I Want My Prostate Out!
BY MARK SCHOLZ, MD & LIZ GRAVES For many men, surgery seems like the best option: “A quick operation and the problem will be gone.” While this thinking may apply …
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Surgical removal of the prostate provides useful information about the size and grade of the cancer enabling physicians to estimate the risk of future relapse more accurately. Such information may be useful in selecting treatment if larger amounts of high-grade cancer are discovered. Recent studies of implementing immediate Testosterone Inactivating Pharmaceuticals (TIP) right after surgery in men found to have advanced disease at the time of surgery suggest that cure rates can be augmented. Also the possibility of administering adjuvant Zytiga or Xtandi can be discussed. The removal of the prostate also creates a “clean slate” by removing all non-cancerous PSA producing tissue. This simplifies the monitoring process as PSA elevations greater than 0.07 allow doctors to be confident about the presence or absence of relapsing cancer.
The disadvantage of a radical prostatectomy is that it entails a major surgical procedure with its attendant discomfort and risks. A urinary catheter remains in place for about a week or two after the operation. Urinary incontinence usually takes several months to be restored. However, in about 10% of men urinary control is never reestablished. Impotence is universal for the first months after surgery. Patients who eventually recover function do so slowly over a 2 to 24 month period. Even after recovery occurs only 5% of men describe their erections as being identical to the erections they had before surgery. Patients with slow recovery are at risk for penile atrophy. To reduce this risk “penis exercises” with prophylactic injection therapy with prostaglandins should be started right after the operation.
It cannot be over emphasized that urologists vary greatly in surgical ability. One of the best measures of surgical skill is determining how often the surgeon leaves cancer behind while trying to remove the gland. The best surgeons get the cancer out 90% of the time. Studies have documented that many urologists – even those operating out of large universities – can leave cancer behind up to 50% of the time. Leaving cancer behind is called a positive margin.
High hopes for robotic surgery have not panned out. Men do recover from robotic surgery more quickly because the operation is performed through a smaller incision. Unfortunately the risk of impotence and incontinence is the same as standard surgery.