Surgery for locally-advanced prostate cancer
Some men are offered surgery to treat their prostate cancer or to help with the symptoms they have. There are three main types of surgery offered.
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.
There are three types of surgery used in men with locally advanced prostate cancer:
Radical prostatectomy The aim of this operation is to treat the prostate cancer by removing the prostate gland. This is only suitable for a small number of men with locally advanced prostate cancer.
Transurethral resection of the prostate (TURP) This operation can relieve symptoms such as difficulty passing urine, but does not treat the cancer.
Subcapsular orchidectomy This is an operation to remove part of the testicles. Sometimes both testicles are removed (bilateral orchidectomy). These procedures are done to reduce the levels of the male hormone testosterone in the body, so you can read more about this in our section about hormonal therapies.
For any type of surgery there are risks such as problems with bleeding or infections. But surgeons have a very high level of expertise and the risks are very small. Surgery for prostate cancer carries the risk of some long-term side effects as well, such as problems with controlling your bladder (urinary incontinence) and the inability to have and maintain an erection (impotence). Your specialist can give you more information about the type of surgery appropriate for you, and its effects.
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. This operation is only suitable for a small number of men with locally advanced prostate cancer, depending on how far the cancer has spread outside the prostate. You can discuss with your specialist whether a prostatectomy would be suitable for you.
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 an operation called a nerve-sparing prostatectomy, which can reduce the risk of erection problems. However, this is often not possible for men with locally advanced prostate cancer.
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
Removing the whole prostate gland may stop the cancer from spreading and may result in a cure. A radical prostatectomy appears to prolong life for some men with fast-growing cancers, but is only suitable for a small number of men with locally advanced prostate cancer.
Although a prostatectomy can get rid of the cancer cells completely for some men, the cancer cells may come back in the surrounding area some time after the operation. If this happens, external radiotherapy may be given to the prostate area. Radiotherapy is given over a larger area, which can cause more side effects. Over half of men who have a prostatectomy for locally advanced prostate cancer will have a recurrence of their cancer and need further treatment with either radiotherapy or hormonal therapy.
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 cuts in the abdomen.
Advantages and disadvantages
Most studies have shown that laparoscopic surgery is as successful at treating prostate cancer as open surgery. Studies have also shown that many men who have laparoscopic surgery recover more quickly from their operation and spend less time in hospital than men who have open surgery.
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 prostatectomy
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After a prostatectomy you will have a drip (intravenous infusion) into a vein in your arm, and a tube (catheter) to drain urine from your 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 may 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 between 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.
Side effects of a radical prostatectomy
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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%) or higher. 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. We have information discussing 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 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 with 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 to 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.
Transurethral resection of the prostate (TURP)
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A TURP is carried out if cancer is blocking the urethra (the tube that drains urine from the bladder) and needs to be removed. A TURP is used to relieve problems with passing urine and does not aim to remove all of the cancer cells.
During the procedure, a tube that contains a miniature camera is passed through the urethra and into the prostate. A cutting instrument attached to the tube is then used to shave off the inner area of the prostate to remove the blockage.
This can be done under a general anaesthetic while you’re asleep or with an epidural. If you have an epidural, the lower body is temporarily numbed with an injection of anaesthetic into the spine. Even though you are awake, you won’t be able to feel anything.
After your TURP
You will be encouraged to get out of bed and will probably be able to walk around the morning after your operation.
You will usually have a drip that gives fluid into your vein. This will be taken out as soon as you’re drinking normally. You’ll also have a tube (catheter) to drain fluid from your bladder into a collecting bag. It’s normal at this stage for your urine to contain blood. To stop blood clots from blocking the catheter, bladder irrigation may be used. This is when fluid is passed into the bladder and drained out through the catheter. The blood will gradually clear from your urine and the catheter can then be taken out. At first, you may find it difficult to pass urine without the catheter, but this should improve. Some men find that they have some urinary incontinence following this procedure, but this usually improves within a few weeks. Most men are able to go home after three or four days. Occasionally, you may need to keep the catheter in for a while after you go home. In this case, the nurse will show you how to look after your catheter before you leave the hospital, and arrangements can be made for a district nurse to visit you at home to help with any problems.
You may have pain and discomfort for a few days after your operation. You will be given painkillers, which are usually very effective. If you continue to feel pain, it’s important to let the doctor or nurse looking after you know as soon as possible, so that a more effective painkiller can be found.
Following a TURP it’s common for men to experience retrograde ejaculation. This means that during ejaculation semen goes backward into the bladder instead of through the urethra in the normal way. Your urine may look cloudy after sex because there is semen in the bladder, but this is harmless.
Occasionally, TURP can cause some long-term difficulties with passing urine. Some men may also find that they have problems getting an erection after having a TURP.
Advantages and disadvantages
Having a TURP can help to relieve problems with passing urine.
A TURP will not get rid of the cancer cells. There is also a small risk of urinary incontinence and some men have problems getting an erection after a TURP.
Getting support after your operation
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If you think you might have difficulties coping at home after your surgery, let your nurse or social worker know when you are admitted to hospital, so that help can be arranged before you go home.
As well as being able to offer practical advice, many social workers are also trained counsellors, who can offer valuable support to you and your family, both in hospital and at home. If you’d like to talk to a social worker, ask your doctor or specialist nurse to arrange it for you.
Before you leave hospital you’ll be given an appointment to attend an outpatient clinic for your post-operative check-up. This is a good time to discuss any problems you have.