Radical prostatectomy involves the surgical removal of the entire prostate, the seminal vesicles and some adjacent tissue. This operation is considered if:
- the cancer is confined to the prostate
- the cancer is at stage T1 or T2. (Note that, although it is difficult to gauge the exact stage of tumour before surgery, magnetic resonance imaging may increase the accuracy of pre-surgery staging (17)
- the man is aged under 70
- life expectancy is greater than ten years
- the patient is in good health.
When treatment choices involving surgery are made, it is suggested that the patient checks whether his surgeon has a lot of experience in the field of prostatectomy and is linked to an oncology centre. The COIN and BAUS guidelines (2) recommend:
'Total prostatectomy should be performed by locally designated surgeons (or rather a urological surgeon with a specialist interest in cancer) and not on an ad-hoc basis.'
Current NICE guidelines (3) suggest that radical prostatectomy should not be carried out by urological multidisciplinary teams who carry out fewer than 50 radical operations (prostatectomies and cystectomies) for prostate or bladder cancers per year (3).
One potential benefit of surgery is that, as well as all the cancer tissue (hopefully) being excised, any remaining prostate tissue is also excised. This can relieve any symptoms associated with benign prostatic hypertrophy (BPH).
While radical prostatectomy is generally well tolerated, and it may get rid of the cancer and reduce mortality compared with watchful waiting, the disadvantages and potential risks associated with the surgery include:
- the need for hospitalisation
- complications of major surgery, including chest infection, bleeding and death
- short-term urinary incontinence (more than 40% of men)
- long-term urinary incontinence (less than 20% of men)
- urethral stricture
- bladder neck contracture
- short-term bowel dysfunction (less than 10% of men)
- erectile dysfunction (over 80% of men).
The COIN & BAUS guidelines (2) suggest:
'Before undergoing total prostatectomy patients should be counselled about the risks of impotence and incontinence.’
Until recently, total prostatectomy resulted in impotence in nearly all patients and caused incontinence in up to 20% (2). Nerve sparing surgical technique may help to improve the outcome for some men. A review of RCTs looking into the effects of prostate cancer treatment on erectile function found a significantly less dysfunction after nerve sparing surgery compared to external beam radiotherapy (EBRT) (18). However, it can be difficult to draw direct comparisons as the age and characteristics of the men having the different treatments varies significantly. Long-term follow-up is needed.