Surgery for locally advanced prostate cancer
Surgery may be an option for some men in the management of locally advanced prostate cancer. It is not a common treatment, as it may not be possible to remove all the cancer if it has moved outside or beyond the gland. The surgery is called a radical prostatectomy.
The aim of surgery is to remove your entire prostate gland and the cancer within it as well as the seminal vesicles, which are glands located behind the prostate that make semen.
The option to remove the prostate may be influenced by how much the prostate cancer has spread to nearby tissues or if other treatments are thought to be more suitable. Other factors such as Gleason Score (grade), PSA and your age and general health will also be taken into account.
Surgery might not be suitable if you have health problems that can increase the risks linked to surgery, such as heart disease or being very overweight. If surgery is not suitable for you, your surgeon will advise you to have one of the other treatments for locally advanced prostate cancer.
It can sometimes be difficult to be sure that the prostate cancer has spread beyond the prostate gland until you have surgery, even if you have had an MRI scan. However, some men may have clear evidence before surgery that the prostate cancer has already moved beyond their prostate gland, and surgery to remove the prostate and possibly the lymph nodes (glands) may still be suggested as part of the treatment. Your doctor or nurse will discuss this with you.
Surgery to remove your prostate gland is a big operation. It has risks such as bleeding, blood clots and infection and may have an effect on the quality of erections and urinary control. The average stay in hospital is 5-7 days but can be shorter or longer. You will need some time to recover at home afterwards as well.
Checking the margins
After your prostate gland is removed, it is sent to the laboratory to be examined and a report is issued describing the grade of the cancer cells and if the edges of the prostate gland are clear of cancer. This is known as checking the margins. Margins are described as negative or positive. Negative margins refer to no cancer cells, while positive margins refers to cancer cells at the edge of the prostate. This is used to predict your response to the treatment along with PSA checks.
Some men will be advised to have radiotherapy as well as surgery if the results from the laboratory show that there is evidence that the prostate cancer has moved beyond the outer shell of the prostate gland and into surrounding areas or that the cancer is too close or extends to or involves the surgical margins or edges.
Your surgeon will talk to you about further treatment with radiation and or hormones. The timing and need for further treatment will be influenced by:
The report from the laboratory on margins ( how much of a rim of normal tissue surrounds the tumour removed)
The Gleason score
Your general health
The overall benefit of offering immediate radiation or hormone therapy after surgery still remains unclear. In some situations, you may not have any additional treatment until there is evidence that the PSA is starting to rise after the surgery or until there is other evidence that the cancer is progressing. This may be seen on scans or you may develop new symptoms.
Research is still examining what is the best way to use these treatments after surgery, when they should be given, and which is best in terms of controlling the prostate cancer. Adding immediate radiotherapy or hormone therapy can add to the risk of more unpleasant side-effects like urinary incontinence, erectile dysfunction, fatigue and hot flushes while maybe not extending the length of your life over all by starting them early on. So sometimes starting these treatments may be delayed for a time. Your doctor and specialist nurse will explain this to you.
What are the types of surgery?
Surgery to remove your prostate gland can be done in a number of ways. You can discuss with your doctor which way is best for you. Not all of the treatments are available in all hospitals in Ireland, so discuss your preference with your surgeon.
Open radical prostatectomy
Laparoscopic radical prostatectomy (keyhole surgery)
Robot-assisted laparoscopic radical prostatectomy (robotic surgery
Open radical prostatectomy
Open surgery means that the surgeon will make a cut to get to the area that needs surgery. There are two ways of doing open surgery. The most common way is through a cut in the wall of your abdomen between your belly button and pubic bone. A radical prostatectomy can also be done through a cut between your scrotum and back passage, though this is less commonly done. Open surgery is available in hospitals throughout Ireland.
[Open radical prostatectomy]
Laparoscopic radical prostatectomy (keyhole surgery)
With keyhole surgery, a number of small cuts are made in your abdomen so that special instruments can remove your prostate. Afterwards, you need less time in hospital and can move around more easily than with open surgery. There is also less risk of needing a blood transfusion or getting a wound infection after keyhole surgery. The long-term side-effects of this type of operation are the same as for open surgery. Only a small number of surgeons in Ireland have had special training to do this operation.
