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cover of book Mayo Clinic on Prostate Health
A selection from:
Mayo Clinic on Prostate Health

Continuing from Chapter 7 (go to previous part)
What Are Your Options?

Removing your prostate gland

The surest way to cure cancer that's confined to your prostate gland is to remove the gland. This type of surgery is called radical prostatectomy.

Until a few years ago, a radical prostatectomy just about guaranteed devastating consequences: Nearly every man who had this procedure became impotent or suffered from diminished sexual function. Many men had bladder problems. In addition, most men had so much blood loss during the surgery that they needed transfusions.

New procedures and instruments developed during the past two decades have changed this surgery drastically. Surgeons now use special techniques to cut free the prostate, while sparing muscles and attached nerve bundles that control urination and sexual function. Methods to control heavy bleeding are now routine.

Because of these refinements, 1 in 4 men with prostate cancer now choose surgery. A decade ago, only 1 in 10 chose surgery.

line drawing showing where incision for retropubic is made line drawing showing where incision is made for perineal approach
With retropubic surgery [left], the prostate gland is removed through an incision in the lower abdomen. Perineal surgery [right] involves removing the gland through an incision between the anus and the scrotal area.

Retropubic surgery

Retropubic surgery is one of two methods for removing the prostate. In this procedure, the gland is taken out through an incision in the lower abdomen that typically runs from just below the navel to an inch above the penis (see illustration).

It's the most common form of prostate removal for two reasons: The surgeon can use the same incision to remove surrounding lymph nodes/ which are tested to make sure the cancer hasn't spread. In addition, the procedure gives the surgeon better access to the prostate, making it easier to save the nerve bundles that control erection.

The night before surgery you'll likely be given an enema or laxatives to clear your rectum of any fecal matter. This reduces the chance of infection if the rectal wall is punctured during surgery, an uncommon but possible risk.

You may choose to be put to sleep during the surgery with general anesthesia, or have an epidural injection that numbs only the lower half of your body. General anesthesia is more common.

After the incision, the surgeon may remove lymph nodes near your prostate and send the sample to a pathologist. Enlarged or suspect lymph nodes can be evaluated by frozen-section techniques to determine if cancer is present. Results are often known within 15 to 30 minutes. If cancer is found, your surgeon may close the incision without removing the gland, or may proceed with the surgery. The decision to proceed in light of positive lymph nodes depends on the number of lymph nodes involved, your age, and associated symptoms. The fewer nodes that contain cancer, the younger your age, and the fewer symptoms you have, the more likely your doctor will be to continue with surgery.

Once the prostate is removed, the surgeon will reconstruct part of your bladder, attaching the urethra and the sphincter muscle located below the site of the now-removed prostate directly to the bladder. This procedure increases your chances of being able to control your flow of urine, though it may take weeks, possibly even several months, for your body to heal enough for you to regain bladder control.

Depending on where the cancer is, your surgeon will try to save the nerve bundles attached to each side of the prostate. These nerves control your ability to have an erection. Surgeons can often spare one or both of these bundles if the cancer isn't too close.

Men in their 40s and 50s who have this nerve-sparing surgery are more likely to retain their ability to have an erection than older men. For some older men -- especially those not sexually active -- the spared nerves don't survive the shock of surgery. On average, half of men who are sexually active before surgery experience impotence or diminished sexual functioning, such as loss of orgasm or reduced sensation, after surgery. For men who already are impotent at the time of surgery, the nerve bundles are generally removed because they're no longer needed and there's a remote chance they could contain some cancer cells.

If even one nerve bundle is spared, it's still possible to have erections. However, because the prostate and seminal vesicles produce most of the seminal fluid, after surgery your ejaculations will contain very little fluid. If neither nerve bundle can be spared, you can still have a normal sex drive (libido) and orgasms, though without normal erections. Chapter 10 discusses devices and medications that can help you achieve an erection if you can no longer do so naturally.

After surgery, recovery in the hospital for 1 to 3 days, and 3 to 5 weeks at home, is typical. You'll also need to use a catheter for about 2 to 3 weeks to give your urinary tract time to heal.

Perineal surgery

With this form of surgery, an incision is made between the anus and the scrotal sac holding the testicles. There's generally less bleeding with perineal surgery, and heavier men recover sooner. Unfortunately, this approach makes it much more difficult -- and sometimes impossible -- for your surgeon to locate and save the nerve bundles attached to the prostate. In addition, the surgeon isn't able to reach nearby lymph nodes. That's why this surgery is less commonly used.

Are you a candidate for surgery?

• Your cancer is confined to the prostate.
• You're healthy enough to withstand surgery.
• Your expected life span is greater than the cancer would let you live.

What are the benefits?

For cancer that's confined to the prostate gland, surgery is the most effective treatment. It can cure your disease.

What are the disadvantages?

• All surgery carries some risk. Though the mortality rate is low, approximately 1 percent of men who have surgery die as a result of complications. Your risk increases with your age.
• You may become impotent. This depends a lot on your age. Between 60 percent and 80 percent of men younger than age 50 who have nerve-sparing surgery are able to achieve normal erections afterward. For men in their 70s, only about 15 percent to 25 percent maintain normal sexual functioning. The skill of your surgeon and the quality of your erections before surgery can affect the outcome. If you had trouble achieving or maintaining an erection before surgery, the chances are greater that you'll be impotent after surgery.
• You may experience incontinence -- at least temporarily. After the catheter is removed, nearly all men have some bladder- control problems for at least a few days. You could have problems for weeks, or even months. If so, medications and treatment can help improve bladder control. About 95 percent of men eventually regain complete control. Most of the remainder experience "stress" incontinence, meaning they can't hold their urine flow when pressure is placed on the bladder, as happens when you sneeze, cough, laugh or lift.
• Recovery can take 1 to 2 months.
• There's a small risk of damage to your lower intestine or rectum. More surgery may be necessary to repair the damage.

[The chapter continues with "Destroying the cancer with radiation."]


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