The operation to remove the prostate, called a radical prostatectomy, is one of the most difficult surgical procedures there is. There are several reasons for this: One is simply the prostate’s hard-to-get-to location deep in the pelvis. Two, there are a lot of blood vessels and important nerves around there, particularly the nerve bundles that are responsible for erection, which sit on either side of the prostate. It takes an expert surgeon to know how to navigate this treacherous terrain, which also includes the rectum, bladder, and a muscle called the urinary sphincter, which you use for urinary control.
And three, there is the urethra. The urethra runs down from the bladder all the way through to the tip of the penis; it’s the tube through which you urinate. Strategically placed between the bladder and the penis is the prostate. Basically, the prostate is like a walnut-sized donut, and the urethra is like a straw stuck right in the middle of it. You can’t take out the prostate without cutting through the urethra. And you can’t leave the urethra cut, because the urine would just spill out of the bladder into your body, so it must be reattached to the bladder. None of this is easy, and all of it needs to be done skillfully.
We’re talking about the difficulty here to make a few key points:
Because this is such an extremely complicated operation, it is vital that you have a skilled surgeon who is an expert on this procedure. It is also important that you understand that this is not an operation to be taken lightly. If you have heart problems or other health concerns, radiation therapy may be a better option for you. If you have cancer that seems to be slow-growing and you are a candidate for active surveillance, this is one of the best arguments in favor of being closely followed instead of taking immediate action.
However, if you have cancer that needs to be treated, and you have a skillful surgeon, radical prostatectomy is an excellent way to get rid of the cancer; it has been the gold standard of treatment for decades, and is most recommended for men who are otherwise healthy and can expect to live at least 15 more years. Because with PSA screening many men are diagnosed when the cancer is confined to the prostate, surgeons are often able to preserve one or both of the fragile, weblike nerve bundles that are responsible for erection.
In addition, surgery is also being performed in clinical trials in men with oligometastasis – cancer that is within the prostate, except for one spot elsewhere. Cancer needs a certain critical mass to thrive, and when the vast majority of cancer is removed, the remaining few cells take such a huge hit that they may take years to bounce back enough to cause a problem. Another point to consider: If it turns out that you need extra treatment, it is easier to get salvage radiation therapy after surgery, than to get salvage surgery after radiation therapy. This is because radiation therapy weakens and damages the prostate and surrounding tissue, and makes it more fragile and difficult to remove.
Another very important point to keep in mind: Don’t make your treatment decision based only on your sex life. Erectile dysfunction can and often does occur after radical prostatectomy, but if the nerve bundles are preserved, the ability to have an erection can slowly return over time. With radiation, erectile function may slowly diminish over time – so with either treatment, there can be ED. But the good news is that there is more and better help for this now than ever before.
The main goals of radical prostatectomy, according to Patrick Walsh, M.D., the Johns Hopkins urologist who invented the “nerve-sparing” procedure, are “removing the cancer in a careful but thorough way, preserving urinary continence, and preserving sexual function, in that order. This is because there are many ways to restore sexual function. Where there’s a will, there’s a way.”
Don’t let fear of side effects keep you from getting treatment while your cancer is most curable. Incontinence (leakage or inability to control urine) is another worry for many men who are thinking about radical prostatectomy. If you have an experienced surgeon, the risk of long-term incontinence is less than 3 to 4 percent, and there are ways to treat it if this remains a problem.
If you are worried about the side effects of treatment – good! You should be. This is why we have emphasized many times on this website that it is absolutely essential to do your due diligence and make sure you have figured out the best form of treatment for you, and found the best doctor to carry it out. And then, if you have cancer that needs to be treated, it is best to get after it soon. Don’t give it time to spread.
If your cancer needs curative treatment and you don’t get it, either with surgery or radiation, and the cancer spreads to distant sites, right now the only thing that’s certain is that you will need hormonal therapy – drugs to eliminate testosterone, the male hormone that helps feed the prostate cancer. If you are on hormonal therapy, it will no longer be a situation of “where there’s a will, there’s a way.” Hormonal therapy reduces the libido to the point where potency is no longer an issue.
So, if you need curative treatment, you have two good options: surgery or radiation. If you choose surgery, there are several different ways to go about it: open retropubic surgery (through a three-inch incision from your pubic area to the belly button); open perineal surgery (made through an incision in the space between the scrotum and rectum); laparoscopic surgery (through several tiny holes made higher on the abdomen, around the level of the belly button); and laparoscopic robotic surgery, the same tiny holes, except the surgeon uses a four-armed robotic machine. (Important point: the surgeon still guides the robot – thus, even if you have the fanciest machine available, with all the bells and whistles, this machine is only as good as the surgeon who’s using it).
