit (PACU) for a recovery period of several hours. You can have ice chips and water as soon as you are fully awake. Family members may also visit in the PACU.
Fluids are given to you through an intravenous (IV) line in a vein. The IV line will remain in place until you can tolerate fluids and food by mouth. Most people do not pass flatus (intestinal gas) for one to two days and do not have a bowel movement until the third day after surgery, depending on how much narcotic pain medication they have had.
The goal during the first few days after your operation will be to prevent the breathing and circulation problems that can develop after any surgery. You must walk at least 100 yards 3-4 times a day to help your breathing and circulation.
The surgeon reviews the final pathology report of the removed prostate and (if applicable) the lymph nodes. Based on this “final pathology,” a follow-up plan is developed. If the pathology report is favorable, the follow-up plan entails regular visits to a physician and a regular PSA test (every 6-12 months). The post-operative PSA level should be in the “undetectable” range (less than 0.1 ng/ml).
If the pathology report shows adverse features (e.g., cancer at the surgical margin or spread of cancer through the capsule of the prostate into the surrounding tissues, seminal vesicles, or lymph nodes) additional therapy may be recommended or at least considered as an option. This may include postoperative radiation therapy and/or hormone treatment beginning 2 to 4 months after surgery.
Erectile rehabilitation programs are usually encouraged beginning shortly after surgery. In general these consist of: oral medications, vacuum pumps, injections and even penile implants. Each come with various side effects, pills are not very effective until spontaneous erections begin to return. Since vacuum pumps draw blood from the veins (rather than the arteries) into the penis, they provide less oxygenation to the tissues. Intraurethral suppositories may be inefficiently absorbed through the urethra and sometimes cause urethral burning. Intracavernosal injections (into the penile shaft) of vasodilators usually provide immediate rigid erections with well-oxygenated arterial blood, but if too large a dose is given, it might induce an erection that will not go away (priapism) and require a visit to the emergency room for treatment.
There is a risk of developing curvature of the penis (Peyronie’s disease) due to scarring from repeatedly injecting into the same site or from kinking or buckling of the penis while having intercourse without a sufficiently rigid erection.
The ability to experience climax (orgasm) is not lost after radical prostatectomy, even in the absence of an erection. However, with orgasm, there is very little to no ejaculate (usually some lubricating mucus from urethral glands, and sometimes urine, if urinary sphincter function has not fully recovered). This fluid is not harmful to you or your partner.
Because the prostate and seminal vesicles have been removed and the vas deferens have been divided, the patient is no longer able to initiate a pregnancy through sexual intercourse (but fertility is still possible through artificial insemination techniques).
Frequently asked questions:
When can I resume normal activity after the surgery?
The time varies, but usually it is between 3-6 weeks.
Will I know if I am cured after surgery?
Not with absolute certainty. The likelihood of cure varies, depending on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for 10 years before cure is virtually certain.
I worry about potency but I am most afraid of incontinence. What are the odds?
That depends mostly on the surgeon and his/her experience. But age and your current level of continence and potency are also key factors. Usually, incontinence is temporary and does not last long, although it can persist for as much as 6-12 months. With more experienced surgeons, the risk of permanent incontinence is rare after prostate cancer surgery.
Where can I get more information?
Patient Brochure: Surgical Management of Prostate Cancer
AUA Guidelines Patient Guides: Prostate Cancer Awareness for Men