Do You Know About Prostate Cancer Surgery?

Prostate cancer is  the most common type of cancer for men in the United States. Tens of thousands of new cases are diagnosed yearly.

There is no doubt about it.  Surgery is an invasive procedure.  There is evidence that surgery for prostate cancer is rampant in the United States with an increase of 60% between 1984 and 1990.  Contrast this with the Watchful Waiting approach used in Europe for the same stage prostate cancer.  Recent studies, however, do show a decrease in the number of men having radical prostatectomy procedures.  

While the medical community would like to see more incidence of the Watchful Waiting approach, patients find the approach too stressful. 

Actual Prostate Surgical Procedure

Let’s discuss the actual surgical procedure.  It is called a radical prostatectomy and is the complete removal of the prostate as well as tissue nearby.  The procedure can be further described by the incision used to accomplish the procedure.  These incisions are:

     Retropubic prostatectomy

          The prostate is reached via an incision in the lower abdomen;

      Perineal prostatectomy 

          The prostate is reached via an incision in the perineum which is the space 
           between  the  scrotum and the anus.

Radical prostatectomy consists of removing the entire prostate gland, the seminal vesicles, both of the ampullae (the enlarged lower sections of the two vas deferens which are the tubes that carry sperm from the testicles to the actual prostate gland) and the other surrounding tissue.  The portion of the urethra that travels through the prostate is cut away as well as the bladder neck and some of the sphincter muscle that controls urine flow.

Dissection of the pelvic lymph node is routine with a retropubic prostatectomy but with a perineal prostatectomy the dissection requires a separate incision.

Radical Prostatectomy

A radical prostatectomy is a serious, complicated, demanding procedure.  The surgery itself will take anywhere from 2 to 4 hours.  The patient will remain in the hospital for approximately 3 days.  He will require a catheter (tube to drain urine) for about 10 days to 2 weeks.  There is a small percentage (5 to 10%) of surgical related problems like bleeding or infection.  The risk of death from the surgery is very minimal and much less for younger men as opposed to older men who may be frail.

Post surgical, long term problems associated with prostatectomy range from sexual impotence, stool incontinence and urinary incontinence.   It is highly unlikely that a man will father children after the procedure.  The reason is that without the prostate, very little ejaculate is produced.

It is common for the majority of men to experience incontinence after surgery and have occasional dribbling when coughing or exerting themselves.  A few will lose all urinary permanently.   Some men are candidates for an artificial urinary sphincter which is implanted surgically or narrowing the bladder opening with injections of collagen.

Possible side effects from a Radical Prostatectomy

Stool or fecal incontinence (loss of normal muscle control of the bowels) may affect some men after their prostatectomy.  This is caused by muscle damage during rectal surgery and stool incontinence is also caused because of a reduction of the elasticity of the rectum.  What this does is shorten the time period between the sensation of the stool and the need to have a bowel movement.   The rectum can be scarred and stiffened by surgery or radiation.

Historically, a prostatectomy always resulted in sexual impotence.  Advances in surgical procedures called “nerve-sparing surgery” may reduce the risk of impotence.  The nerve sparing technique avoids cutting the two bundles of nerves and vessels that run along the surface of the prostate gland that are needed for an erection.

Unfortunately, this procedure is not viable for everyone, if the cancer is too large or if it is located too close to the nerves.    Under these circumstances, even with this technique many men (especially older men) will become impotent.

The fact is that most men will lose a degree of sexual function and if a man has a problem with erections before treatment, the nerve-sparing surgery is not indicated.

The chances of impotence run the gamut from 20 to 90% depending on age, stage of the disease and the type of surgery.

Radiation Therapy

Radiation therapy consists of using very high energy x-rays.  They are delivered by an external beam from a machine or actually implanted in the prostate to kill cancer cells.

External Beam RadiationTherapy

This treatment can also be used to treat men whose cancer tumors have advanced into the pelvis and can’t be removed with surgery if they have no indication of lymph node invasion.   Radiation therapy can also reduce tumors and relieve pain for men who have advanced disease.

External beam radiation therapy treatments are usually conducted 5 days a week for up to 6 or 7 weeks.  The treatments are painless with each session lasting just a few minutes.  Sometimes, if the tumor is extremely large, hormonal therapy may begin during the radiation therapy and can continue for several years.

Hormonal therapy prevents cancer cells from receiving the hormones that feed their growth.  In prostate cancer, male hormones are blocked with hormonal drugs or by surgically removing the testicles

How External Beam Radiation targets the Prostate Gland

The prime target of the external beam radiation is the prostate gland itself as well as irradiating the seminal vesicles as they are a common area of cancer spread.  It was once believed that irradiating the lymph nodes in the pelvis was necessary, but the long term benefits have proven that this only applies to certain situations.

Since a radiation beam is passed through normal tissue to reach the prostate, there is the risk of killing healthy cells.   Diarrhea is a side affect when radiation is applied to the rectum but diarrhea, in addition to fatigue caused by the radiation, will usually disappear when treatment is completed.

One of the long term affects of radiation is proctitus.  This presents as inflammation of the rectum, bleeding, bowel problems such as diarrhea and cystitis which is an inflammation of the bladder.  This usually leads to problems with urination.  Radiation therapy also results in impotency for 40 to 50% of men treated.

Some of these side effects may be minimized by using higher energy radiation beams that can be more precise in targeting the affected area.  Coupled with computer technology, treatments are tailored to exactly match the anatomy of the man being treated.  This type of state of the art equipment is not always readily available.

