Surgery for early (localised) prostate cancer
Some men have surgery to remove the prostate gland.
Your doctor will discuss the operation with you. It’s important you understand what it involves, the possible side effects, and whether or not there are other treatments that may be more appropriate for you. Your doctor may also be able to discuss how successful it might be in treating your cancer.
A radical prostatectomy is carried out by a urologist - a surgeon who specialises in operating on the prostate, kidneys and bladder. The whole prostate gland is removed, either through a cut made in the tummy area (abdomen) or through a cut made between the scrotum and the back passage. This operation is known as an open prostatectomy.
The aim of the operation is to get rid of all of the cancer cells. It’s only done when the cancer is thought not to have spread beyond the prostate.
Surgery is usually offered to men who are well and who don’t have other serious health problems. This may mean you’re more likely to be offered surgery if you’re younger. But each man is assessed individually and older men may be offered surgery.
The operation often causes the inability to have and maintain an erection (impotence) and the inability to father children (infertility). It can also cause problems with controlling your bladder (urinary incontinence). Sometimes it’s possible to do a type of operation called a nerve-sparing prostatectomy, which reduces the risk of some of these problems.
As doctors can’t predict which men will be affected by these side effects, it’s important that you’re fully aware of the risks beforehand. Your doctor will discuss the operation, its possible side effects and other treatment options with you.
Advantages and disadvantages of radical prostatectomy
Removing the whole prostate gland may stop an early cancer from spreading, and may result in a cure. A radical prostatectomy appears to prolong life for some men with fast-growing cancers, but for men with small, slow-growing cancers, the benefits are unclear and probably only apply to younger men.
For any type of surgery there are risks, such as problems with bleeding or infections. But these days, surgeons have a very high level of expertise and the risks are very small. With this type of surgery in particular, there’s also the risk of some long-term side effects such as problems with incontinence and impotence.
Laparoscopic radical prostatectomy
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With a laparoscopic prostatectomy your surgeon doesn’t need to make a large cut. Instead they can take out your prostate gland using only four or five small cuts (about 1cm each) in your tummy area (abdomen). The surgeon uses specially designed instruments that can be put through these small cuts. This type of surgery is also known as keyhole surgery.
After making the small cuts the surgeon uses carbon dioxide gas to fill the abdomen. A tiny video camera shows a magnified view of the prostate gland on a video screen.
The prostate gland is then cut away from surrounding tissues and removed through one of the small cuts in the abdomen.
Robotic-assisted laparoscopic radical prostatectomy
Sometimes, laparoscopic prostatectomy can be carried out using a machine. This approach is called a robotic-assisted laparoscopic prostatectomy. Instead of the surgeon and assistant moving the camera and instruments, they are attached to robotic arms. The robotic arms can move very delicately, steadily and precisely.
The machine used in robotic laparoscopic prostatectomy is called a da Vinci® machine - so this type of surgery is sometimes called the da Vinci prostatectomy. Only a few surgeons in the UK are trained in this technique and there are only a few robot-assisted systems, so this treatment is not yet widely available. Your specialist can tell you if it might be appropriate for you and whether or not it may be available.
Advantages and disadvantages
Most studies have shown that laparoscopic surgery and robotic-assisted laporoscopic surgery are as successful at treating prostate cancer as open surgery. Studies have also shown that many men who have robotic surgery recover more quickly from their operation and spend less time in hospital.
Because this type of surgery hasn’t been used for as long as open prostatectomy, there’s still very little information about the long-term side effects, such as impotence and incontinence.
After your operation
After a prostatectomy you will have a drip (intravenous infusion) into a vein in your arm, and a tube (catheter) to drain urine from the bladder. If you’ve had an open prostatectomy you’ll have either an abdominal wound or a wound between your scrotum and your anus. You may have a small tube in the wound to drain any excess fluid that is produced. This tube is usually removed after a few days.
After your operation you may have some pain or discomfort, which might continue for a few weeks, particularly when you walk. Taking painkillers regularly should ease this, so let the staff on the ward know if you’re still in pain.
You will probably be ready to go home 3-7 days after your operation. The catheter often stays in place for a short while once you go home. This allows urine to drain freely while the urethra heals and any swelling goes down. It can be removed at the outpatient clinic or at home by a district nurse 1-3 weeks after the operation.
Men who've had a laparoscopic prostatectomy will have several small cuts in the abdomen and are usually ready to go home earlier than men who’ve had an open prostatectomy. Your catheter will probably stay in for 1-3 weeks to allow the urethra to heal. Arrangements can be made for a district nurse to visit you at home to make sure your catheter is working well. If you have any problems, contact your doctor as soon as possible.
Care after an operation
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If you think you might have any difficulties coping at home after your surgery, let your nurse or social worker know when you’re admitted to hospital so that help can be arranged.
As well as offering practical advice, some social workers are also trained counsellors who can offer valuable support to you and your family, both in hospital and at home. If you don’t have a social worker but would like to talk to one, ask your doctor or specialist nurse to arrange this.
Before you leave hospital you’ll be given an outpatient appointment for your post-operative check-up. This is a good time to discuss any problems you may have.
Most men return to their normal activities 2-3 months after surgery for prostate cancer.
Side effects of a radical prostatectomy
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Problems getting an erection (impotence)
Surgery to the prostate can cause problems getting an erection (sexual impotence). This is caused by reduced blood flow to the penis due to damage to the arteries or nerves. Nerve-sparing techniques have reduced the risk of these problems, but often the need to remove all of the cancer cells makes it impossible to avoid nerve damage.
Lots of studies have looked at how many men might be impotent following a nerve-sparing radical prostatectomy. The numbers tend to vary as it depends on different factors, such as whether or not you had erection problems before treatment, your age, and whether the surgeon was able to spare some or all of the nerves.
As a guide, in men who have had a nerve-sparing prostatectomy, the risk of erection problems after radical prostatectomy may be 7 in 10 (70%). The risk increases with age and may be higher if nerve-sparing techniques are not used (or if impotence was a problem before treatment for prostate cancer).
It’s important to know that the ability to have an erection can gradually return for some men if surgery is the only treatment they need. It can sometimes take as long as a year or two for this to happen. However, it’s much less likely to come back if you have further treatment after surgery, such as hormonal therapy or radiotherapy. Our section on sexuality discusses ways of coping with erection problems.
The prostate gland produces semen, which is normally mixed with sperm from the testicles. Removing the prostate gland makes it impossible for men to ejaculate, and although there is still sperm, it can’t get out of the body. This causes infertility. If you want children after your treatment, it may be possible to store your sperm before your operation.
It’s still possible for men who have had their prostate gland removed to have an orgasm, but there will be no ejaculation. This is known as a dry ejaculation.
Problems controlling your bladder (urinary incontinence)
Problems controlling the bladder as a result of radical prostatectomy are a less common side effect. Most men have some incontinence when the catheter is first removed, but this usually improves with time. About one year after the operation 8-14% of men will leak an occasional drop of urine. Your doctor or specialist nurse may be able to refer you to a continence team, who can give specialist advice about coping with this problem.
Some men may need to wear an incontinence pad, but it’s very rare to be completely incontinent and need a permanent catheter. Another less common effect of surgery is scarring of the bladder, which can make it difficult to pass urine. This is fairly easily treated with minor surgery called bladder neck dilation.