Prostate surgery is a procedure that is indicated for the treatment of localized prostate cancer, when the disease has not yet progressed and has not affected other organs. The aim of prostate surgery is to completely remove the prostate so that the cancer can be to be definitively cured.

Although prostate surgery is very effective and can cure localized prostate cancer, the doctor may also advise radiation therapy following surgery to eliminate any malignant cells that may have remained in the area.

Surgery for prostate cancer, also called radical prostatectomy, is performed by an oncological or urological surgeon, in a hospital setting. It should be recommended by a doctor, after assessing the all the possible risks and complications and evaluating the benefits for the patient.

When it's indicated

Prostate surgery is indicated for the following cases:

Localized prostate cancer, meaning the tumor is confined to the prostate and has not spread to the tissues around the prostate or to other organs, like the lymph nodes, bones, liver, lungs, bladder or intestines
Locally advanced prostate cancer, in which the cancer has spread to the external area of the prostate, and surgery is performed in combination with other treatments.

Surgery to remove the prostate is normally performed on men under 75 years of age who are considered to be at low to intermediate surgical risk. Patients with chronic diseases, such as diabetes or hypertension, will ideally have these well-managed.

Radical prostatectomy is only performed with the recommendation of an oncologist and is ultimately performed by an oncological or urological surgeon.

How to prepare for surgery

To prepare for prostate surgery, it is important to clarify any questions your may have with your doctor. The doctor should explain the technique that will be used, risks, complications, recovery and expectations for the surgery.

Furthermore, it is important to inform the doctor of any allergies you may have to medications, foods or any other substance, and you should also disclose all the medications you frequently use, including supplements, vitamins, teas or natural remedies.

In some cases, the doctor may ask you to stop taking medications a few days before surgery to prevent bleeding or hemorrhaging.

Before undergoing surgery, all tests ordered by the doctor should be carried out. On the day before surgery, the doctor may advise you to fast for at least 8 hours.

How it's done

Surgery for prostate cancer is performed by a urological or oncological surgeon, in the hospital, under general anesthesia. However, it can also be performed with an epidural, depending on the surgical technique performed.

During surgery, the entire prostate is removed, in addition to the tissues surrounding the prostate, like the prostatic urethra, the seminal vesicles, and the ampullae of the vas deferens.

This surgeon may also perform a lymphadenectomy, which consists of removing lymph nodes in the area around the prostate.

The surgery typically takes about 2 hours and patients will typically stay in hospital for an additional 2 to 3 days for monitoring.

Types of prostate surgery

To remove the prostate, surgery can be performed through a robot-assisted approach. Another option is laparoscopic surgery, which involves making small small holes in the belly and inserting instruments and removing the prostate through them. The doctor may also consider alaparotomy, which involves a larger incision in the skin.

The main types of surgery used are:

Radical retropubic prostatectomy: in this technique, the doctor makes a small cut in the skin near the navel to remove the prostate;
Radical perineal prostatectomy: a cut is made between the anus and scrotum and the prostate is removed. This technique is used less frequently than the previous one, as there is a greater risk of affecting the nerves responsible for erection, which can cause erectile dysfunction;
Robotic radical prostatectomy: in this technique the doctor controls a machine with robotic arms resulting in a more precise technique that results in a lower risk for complications
Transurethral resection of the prostate: it is generally performed for the treatment of benign prostatic hyperplasia, however, in cases of cancer in which radical prostatectomy cannot be performed but there are symptoms, this technique can be used.

In most cases, the most recommended prostate surgery is robot-assisted surgery, because it is associated with less pain, lower blood loss and a faster recovery time.

What is recovery like?

Recovery from prostate surgery is relatively quick. The doctor will generally advise rest and avoiding exertion,for approximately 10 to 15 days.

After this time, you can return to day-to-day activities, such as driving or working, however, heavy exertion is only allowed 90 days after the date of surgery. Sex can be resumed after 40 days.

Post-operatively after a prostatectomy, it is necessary to have a bladder catheter, a tube that will carry urine from the bladder to a bag. This is because the urinary tract becomes very inflamed from the surgery, which can block the passage of urine. The catheter should be used between 7 and 15 days and should only be removed as advised by a doctor.

In addition to surgery, it may be necessary to undergo hormone therapy, chemotherapy and/or radiation therapy to kill any lingering malignant cells that were not removed during surgery or that have spread to other organs. This can prevent further growth and spread.

Possible complications

In addition to general risks, such as infection at the incision site or bleeding, surgery for prostate cancer can have other critical consequences, such as:

1. Urinary incontinence

After surgery, men may have some difficulty controlling urine output, resulting in urinary incontinence. This incontinence can be mild or total and can last for weeks to months after surgery.

This problem is more common in older men, but it can happen at any age and depends on the degree of cancer development and type of surgery performed. Treatment for this sequela usually begins with physiotherapy sessions, which will utilize pelvic exercises and small instruments, such as biofeedback, and kinesiotherapy. In the most extreme cases, surgery can be performed to correct this dysfunction.

2. Erectile dysfunction

Erectile dysfunction (ED) is one of the most worrying complications for men. However, with the emergence of robotic surgery, rates of erectile dysfunction have decreased. Post-op ED typically occurs due to nerve damage in the nerves surrounding the area operated on.

ED is more common in cases of very developed cancer in which it is necessary to remove a larger quantity of tissue, and possible nerves as well.

In other cases, erections may be affected simply due to inflammation of the tissues around the prostate. This swelling can compress surrounding nerves, but will generally improve within months to years after surgery.

To help promote erections in the first few months post-op, the urologist may prescribe medications, such as sildenafil, tadalafil or iodenafil.

3. Infertility

Surgery for prostate cancer severs the connection between the testicles, where sperm are produced, and the urethra. Therefore, man will no longer be able to father a child by natural means. The testicles will still produce sperm, but it will not be ejaculated.

As the majority of men affected by prostate cancer are older adults, infertility is not a major concern, but younger patients may still want to have children. These patients are advised to speak with their urologist to evaluate the possibility of preserving sperm prior to or after surgery.

Post-op tests and follow-ups

After completing treatment and surgery prostate cancer, a PSA test should be carried out serially for 5 years. Bone scans and other imaging tests may also be performed annually to monitor for stability or any changes.

Men who undergo prostate surgery may be affected psychologically and sexually, which is why a psychological consult is advised in the first few months post-op.

Can the cancer return?

Yes, men diagnosed with prostate cancer and treated with curative intent may experience recurrence of the disease and may require additional treatment. Therefore, regular follow-up and testing with a urologist is strongly recommended.

Ideally, post-op patients should maintain healthy habits and avoid smoking. They should adhere to any monitoring and testing the doctor advises, as cancer recurrences are best treated if caught early.