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Prostate Cancer

Prostatectomy

Q. What exactly is a prostatectomy?

A. Specifically, this means the removal of the entire prostate, the seminal vesicles (small sac-like organs attached to the back side of the prostate) and some surrounding tissue. This can be done through a lower abdominal incision (retropubic prostatectorny), through a small incision in the perineum (the space between the scrotum and the anus), or it can be done laparoscopically (multiple very small incisions) using small cameras and instruments to work inside the pelvis.

See the section on “da Vinci Prostatectomy” for more information regarding the laparoscopic option.

Q. Why is prostatectomy still popular when there are non-surgical and less-invasive treatments available?

A. Some of this has to do with physician and patient preference, but the major factor is probably the prostatectomy's long history of effectiveness. Cure rates in the 90+ percent range are expected when the tumor proves to be confined to the prostate. Although there is certainly some debate in this area, long-term (15 +-year) survival rates are generally believed to be somewhat better than with the other treatment options.  PSA is expected to be undetectable after prostatectomy, and this makes follow up fairly simple and worry free.

Q. What happens during a typical hospitalization for a prostatectomy?

A. You are admitted to the hospital on the same day of the surgery, having taken laxatives at homeprior to arrival. Some patients have also set aside some of their own blood according to their own and their surgeon's preference. The surgery itself is performed under general or occasionally spinal anesthesia and usually takes two to four hours.

Following surgery, you spend several hours in the Recovery Room and then are transferred to a regular hospital room for the remainder of your stay. The typical stay in the hospital is one to three days if there are no complications. You have a catheter draining your bladder and this stays in for approximately 10 days. You are taught how to care for this. Very quickly after surgery, you are encouraged to do deep breathing exercises, to get out of bed and to begin walking. The diet is slowly advanced, first to clear liquids and then usually to solids before discharge. IV lines and drains are removed prior to discharge.

Q. What is follow-up care like?

A. An office appointment at about 10 days after surgery is necessary to remove any skin staples and the catheter. After this, you will be expected to get PSA blood tests at regular intervals, usually every three to four months for the first two years and then less frequently thereafter.  You will be taught exercises that will aid in recovery of urinary control. You will also be given the option of medicine or injections for the purpose of sexual rehabilitation. This is highly recommended to begin soon after surgery for patients who wish to resume having sexual intercourse in the future.

Q. How long does full recovery take?

A. Of course this varies widely from patient to patient, but there are some general rules of thumb. You should not drive a car for 10 days after surgery and should not lift anything over ten pounds for six weeks. After the catheter is removed, there is a period of incontinence (involuntary urinary leakage) lasting from a few days to several months, depending on the individual. Patients are generally tired and require extra rest for about a month after surgery.

Patients who have a non-strenuous job and who have the desire to, can usually go back to work part-time after the catheter is removed. Patients who do heavy manual labor typically need to be off work for 8 to 12 weeks.

Q. What are some of the drawbacks of prostatectomy?

A. Even though prostatectomy has been refined and considerably improved during the past 15 years, it is still a major operation and has significant risks. One drawback is that, despite our best testing and effort before the surgery, we will find out about 20 percent of the time after the prostate is removed that the tumor goes beyond the capsule  of the prostate. For these men, the long-term cure rate is lower than the 90+ percent spoken of when the cancer is contained.

Q. What risks and complications are associated with prostatectomy?

A. Certainly most patients do just fine, but some of the most important and most frequent risks are as follows:

  • Bleeding - This surgery always involves some blood loss. The chance of needing to use banked blood is less than 10 percent and is even lower (about four percent) when the patient has donated his own blood for his surgery. For patients having robotic prostatectomy, blood loss is significantly less.

  • Infection - Wound infections or urinary infections are unusual.

  • Impotence - Even with modern "nerve-sparing" techniques, loss of potency is experienced in at least 30 percent of patients. The younger the patient and the better his potency before surgery, the better his chance of being potent afterward.

    Currently, we are using a device called "Cavermap," which allows us to better identify nerves during surgery. Preliminary information suggests that this device allows return of potency in about 70 percent of ideal patients. We also make use of postoperative "rehabilitation" to improve potency rates. Many treatments for impotence are available if this side effect does occur.

  • Incontinence - All patients have some leakage immediately after the catheter comes out. About two percent of patients will still have enough leakage that they require a pad for a year after surgery. About 20 percent of patients will have a slight or very infrequent amount of leakage not requiring pads.

  • Damage to adjacent organs - Less than one percent of the time, structures such as the rectum or ureters can be damaged during the operation. Usually these injuries can be repaired at the same time as the initial surgery.

  • Death - Less than one percent of the time, a patient can have a catastrophic problem such as a heart attack during or after surgery that can lead to the patient's death.

Q. How will my  lifestyle be changed by having my prostate removed?

A. Really very little. After the initial post-op period, you should feel well. You should urinate normally and carry on all activities as you did before. You are no longer fertile and may need assistance to be potent, but these are the only usual changes.

Pros & Cons

Pros: Cons:
Widely considered to be the gold standard (the standard by which other treatments are judged) It is still a major operation with considerable discomfort and time away from normal activities
Long term cure rates are well proven and compare favorably to other treatments Many patients are not good candidates for surgery for a variety of reasons
The surgery has improved dramatically over the past 15 to 20 years:
  • Faster
  • Less blood loss
  • Less invasive
  • Shorter hospitalization
  • Less risk of impotence and incontinence
The quality of results is dependent upon the patient, the surgeon, and the institution where the surgery is performed
PSA is usually 0 after surgery which makes follow up easier and less anxiety provoking The chance of long term urinary incontinence is the highest of all the major treatments
Urination is usually very comfortable, even improved, after surgery As with other treatments, there is no guarantee of cure
  Some patients are not pleased with the results, for a variety of reasons
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