Trying to navigate treatment choices for a diagnosis of localized prostate cancer can be a bit of a nightmare. Once you jump on-line you’ll realize that there are an array of different treatment choices that range from active surveillance through various forms of surgery, different types of radiation treatment and novel or experimental treatment options where we either heat the prostate freeze the prostate or pass electricity through various parts of the prostate. It’s important to note one size does not fit all and there are without question nuances to the different treatment choices that are applicable for different types of disease different shapes and sizes of prostates and different individual characteristics that we as men all have.
In this video specifically, we’re going to explore surgery which is called a radical prostatectomy. A quick bit of revision with regards to some of the anatomy down in the pelvis: we have the bladder on top. Below the bladder is the prostate. At the back of the prostate there are two structures called the seminal vesicles. They’re a reservoir for ejaculatory fluid.
A radical prostatectomy can be performed in lots of different ways. It can be done traditionally in an open surgery or performed robotically which is a type of laparoscopic or keyhole surgery. The aim of a radical prostatectomy is to completely remove the prostate together with the seminal vesicles to affect cure from prostate cancer. In light of the location of the prostate, which in essence, is deep within the pelvis and it’s sandwiched in between the base of the bladder and the pelvic floor and because of the crucial structures that are close by the prostate there are certain aspects from a functional perspective that people need to be aware of when looking at their treatment choices.
In our previous video we’ve discussed some of the key aspects that you need to be aware of when it comes to understanding prostate cancer namely the Gleason score, the PSA blood test, and how the prostate feels. If you haven’t watched that video please find the link at the end of this video.
When we look at treatment choices for prostate cancer there are three outcome measures that are crucial. These include the likelihood of curing the cancer or oncological efficacy and we look at functional outcomes. Now from a functional perspective there are two key areas of concern. One is from a urinary point of view and the second one is from a sexual function perspective.
If we look at outcomes from a cancer point of view ultimately this will depend upon an individual’s cancer characteristics. Every individual following this surgery or every individual with a prostate cancer diagnosis has their own individual blueprint of what type of prostate cancer that they have. We make decisions from a treatment perspective, on the basis of clinical features of prostate cancer, but following surgery we get more definitive answers because we have pathological features. At the lab, they tell us what type of cancer someone has looking specifically at what was the Gleason score. The thing to be aware of with the Gleason score, is it can change from prostate biopsy through to the final pathology. The risk of change is about 10 to 15 percent. Now you may say to me “how can that happen?”
In essence, this is a by product of sampling error. When you have a prostate biopsy, a needle is placed into the prostate several times to get a sample of someone’s prostate tumor. When someone has robotic surgery to remove their prostate we have the ability to look at the entire prostate and the tumor in its entirety so we get a better handle on the specifics with regards the Gleason score. In addition to that we determine how big or how small a particular tumor is. Is it within the prostate or has it grown to the shell? Are the resection margins clear of cancer?
The resection margin really refers to whether or not there is a cancer cell at the edge when we’ve removed the prostate. The more aggressive features there are to a tumor the greater the risk of recurrence and if we have recurrence there is a greater requirement for additional treatment.
When we remove the prostate, the pelvic floor muscles themselves, do become a little bit bruised and also the anastomosis or the join between the bladder and the outlet pipe causes that muscle not to work as well as it currently dose. In the immediate post-operative period the majority of men do experience some urinary incontinence, but for the majority of men it usually takes around three to four months. Some men can be a little bit slower than others to recover.
There are some risk factors that will slow down an individual’s recovery. They include carrying excess weight (or an elevated BMI),being an older man, having a large prostate or alternatively more aggressive prostate cancer features. Those characteristics do increase the risk that you will experience a slower return of urinary control.
If we look at sexual function which is really is two things: it’s ejaculation and also it’s erectile function. Just about all of the fluid that a man sees when he ejaculates comes from the prostate and the seminal vesicles. We remove these structures so there will be no emission of fluid should a man have an orgasm after surgery.
Erectile function however, is dependent upon a few different criteria, but from an anatomical point of view there needs to be intact neurovascular bundles. In essence these are the nerve and the vascular supply to the penis. If a man has good erectile function before surgery and the disease profile of the cancer characteristics mean that it is safe to preserve those nerves then that man has a reasonably high chance of erectile function recovery.
However, an important thing to be aware of it takes time usually about a year to a year and a half for men to fully regain erectile function.
So there you have it. There’s an introduction into radical prostatectomy which is a surgical treatment for the management of localized prostate cancer. The issues again to summarize that we’ve discussed relate to our ability to cure cancer with this approach and the functional issues that you need to be aware of before selecting any prostate cancer treatment.