Prostate Cancer Surgery: Radical Prostatectomy

Prostate cancer is a malignant disease of the prostate seen in advanced ages. It is the most common cancer in men among urological cancers. It is a familial disease. It is more common in western societies. In our country, its incidence has increased in older men. It is a disease that can be treated with surgery at a very high rate when diagnosed in the early stages.

How is prostate cancer diagnosed?

Prostate cancer does not give very specific symptoms in the early stages. It is quite easy to diagnose cancer with detailed questioning of the patients, examination, laboratory tests and radiological examinations.

• Prostate examination: Prostate examination is done rectally. Normally, the prostate is elastic and symmetrical. If there is cancer, a painful and hard prostate is palpable, the prostate has enlarged asymmetrically.

• Prostate specific antigen (PSA) test: PSA test is very important in the diagnosis of prostate cancer. PSA is also used in the postoperative follow-up of patients. The value of PSA varies according to age, prostate size and presence of prostate infection. In general, it should be below 4ng/ml. Values ​​above this should be investigated.

• Multiparametric prostate MR (MPMR): MPMR should be performed in patients with suspected cancer based on PSA and examination results. In this way, cancer or infection can be differentiated. Biopsy should be taken from patients according to MPMR results.

• Prostate biopsy: A biopsy must be taken from patients with suspected cancer in MPMR. A biopsy should be taken from the focus of suspected cancer. This procedure is possible with the fusion biopsy method. With fusion biopsy, the diagnosis is made by taking a biopsy directly from the suspicious area.

Stages of prostate cancer

Cancer staging indicates the extent of cancer spread to neighboring and distant organs. Staging is very important in planning cancer treatment. We can summarize the staging of prostate cancer as follows:

• Stage-1: Cancer is only in the prostate. Sometimes it may be too small to be felt on rectal examination. A Gleason score of 6 or less. PSA level is below 10 ng/ml.

• Stage-2: The cancer is in the prostate. However, the structure of the tumor is more malignant. It can be clearly felt on digital examination or the tumor grade may be high.

• Stage-3: The cancer has spread beyond the prostate. It usually spreads to the seminal vesicles. However, it has not spread to the bones and lymph nodes.

• Stage-4: Cancer has spread to the bladder, rectum or surrounding tissues (other than the seminal sacs). In addition, there may be spread to neighboring lymph nodes and bones.

What is active follow-up in prostate cancer, to whom?

Prostate cancer is a slow-growing type of cancer. Radical prostatectomy is performed on patients with good general health and a 10-year life expectancy. In some patients, it may be necessary to follow up without surgery. Patients in this situation should come to the Urologist for control at regular intervals.

If there is an increase in the PSA level in the examinations, if the mass continues to grow in the examinations, surgery is absolutely necessary. This is called active tracking. Radical prostatectomy should be performed in patients who cannot come to active follow-up.

Patients with prostate cancer who are candidates for active follow-up are as follows:

• PSA level: less than 10 ng/ml

• Gleason grade (grade): If the Gleason grade is below 6

• If the cancer is very small, in a single focus and limited to the prostate

What is radical prostatectomy and for whom?

Radical prostatectomy is performed in patients whose prostate cancer has not metastasized, that is, it has not protruded beyond the prostate membrane. During radical prostate surgery, the entire prostate gland, seminal vesicles, part of the semen ducts and lymph nodes of the prostate are removed.

Stage 1 and Stage 2 patients are the most suitable patient group for radical prostatectomy surgery. In addition, patients who will be operated on should have a suitable general health status, with a life expectancy of at least 10 years.

What are the alternative treatments to radical prostatectomy?

In patients with non-metastasized and organ-confined prostate cancer, the gold standard, that is, the best treatment, is radical prostatectomy. Sometimes patients cannot or do not want this surgery due to their health conditions. In this case, patients should be offered alternative treatments.

An alternative to prostate cancer surgery is radiotherapy. It is possible to obtain positive results with radiotherapy in suitable patients and experienced centers. In addition, alternative treatments called focal therapy and aimed at destroying cancer directly can be applied to patients who do not want the surgery or cannot remove the surgery.

What are the prostate cancer surgery methods?

Prostate cancer was previously an operation performed with open surgery. Today, open surgery is still performed and the success rates are quite high. However, with the advancement of technology in recent years, there have been developments in prostate cancer. The surgical procedure is the same in all methods.

Prostate cancer surgery methods include:

• Open surgical method (open radical prostatectomy)

• Laparoscopic surgery method (laparoscopic radical prostatectomy)

• Robotic surgery method (robotic radical prostatectomy)

What are the complications of prostate cancer surgery?

Complications of radical prostatectomy surgery are examined in two main groups as early and late complications:

Early complications:

• Bleeding: It may occur during the operation or in the early postoperative period. Generally, there is not much bleeding in the surgeries.

• Neighboring organ injuries: Although rare, injuries to the bladder, large intestine and running veins may occur during prostate surgery.

• Lymphocele: It is the collection of lymph fluid in the parts of the lymph nodes removed by surgery.

• Wound infection can be seen in the early postoperative period.