[Laparoscopic radical prostatectomy (keyhole surgery)]
Robot-assisted laparoscopic radical prostatectomy
This operation is like keyhole surgery but with the use of a computer and robotic arms to help remove your prostate. As with keyhole surgery, less time is needed to recover after the operation. There is also less risk of needing a blood transfusion or getting a wound infection. Robotic surgery is fairly new to Ireland. At present it is available to patients with private health insurance and takes place in only a few private hospitals in the country. There are a few surgeons in Ireland who are specially trained to do this operation. At present, long-term follow-up is still needed to evaluate fully the use of robotic surgery and how it compares to open surgery in the treatment of locally advanced prostate cancer.
To make sure you are fit for surgery, you will need some tests. For example, blood tests, a heart tracing test (ECG), chest X-ray and a physical exam. An anaesthetist may also examine you to make sure you are fit for surgery. He or she will also discuss pain relief with you.
Prostate surgery has the same risks as any big operation. These include bleeding and the need for a blood transfusion, chest infection, blood clots and wound infection. Your doctor will discuss these risks and the side-effects of surgery before you sign a consent form.
Before surgery, a physiotherapist or nurse might show you how to do simple exercises to strengthen the muscles that help control your urinary flow. These are called pelvic floor exercises. You will also be shown how to do deep breathing and leg exercises to prevent a chest infection or blood clot after surgery. You may be given some elastic stockings to wear and an injection of an anti-clotting drug like heparin to reduce the chance of blood clots forming in your legs.
You cannot eat or drink anything for a few hours before surgery. The operation takes between 2 and 4 hours but you will spend some time in the recovery room while recovering from the anaesthetic.
When you wake up, you may have drips and tubes attached to your body. For example:
A drip into your arm or neck to give you fluids until you can drink again
A tube (catheter) to drain urine into a bag
One or two small drains near your wound to drain away any fluid
A tube into your back which gives you drugs to relieve any pain
When you begin to drink again, the drip will be removed. All other tubes and drains will be taken out over the first couple of days, except for the urinary catheter. You will go home with this tube for between 1 and 3 weeks.
The urinary tube will stay in place for between 1 and 3 weeks after your surgery. The urine you make will pass through the tube into a drainage bag. Before you go home, your nurse will show you how to look after the drainage bag. The catheter drainage bag will be worn inside your trousers and will be secured around your lower leg.
It is important that the urine can drain easily from your bladder and into the drainage bag. Try to drink plenty of fluids every day - between 1.5 and 2 litres is often best - so as to reduce the risk of getting an infection. Wash your hands before and after handling the catheter. When washing the catheter entry tip, wash in a one-way direction away from your body. Speak with your nurse if you notice any leaking around the outside of the catheter or if you notice that the catheter is not draining correctly.
You might experience bladder spasm while the tube is in place. This often feels like a strong urge to pass urine, despite the tube being there. This is normal, but talk to your nurse if this happens to you a lot. Bladder spasms may happen when your bowels move. Your doctor can prescribe medication if this becomes a problem for you.
You will likely have a special pump for relieving pain. This gives you a constant supply of painkillers, either into your spine (epidural) or into a vein in your arm. Your nurse will show you how to use it. Often the pump is a patient-controlled pump. This means there is a button on the pump that you can press to release the medication when you need it. When you no longer need the pump, you can have painkilling tablets. Let your nurse know if you are in any pain so that they can adjust the painkillers for you. You may have mild discomfort for several weeks. Your doctor will give you a prescription for painkillers to take home with you if needed.
Healing of the wounds after surgery usually takes a few weeks. Sometimes wounds may appear swollen and bruised slightly but this settles down with time. Healing on the inside of your body will take a bit longer.
The position and appearance of the scar left by the wound will depend upon the type of surgery you've had. With open surgery you will have one cut (incision), which will either be closed with stitches, surgical clips or staples, whereas with keyhole or robotic surgery you will have a number of smaller cuts.
It is important to keep the wounds clean and dry until they have healed. Immediately after surgery your wound will be covered with a dressing. Your nurse will advise you how often this will need to be changed and when it can be removed entirely.
Your wound clips might be removed before you leave hospital, or your practice nurse, public health nurse or GP might remove them when you go home. Contact your GP or the hospital as soon as possible if your wound becomes swollen, red or painful. This could be a sign of infection.
Avoid heavy lifting and manual work for up to eight weeks after the surgery. Your doctor or nurse will be able to advise you about this and also when you can return to driving.
The anaesthetic during surgery may slow down your bowels. As a result, it may take a day or two before you can start eating and drinking normally again. But you will quickly be able to take sips of water. The amount of fluids you can take will then be increased. The risk of your bowels being affected like this is less with keyhole or robotic surgery.
Infection and blood clots
A physiotherapist will help you with breathing exercises to help prevent a chest infection. He or she will also show you how to avoid pain when you cough or move in bed. You might find it helpful to hold a pillow or folded towel over your wound when you cough for the first few days.
