This article originally appeared in the February 2005 Harvard Men’s Health Watch and is provided courtesy of Harvard Health Publications.

Prostate cancer surgery: Is nerve-sparing safe?

Prostate cancer will be diagnosed in an American man once every three minutes each year. Every one of these 230,000 men will have to decide which treatment is best for him. It’s an important decision but a hard one — not because of dire implications, but because there are so many good options for managing tumors confined to the prostate itself. Surgery, external beam radiotherapy, and radioactive “seed” implants (brachytherapy) all have their advantages, and newer treatments such as cryotherapy, which destroys prostate tissue by freezing it, are entering the picture. To complicate matters further, combinations of hormonal therapy with radiation or, possibly, surgery are also very promising. And for older men with low-grade tumors, watchful waiting can also be an option.

Randomized clinical trials are needed to decide which treatment is best for which patient. This research is complex and slow, however. In the meantime patients should consult with several physicians from different fields, such as urological surgery, radiation oncology, and medical oncology, in addition to their own doctors.

Many patients decide to “get it all out” with an operation that removes the entire prostate. Indeed, a radical prostatectomy can be an excellent choice, particularly for younger men in good general health with moderate to high-grade tumors. But younger men are particularly distressed by the prospect of impotence, a nearly universal occurrence following the standard operation. That’s why Dr. Patrick Walsh developed the nerve-sparing radical prostatectomy in the 1980s. While it has enabled many men to retain erectile function after surgery, some doctors have worried that the less extensive operation may leave cancer cells behind. It’s a dilemma for patients, but a study from the University of Miami should help ease the worry.

The standard operation
The radical prostatectomy is designed to cure cancer by removing the entire prostate gland along with the seminal vesicles and surrounding tissues. It is not an easy task. The prostate lies deep within the body, wedged between the rectum and bladder, wrapped around the urethra, and surrounded by important nerves that are vulnerable to injury (see figure).

Surgeons can approach the prostate in two ways. Most favor the retropubic approach, using an incision in the lower abdomen or the newer laparoscopic technique. In both, if the surgeon suspects the cancer may have spread to the patient’s lymph nodes, he removes the nodes and rushes them to a pathologist standing by to examine them. If cancer is present, surgery is not likely to cure the disease, so the operation usually goes no further, and the patient will be offered radiation or hormonal treatment. But if the lymph nodes are negative, the surgeon will carefully separate the prostate and seminal vesicles from the surrounding tissues.

To actually remove the gland, he will have to cut through the urethra just below the bladder, but he’ll sew the tube that carries urine out from the bladder back together once the prostate is out. The gland is then sent to the pathology laboratory for evaluation. If cancer is present only within the prostate, the operation has the potential to cure, but if the tumor has already extended through the capsule surrounding the gland, additional treatment is often recommended.

Most radical prostatectomies are performed under general anesthesia, but spinal anesthesia is also an option. The operation is quite safe, with a mortality rate below 1% in most centers. After spending three to five hours in the operating room, the average patient will spend just two to four days in the hospital. Even so, he will need to recuperate at home for several weeks, and he will have to urinate through a Foley catheter for one to three weeks while the urethra heals.