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Prostatectomy
For prostate cancer

Nearly 250,000 men are diagnosed each year with prostatic cancer and over 35,000 men will die. One of the therapies for this common problem is radical prostatectomy, removal of the entire prostate gland

  • The development of Prostate Specific Antigen (PSA), a simple blood test, has significantly improved screening for the disease
  • Improvement in biopsy methods has also helped to improve the diagnosis
  • In the younger patient the disease is more malignant while in the very elderly the disease is relatively less aggressive. This may be due to the fact that slow growing prostate cancer has many more years to spread in the younger patient

Anatomy and Physiology

  • The prostate is a walnut-sized gland that lies just below the urinary bladder and surrounds the urethra, the tube within the penis through which urine passes from the bladder (Figure 1)
  • The glandular cells that make up the prostate gland add important nutrients and fluid to the semen, which is the fluid containing sperm
  • A thin capsule of fibrous tissue, and then a layer of fat surround the gland
  • The front wall of the rectum lies only a few millimeters behind the gland
  • Lying on each side in the interval between the prostate and the rectum are nerves and blood vessels
  • Surrounding the urethra just beyond the prostate is the urinary sphincter that prevents involuntary leakage of urine
  • Leading from each testicle lying in the scrotum is a tube, the vas deferens, which conducts the sperm to the urethra as the urethra passes through the prostate
  • Veins of the prostate drain towards the heart via connections that lie alongside the spine
  • Lymph, a watery fluid found in all tissues, flows away from the prostate via very small channels called lymphatics to lymph nodes along the wall of the pelvis on both sides. The lymph nodes acts to filter out bacteria and cancer cells before the fluid flows further upstream towards veins that eventually empty into the heart
Figure 1 - Anatomic relationship of the prostate gland to the urinary bladder and urethra.

Pathology

  • A disease commonly seen in men as they age is a benign (non-malignant) enlargement of the prostate called benign prostatic hyperplasia (BPH)
    1. This enlargement may cause obstruction to the outflow of urine from the bladder
    2. If severe enough, surgery for removal of the obstructing portion of the prostate tissue may be necessary to allow urine to flow freely
  • Prostatic cancer is a malignant (uncontrolled) growth of the glandular cells of the prostate gland
    1. Prostate cancer generally grows slowly over a period of years, but may grow rapidly and spread outside the prostate gland
    2. The male hormone, testosterone, which is produced in the testes, stimulates growth of this cancer
    3. As the cancer grows, it eventually extends through the capsule of the gland from which it may spread locally to the bladder and seminal vesicles or spread distally to the lymph nodes of the pelvis, bones of the spine, liver, lung and occasionally other tissues
  • Prostate cancer is commonly graded according to the Gleason Scale (1-10), which is a method of describing the cancer based on how the cells look and how they are arranged. The higher the Gleason grade the worse the cancer
    1. A low grade (Gleason 2-4) tumor has more normal looking cells and is slower growing
    2. A high grade (Gleason 8-10) tumor has very abnormal cells and is much more aggressive and likely to spread (metastasize) outside the prostate
    3. The treatment options are varied and determined by age, tumor grade, and degree of metastasis
  • Cancer growth is categorized by the TMN staging system (Adopted by the American Joint Committee on Cancer and the International Union Against Cancer) and is used to determine treatment Place in separate box TNM staging system
  • Primary tumor (T)
    1. TX. Primary tumor cannot be assessed
    2. T0. No evidence of primary tumor
    3. T1. Clinically not apparent tumor, not palpable on rectal exam or visible by imaging
      • T1a. Tumor is incidental finding in 5% or less of tissue resected for benign enlargement of prostate
      • T1b. Tumor incidental finding in more than 5% of resected tissue
      • T1c. Tumor identified by needle biopsy (e.g., because of elevated PSA) T2. Tumor confined in prostate
    4. T2a. Tumor involves one lobe of prostate
      • T2b. Tumor involves both lobes
    5. T3. Tumor extends through the prostatic capsule
      • T3a. Extension through capsule on one or both sides
      • T3b. Tumor invades adjacent seminal vesicle(s)
    6. T4. Tumor is fixed or invades adjacent structures other than seminal vesicles such as bladder neck, rectum, pelvic muscles or pelvic wall
  • Regional lymph nodes (N)
    1. NX. Regional lymph nodes cannot be assessed
    2. N0. No regional lymph node metastasis
    3. N1. Metastasis present in regional lymph node(s)
  • Distant metastasis
    1. (M) MX Distant metastasis cannot be assessed
    2. M0. No distant metastasis
    3. M1. Distant metastasis
      • M1a. Beyond regional lymph node(s)
      • M1b. To bone(s)
      • M1c. To other site(s)
  • After a complete workup, the prostate cancer is staged to aid in treatment
  • Jewett staging system is often used and very similar to the TMN system
    1. Stage A. Cancer incidentally found at surgery for prostatic enlargement
      • A1. Cancer is small and low grade
      • A2. Cancer is high grade or throughout the specimen
    2. Stage B. Cancer found by digital exam and limited to the prostate
      • B1. Cancer limited to one side of the prostate
      • B2. Cancer on both sides
    3. Stage C. Cancer spread to tissues directly surrounding the prostate
    4. Stage D. The cancer has metastasized to the lymph nodes or bone
      • D1. Cancer spread only to pelvic lymph nodes
      • D2. Cancer spread to bones

