Surgery involves complete removal of the prostate gland. It is a highly effective treatment with good long-term results in the appropriately selected patient. Surgery may be performed as a laparoscopic (keyhole) procedure, robotic-assisted laparoscopic (keyhole using a computer interface) procedure or by standard open surgery. The results of all of these in terms of cancer control, potency and continence are the same. Laparoscopic and robotic approaches potentially offer a faster recovery with less blood loss and less transfusion risk. Irrespective of the way the surgery is performed, the major long-term side-effects of surgery include impotence and incontinence.
Impotence - The risk of impotence varies depending on your age and health and whether the nerves to the penis are removed or whether one or both of them are spared. If you have excellent erections before the operation, your chance of regaining your erections at 1 year, either spontaneously or with tablets, is approximately 70% if both nerves are spared, and 20-30% if only one is spared. Erections tend to improve over time for 1-2 years after the surgery but it is possible that they may never return and you would need to consider using a vacuum pump, injections or possibly require a prosthesis to achieve intercourse. Should your erections recover sufficiently for intercourse, it is important to note that they are not likely to be as strong as prior to the operation. It is highly likely that you will need to use tablets, injections or vacuum devices for some time (months / years) after the operation.
Incontinence - You are likely to leak urine after your operation and will need to wear continence pads for the first few weeks or months. It is vital that you perform pelvic floor exercises. In general, 25% of patients are pad free within 1 week, 70% within 3 months and 90% at 1 year. Therefore, there is a 10% chance that at 1 year after the operation you will need to wear incontinence pads. Usually this is a security pad to catch small amounts of urine however approximately 2% of patients have severe incontinence which may require further surgery by way of injectable agents, a male urethral sling or an artificial sphincter. There is a chance that the incontinence will be permanent.
Advantages of surgery
- The prostate gland is completely removed.
- Additional radiotherapy can still be applied if the cancer is at a high risk of recurring.
Disadvantages of surgery
- Major surgery, even if it is performed using key-hole techniques
- Other risks including rectal injury (which may require a colostomy bag), ureteric injury, anaesthetic problems, heart attack, stroke, major bleeding, blood transfusion, unexpected return to the operating room, a small risk of death from the procedure, fistula (abnormal connection between the bladder and the rectum), blood clots in the legs and lungs, recurrence of cancer, anastomotic stricture (scarring at the junction between the bladder and the urethra), inability to pass urine, and urine leakage, requiring prolonged drain placement and prolonged catheterisation.
- Risk of a positive margin which may imply that the cancer has not been completely cleared.
- Possible need for radiotherapy after the operation or hormonal therapy after the operation.