Don’t just pick the procedure; instead, the procedure should be what’s best for you and your particular situation. For example, if you have had previous abdominal surgery, either open surgery or an “extraperitoneal” laparoscopic procedure might be better for you than the robotic procedure, which is usually performed using a “transperitoneal” approach. Trans means “through.” The peritoneum is the membrane that envelops your intestines and abdominal organs. In a transperitoneal technique, the surgeon cuts right through this membrane to get to the prostate – so if you’ve had a ruptured appendix or colon, for instance, there might be some scar tissue in your abdomen that might make this more difficult. The open technique “steers clear of the whole area,” says Edward Schaeffer, M.D., Ph.D., Chairman of Urology at Northwestern University, “because it is performed outside the peritoneal cavity.”
On the other hand, if you have ever had mesh placed across both sides of your abdomen to repair a hernia, the robotic procedure might be a better way to go, Schaeffer adds. “Sometimes this mesh is right under where we need to make the incision during open surgery, and this can complicate access to the prostate. But the robotic procedure avoids going through the mesh, because it takes place underneath it.”
If you have a very large prostate, greater than 100 grams, open surgery is most likely better for you, because it gives the surgeon more room to work.
Note: If you are very overweight, most surgeons would recommend that you take a couple months and lose a few pounds. There are extra physical challenges trying to remove an organ that’s already hard to get to, when the surgeon needs to work around a lot of abdominal fat; in addition, the extra weight of the abdomen pushing on the diaphragm can make it harder for the anesthesiologist to keep good air flow to the lungs. Your cancer won’t have a sudden growth spurt in the next few weeks or months. A bonus: losing weight will not only help you recover better from the surgery, but will make it more likely that your cancer won’t return.
Which procedure is better? Several things to consider here, starting with two very important words: Surgical margins. When the surgeon removes the prostate and sends it to the pathologist, one of the things the pathologist does is to see whether there are any cancer cells in the margins – the very edges of the removed prostate. Expert surgeons, such as Walsh and Schaeffer, usually have cancer cells present – this is called positive surgical margins – in fewer than 4 percent of their patients who undergo open prostatectomy.
But these rates vary. A lot. “The wide range of positive margins is a pretty good indicator that a lot of surgeons do not perform the open procedure very well,” says Schaeffer, “and when someone claims to be doing a better job of removing the cancer using the robot, maybe that’s because this surgeon was not very good with open surgery.” Similarly, the positive margin rates with the laparoscopic procedure, including the robotic-assisted procedure, are all over the board, too.
“The expert surgeons who have done hundreds or thousands of these procedures are the minority,” he cautions, “and the best place to find them is at centers of excellence. But the published margin rates for prostatectomy – open or robotic – from these high-volume centers are not generalizable to all surgeons.” Experienced surgeons can feel and see changes in tissue that say, “there’s cancer here,” and when this happens, they remove a little bit more tissue than they would otherwise. That experience, and just a few extra millimeters of tissue, can make the difference between a positive surgical margin and a negative one.
Final decision: Go with your gut. Once you have determined the right procedure, the last choice is up to your gut. There’s a difference between cockiness and quiet confidence, especially when that person is going to be cutting into your body. You don’t want the surgeon who just talks the talk, as they say, but walks the walk. You want a surgeon who knows how to do the procedure, expertly, and who also cares about how you’re doing after it’s over. The best doctors are available for their patients. Some of them, like Walsh and Schaeffer, give patients their cell phone number for issues that come up after business hours. (Note: This is not a privilege to abuse! If your doctor trusts you enough to give you his or her cell phone number, use if it you need to, but not for something that can wait a few hours. Doctors need their sleep, too.) What we’re talking about here is putting yourself into good hands – those of your surgeon, and also of the nurses who will be taking care of you while you’re in the hospital. By the way, that’s another good sign: Does your surgeon mention the nursing care? The best ones know full well the importance of good nursing care, and they’re proud of the nurses on their team. A good nurse can make your hospital stay as close to pleasant as a hospital stay gets; a bad one can make your life miserable.
Are you in good hands? If you feel comfortable with the procedure, and you trust your surgeon, then you’re as ready as you’ll ever be for major surgery, for recovery, and for getting on with the rest of your life.