You should move your legs and do your deep breathing exercises at least once an hour, even when in bed. This will help to prevent blood clots.
On the day after surgery, your nurses will help you get out of bed and take you for a short walk. These walks will become more frequent and longer as you get better. Soon you will be able to go for walks on your own.
Preparing for discharge
If you have surgery, it is best to make some preparations before you leave hospital to help you manage at home. Ask to speak to a medical social worker about the community services that are available, especially if you live alone. Usually, the public health nurse in your area will visit you at home. Use whatever help is available.
If dressings are needed for your wound, make sure you have some supplies at home before the discharge date. Ask for a contact name and telephone number at the hospital so that you can talk to somebody if you have a problem. You may also need help in getting supplies of incontinence pads.
On the day you go home, you will often also be given an appointment to go back to the hospital to see the surgeon, usually about 6 weeks after the operation.
You will also be given a date to have your urinary tube (catheter) removed (1-3 weeks after the operation).You will need to return to the hospital or go to your GP to have the urinary tube removed. This takes just a few moments.
Most likely you will experience some leakage of urine once the tube is removed. This is not unusual and normally improves with time. Your nurse will give you an incontinence pad to wear at this time. She or he can also give you information about how to get a supply of pads for yourself.
You can also talk to the public health nurse or a pharmacist about the special incontinence pads for men that are available. Make sure you have a supply at home before the urinary tube (catheter) is removed.
It is a good idea to have some spare pads with you on the day the catheter is to be removed so that you are prepared in case there is some leakage of urine on your way home.
You may find it helpful to visit our section Urinary symptoms, catheters and prostate cancer treatment which has more information on how to manage urinary problems, as well as advice on how to do pelvic floor exercises.
Regular light, gentle-paced exercise like taking short walks will help build up your strength again after the surgery.
You may notice a change in your bowel habits after surgery. If you are constipated, you might be given some laxatives or you may need to drink more fluids and include more high-fibre foods in your diet. Remember if the problem continues, talk to your doctor or nurse who can give you medication to help.
If you have a worry or symptom that is causing you concern before your check-up date, contact your doctor, nurse or hospital ward for advice.
What are the side-effects of surgery for locally advanced prostate cancer?
The main side-effects of surgery are:
Leakage of urine (urinary incontinence)
Problems with erections (erectile dysfunction)
The length of time that these side-effects can trouble you varies. It is impossible to predict how it will be for you, as each individual differs. Talking to your doctor or nurse, or another man who has had surgery for prostate cancer may help you to understand the impact of these side-effects on your daily life.
The risk of urinary leakage is the same for open, keyhole and robotic surgery. You can talk to your surgeon or nurse about the risk of urinary incontinence before you consent to surgery. Urinary incontinence means you cannot control the flow of your urine. Almost all men will have trouble with leakage of urine in the first weeks and often months after surgery. This means that you most likely will need to wear an incontinence pad to collect the leaked urine.
The amount of leakage can vary from some drops when you exercise, cough, sneeze or laugh to a much larger amount. As a result, you will need to wear pads to stay dry and comfortable. As time goes on, you are likely to regain control of your urine flow and will no longer need to wear pads. Or perhaps you will only need one pad a day or just when you exercise. A small number of men do not regain complete control over their urine flow and need to continue wearing pads. It is important to tell your surgeon if this happens.
Surgery is rarely necessary for problems with incontinence. However, there are certain surgical techniques which may help improve the situation, such as sling surgery. If you doctor feels that surgery is appropriate for you he or she will discuss with you which surgical technique would be most helpful.
Tips for coping with urinary incontinence
Remember that urinary incontinence usually improves with time.
Be prepared to cope with the leakage of urine in the first weeks after surgery - make sure you have a supply of incontinence pads at home.
Doing pelvic floor exercises can improve the problem. Ask your doctor to refer you to a physiotherapist to make sure you can do the exercises properly.
If you have a medical card, your public health nurse can assess your incontinence and help with a supply of pads. If you have problems that persist, do contact your public health nurse or doctor for advice and help. If your incontinence persists for a long time, they can also refer you to a continence adviser who can show you ways to cope. You can also contact a continence adviser through your local HSE office for more information. (External link)
For more information, visit our section Urinary symptoms, catheters and prostate cancer treatment or contact our Cancer Nurseline Freephone on 1800 200 700.
