Introduction

Prostate cancer

One of the most common types of cancer in men around the world is prostate cancer, particularly in men aged 65 and older. Prostate cancer occurs in the prostate, which is a small gland shaped like a walnut. This gland is situated below the bladder and in front of the rectum in men and individuals assigned male at birth. This tiny gland produces a fluid that combines with semen, helping to maintain the health of sperm for conception and pregnancy.¹

Importance of treatment options

Understanding the available treatment choices for prostate cancer is essential for making well-informed decisions. Surgery is a primary treatment option, particularly when the cancer remains localised to the prostate. One often performed surgical procedure is known as radical prostatectomy. This involves the complete removal of the prostate gland to help stop the spread of cancer.

This operation is frequently advised for men who have early-stage prostate cancer. Radiation therapy is sometimes used with surgery to improve outcomes. However, it is crucial to note that surgery may cause side effects such as trouble managing urine and changes in sexual function. Therefore, patients must address these potential risks with their doctors to make the best decision for their circumstances.¹

Types of surgery for prostate cancer

Radical prostatectomy

Description

One of the main ways to treat prostate cancer is through surgery. These days, surgery is the only way to get rid of your prostate gland. This is a radical prostatectomy.

Indications

Radical prostatectomy is typically performed on men with early-stage prostate cancer that has not progressed beyond the prostate.

Types of radical prostatectomy

• Open prostatectomy: The surgeon usually creates an incision in the lower abdomen to take out the prostate
• Laparoscopic prostatectomy: Laparoscopic surgery is a technique that allows for smaller incisions during surgical procedures. It refers to undergoing a surgical procedure without requiring a large incision in your abdomen. Surgical instruments and a laparoscope are inserted through these small cuts to operate
• Robotic-assisted prostatectomy: Five or six tiny incisions are made in the lower part of the stomach by the surgeon to remove the prostate. The surgeon works with surgical tools that are attached to robotic arms while sitting at a computer console. With robot-assisted surgery, the surgeon can make very accurate moves. It might not hurt as much as open surgery, and you might be able to get better faster

Candidates for prostate cancer surgery

Factors influencing surgical decisions

Age

Age plays a crucial role in determining if surgery is appropriate. Younger men, particularly those with a longer life expectancy, are more likely to have surgery to remove the cancer fully. Older men, especially those with other health issues, might choose less aggressive options like active surveillance to steer clear of surgical risks.²

Overall health

A patient's overall health and any existing medical conditions are key factors in deciding if surgery is suitable. Surgery can be a viable option for healthy men to remove the cancer completely. For men with serious health issues, the risks of surgery may be greater than the benefits, prompting recommendations for alternative treatments.³

Stage of cancer

Surgery is usually an option for early-stage prostate cancer when it remains localised to the prostate. If cancer has spread beyond the prostate, surgery might not work as well, and treatments like radiation or hormone therapy could be better options.

Life expectancy and patient preference

Life expectancy helps determine if surgery is appropriate. Men with a longer life expectancy may gain more from surgery, as cancers that remain untreated have a greater risk of cancer returning. Patient preferences about surgery side effects, like urinary incontinence and erectile dysfunction, are important. Some men might focus more on avoiding side effects than on the possible benefits of surgery.³

Risks and complications of surgery

General surgical risks

After any surgery, there is a chance of issues or complications. Some complications can be severe. The risks include:

• Bleeding
• Urinary tract infection
• Difficulty obtaining and maintaining a firm enough erection suitable for intercourse, also referred to as erectile dysfunction
• Not being able to control your bladder, also known as urinary incontinence. Most of the time, this goes away on its own
• In rare cases, there can be damage to the intestine or rectum

Recovery and post-surgical care

Immediate recovery

Following surgery, you can anticipate that:

• You will probably receive pain medicine through an IV, a tube placed in a vein. After the IV tube is taken out, your surgeon might provide you with prescription pain medication to help manage any discomfort
• Your surgeon will probably ask you to start walking the same day or the day after your surgery. You'll also practice some movements for your feet while lying in bed

 Long-term recovery

• Catheter care: Typically, the catheter remains in place for 7 to 10 days. Following removal, it is common to experience temporary urinary incontinence; however, this condition tends to improve with pelvic floor exercises
• Wound care: You will have dressings placed over your surgical wounds. The stitches will be removed, and any changes will occur approximately 7 to 10 days following the surgery. Before you leave, you will get guidance on how to care for your wound
• After surgery, you'll have regular follow-up appointments to check your PSA levels, which ideally should be low or undetectable. The initial check-up typically occurs four weeks after the surgery, followed by appointments every three months during the first year
• Getting back to activities: It may take 6 to 8 weeks for a complete recovery. Begin by slowly boosting your activity level, like incorporating daily walks, to rebuild your strength. It's important to follow your doctor's recommendations for a safe recovery

Alternatives to surgery

Radiation therapy

Radiation is used in radiotherapy to eliminate cancer cells. This treatment is a viable option for curing prostate cancer that remains localised to the prostate or has only minimally spread. Radiotherapy can help slow down the progression of prostate cancer that has spread, as well as provide relief from symptoms.

Typically, you will receive radiotherapy as an outpatient at a nearby hospital. The program consists of brief sessions conducted five days a week, typically lasting between four and eight weeks.

Radiotherapy can lead to various side effects. Before starting radiotherapy, you might be given hormone therapy to enhance the likelihood of a successful outcome. After radiotherapy, hormone therapy might be suggested to lower the risk of cancer cells coming back.

Hormone therapy

Hormone therapy may also be suggested following radiotherapy to lower the likelihood of cancerous cells returning. Prostate cancer cannot be cured by hormone therapy alone. This treatment can help slow down the progression of advanced prostate cancer and ease symptoms. Hormones play a crucial role in regulating the growth of cells within the prostate. Prostate cancer specifically requires the hormone testosterone for its growth.

The aim of hormone therapy is to inhibit the effects of testosterone. This can be achieved by halting its production or preventing your body from utilising it effectively. Hormone therapy can be administered in the following forms:

Injections that prevent your body from producing testosterone, tablets that either block the effects or lower testosterone production, or a combination of both options.

The primary side effects of hormone treatment stem from their impact on testosterone levels. Typically, they resolve once the treatment is discontinued. These may involve a decrease in sexual desire and difficulties with erections, which tend to occur more frequently with injections compared to tablets.

Active surveillance

Active surveillance aims to prevent unnecessary treatment for non-threatening cancers while ensuring prompt care for those who require it. Active surveillance includes regular PSA tests, MRI scans, and occasionally biopsies to detect any signs of progression at the earliest opportunity.

If these tests show that the cancer is changing or getting worse, you can then decide on the next steps for treatment.

Summary

• Prostate cancer frequently occurs in men aged 65 and older
• Radical prostatectomy is a frequently chosen surgical procedure for localised cancer, but it does come with potential risks, such as urinary incontinence and erectile dysfunction
• It typically takes about 6 to 8 weeks for recovery, during which follow-up PSA monitoring will be conducted
• Options to consider are radiation therapy, hormone therapy, and active surveillance for cases that are low risk
• Choosing a treatment involves considering factors such as age, overall health, and cancer stage. It's crucial to make informed decisions in collaboration with your doctor to achieve the best possible outcome