History and Exam

  • Making the diagnosis of prostate cancer may be difficult
  • There are no classic signs of prostate cancer. In fact, there may be no symptoms at all in the presence of an advanced cancer
  • Prostate cancer is best initially detected by digital rectal exam
    1. This is the easiest and most important test
    2. The doctor looks for any enlargement, irregularity or firmness of the gland
    3. Any man over 50 years of age should have this test annually

Tests

  • Prostate Specific Antigen (PSA) is a test to detect an enzyme normally produced by the prostate
    1. When the prostate gland is irritated a small increase in PSA may occur
    2. When cancer occurs, PSA may go into the hundreds
    3. The normal level of PSA is 0 to 4.0, but this range is not definite
    4. Other causes of an elevated PSA are urinary tract or prostate infection, catheter in the bladder, recent prostate surgery or biopsy and benign enlargement of the prostate
    5. A normal PSA does not guarantee that the individual is prostate cancer free
    6. Any man over 50 years of age should have this test annually
  • Prostatic ultrasound
    1. If the digital rectal exam or PSA is suspicious for cancer, it should be followed up with a prostate ultrasound and biopsy (Figure 2)
    2. The ultrasound probe is placed in the rectum opposite the prostate gland
    3. The ultrasound beam is then bounced off of the prostate and recorded. The pictures produced are reviewed for evidence of tumor
    4. Nodular tumors are usually detected by ultrasound, however, an infiltrating tumor may not
  • Biopsy of the prostate is accomplished through a thin needle inserted into the prostate via the rectum and attached to a biopsy gun
    1. Thin slices of tissue are obtained and examined by a pathologist for tumor
    2. Biopsy sites are guided by the ultrasound
    3. Several random biopsies are also taken because many tumors are not detected by ultrasound
    4. It is important to note that a negative prostate ultrasound and biopsy does not mean that one is cancer free. There is about a 15% sampling error
    5. If prostate cancer is suspected, repeat testing may be necessary in 4-6 months
  • In order to determine treatment options, it may be necessary to carry out several tests to determine the extent of spread of the disease
    1. Bone scan. A small amount of radioisotope is injected into the blood and absorbed into the bones in the areas affected by the cancer. This is imaged on a special scanning device. The spine is the most common site outside of the pelvis for prostate cancer to metastasize
    2. CAT (computerized axial tomography) scan. This test examines the inside of the body through the creation of computerized X-ray images. A CAT scan of the pelvis may demonstrate enlargement of the prostate gland or pelvic lymph nodes
    3. MRI (magnetic resonance imaging) scan. This test creates detailed computerized images of the internal organs and bones by detecting the changes in the tissue molecules when subjected to a strong magnetic field
Figure 2 - Prostatic ultrasound showing cancer within the prostate gland. Courtesy D. Bahn, MD

