Prostate Cancer Surgery: What Are My Options?

Prostate cancer ranks as the most prevalent cancer, excluding skin cancers, affecting men in the United States.

According to the National Cancer Institute (NCI), about 165,000 new cases of prostate cancer are diagnosed each year.

It accounts for nearly ten percent of all cancer diagnoses. Each year, about 30,000 deaths are attributed to it.

By itself, cancer confined mostly to the prostate gland has a five-year survival rate of nearly 100 percent.

Of course, if cancer has already spread to other areas when first detected, the five-year survival rate is much lower – roughly 30 percent.

The NCI has published a general overview of prostate cancer as well as details on the scope of treatments for it. (1)

Types of Prostate Cancer treatments

As with most cancers, prostate cancer has multiple treatment options. Each option has a range of side effects that may affect a man in different ways.

Some men might find the potential side effects of a particular treatment acceptable.

Others may have great dismay about one or more side effects. Today, a man diagnosed with prostate cancer has more options for treatment than ever before.

Each individual should carefully assess their options and select a treatment that aligns best with their personal needs.

According to the NCI, the most common treatments are:

• Watchful waiting or active surveillance
  
  

• Surgery
  
  

• Radiation therapy and radiopharmaceutical therapy
  
  

• Hormone and bisphosphonate therapy
  
  

• Chemotherapy
  
  

• Biologic therapy

Several other procedures are being evaluated or tested in clinical trials. Each man should carefully consider all options before submitting to treatment. Prostate cancer is typically slow-growing.

Time spent reviewing all options, getting second opinions, or employing an independent consultant can often prevent mountains of future heartache.

Excepting the watchful waiting option, all treatments for prostate cancer have side effects. Some may be debilitating, especially to a man that is highly sexually active.

Note that the watchful waiting option is only available for low level (stage 1) early prostate cancer.

The second option, surgery, is the most commonly used. This article is specifically about the surgical option. (See the NCI article referenced above for other options.)

Types of Surgery

For prostate cancer, the most common surgical procedure is a radical prostatectomy. It is the complete surgical removal of the entire prostate gland.

While there are other types of surgery for prostate issues, they are typically used for conditions other than prostate cancer.

There are three common variations for a radical prostatectomy. They vary by the surgeon’s approach to the body and are:

•Retropubic prostatectomy

• Perineal prostatectomy

• Laparoscopic prostatectomy

The object of each of these procedures is to remove the prostate gland altogether, seminal vesicles (where the prostate stores fluid for ejaculate), and the vas deferens (the tubes that deliver sperm cells for ejaculation).

In the first, an incision is made in the abdominal wall from approximately the belly button to the pubic bone (just above the penis).

In a perineal prostatectomy, the incision starts at the bottom of the scrotum and goes almost to the anal opening.

A laparoscopic prostatectomy approaches the prostate through several small incisions in the abdomen through which lighted magnifying instruments and cutting tools are inserted. A flexible bag is often inserted to remove the prostate tissue and other removed tissue.

Advantages and Disadvantages of Radical Prostate Surgery

All surgery carries the risk of complications such as; bleeding, infection, stroke, heart attack, blood clots, and adverse reactions to anesthesia.  

Most prostate surgeries necessitate a brief hospital stay to mitigate the potential complications.

Typically, the surgery also removes lymph nodes in the surrounding area to check them for cancer metastasis. Each procedure has advantages and disadvantages:

• A retropubic prostatectomy is the most commonly performed procedure of the three above. Its most powerful advantage in that it has the highest success with erectile nerve-sparing techniques. 
  
  

• Perineal prostatectomy is lesser used today due to its inherent difficulty in preserving erectile nerves. It is also more challenging to remove lymph nodes with this procedure.
  
  However, compared to the abdominal retropubic approach, it is quicker to perform and typically results in less blood loss and complications. A report suggests this procedure may have specific advantages for obese men. (2)
  
  

• Laparoscopic and robotic laparoscopic prostatectomy have been growing in popularity in recent years. The small openings required for the laparoscopic surgical tools heal faster than a large incision.

Faster healing times promote shorter hospital stays and less blood loss. The main disadvantage is that a laparoscopic approach is not as effective for nerve-sparing as the retropubic approach.

This procedure requires the most surgical skill and training for surgeons performing it, especially with the robotic approach.

