A surgical operation to remove the whole prostate gland together with the seminal vesicles is called a radical prostatectomy. The prostate is normally taken out through the abdomen (called the 'retro-pubic approach'). For patients with intermediate grade prostate cancer the pelvic lymph nodes (part of the immune system) may be removed. For high grade cancers, they should be removed. Radical prostatectomy is normally offered to those with localised cancer, a life expectancy of 10 or more years, and where the man’s age and general health allow. In some cases surgery may be considered for locally advanced cancer.
Nerve-sparing surgery, which aims to preserve erectile function, is normally undertaken where possible. If the cancer is found close to the edge of the prostate, this lessens the chance of a complete cure. Nerve preservation does not necessarily ensure that erections can be subsequently achieved, as the nerve bundles lie extremely close to the prostate.
Surgery is now only performed in larger specialist cancer centres, where a greater number of operations are done. The greater the experience of the surgeon, the greater the likelihood of a satisfactory result.
Advantages and disadvantages of surgery
How is the operation performed?
It is always performed under a general anaesthetic. The urethra is cut during the operation and, after removal of the prostate, is then reconnected to the bladder with stitches. The patient wakes with a catheter in the penis (which stays in place for a period after leaving hospital), tubes in the abdomen and arm drip(s), which are both removed during the hospital stay.
After the operation
Painkillers are prescribed as needed, and the wound dressings removed. Constipation can sometimes be a problem after surgery. Only prescribed laxatives should be taken, and straining should be avoided. Blood in the catheter can be seen in some cases, often after opening the bowels, but this need not be a concern unless it becomes severe. Advice will be given on using the catheter.
After removal of the catheter (some 10 days later), some slight incontinence should be expected in many cases but, with the pelvic floor exercises that you will be given, this should return to normal over time. This can last from three to six months. You will be given incontinence pads to wear for this period. In very few cases incontinence is permanent. This can, however, be considerably improved by an operation to fit a device to help enable controlled urination - see Long-term Severe Incontinence.
Follow up care
After the operation the prostate will be sent to the pathology lab for analysis. This will reveal the extent and grade of the cancer, and whether it remained enclosed within the prostate, or whether it extended up to or beyond the cut edge of the prostate. The presence of cancerous cells in these surgical margins is called a positive surgical margin. If found, or if cancer is found to be outside the prostate, there is a greater likelihood of a recurrence of the cancer over time. Radiotherapy or hormone treatment may be recommended in this event.
Following a prostatectomy a high sensitivity PSA (down to 2 decimal places) is usually required. A sustained high sensitivity PSA result after the operation of less than 0.05ng/mL over several years will indicate the likelihood of a cure (but note that the nationally agreed target standard is <0.2ng/mL). This test will be required quarterly for 12 months, then 6 monthly until five years after and thereafter annually for the rest of a man’s life. Should PSA levels increase, further treatment, such as radiotherapy or hormone therapy, will be advised.
Side effects of surgery
1. Ejaculation. As the seminal vesicles that produce man’s ejaculate as well as the prostate are removed, ejaculatory function is lost. Orgasm is always possible but it will be dry. Although this is a concern, some men report the experience as being enhanced. (Should a younger man who wishes to father children consider surgery, opportunities for sperm banking should be discussed.)
2. Erections. After nerve-sparing surgery partial erections normally occur, and better function can return over time. In some cases useful erections can take up to 3 years after the operation to return. To aid recovery, urologists now recommend the use of low-dose Viagra (or similar) on a regular basis. Other methods of obtaining erections are available on the NHS (see Sexual Problems).
3. Continence. Some slight incontinence is common for a few months, as the sphincter (the muscle that controls the urine flow) is tethered by dissolvable stitches. Pelvic floor exercises, done before and after the operation, may aid speedier return to normality (see Problems with Continence). At the hands of a trained surgeon, incontinence is rarely permanent. Weight loss, if appropriate, will help.
Methods of surgery
Three main methods of surgery are now used: open, keyhole (or laparotic), and robotic. Current research is showing no appreciable difference in long-term outcomes. You can read about each of these in their individual sections (see Menu at the top left of this page).