Treatment Plan

  • Treatment for prostate cancer is best determined by the treating physicians, urologist, family physician, oncologist (cancer doctor), and radiotherapist
  • Here is a general guide to treatment related to the Jewett system. (Relating treatment to the TMN system can be done by comparing the two systems
    1. Stage A1. Treatment depends on the age and general health of the patient. Most men will not die of a stage A1 tumor and need only be followed by monitoring the PSA. Men in their 50's or early 60's in otherwise good health may live long enough for the cancer to enlarge and possibly lead to death. These individuals may wish to consider radical prostatectomy or radiation therapy
    2. Stage A2. With a more aggressive tumor, men under 70 in good health may consider radical prostatectomy. Men over 70 should have radiation. Very old men or those in poor health may option for no therapy or hormone therapy
    3. Stage B1. With the cancer confined to the prostate, radical prostatectomy or radiation is indicated. Men over 80 or in poor health may option for observation only
    4. Stage B2. This is usually treated with radical prostatectomy for those individuals under 70 in good health and radiation for the others. Hormone therapy may be considered when life expectancy is short
    5. Stage C These men with cancer beyond the prostate are probably best treated with radiation. In young men, radical prostatectomy may be considered on the chance that the procedure could be curative
    6. Stage D With the cancer spread more widely, elimination of the male hormone may be helpful since the male hormone stimulates growth of the tumor. Radiation is usually not helpful because of the wide extent of the tumor

Surgical Procedures

  • Radical prostatectomy is not an option for all men with cancer of the prostate
    1. For consideration of surgery, the cancer should be confined to the gland
    2. Once the cancer has spread beyond the gland, the chance of complete removal of the tumor is dramatically reduced
    3. There are two ways to remove the prostate gland for cancer, the retropubic and perineal approaches
  • Retropubic approach
    1. An incision is made from just below the umbilicus down to the pubic bone
    2. The bowel is retracted up and out of the way so as to allow the exposure of the lymph nodes that lie in the drainage distribution of the prostate gland
    3. At this point, the lymph nodes are removed and given to the pathologist. If cancer is found in several nodes then the tumor has spread and removal of the prostate gland is probably to no avail
    4. If only one or two nodes are involved with the remainder clean of cancer, then the surgeon has to decide if removal of the prostate will be curative
    5. The prostate is removed by dissecting the urethra near the prostate and then cutting through the urethra to separate the urethra from the prostate. (Figure 3)
    6. The prostate with inserted catheter is then separated from the rectum behind (Figure 4)
    7. The neurovascular bundle containing nerves and blood vessels are separated from the prostate (Figure 5)
    8. The nerves on either side of the prostate are important in erection of the penis. Removal or damage to these nerves results in impotence
    9. When possible the urologist will usually try to save these nerves, or only try to remove the nerves on the side of the tumor. If the nerves are damaged, it may take a year or more for erectile function to return
    10. When the cancer is close to the nerves, nerve sparing may be impossible without leaving some cancer behind
    11. The purpose of radical prostatectomy is to achieve a cure. Sparing nerves for potency is only a secondary consideration and may not be always possible
    12. When the prostate gland is removed (Figure 6), a small hole is left in the urethra that must be closed by placing sutures between the urethral stump and the bladder neck (Figure 7 and 8)
Figure 3 - The prostate gland is separated from the urethra lying just beneath the pubic bone. © T. Graves, MD Figure 4 - The prostate gland is elevated off the rectum. © T. Graves, MD
Figure 5 - The nerves and vessels going directly to the prostate are separated from the prostate while preserving the neurovascular bundle. . © T. Graves, MD Figure 6 - The prostate gland is separated from the bladder and removed. © T. Graves, MD
Figure 7 - The urethra is sutured to the bladder. © T. Graves, MD Figure 8 - Diagram showing the relationship of the bladder, prostate and urethra before and after removal of the prostate gland. © T. Graves, MD
  • Perineal approach
    1. An incision is made between the legs, just behind the scrotum
    2. In an obese man, this may be an easier approach because it avoids having to work around the fat laden pelvis and abdominal wall
    3. The disadvantage of this approach is that the lymph nodes cannot be removed for examination first
    4. With a low PSA, this may be reasonable since the nodes will probably be normal
    5. Another drawback to this approach is that it makes nerve sparing more difficult

