What are the alternatives to surgery?

Most men will choose either radical prostatectomy (surgery) or radiation treatment. Newer options include cryotherapy (freezing) and other energy sources such as radiofrequency. However, experiences with these newer methods are limited and only short-term results are available.

When is surgery the preferred treatment for prostate cancer?

In general, the result of prostate cancer surgery is best when the cancer is still confined to the prostate gland. Some patients with palpable tumors that may have spread just to the immediate area outside of the prostate capsule may also be treated by surgery.

Since surgery is more invasive, the patient's general health status and tolerability for the stress of surgery are important factors. Younger men with prostate cancer who are otherwise healthy (less than 65 years old) tolerate surgery well. The risks of surgery are noticeably lower in healthy men under 55 years old. These healthy men have a 10-year or more life expectancy and would stand to benefit most from surgical treatment.

What are the benefits of surgery?

Most men will choose between surgery and radiation. With surgery the entire prostate gland is removed whereas the prostate remains in its usual place in the body for radiation treatment. A typical radical prostatectomy procedure (surgery) takes about two to three hours of operating time, and two to three days of hospitalization. Radiation therapy when delivered by external beam takes place over a 7-week period with patients receiving daily dosing five days a week. Brachytherapy is an outpatient procedure done under general anesthesia, and involves inserting radioactive seeds into the prostate gland with the treatment dosage be emitted over time. It is currently popular because of its minimal invasiveness, but it has limited long-term data and may be limited to cases of lower grade disease. It is considered to be a reasonable alternative for older men who want to have treatment rather than being observed.

Many men find the immediate result of surgery appealing. Within eight weeks after surgery, the blood PSA level should be at an undetectable level (<0.1 ng/ml). With radiation therapy, the PSA will slowly decline over time, often taking over 2 years before it reaches its lowest level which is rarely an undetectable level. During this follow-up period, the PSA level may also "bounce" up and down, making the follow-up process even more difficult, and sometimes causing a lot of anxiety for some patients.

What are some risk factors associated with prostate cancer surgery?

The two main risks that concern most men are urinary incontinence (urine leakage) and impotence (weak or loss of penile erection). Most men will have some problem with incontinence during the immediate period after the urinary catheter is removed. Long-term problem with leakage is rare, with occurrence in less than 5 percent of patients. Older patients (> 65 years old) are at higher risk, likely due to loss of tissue and muscle tone as a natural part of aging. These patients also tend to have more chance for loss of erections because most of these men are already experiencing some degree of erection difficulties before undergoing surgery. Younger men will likely see gradual recovery of erectile function over time, sometimes needing only Viagra® for full function. There are effective options available for the rare cases of severe problems.

Other potentially serious risks are extremely rare, and include injury to blood vessels and nerves, rectal and bladder injury, and excessive bleeding requiring blood transfusion.

What are the different types of prostate cancer surgery?

The different types of surgery are really different surgical approaches to the prostate area. The most common technique is a retropubic approach which is through a vertical (up and down) incision made over the lower abdomen. This approach allows viewing of the pelvic lymph nodes for sampling (removal) if necessary. Another approach is through the perineum (perineal approach) which is the area between the scrotum and the anus (between the legs). The lymph nodes are less accessible with this approach. More recently, prostate cancer surgery by laparoscopy is being done mainly at major university centers. This technique is considered less invasive, but the technique is still being refined. The overall result of this approach still has not surpassed open surgery, but surgeons are hopeful that it will become a standard technique in the future.

In the absence of high-grade, bulky tumor, nerve-sparing procedures are offered to most men. The chance of preserving erectile function is improved, especially when bilateral nerve-sparing is successful.

What can I expect after surgical treatment?

Your initial recovery in the hospital consists of pain control with oral medication and resumption of a regular diet usually by the second day. You will be discharged from the hospital with a catheter in place with clear instructions on care of the catheter and the incision. At home, you are encouraged to take regular walks inside or outside of your home, and to gradually resume regular activities. However, you should not drive, operate machinery, lift heavy objects (>5 lbs), or perform strenuous work until given clearance by your doctor.

The catheter is usually removed between two and three weeks after the day of surgery. You will be given instruction on exercises aimed at strengthening the urinary sphincters. Urinary control will gradually return over the next few weeks to several months.

Likewise, erectile potency will take some time (up to a year) to return following surgery. Additional therapies may be suggested to you while awaiting spontaneous recovery of function. They include oral medication (e.g. Viagra®), vacuum erection device, and injection drugs (e.g. Caverject®). You should retain the ability to have an orgasm. However, the orgasm is "dry" with very little (if any) ejaculation (no semen).

The final pathology will be discussed with you, and any additional treatment recommendations will be made. The first PSA determination after surgery usually takes place between 8 and 12 weeks, and should be less than 0.1 ng/ml.

Frequently asked questions:

When can I resume normal activity after surgery?

The specific time varies, but usually it is between three and six weeks.

Will I know if I am cured after surgery?

Not completely. The chance of recurrent disease depends on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for ten years before cure is certain.

Glossary Terms

abdomen - also referred to as the belly;
anus - opening where feces (stools) leave the body;
catheter - a rubber tube passed through the urethra into the bladder to drain urine;
ejaculation - release of semen from the penis during sexual climax;
erection - the swollen and stiffened state of the penis usually as a result of sexual arousal;
impotence - also known as erectile dysfunction or ED; the inability to get or maintain an erection for sexual activity;
incision - surgical cut for entering the body to perform an operation;
incontinence - loss of bladder (urinary) or bowel (fecal) control;
lymph nodes - produce special cells that help fight off foreign agents invading the body; can be invaded by tumor or cancer cells;
orgasm - the climax of sexual excitement;
palpable - able to be felt by touch; for example, a prostate tumor felt by rectal examination;
pathology - the nature, origin, cause, process and extent of a particular disease;
prostatectomy - surgical procedure for removal of the prostate; radical means complete removal;
scrotum - the sac that hangs below the penis and contains the testicles;
semen - thick whitish fluid that carries sperms through the penis during ejaculation;
urethra - the channel through which urine passes from the bladder to the outside; it also serves as the channel through which semen is ejaculated;
urinary incontinence - involuntary loss of urine or urine leakage;
urologist - a physician and surgeon who specializes in diseases of the male and female urinary systems, and the male reproductive system;

*  This information is not intended to substitute for a consultation with a urologist. It is offered to educate patients on the basis of urological conditions in order to get the most out of their office visits and consultations. Please see our web page disclaimer for addition information.

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