Simply put, radical prostatectomy is feasible for patients with early stage prostate cancer. Its main indications are twofold.
1. the clinical stage of the tumor is early, i.e. organ-limited prostate cancer without lymph node and bone metastasis.
2. The patient’s life expectancy is greater than 15 years. The reason for this stipulation is that radical surgery can only completely remove the tumor inside the prostate, and once the tumor metastasizes to the bones and surrounding lymph nodes, surgery is no longer able to remove these lesions; and when the patient’s life expectancy is only 10 years or less, even if he or she receives radical prostate cancer surgery, he or she cannot benefit from such surgery. This is because there is a high probability that such a patient will die from other diseases, not from prostate cancer, within 10 years even without treatment.
So what is the procedure of radical prostate cancer surgery?
Radical prostate cancer surgery is usually performed under general anesthesia, and the incision is made in the lower abdomen, extending from the level of the pubic bone upwards, 12-15 cm long. The excised lymph nodes are immediately sent for examination, which is called “intraoperative frozen section pathology”. If the lymph nodes have significant metastases, then the patient’s prostate cancer is no longer an early organ-confined tumor and the surgery should be stopped in principle, whereas if no metastases are found in the lymph nodes, then the surgery will continue. This step is important because if the urethra is dissected too close to the prostate, it can cause residual prostate cancer cells, but if it is too far from the prostate, it can damage the urethral sphincter and cause postoperative urinary incontinence.
The prostate is then removed at the neck of the bladder, and the vesicourethral glands and vas deferens are also removed on both sides. Finally, the urethra is reconstructed to connect the bladder to the transected urethra, which we call an anastomosis.
After the bladder neck is anastomosed to the urethra, a catheter with a balloon is passed through the penis and into the bladder before the end of the surgery. In the final stage of the surgery, the surgeon also places a drainage tube inside the pelvic cavity, which can easily drain the blood and fluid inside the pelvic cavity to prevent postoperative infection.
This is the entire procedure of radical surgery for retropubic prostate cancer, which usually takes about 3 hours. Of course, the surgery time may vary according to the local anatomical characteristics of the prostate gland of different patients, and there is no direct relationship between the surgery time and the surgical result.
Post-operative complications exist with any surgery. So, what are the complications of radical prostate cancer surgery?
1. Urinary Incontinence
Urinary incontinence is one of the most dreadful complications after radical prostate cancer surgery, most of the patients will not experience permanent incontinence, and even if it occurs, the degree of incontinence is mild and only occurs during strenuous exercise.
There are three factors associated with postoperative urinary control, the first being the function of the patient’s sphincter prior to surgery and the second being the level of prostate removal versus urethral reconstruction by the surgeon. The third factor is the degree of preservation of the neurovascular plexus.
The objective criterion for incontinence-free is that the absence of urinary pads at any time is considered incontinence; the opposite is considered incontinence.
2. Sexual dysfunction
For classical, non-sexual nerve-preserving radical transpubic posterior prostate cancer surgery, the incidence of postoperative sexual dysfunction is almost 100%. However, even for radical prostate cancer surgery with preservation of the sexual nerve, sexual dysfunction occurs in 14.0 to 88.4% of cases after surgery.
The causes of erectile dysfunction after radical prostate cancer surgery may be due to nerve and vascular injury caused by the surgery, injury to the neurovascular bundle that may lead to decreased oxygenation of the cavernous smooth muscle, resulting in decreased or lost erectile function, and possibly even cavernous fibrosis and impaired venous closure. However, the preservation of the neurovascular bundle during surgery does not guarantee the recovery of sexual function after surgery.
3. Urethral stricture
Urethral stricture is another complication that affects the normal urinary function of patients after radical prostate cancer surgery, including bladder anastomotic stricture and bladder neck contracture, the incidence of which is 0.48%~32% and usually appears 1~6 months after surgery. The incidence of postoperative urethral stricture is significantly increased in patients who smoke, have preoperative coronary vascular disease, primary hypertension and diabetes mellitus, which may be related to their causing microangiopathy of the anastomosis, local ischemia, and scar formation during the healing of the anastomosis.
Other complications of radical prostate cancer surgery include venous thrombosis, intraoperative hemorrhage, rectal bladder injury, and bladder neck contracture.
Although many complications after radical surgery have been described above, it should be understood that the incidence of these complications is not very high. With the improvement of medical treatment, their incidence will be further reduced, and, even if they occur, doctors still have ways to deal with them.