To treat prostate cancer, doctors perform tens of thousands of surgeries each year. In recent years, one procedure -- called a radical prostatectomy -- has become a fine art, says J. Brantley Thrasher, MD, a professor of urologic surgery at the University of Kansas Medical Center in Kansas City. While side effects like incontinence and impotence are still major concerns, most patients respond well to the surgery, Thrasher says.
In fact, many men respond almost too well. "They feel so good after the surgery that they start to push themselves too hard," he says. One of his recent patients went on a two-mile jog -- while still wearing a catheter. "I told him he needed to slow down and rest for a while."
If you have a radical prostatectomy in your future, you'll want to know what to expect. Here's a closer look at this procedure. As you'll see, your life won't necessarily take a turn for the worse after prostate surgery. In fact, it just might get better.
Why do surgeons perform radical prostatectomies?
According to the Food and Drug Administration, radical prostatectomy is considered to be the most definitive treatment for many men with prostate cancer, a disease that kills about 30,000 American men each year. Depending on their age and the stage of their cancer, however, some men do well with a less invasive treatment.
Surgeons perform the surgery only when the cancer appears to be confined to the prostate and nearby lymph nodes. In a radical prostatectomy, the surgeon removes the entire prostate gland (and attached seminal vesicles) together with a small part of the bladder and, if necessary, the pelvic lymph nodes. Newer surgical techniques make it easier for doctors to spare the nerves that are necessary for urinating and achieving an erection.
There are other options for treating prostate cancer, including radiation therapy and watchful waiting. According to the National Cancer Institute, "treatment patterns are strongly influenced by age, with younger men tending to have radical prostatectomy, middle aged men tending to have radiation therapy, and older men tending to have conservative approaches (no treatment or hormone therapy)."
Many patients and their doctors, however, opt for the more aggressive surgical approach. According to a report in the February 2001 issue of Geriatrics, relatively healthy patients under age 65 are especially good candidates for having a radical prostatectomy. For one thing, healthier men generally have the strength to handle a major operation. Radical prostatectomy also gives them the best chance of a long-term cure. Even if a young patient lives another 40 to 50 years or longer, the cancer isn't likely to ambush him later in life.
How should I prepare for surgery?
The Web site of the University of Pittsburgh Cancer Institute advises that patients about to undergo prostate surgery avoid taking aspirin products for 10 days before surgery to reduce the risk of excess bleeding. For extra protection, you should also stop using other anti-inflammatory drugs like ibuprofen or naproxen.
It's a good idea to stop using certain herbal remedies before surgery, too. According to a July 2001 study in the Journal of the American Medical Association, patients should discontinue taking ginseng, St. John's wort, and garlic supplements one week before surgery because they can also increase the risk of excessive bleeding. If you're taking gingko, you should stop taking them 24 to 36 hours before an operation, according to the study.
You may also be advised to donate one or two units of your own blood within a month of surgery. That way, if you need a transfusion, you will receive your own blood. On the day before the surgery, your surgeon may put you on a liquid diet or make other dietary restrictions. You may also need to take laxatives or have an enema to clean out your colon.
What happens during a radical prostatectomy?
Here are the highlights of the procedure, as described on the University of Pittsburgh Cancer Institute's Web site:
Surgeons can reach the prostate in two different ways. In one procedure, the surgeon operates through an incision in the abdomen. This approach is called a radical retropubic prostatectomy. It's relatively complicated, but it allows the surgeon to remove any cancerous lymph nodes in addition to the prostate. When operating through the abdomen, the surgeon also has a better chance of sparing nearby nerves, which means that you'll be less likely to suffer from erectile problems after the operation.
The other option is to operate through an incision in the area between the scrotum and the anus, a procedure called a radical perineal prostatectomy. This approach is quicker, is less likely to cause serious bleeding, and requires relatively little healing time. It may also be the best choice for obese men. (Extra fat makes abdominal surgery tricky.)
Before removing the prostate, your surgeon must cut through your urethra, the tube that carries urine from the bladder. He will then remove your prostate, trying to spare as many nearby nerves and blood vessels as possible. The surgeon will also remove your seminal vesicles, the tubes that carry sperm from the testicles to the urethra. The vas deferens, small ducts that store sperm, will either be removed or tied off. The urethra is then sewn back together.
