Prostate cancer surgery: Types and what to expect
Radical prostatectomy is not the only form of treatment for prostate cancer, and not everyone who has the condition will have surgery.
Surgery is just one of the treatment options available for prostate cancer.
Prostate cancer is the second most common form of cancer in American men, behind skin cancer. The American Cancer Society estimate that there will be around 161,360 new cases of prostate cancer in 2017, and 26,730 deaths from the disease.
The prostate is a gland that sits between the penis and the pelvis and produces the white sticky liquid that is mixed with sperm to make semen.
The type of treatment offered depends on how advanced the prostate cancer is. This is known as the stage of cancer.
- Stage 1: The cancer is smaller than one half of the prostate and is contained within the gland. This is known as localized prostate cancer.
- Stage 2: The cancer is larger than one half of the prostate, but is still located within the gland. This is also known as localized prostate cancer.
- Stage 3: The cancer has broken through the outer layer of the prostate and may have spread into the seminal vesicles, the tubes that carry semen. This is known as locally advanced prostate cancer.
- Stage 4: The cancer has spread to another part of the body. This may be nearby lymph nodes or organs such as the rectum or bladder, or the pelvis, bone, lungs or liver. This is known as advanced or metastatic prostate cancer.
Men diagnosed with prostate cancer may be offered surgery, depending on various factors. These include their age, overall health, and the stage of the cancer.
Not everyone who is diagnosed will be treated for prostate cancer, as the treatments come with side effects that can affect quality of life.
Because prostate cancer grows slowly, doctors may recommend watchful waiting or active surveillance, if the condition is not causing any symptoms. Watchful waiting or active surveillance mean being monitored closely for signs that the cancer is growing. Treatment will only be offered if and when it is necessary.
Types of surgery
There are two main types of prostate cancer surgery: radical prostatectomy and transurethral resection of the prostate (TURP).
A radical prostatectomy may be offered to men with localized prostate cancer who are otherwise fit and healthy. If the cancer has spread outside of the prostate, this operation may not be suitable.
During a radical prostatectomy, the whole prostate gland, and the cancer within it, are removed. The seminal vesicles are also taken out, along with the nearby lymph nodes, if there is a risk the cancer may have spread to them.
The type of radical prostatectomy performed will depend on the hospital.
Laparoscopy is carried out by making several small cuts into the abdomen and removing the prostate.
Keyhole surgery, also called a laparoscopy or minimally invasive surgery, involves the surgeon making five or six cuts in the abdomen to remove the prostate. This is done by hand with the surgeon guided by a camera and lighted tube.
In robot-assisted surgery, the surgeon uses three robotic arms controlled from a computer.
During open surgery or retropubic prostatectomy, a single cut is made in the stomach. A less common form of open surgery is a perineal prostatectomy. This is when a cut is made between the testicles and the back passage.
Removing the prostate can remove the cancer if it is contained within the gland.
The prostate is involved in making semen. Removing it means that men are unable to ejaculate or to father children through sex.
After surgery, men experience "dry orgasms," which is the sensation of orgasm without the ejaculation. This may feel different to the experience men are used to having.
Men planning on having a radical prostatectomy can consider storing sperm for fertility treatment at a later date.
As with all surgery, the removal of the prostate gland carries risks. These include:
- injury to nearby organs such as bowel and nerves
- blood clots
After surgery, most men cannot control their bladder properly. Some may experience stress incontinence, which means leaking just a few drops of urine during exercise, coughing, or sneezing. Others may need absorbent pads or pants, though this usually improves with time.
Some men have difficulty urinating after the operation, and this can happen gradually or very suddenly.
Most men who have this kind of surgery suffer erectile dysfunction. Surgeons will try to save the nerves that control erections, but this is not always possible. Even if nerves are saved, many men still have difficulty with erections.
It can take between a few months and 3 years for erections to return, but some men will always need help or medication.
A TURP operation does not cure the cancer. It helps with one of the most common symptoms of prostate cancer, which is difficulty passing urine. This happens when the enlarged prostate presses against the urethra, causing it to narrow.
It is carried out under general anesthesia and involves a surgeon passing a thin metal tube with a camera on the end through the penis to the urethra.
A small wire loop is then put through the tube and heat is used to remove small parts of prostate tissue. During the operation, fluid is passed through the bladder to flush away the removed tissue.
Banking sperm is one option for men who would like to father children after their operation.
Possible side effects of TURP include:
- problems urinating, though this usually improves over time
- stress incontinence, affecting around 2 percent of patients
- blood in urine for the first couple of weeks after the procedure
- urine infection
- slow urine flow caused by scar tissue from the operation, affecting 4 percent of patients
- erectile dysfunction, affecting up to 7 percent of patients
Around 65 percent of men will suffer retrograde ejaculation. This means that semen is passed into the bladder during orgasm rather than being ejaculated.
Men who have retrograde orgasm experience orgasm differently and may not be able to father children through sex. Banking sperm is a treatment option for this side effect.
The outlook for men diagnosed with prostate cancer is good. According to the American Cancer Society, the 5-year relative survival rate for prostate cancer is almost 100 percent.
However, many men say that being diagnosed with prostate cancer changes their life. A diagnosis and surgery can affect everyday life, work, and relationships.
Managing erectile dysfunction
Phosphodiesterase type 5 (PDE5) inhibitors are drugs that help men get and keep erections. The best known of these is Viagra.
A range of creams, pumps, and implants may also help, and men can be offered testosterone replacement therapy.
Managing urinary incontinence
Absorbent pads or pants or a urinary sheath, which drains urine from the penis to a bag, can help manage symptoms of urinary incontinence.
Healthcare teams also recommend pelvic floor exercises to strengthen the muscles used during urination.
For more severe cases, surgical options, such as an artificial urinary sphincter or internal male sling, may be suggested.