Side Effects of Radical Prostatectomy

In addition to the side effects common to all surgeries, radical prostate surgery has several effects specific to the male anatomy.

Retrograde ejaculation is unavoidable with any radical prostate surgery. This is where the man’s ejaculate does not exit from the penis but instead is directed backward to the bladder.

Retrograde ejaculation generally does not affect orgasmic sensation. Orgasms can still occur, even with a non-erect penis, but all prostate surgery affects orgasmic sensation.

Some men claim orgasms are better, but the more typical response is that the orgasm sensation is deteriorated.

Other potential surgical side effects are; urethral strictures, rectal incontinence, and rectal injury. Fortunately, these are relatively rare.

Can Prostate Cancer surgery cause sexual dysfunction?

The most commonly reported side effects, in order of occurrence, are:

• Inability to have or maintain an erection.
  
  

• Difficulty reaching orgasm.
  
  

• Urinary Incontinence.
  
  

• Penile shrinkage.
  
  

The inability to have a healthy erection (ED) and orgasms are typically the most debilitating side effects of prostate surgery.

Many men already have a degree of erection problems prior to surgery, but the procedure infinitely complicates any pre-existing dysfunction.

For example; prior to surgery, a man may have ED that occurs often. However, he may still have sporadic erections, occasional nocturnal erections, and satisfying orgasms.

However, after surgery, he will likely be unable to have an erection regardless of the level of stimulation.

According to a report in the New England Journal of Medicine, up to 75 percent of men will experience ED for at least six months or longer. About 45 percent will recover function within two years, but the remainder may never recover erectile function. (3)

In addition to ED, most men find orgasms are different after prostate cancer treatment. They may not feel as intense, and there is no ejaculate. Also, it may take considerably more stimulation to achieve an orgasm than it did before surgery.

Urinary incontinence is also a common side effect. This is usually self-resolving, but it may take months to stop.

Penile shrinkage is commonplace with prostatectomy. A radical prostatectomy negates critical processes that keep the penis and surrounding tissues from atrophy.

Urologists start patients on a penile rehabilitation program within a few weeks after the surgery.

In a healthy man, nocturnal (nighttime) erections are used by the body to maintain good blood flow, and muscle and nerve tone in penile erectile tissue.

A rehabilitation program may include the use of erectile dysfunction drugs (Viagra, Cialis, etc.) as well as a vacuum erection device (aka, penis pump), to mimic the lost natural body functions that keep penile tissue and nerves healthy.

Some men experience the development of Peyronie’s disease about a year after surgery.

Peyronie’s is defined as a bent penis in any direction. The most common bend is upward. It seems to result from the development of scar tissue inside the penis.

Nerve-sparing

Radical retropubic prostatectomy is most effective to preserve a man’s erectile nerves. It can substantially limit the duration of post-surgical ED but requires a surgeon to be highly skilled and trained in the process.

In this type of procedure, the surgeon takes care not to damage the erectile nerves that surround the prostate as it is removed.

Preventing injury to these nerves dramatically improves the chances of a man recovering erectile function within two years of the surgery. (5)

Other considerations

Prostate cancer is not as life-threatening as other cancers. After a diagnosis is made, the quality of life issues may be more important than immediate aggressive treatment.

Perhaps the most crucial consideration is the decision to choose surgery versus watchful waiting or active surveillance.

Active surveillance or watchful waiting is a viable option if the cancer is known to be confined to the prostate gland, small in size, and is not aggressive. However, this decision must be made in conjunction with an expert professional.

An organization that provides expert professional advice to men with prostate cancer is the Prostate Cancer Research Institute (https://pcri.org/). They offer a free hot-line for patients and caregivers to help them choose a specific treatment plan.

Every man diagnosed with prostate cancer should, at a very minimum, visit their site and spend a good amount of time reading the material or consulting with them. Statistics have shown that some men using watchful waiting may eventually need treatment due to the cancer advancing.

In many cases, surgery is recommended by a doctor as the safest approach. But this recommendation often does not take into account the value a man places on his sexual ability.

A complete and permanent loss of erectile function with no hope for recovery can be distressing for many individuals, particularly those who have consistently enjoyed a robust sexual drive and capability.

Conclusion

Before choosing any treatment to treat prostate cancer, it is worth investigating all options.

All prostate treatments carry side effects, and one should choose a procedure where the side effects are less life-altering.

Next Up

Find out How to Reduce Your Risk of Infection After Prostate Surgery.