Overview
There are several options to treat prostate cancer: conservative and surgical. Conservative options include hormonal therapy, radiotherapy, targeted therapy, and immunotherapy. Surgery is a common choice to try to cure prostate cancer if it is localized and has not spread outside the prostate gland.
Surgical options, too, are of various types, each done as per the indications and the discretion of the surgeon. The three main types of surgeries used in prostate cancer are:
- Radical prostatectomy
- Laparoscopic prostatectomy with or without robotic technique
- Tansurethral resection of the prostate
Each type of prostate cancer surgery comes with its own approach, indications, benefits, risks, success rate, and outcome.
The choice of the surgery to perform on the patient depends on the status of the prostate cancer and ultimately on the discretion and expertise of the surgeon.
When is surgery indicated in prostate cancer?
Surgery for prostate cancer is a major surgery and is indicated when the cancer is confined to the prostate gland and has not spread beyond the prostate. It offers an excellent long-term prognosis.
There are various types of surgeries for prostate cancer and they all remove the entire prostate gland.
However, there is one type of surgery, which the surgeon performs mostly for benign prostatic hyperplasia (BPH) and which is sometimes required for prostate cancer. It is called transurethral resection of the prostate (TURP) and is done when the prostate cancer has spread to the neighboring tissues. It is done not for cure but to relieve the symptoms of the patient, which are mostly urinary.
Types of surgery for prostate cancer
There are three types of prostate surgery:
1. Open radical prostatectomy can be of two types depending on where the surgeon takes the incision in the skin to approach the prostate.
- Radical retropubic prostatectomy (RRP). For this open surgery, the surgeon makes an incision in your lower abdomen, from below the umbilicus down to the pubic bone,
- Radical perineal prostatectomy. In this open operation, the surgeon makes the incision in the perineum. (between the anus and scrotum).
2. Laparoscopic prostatectomy. This is a minimally invasive surgery procedure in which the surgeon uses a laparoscope and removes the malignant prostate and the semnal vesicles through small incisions made in the lower abdomen.
- Laparoscopic radical prostatectomy. Here the surgeon uses only the laparascope to remove the prostate.
- Robotic-assissted laproscopic radical prosatectomy. In this type of surgery, the laparoscopic surgery is done using a robotic system.
3. Transurethral resection of the prostate (TURP).
Open radical prostatectomy
A prostatectomy may involve partial or complete removal of the prostate and is performed to treat prostate cancer and benign prostatic hyperplasia (BPH).
All surgeries of the prostate are performed after a confirmed diagnosis of prostate malignancy with the patient being subjected to bone scans, computed tomography (CT), and magnetic resonance imaging (MRI), and biopsy to identify if the cancer is localized or spread outside of the prostate.
A radical prostatectomy involves complete removal of the prostate gland including the malignant tumor cells and sometimes the seminal vesicle glands.
There are several types of radical prostatectomy classified according to the approach the surgeon chooses:
Open radical retropubic prostatectomy (RRP)
In this approach, the surgeon removes the prostate through an incision (about 8 inches) in the wall of the abdomen. The most common approach the surgeon uses to make an incision in the skin of the abdomen is between the umbilicus and the apex of the pubic bone.
He may also remove the nearby lymph nodes through the same incision to reduce the risk of metastasis.
He makes sure to protect the urinary bladder from damage and also the nerves that control penile erection.
RRP is usually used in cases of early prostate cancer and is done under general, spinal or epidural anesthesia. Rarely, a blood transfusion may be required.
Post-surgery, a Foley catheter is required to be in place for two to three weeks.
Complications such as urinary incontinence and impotence can occur but their occurrence is related to the technique, experience, and skill of the surgeon.
Improvements in the technique of RRP surgery have dramatically decreased the frequency of most of these worrisome complications. As a result, most patients enjoy a problem-free quality of life after undergoing radical prostatectomy.
Open radical perineal prostatectomy
In this type of radical prostatectomy, the surgeon removes the entire prostate through an incision made in the area between the testicles and anus. This area is called the perineum. He may also remove the lymph nodes through a separate incision in the abdominal wall.
This surgery takes about one hour. It is indicated in select men who have an early, well-defined, and localized prostate cancer. It is a less commonly used method than the retropubic or the robotic method of prostate surgery.