Complications

  • There are several potential complications to radical prostate surgery. These risks are balanced by the benefit of cancer removal
  • Excessive hemorrhage. Because the prostate is surrounded with a very rich plexus of blood vessels that can easily bleed during surgery. This may result is significant blood loss and the need for blood transfusions
  • Impotence. Because of the involvement of the nerves surrounding the prostate (see above), the patient may not be able to have an erection
  • Incontinence. Leakage of urine may occur because of the injury to the nerves and direct involvement if the urethra
  • Bladder neck contracture. This may occur because of the scar tissue that is formed when the urethral stump is sutured to the bladder neck. This can cause difficulty in urination and may require dilatation
  • Infection. This can occur in any operation, but may be more of a problem because of the close proximity of the rectum
  • Tear into the rectum. This occurs because of the close proximity of the rectum to the prostate gland. This may require a colostomy while the hole in the rectum is healing following repair
  • Deep venous thrombosis (DVT) and pulmonary embolism. Blood clots may develop in the legs or deep pelvic veins. This can be dangerous because at any time the clot may break loose and travel to the lung causing difficulty in breathing or, if the clot is large, sudden death

Postoperative Care

  • Patients may have a tube through in the nose that goes into the stomach to drain the stomach for a few days. The tube is removed after the bowel regains function and the patient started on a diet
  • A catheter is left in the urinary bladder to drain urine
  • Pelvic surgery is associated with higher rates of clotting in the veins of the thighs. Blood thinners or calf compression devices are used to prevent clot forming until the patient is walking
  • Approximately 3 - 7 days are spent in the hospital

After Care

  • Infection in the incision can occur. The incision may be tender or red or if the infection has progresses there may be frank drainage of pus. The doctor must be contacted if this occurs. Opening the incision and draining the pus along with antibiotics usually takes care of the problem
  • The patient is sent home with a catheter in the bladder so that there is no obstruction to the outflow of urine. The catheter may remain for as long as 3 weeks. There may be an occasional leakage of urine around the catheter
  • Irritation from the catheter may cause bladder spasms with a cramping feeling in the lower abdomen. The doctor may prescribe medication for the spasms if necessary
  • It is important to stay active after surgery, but not strain. Moderate walks are an excellent start and tend to minimize the formation of blood clots in the legs, which can still occur for several weeks after discharge. For this reason it is also best to wear support stockings for six weeks
  • A return to light sports can begin in six to eight weeks

Alternative Therapies

  • Cryosurgery of the prostate
    1. This is a relatively new technique in which probes are inserted into the prostate under ultrasound control
    2. Liquid nitrogen is then passed through the probe
    3. The tissue around the probe freezes and dies
    4. Proponents of this method feel that there are fewer complications than with prostatectomy
    5. The method is still being evaluated and there is no long-term follow up as yet
  • Radiation. There are two types of radiation that may be used to treat prostate cancer:
    1. External radiation: This is the most common type of radiation used to treat cancer. High-energy radiation is focused on the area of the cancer from a source outside the body. This is administered over a period of 6-8 weeks. Each dose is usually for 15-20 minutes per day. Complications such as bladder and rectal irritation and impotence are not uncommon
    2. Interstitial radiation: This is sometimes referred to as brachytherapy. Small radioactive seeds, each about the size of a grain of rice, are inserted into the cancer. The radiation extends to a controlled amount around each seed. Like external radiation, bladder and rectal irritation and impotence are the most significant common complications
  • Hormonal Therapy
    1. Prostate cancer is sensitive to the male hormone, testosterone
    2. By removing this hormone, prostate cancer usually stops growing and sometimes regresses
    3. There are four types of hormonal therapy
      • Orchiectomy. This the surgical removal of the testicles and eliminates almost all of the testosterone produced in the male
      • Administration of female hormone, diethylstilbestrol. This suppresses testosterone. It has significant side effects including heart attack and blood clots. This is less used because of the newer medications
      • LHRH analogs (Lupron, Zoladex). This medication stimulates the production of a burst of testosterone. The body's response to the overshoot then suppresses testosterone to very low levels
      • Androgen blockade (flutamide, bicalutamide, nilutamide). This class of drugs blocks the ability of cells to absorb testosterone