Prostate Cancer Procedures

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 influence the progression of the disease.  For men in the United States., the overall lifetime risk of being diagnosed with prostate cancer is 1 in 7.

In men who undergo regular prostate cancer screening and are diagnosed with prostate cancer, approximately 80-90% will have a tumor confined to the prostate. A complete removal of the prostate—also known as a radical prostatectomy—is the best course of action.

ANATOMY

The prostate gland, a chestnut sized organ, is located just below the bladder at the site where the bladder connects to the urethra. Its function is to produce semen, which supports sperm nourishment and transport.

When it becomes enlarged due to cancerous tumors, it interferes with the urethra’s function of carrying urine from the bladder to the opening of the penis.

EVALUATION

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 (prostate-specific antigen) level less than 20 and a Gleason score of less than 8 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.

SURGERY

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.

There are different types of procedures used to remove the prostate:

• Retro Pubic Prostatectomy – During this procedure, the surgeon makes an incision through the lower abdomen 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 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 – This 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-assisted laparoscopic 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.

RECOVERY

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% of all surgical cases. However, when it does occur, there are procedures that can solve the problem.

Erectile dysfunction occurs as 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.

IS SURGERY FOR ME?

With the guidance of your physician, only you can make the final decision on whether to go through with surgery. You must weigh the risks versus the rewards and try to envision your life after surgery. Look past the short-term pain associated with the procedure and try to imagine the impact on your lifestyle. Once you review the pros and cons with your physician and understand the procedure to the best of your ability, only then can you make the decision right for you.