What will happen during recovery in the hospital?
According to Dr. Thrasher, the average hospital stay is brief and uneventful. When you wake from the anesthesia, you'll understandably feel a little sore. You'll have a catheter in your penis that will carry urine to a bag. The catheter needs to be in place until your urethra heals, usually about two or three weeks. Within a few hours of the surgery, most patients are able to move around and eat a normal dinner. You can probably go home in two or three days.
What can I expect when I get home?
Once you get home, you'll have to take good care of your catheter. Examine it regularly to make sure it's securely in place. The University of Pittsburgh Cancer Institute recommends cleaning the opening of the penis with a 50/50 solution of water and hydrogen peroxide or an antibiotic ointment provided by your doctor. At home, the catheter should drain into a large bag. When you want to go out, you can wear a smaller bag under your pants leg.
Talk to your doctor about pain management. Many patients can get by with over-the-counter medications like ibuprofen, but some need stronger prescription medications, especially in the days immediately following surgery.
You may feel surprisingly good after the surgery, but don't go overboard. "Too many patients want to prove their manliness," Thrasher says. "They need to rest and give their wounds a chance to heal." He tells patients not to lift anything heavier than 10 to 15 pounds for at least six weeks. Many patients can quickly return to work, as long as it's not too strenuous, he says.
What are the possible long-term side effects of a radical prostatectomy?
Men recovering from a radical prostatectomy often face two potentially life-changing complications: Incontinence and erectile dysfunction. In the past, these side effects were devastating and practically inevitable. More than half of the men surveyed in a recent study also reported some difficulties in these two areas. But thanks to nerve-sparing surgery and other improvements in surgical techniques, these side effects now tend to be less serious, and some men don't experience them, Thrasher says. "The complications of all types of prostate cancer treatments have continued to decline since the 1990s," he says. "We're getting better at what we do."
For many patients, urinary or sexual problems are only temporary obstacles, Thrasher says. "Patients will come to me and say that they dribble a little urine when they lift their golf bag over their heads," he says. They quickly learn to how to clench the muscles around the bladder to avoid such accidents. Men who have trouble achieving erections can often return to normal -- or near-normal -- with the help of sildenafil (Viagra) or other treatments for sexual dysfunction, he says. Younger patients (age 65 and under) are especially likely to respond to such treatments.
Keep in mind, however, that your sexual machinery has changed. You can still have orgasms, but they will be dry. Without a prostate or seminal vesicles, your body will no longer be able to produce semen, so you won't be able to father a child. If you see children in your future, ask your doctor to collect sperm samples before the operation.
A recent survey of 247 patients treated at the University of California at Los Angeles Medical Center highlights some of these types of problems. As reported in the August 2001 issue of The Journal of Urology, two years after the surgery, 60 percent of patients still had some trouble achieving or maintaining erections. Thirty months after the surgery, 37 percent still reported some loss of urinary function. Despite these setbacks, however, most patients had an upbeat attitude. On the whole, any complications tend to be overshadowed by the relief of being cancer-free, Thrasher says. More than 90 percent said their overall quality of life was back to normal within six to nine months of the surgery. Younger men proved to be especially likely to rebound quickly from the operation.
All in all, most men who opt for a radical prostatectomy are happy with their decision, Thrasher says. Surgery is hard on the body, but it's nothing compared to cancer.
Interview with J. Brantley Thrasher, professor of urologic surgery at the University of Kansas Medical Center
Litwin MS, et al. Life after radical prostatectomy: A longitudinal study. The Journal of Urology. August 2001. 166: 587-592.
University of Pittsburgh Cancer Institute. Prostate Cancer: Radical retropubic prostatectomy. February 2002.
University of Pittsburgh Cancer Institute. Prostate Cancer: Radical Perineal Prostatectomy. February 2002.
U.S. Food and Drug Administration. Prostate Cancer: No one answer for testing or treatment. May 2000.
Herbal Medicines and Perioperative Care Michael K. Ang-Lee; Jonathan Moss; Chun-Su Yuan JAMA. 2001;286:208-216
National Cancer Institute. Prostate Cancer.