Internal Radiation Therapy

Internal Radiation Therapy is a procedure that delivers a very high dose of radiation to tissue in the immediately affected area and minimizes the damage to healthy tissue like the rectum and the bladder. 

This is accomplished by inserting dozens of tiny seeds that are radioactive directly into the prostate gland.  The therapy depends on ultrasound or CT that guides placement of very thin needles through the skin of the perineum.  The needles deliver the tiny seeds (made up of radioactive palladium or iodine) directly into the prostate using a pre-determined, customized pattern created by extremely sophisticated computer programming.  This high tech process allows the needles and seeds to directly conform to the size and shape of each prostate.

This procedure is normally completed in just an hour or two.  It is done under a local anesthesia and the patient goes home the same day.

Radiation is emitted from the seeds for up to several weeks.  Once insertion is complete, the seeds remain in place causing no harm whatsoever. 

Some physicians use a different approach.  They will use a more powerful radioactive seed and implement over several days.  These are temporary implants.  This procedure requires hospitalization and may be combined with low doses of external beam radiation.

Long Term Results of Internal Radiation Therapy

Long term results are not yet in on this procedure primarily due to the fact that internal radiation therapy is still a recent process and is limited to just a few patients.  However, after 5 years more than 90% of patients treated still remain cancer free.

The procedure is not recommended for large, advanced tumors or for men who were previously treated with transurethral resection of the prostate (TURP) or Benign Prostatic Hyperplasia (BPH).  These men are at a higher risk for urinary problems.  When a man has small, well-differentiated tumors it is an option that has fewer side effects as well as being less invasive.  It is less costly than external radiation or surgery and requires a shorter hospital stay.

Discomfort experienced post-implant is usually controlled by oral painkillers and a man can expect a few weeks of incontinence.  Long term problems like prostatitis (inflammation of the prostate gland) are infrequent and usually not severe in nature.  Only 15% of men under the age of 70 experience sexual impotence and 30 to 35% of men over the age of 70.

Treatment options for cancer spread beyond the prostate.

In this situation the localized therapies just won’t be enough to stop the growth.  This is Stage III and radiation therapy will most likely help by keeping the tumor in check.   Radiation combined with hormonal therapy will help to slow the growth. 

Hormonal therapy

We briefly touched on this subject in the previous chapter, but now let us explore this therapy.

With hormonal therapy, the goal is to cut off all production of male hormones, such as testosterone, resulting in castration.  Castration can be surgical or medical but the end result is the same and for good reason.

Prostate cancer cells can actually “feed” on male hormones causing them to grow.  Blocking the hormones with an antiandrogen (drugs that block male hormones from circulating in the blood) will slow the growth of the cancer cells.  This process is the equivalent of a medical castration.

There are numerous approaches to the use of hormonal therapy.  Different drugs have been combined to test the results.  An example of one such combination is known as maximum androgen blockade.  This is a total hormonal therapy usually combined with either surgical or medical castration.  An antiandrogen pill is ingested each day for months or years. 

Evidence as to the efficacy of this approach has proven that there is no significant difference in the effectiveness of this process as opposed to standard hormonal therapy.  However, surgical and hormonal therapies in combination do seem to relieve symptoms.

When considering surgical castration versus medical castration, it’s important to keep one fact in mind.  Medical castration can be reversed simply by ending use of the drug.  Oddly enough, in some cases ceasing the hormonal treatment has temporarily interrupted the growth of the cancer.

While hormonal therapy in the case of metastatic cancer seems to work, sadly, the reprise is only temporary.  Remission will normally last for 2 or three years.  At some point, those cancer cells that do not need testosterone to grow will begin the growth cycle again.  If this takes place a second array of hormonal drugs (progesterone or hydrocortisone to name two) may be considered.

Clinical Trials

Investigating the possibility of participating in clinical trials is always an option for treatment.  Clinical trials are usually new drugs, combination of drugs or mechanical in nature.

Cryosurgery

This process is used to kill prostate cancer cells by freezing them.  Similar to the tiny radioactive seeds delivered through thin needles that we discussed previously, rather than seeds liquid nitrogen is passed through thin probes that are passed through needles that have been passed through the perineum directly into the prostate.  The liquid nitrogen will form a ball of ice from the cancer cells and as the frozen cells thaw out they break up.  This procedure will take a couple of hours under anesthesia which can be either local or a spinal and a 1 or 2 day hospital stay.

There is a downside to this treatment.  Even though a “warming catheter” is inserted into the penis to protect the urethra, the overlying nerve bundles usually freeze as well rendering the man impotent.

Chemotherapy

While chemotherapy is an aggressive approach, according to the medical community it is not necessarily effective as a choice to fight the slow growing prostate cancer cells.

This does not mean that it should be ruled out entirely.  New anti-cancer drugs are always being studied and released.  There are a few currently under study that are being included surgical or radiation therapy in men at Stage III prostate cancer.

Another study includes them in the regimen along with hormonal therapy.  This is specifically being used for men with advanced cancer that is not responsive to hormonal therapy by itself.

Early Hormonal Therapy

Just as the name signifies, this is the practice of starting hormonal therapy immediately upon the diagnosis of prostate cancer.  The goal is to slow the growth of cancer cells that have grown beyond the prostate and into surrounding tissue and even the lymph nodes.  Sometimes early hormonal therapy helps in shrinking the tumor.

DISCLAIMER: Note that the contents here are not presented from a medical practitioner, and that any and all health care planning should be made under the guidance of your own medical and health practitioners.