Note: The information provided below is basic information only. The content of this section will be upgraded in the near future to offer a more detailed commentary on the first-line surgical treatment of early stage (localized) disease.
Surgical treatment for prostate cancer is most common among relatively younger (≤70 years) and healthier patients whose tumors are believed to be confined to the prostate (i.e., clinical stages T1N0M0 or T2N0M0). In appropriate cases, selected clinical tests may be performed in an attempt to clearly rule out gross evidence that the tumor extends beyond the prostate. These tests potentially include CT or MRI scans.
There are three basic forms of radical surgery for removal of the prostate (an operation that is older than you might expect):
Open radical retropubic prostatectomy (RRP), in which the surgeon cuts downwards through the lower part of the abdomen to be able to remove the prostate
Open radical perineal prostatectomy (RPP), in which the surgeon cuts upwards through the perineum (the space between the scotum and the anus), and
Minimally invasive or laparoscopic radical prostatectomy (LRP), in which very small incisions are made into the abdomen, and the surgery is carried out using tools that the surgeon manipulates remotely (“at a distance”)
In recent years it has become common for many surgeons to carry out laparoscopic radical prostatectomy using a so-called “robot” to assist with certain parts of the procedure, but such equipment is not essential, and some of the most skilled laparoscopic prostate cancer surgeons do not use such equipment.
At the end of the day the objective of all three types of surgery is precisely the same: the complete removal of the prostate, together with the seminal vesicles, and the elimination of all localized prostate cancer, followed by reattachment of the ureter to the bladder neck.
Ideally the operation is completed without damage to either of the two neurovascular bundles, so that the patient also has the highest possible chance of regaining full erectile function after a period of recovery. However, to quote Dr. Patrick Walsh (the man who developed “nerve-sparing” prostatectomy) and his co-author, Janet Farrar Worthington, from their original book The Prostate: A Guide for Men and the Women Who Love Them:
Think about what is really important! The primary goal here isn’t to preserve potency, but to get rid of the cancer in a careful but thorough way.
Prostate cancer surgery is first and foremost a “life-sparing” operation and is all about getting rid of your cancer. Making sure you can have erections later on (“nerve-sparing”) is an added benefit, because if you don’t get rid of the cancer you may not be alive to have erections anyway!
All forms of surgery for removal of the prostate are associated with a series of well-known complications. These include:
Lack of bladder control (urinary incontinence)
Urethral stricture (scarring of the join between the ureter and the bladder neck, leading to difficulty in urination)
Normal risks associated with anesthesia and any major surgical procedure.
Lower complication rates are usually found among highly skilled surgeons who carry out a significant number of prostatectomies on a regular basis. In other words, practice appears to make the surgeon more competent. However, even the best surgeons have patients with unexpected complications. Any form of prostatectomy is a major operation and has risks attached.
There are two important potential benefits of laparoscopic surgery compared to any form of open surgery:
Less blood loss during surgery because of the less invasive nature of the procedure, and
A shorter recovery time post surgery
Having said that, a talented, experienced surgeon using an open surgical procedure is always likely to be a better bet than a less talented, less experienced surgeon using a laparoscopic procedure (with or without robotic assistance). The patient should always remember that his objective is the surgical removal of all tissue that may harbor prostate cancer, with minimal risk for complications. The skill and experience of the surgeon are the primary determinants of this outcome, not the technique or the equipment he or she has decided to use.
Patients considering surgery are advised to review the article on “How to pick a prostate cancer surgeon” elsewhere on this site. For preliminary information about the effectiveness of watchful waiting compared to radical surgery (based on a single, large, randomized, multicenter Scandinavian trial), please click here.