Radical perineal prostatectomy achieves the same rate of cure as retropubic surgery and there is less blood loss and faster recovery. However, there is an increased risk of fecal incontinence.
It is more suitable in men under the age of 70 years, without any serious medical problems, with a Gleason score of less than 8 and a PSA value of less than 10.
It may also be more suitable in obese men with prostate cancer, in men with a history of previous abdominal operations, and in men who have had a recurrence of prostate cancer after radiotherapy.
Laparoscopic prostatectomy
Prostatectomy is surgical removal of the prostate and seminal vesicles indicated in prostate cancer. Laparoscopic prostatectomy means the surgeon performs the prostatectomy using the laparoscope, which maked the surgery minimally invasive.
It is also done with the help of a sophisticated robotic surgery system by surgeons who have acquired the skill of robotic surgery.
Laparoscopic radical prostatectomy
This is a minimally invasive type of radical prostatectomy, which is done using a laparoscope. The surgeon makes five or six tiny incisions (less than half-inch) in the abdomen to remove the cancerous prostate as opposed to one large incision made in the retropubic and perineal prostatectomy. The surgery is done under general anesthesia.
Although laparoscopic prostatectomy surgery takes approximately 3 hours to perform, there is less abdominal trauma, a better cosmetic appearance of the abdominal wall, and recovery is typically faster.
He performs this procedure using a laparoscope, which consists of a camera and a lighted tube to guide him.
Laparoscopic prostatectomy patients need to have a Foley catheter in place after surgery, which in most cases is removed on the third day after surgery.
Robotic-assissted laproscopic radical prostatectomy
In this robotic radical surgery for prostate cancer, the surgeon uses a sophisticated robotic surgery system in which the computer controls a robotic machine with four arms. It is a laparoscopic procedure.
It provides enhanced vision, control, and precision to the surgeon that allows him to operate on the prostate with great precision.
Miniaturized robotic arms are passed through several small keyhole laparoscopic-type incisions into the patient’s abdomen, which allows the surgeon to take out the prostate and nearby tissues.
During a robotic-assisted radical prostatectomy, the surgeon has a magnified view of the structures that surround the prostate gland (e.g. nerves, blood vessels, and muscles), which allows him to preserve these vital structures. Visual magnification is up to ten times.
This is made possible with a three-dimensional endoscope and image processing equipment. The surgeon eventually removes the prostate through one of the keyhole incisions.
Benefits of Robotic Surgery. Compared with traditional open surgery, patients who undergo robotic-assisted radical prostatectomy experience less blood loss, less pain, and shorter hospital admissions.
Risks of this surgery include bleeding, infection at the surgical site, and damage to adjacent tissues.
Transurethral resection of the prostate (TURP)
TURP is performed mostly to treat men who have BPH. In prostate cancer patients, it is used more to give symptomatic relief to the patient rather than for cure. Such symptoms are mainly of urinary nature.
In this surgery, the surgeon inserts a resectoscope into the urethra from the tip of the patient’s penis till it approaches the prostate.
He then passes either electricity through a wire to heat it or a laser is used to cut or vaporize the excess tissue that is pressing onto the urethra. This procedure takes about an hour and is done under spinal anesthesia.
After the surgery, a catheter is left inserted into the urethra for a day or two to drain the urine till the prostate heals. You stay in the hospital for a day or two and are discharged after the catheter is removed. You are fit to start working after 1 to 2 weeks.
Side effects of TURP
- Blood in the urine after surgery
- Urinary tract infection
The outcome of prostate cancer surgery
The earlier prostate cancer is detected and treated, the more likely it is for a man to be successfully treated to help him remain disease-free. Prostate cancer prognosis remains among the best of all cancers.
Radiation therapy has traditionally been the main treatment for prostate cancer, but about 25 percent of the men treated with radiation have a recurrence within five years after the therapy.
Radical prostatectomy significantly improves the outcome of prostate cancer treatment when traditional radiation therapy has failed to eradicate the cancer
Researchers found that after treatment with radical prostate surgery, 88.6 percent of men were still alive after 10 years and 72.7 percent of men were still alive after 20 years.
Approximately 80 percent to 85 percent of all men with prostate cancers detected in stages I, II, and III and treated with surgery will remain disease-free after five years.
The recurrence of prostate cancer after treatment is determined by rising PSA levels. About 20 to 30 percent of men will relapse after the five years mark, following the initial therapy.