Erectile problems after surgery to your prostate gland can include:
Erectile dysfunction (impotence)
Shortening of your penis
Surgery to your prostate gland often leads to problems having or keeping an erection. This is called erectile dysfunction (ED) or impotence. It is caused by damage to blood vessels or nerves near your prostate. Erectile dysfunction is quite likely after surgery for locally advanced prostate cancer, because both of the nerve bundles that sit near the prostate gland may be affected by the surgery or may need to be removed.
Even a small amount of damage to nerves can lead to erections failing, especially if you are older and have high blood pressure or other medical conditions such as diabetes.
If you had problems with erectile dysfunction before surgery, you are more likely to have these problems after surgery too. Up to 7 in 10 men have erectile dysfunction after surgery to remove the prostate gland. Erections are often not as good as they were before surgery and you may never get back the ability to have an erection without treatment.
Early treatment for erectile dysfunction
Taking medications or using vacuum therapy for erectile dysfunction soon after surgery may improve erections. Persistence, time and patience after surgery are needed, so that you can explore the various combinations of treatments available and discover what methods are comfortable and work best for you and your partner.
Give yourself plenty of time to get used to using the treatments correctly and to finding ways of introducing them and integrating them into the intimate aspects of your relationship with your partner.
Remember that you can discuss any concerns you have in relation to erections with your doctor or nurse as they will be able to give you further advice, information and support.
For further information please visit the section Sex, erectile dysfunction and prostate cancer. Call the Cancer Nurseline Freephone 1800 200 700 or visit a Daffodil Centre to talk to a cancer nurse in confidence.
You might also find it helpful to read the section on Communication and intimacy with your partner, which has tips on being intimate after prostate cancer treatment and contact details for professionals who can help.
After prostate surgery, an orgasm will not cause an ejaculation of semen. This is known as a 'dry orgasm'. Many men describe the sensation of orgasm as different to their orgasm before surgery. A few men describe it as lasting longer, others describe some pain after orgasm in the early days, or some simply describe it as different.
A dry orgasm means that you cannot father a child in the future. If you are planning to have children, it may be possible to store your sperm before surgery. These can then be used later in fertility treatments. In Ireland, this is done at Rotunda IVF, at the Rotunda Hospital in Dublin. Talk to your surgeon if you think you might wish to father children after your surgery.
Shortening of your penis
Up to a year after surgery you may notice the length of your penis has shortened. It is not clear what causes this shortening. Some treatments for erectile dysfunction that encourage blood flow into your penis, such as tablets or a vacuum pump, may help to prevent it.
It often helps to talk to another man who might have gone through a similar experience of prostate cancer. The Irish Cancer Society has a one-to-one support programme: Survivor Support. All of our Survivor Support volunteers have been carefully selected and trained to give support, practical information and reassurance when you need it most.
If you would like to speak to a volunteer who has had prostate cancer, call our Cancer Nurseline Freephone on 1800 200 700 and we can put you in contact with a volunteer.
If you have had lymph nodes (glands) removed from your pelvis during surgery there may be a small risk in the future of developing lymphoedema.
This is a type of swelling that might happen in one or both legs, the tummy or around the genital area. The lymph nodes (glands) are part of the lymphatic system. The lymphatic system is a transport system that transports fluid called lymph. The lymph nodes act as a filter system and work by helping to remove waste substances that enter our bodies. If lymph nodes are removed during surgery the filtering mechanism may not work as well and a backlog of fluid called lymph can build up in the tissues under the skin and cause swelling.
Lymphoedema can occur straight after surgery or it can develop later, sometimes many years after treatment.
If you would like further information and advice about lymphoedema you can download our factsheet: Reducing your Risk of Lymphoedema.
You can also call our Cancer Nurseline on Freephone 1800 200 700 if you would like a copy to be posted to you or if you would like to discuss your concerns with a cancer nurse in confidence.
You can also pay a visit to the local Daffodil Centre to speak to a cancer nurse or to get copies of our publications.
Follow-up after surgery
You will usually be given an appointment to meet your urologist for a post-surgery check-up about six weeks after your operation. This meeting gives the urologist the chance to check that your wounds have healed. Your urologist will discuss with you the detailed report issued from the laboratory on the tissue that was sent off for examination during the surgery. For help understanding the results see the section: How is prostate cancer staged and graded?
You can expect that you will have your PSA blood level checked and also have a physical examination. The doctor will discuss with you if there is a need for further treatment now or as a possibility in the future.
Remember that these hospital follow-up visits give you the chance to talk about any side-effects or worries you may have such as urinary or erectile problems. By talking through any problems you may be experiencing as a result of your prostate cancer treatment you can be offered further support and help to manage them.