Treating Prostate Cancer, Part IV: Surgery

About 186,320 American men will be diagnosed with prostate cancer this year. Most cases will be diagnosed by PSA (prostate-specific antigen) screening, with transrectal ultrasound-guided prostate biopsies. And most patients will have early disease that appears confined to the prostate itself.

Men with early prostate cancer face a choice of management options. The major choices are active surveillance, radiotherapy, and surgery. More often than not, men choose surgery. That means a radical prostatectomy to remove the entire gland. It's an obvious choice for men who want to "get it all out" and a reasonable option for any generally healthy man with a life expectancy greater than 10 years.

Most American urologists view the radical prostatectomy as the "gold standard" therapy for localized prostate cancer. But before a man submits to the knife, he should understand the advantages and disadvantages of surgery. And in the increasingly complex world of prostate cancer, he may be offered a choice of surgical techniques.

The operations

The radical prostatectomy is not a single operation but a family of closely related procedures. Dr. Hugh Young began it all in 1904 when he introduced the perineal approach. The retropubic approach was developed in 1945 and quickly became the standard method of removing the gland. Then, in 1983, Dr. Patrick Walsh introduced the anatomic radical prostatectomy, which is better known as the "nerve-sparing" operation designed to preserve erectile function. Improvements in anesthesia and post-operative care followed in the late 1980s and early '90s, making the operation safer and hospital stays shorter. And since 1998, the less invasive laparoscopic radical prostatectomy and its variants have grown in popularity.

All these approaches have a common goal: to cure prostate cancer by removing all the disease. As a result, the operation removes the entire prostate gland along with the seminal vesicles and surrounding tissues. It's not an easy task. The prostate lies deep within the body, guarded by the narrow male pelvic bones, wedged between the rectum and bladder, wrapped around the urethra, and surrounded by important nerves that are vulnerable to injury (see figure).

Surgeons can perform an open prostatectomy from either of two directions. The older perineal prostatectomy uses an incision in the area between the anus and scrotum. But most doctors now favor the retropubic technique, which uses an incision in the lower abdomen. Its main advantage used to be that it allowed surgeons to inspect pelvic lymph nodes and remove suspicious ones to be sure they do not contain cancer before operating on the prostate itself; in the era of PSA screening and advanced imaging, however, lymph node removal is rarely necessary. Even without that advantage, most urologists believe the retropubic approach gives them a better view of the reclusive gland, reducing the risk of nerve injury and rectal complications.

If the lymph nodes appear normal, the surgeon carefully separates the prostate and seminal vesicles from the surrounding tissues. To actually remove the gland, the doctor has to cut through the urethra just above the bladder, but will sew the tube that carries urine out from the bladder back together once the prostate is removed. Once removed, the tissue is sent to the pathology laboratory for microscopic evaluation. If the cancer is confined to the prostate itself, the operation has the potential for cure, but if the tumor has already extended through the capsule surrounding the gland additional radiation or hormonal treatment may be recommended.

The nerve-sparing prostatectomy is an important variation on the theme. It is designed to protect and preserve the fine network of blood vessels and nerves that run along both sides of the prostate. If the nerves are not damaged, there is a greater chance that the patient will preserve his potency, but the operation requires special skill. Some doctors are concerned that a nerve-sparing operation may be more likely to leave some cancer cells behind, but 20 years of experience at major medical centers provides general reassurance that the nerve-sparing operation controls prostate cancer as well as standard surgery.

Nearly all radical prostatectomies are performed under general anesthesia, but spinal anesthesia is also an option. The operation is quite safe, with a mortality rate below 1% in most centers. After spending three to five hours in the operating room, the average patient will spend just one to four days in the hospital. Even so, he will need several weeks to recuperate at home and will have to urinate through a Foley catheter for one to three weeks while his urethra heals.

Like other minimally invasive operations, the laparoscopic prostatectomy aims to accomplish exactly the same goals as its traditional open counterpart. The difference is access. In the laparoscopic procedure, surgeons use small incisions, usually about a half-inch in length, to enter the body. Because they can't put their hands through such small openings, they use tiny instruments to repair damaged tissues or remove diseased organs. If all goes well, minimally invasive operations achieve the usual therapeutic goals with less postoperative pain, shorter hospitalizations, and faster recoveries.

The first laparoscopic radical prostatectomies were performed in 1991, using the retropubic approach. Like other abdominal laparoscopic operations, they required filling the abdomen with gas under general anesthesia. And they succeeded in removing the prostate gland and seminal vesicles, just like the open operation. Nevertheless, the operation did not take the urological world by storm. The early operations were very slow, taking an average of more than nine hours, and they did not offer any advantages over the standard approach.

Since 1998, however, laparoscopic prostatectomies have improved greatly. The reason is experience. The open operation is difficult and delicate in its own right, and it's important to have an experienced urologist (see "Selecting a surgeon"). The laparoscopic prostatectomy requires even more training. The learning curve is steep, but urologists who have 40 to 60 operations under their belts are reporting results quite comparable to those of standard surgery. With an experienced team, the laparoscopic operation is nearly as fast as the ordinary operation and requires fewer blood transfusions, produces less pain, and allows a quicker recovery and return to activities. The complication rates are similar, and surgeons can perform nerve-sparing operations with either approach. Because the operation is relatively new, long-term results are not available, but early results are generally favorable.