Prostatectomy: Know Your Surgeon And Understand Your Risks

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Men's health
Article Date: 03 Aug 2007 - 0:00 PST

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You've been diagnosed with localized prostate cancer, and after talking with your urologist, you've decided to undergo radical prostatectomy, or surgical removal of the prostate.

Now that you've made a treatment choice, more questions remain: Which surgical technique is the best? Will it render me incontinent or impotent? What happens after surgery?

However, one question may be the most important, according to a new study involving a Cleveland Clinic researcher: Who will do the surgery?

"There's very clear evidence that shows that the experience of the surgeon is the most important factor in determining the likelihood of a cure, the return of continence and the return of potency," said Eric Klein, M.D., head of the Section of Urologic Oncology at Cleveland Clinic's Glickman Urological and Kidney Institute and one of the study's authors, according to the Cleveland Clinic's Men's Health Advisor. "The most important factor is finding the most experienced surgeon you can and querying him or her on their results."

When opting for prostatectomy, it's important that you not only know your surgeon's experience, but also understand the risks and side effects of surgery and your long-term outlook.

Prostate surgery: Who over how?

For years, most urologic surgeons have used standard radical retropubic prostatectomy, an open surgery in which the surgeon removes the prostate through an incision (about five to eight inches long) in the lower abdomen.

However, minimally invasive laparoscopic surgery is becoming more popular. In this more challenging operation, the surgeon makes five small incisions and uses a tiny camera and specialized instruments to remove the prostate. In a newer laparoscopic technique, robot-assisted surgery, the surgeon removes the prostate with the help of several robotic arms that mimic his hand movements and allow for more precision.

The laparoscopic approach affords the surgeon a magnified view of the prostate. Advantages for the patient include less blood loss, shorter hospital stays and the potential for a faster recovery.

However, these advantages may not matter to you as much a year or more after surgery, Dr. Klein said, and he advises his patients to look at the long-term picture. "You're going to care about whether you're cured, whether you're continent and whether you're potent. When you focus on those, the primary factor becomes experience of the surgeon and not the tools that are used to perform the surgery," he said.

According to Dr. Klein, the recent study found that patients of surgeons who have performed more than 1,000 prostatectomies are about 10 percent more likely to be cured of their cancer than those whose surgeons have done 250 to 999 of the procedures and 30 percent more likely than those whose surgeons have done fewer than 50.

He said preliminary data from another multi-center study in which he participated suggest that men who underwent open surgery had better potency results than those treated with laparoscopic or robotic surgery. "The point it makes to me is there's nothing magical about a laparoscope or a robot," he said. "It's still the surgeon who decides where to cut and where not to cut while doing the surgery."

Dealing with side effects

Prostatectomy is delicate surgery and often affects the nearby urinary sphincter (which controls urine flow through the urethra) and the nerves that allow men to have erections. As a result, most men experience some form of urinary incontinence and impotence (also known as erectile dysfunction, or ED) after a prostatectomy.

Fortunately, post-operative incontinence usually isn't permanent. Most patients regain continence within six to 12 weeks after surgery, some more gradually than others. Some will experience long-term stress incontinence urine leaks when coughing, sneezing or exercising that require men to wear protective pads. Less than one percent suffer from severe incontinence that requires the surgical implanting of an artificial sphincter or urethral sling to control urine flow, Dr. Klein said.

Bilateral nerve-sparing prostatectomy, which preserves the nerve bundles on either side of the prostate, has improved rates of ED after surgery. In the best surgical hands, about 75 percent of all patients who undergo this procedure will regain potency within 12 to 14 months after surgery, according to Dr. Klein.

Others may regain sexual function with the help of drugs such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). Many urologists recommend using these medications immediately after surgery to promote an early return of erections. Other treatments such as vacuum erection devices and injections of a substance known as prostaglandin E1 directly into the penis may be used if the ED drugs fail to work. A final option is a penile implant, using inflatable devices or silicone rods.

Several factors may affect your ability to have an erection after a prostatectomy: your age, medical condition, ability to get an erection before surgery and whether the nerve bundles were damaged. Older men and those with other health problems, such as cardiovascular disease or diabetes, usually have more difficulty regaining potency.

"Most patients can expect a return to regular physical activity within a few weeks, regardless of how the surgery's done, and good results with continence and potency," Dr. Klein said.

After your surgery

If you're like the majority of prostatectomy patients with low- or intermediate-risk prostate cancer, you'll receive a favorable pathology report after your surgery and require no additional treatment. You'll follow up with your urologist shortly after surgery and return periodically for blood tests to measure prostate-specific antigen (PSA).

However, if the pathology report reveals lingering cells that may be cancerous, you may need external-beam radiation therapy or other systemic treatments once you recover from surgery, usually about three to six months later.

What You Can Do:

-- Ask your surgeon about the number of prostatectomies he or she has performed and the results of those procedures.

-- Have your doctor explain the risks and benefits of prostatectomy and other treatments, such as radioactive seed implants (brachytherapy) and external-beam radiation therapy.

-- Prostatectomy causes sterility, so if you still hope to father children, talk to your doctor about banking your sperm before surgery.

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