• Wound healing problems may occur.

Late complications:

• Bladder neck stenosis

• Urinary incontinence

• Impotence (erectile dysfunction)

• Urethral stricture

What are the advantages of robotic and laparoscopic surgery?

Laparoscopic and robotic surgery have some advantages over radical prostatectomy performed with open surgery.

We can list them as follows:

• Bleeding is less

• Less hospital stay

• Less urinary incontinence

• Erectile dysfunction (impotence) development is less

• Patients return to their daily work earlier

• Post-operative pain is less

• The scar is smaller

What does nerve sparing and bladder neck sparing radical prostatectomy mean?

The prostate is an organ located just below the bladder. The vessels and nerves that go to the penis pass from the back and sides of the prostate. It is very important to protect the vessels and nerves of the penis in prostate cancer surgeries. If the nerve is not protected and damage develops during surgery, erectile dysfunction (ED, impotence, erectile dysfunction) occurs. During surgery, nerves on both sides must be protected.

This surgery is called “nerve-sparing radical prostatectomy surgery”. Care should be taken to protect the nerves in all open, robotic and laparoscopic surgeries. Especially if the patients are young and their erections are normal, the nerves should be protected by paying more attention to these people.

An important point to be considered during radical prostatectomy surgery is the protection of the bladder neck. Bladder neck preservation is very important both in preventing postoperative urinary incontinence and in preventing the development of bladder neck stenosis. We take care of this situation during our operations.

Is radical prostratectomy performed in metastatic prostate cancer?

Radical prostatectomy surgery is not performed in metastatic prostate cancers that have spread to the body by passing the prostate membrane. These patients have passed the radical prostatectomy stage. Hormone therapy and chemotherapy are applied to these patients in treatment.

If patients with metastatic prostate cancer have problems such as difficulty urinating and inability to urinate, this condition should be treated. In such patients, prostate surgery is performed with endoscopic, that is, closed methods. For this purpose, TUR-P and HOLEP surgeries are widely used. We perform HOLEP surgery on such patients. HOLEP surgery is a laser surgery and has many advantages over TUR-P surgery.

Endoscopic prostate surgery is called palliative surgery because radical prostatectomy cannot be performed and because it cannot urinate. The purpose of these surgeries is not to eliminate the cancer, but to relieve the patients and enable them to urinate. In the future, these patients may need a repeat TUR or HOLEP, because there may be recurrence because the cancer is not completely eliminated.

What is penile rehabilitation after radical prostatectomy, how is it done?

One of the most important problems after radical prostatectomy is the development of erectile dysfunction (impotence) in patients. Care is taken not to damage the penile nerves during surgery in young and erect patients. However, in some cases, if the cancer also involves the nerve, the nerve cannot be protected and erection problems develop. It is very important to protect the nerves bilaterally if possible.

It may take a long time for erections to return to normal in post-operative patients. It may take a few months or sometimes 1-2 years. During this period, a penile rehabilitation program is applied to support patients. Penile rehabilitation includes general treatments for maintaining an erection after nerve-sparing prostate cancer surgery. The methods used for penile rehabilitation are:

• PDE5i group drugs: Oral erectile dysfunction drugs called phosphodiesterase 5 inhibitors (PDE5i) are widely used in penile rehabilitation. Patients are started immediately after the operation, from the moment the patient begins to take it orally. In some studies, it has been reported that better results are obtained by starting 2-3 weeks before the surgery. These drugs should be continued at low doses and for a long time.

• ESWT therapy: Penile shock wave therapy (ESWT) is a method we apply to patients with erectile dysfunction. We frequently apply the ESWT method to our patients for penile rehabilitation after prostate cancer surgery. This treatment can also be used together with PDE5i group drugs. In this way, more positive results are obtained with combined treatments. We also apply combined treatments to our patients.

• Penile injections: Drugs applied to the penis and providing erection are also used for penile rehabilitation.

• Urethral gels: Drugs that are squeezed into the urethra and provide erection are another treatment method used for penile rehabilitation.

• PRP (P-shot), stem cell treatments: These treatments are also used for penile rehabilitation. However, they are not routine and highly effective treatment methods.

Implantation of a penile prosthesis after prostate cancer surgery

One of the problems encountered in patients after prostate cancer surgery is erection problem. If the patients did not get the expected result from penile rehabilitation, then the treatment option is penile prosthesis surgery. There are two types of penile prosthesis: flat (one-piece) and inflatable (three-piece, hydraulic).

Three-piece ones are more suitable and patient satisfaction is higher. Penile prosthesis is the treatment we recommend as the last treatment option for our patients who do not respond to current treatments. Appropriate prosthesis is placed according to the socioeconomic status of the patient.

In summary: Prostate cancer is one of the most common urological cancers in elderly men. If it is diagnosed at the appropriate stage, the life expectancy is very high with surgical treatment. Radiotherapy (radiation therapy) is an alternative for those who cannot undergo surgery. Robotic surgery is more preferred as a surgical option. Penile rehabilitation is applied against erectile dysfunction after surgery. If the erection problem persists and does not improve, the last option is penile prosthesis surgery.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY

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