What does surgery involve?
Radical prostatectomy involves removal of the prostate, seminal vesicles and, in many cases, the pelvic lymph nodes. It can be performed through either an open or robotic approach. In localised prostate cancer the goal of this operation is eradicate the disease while preserving continence and, if possible, erectile function. It is suitable for men who have a life expectancy of greater than ten years.
Surgery has not been shown to improve survival in men with low volume, Gleason Grade 6 (ISUP Group 1) prostate cancer. These men are better managed with active surveillance, with a plan to undertake surgery or radiotherapy if more aggressive disease develops. Intermediate risk cancers, however, clearly benefit from surgery, with improved overall and cancer-specific survival.
In high-risk or advanced disease, radical prostatectomy can be used in combination with radiotherapy and androgen deprivation therapy (ADT) as part of a multimodal approach to maximise cancer control and delay time to disease progression. Patients with high-grade cancers confined to the prostate have a good outcome after prostatectomy, as do locally advanced cancers through multimodality treatment.
What is the rationale for removing the lymph nodes?
Examination of the pelvic lymph nodes under a microscope is the best way to determine whether they have been involved with cancer. This information can be used to guide management after radical prostatectomy. For example, men with a small number of positive lymph nodes may benefit from postoperative radiotherapy and ADT.
Current European guidelines recommend that lymph nodes should be removed in men with intermediate risk prostate cancer if the estimated probability of having positive lymph nodes exceeds 5%. A pelvic lymph node dissection should be performed in all men with high-risk disease.
However, it has yet to be proven that removal of the lymph nodes, in and of itself, provides a survival benefit for men with prostate cancer.
What are the possible side effects of radical prostatectomy?
- Loss of bladder control (incontinence) – 5-10% at 12 months
- Erectile dysfunction (impotence) – incidence varies
- Lack of semen during orgasm (dry orgasm) – all cases
- Urine leakage during orgasm – incidence varies
- Bleeding requiring blood transfusion – uncommon with robotic surgery
- Infection – uncommon
- Penile shortening – uncommon
- Lymphatic fluid collection – uncommon
- Bladder neck contracture – 1%
- Rectal injury, which may need formation of a temporary stoma to divert bowel contents – rare
What is the risk of incontinence after prostatectomy?
Most men experience some form of incontinence after surgery. The majority of men regain control of their bladder in the months following their operation. Younger men (<65 years) will recover bladder function earlier and more completely than older men (>75 years).
We expect 90% of men to recover bladder function by 12 months after surgery, which is defined as using either zero pads or one small security pad for strenuous activities (golf, picking up the grandkids, etc). Depending on the degree of incontinence, men who fail to recover bladder function after 12 months may require further treatment.
What is the likelihood of recovering erectile function after surgery?
Men are more likely to recover erectile function after surgery if they have good erectile function to begin with, are younger than 60 years old, and have undergone nerve-sparing surgery. This recovery is gradual and can take several months. Some men notice their erections continue to improve for up to three years after treatment for prostate cancer. Nerve-sparing surgery is not appropriate if there is a risk of leaving cancer behind.
What is penile rehabilitation therapy?
Penile rehabilitation therapy involves taking medications to increase blood flow to the penis, thereby reducing the scarring of erectile tissue that occurs from prolonged lack of oxygen from not having erections. It is usually started within two months of surgery. Although the optimal treatment strategy is still unknown, a typical regimen may involve taking a small dose of Viagra or Cialis every night.
Is robotic surgery better than open surgery?
At the end of the day, the most important factor that will determine the outcome of prostate cancer surgery is the surgeon. Having said that, robotic prostatectomy has been shown to be a faster operation with a shorter length of hospital stay, lower blood loss, and lower transfusion rates when compared to open surgery. Recent systematic reviews of major research studies have shown improved 12-month urinary continence, improved 12-month potency and equivalent early cancer outcomes with robotic prostatectomy compared with open and pure laparoscopic surgery. We currently await the longer-term results of a recent randomised-controlled Australian study, which found fewer perioperative complications with robotic surgery but no difference in functional (continence and potency) outcomes at 12 weeks.
As this is a surgical website, the discussion of radiotherapy shall remain brief. We recommend that interested patients seek the opinion of an experienced radiation oncologist.
Radiotherapy is generally offered as an alternative to surgery, particularly in men in whom surgery may not be appropriate. Radiotherapy has a role in multimodality treatment after surgery, and also for situations where not of all the cancer has been removed after prostatectomy. Surgery is still an option in situations where prior radiotherapy has failed to cure cancer, although in this setting the functional outcomes are worse.
How does radiotherapy work?
Radiotherapy uses high-energy radiation to cause fatal damage to cancer cells. This radiation is either produced in machine called a linear accelerator and directed towards the prostate in a beam, called external beam radiotherapy (EBRT), or emitted from radioactive seeds injected directly into the prostate, called brachytherapy.
What are the possible side effects of EBRT?
- Inflammation of the bladder, causing burning pain, urgency and bleeding – 20%
- Blood in the urine – 18%
- Inflammation of the rectum, causing bleeding, diarrhoea or faecal urgenchy – 30% (long term 3%)
- Urethral stricture – 4-8%
- Incontinence – 1%
- Erectile dysfunction – 25-60%
- Pain on ejaculation
- Dry orgasms
- Skin irritation
- Secondary cancer in up to 1 in 70 patients, which may take several years to develop
What are the possible side effects of brachytherapy?
- Worsening bladder symptoms – 20%
- Inability to pass urine – 1.5-22%
- Need for a TURP after seed implantation – up to 8.7%
- Incontinence – 0-19%
- Inflammation of the rectum – 5-21%
- ED in 40% of patients after 3-5 years
- Blood in the semen, painful ejaculation
- Radioactive seeds migrating to other parts of the body- 10%
- Urethral stricture – 10-25%
- Abnormal connection between urethra and rectum, causing faeces in the urine or vice versa 2%