Surgical Procedures: Surgery and Staging for Prostate Cancer

Cancerous cells in the prostate are called prostate cancer. The prostate gland is a walnut-sized gland found only in men. It surrounds the urethra (tube that drains urine), sits below the bladder, in front of the rectum. It makes seminal (semen) fluid. The most common type of prostate cancer is called adenocarcinoma.

What is staging and how is it performed?

Staging is a way to find out how far the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. These tests may include:

• Physical Exam: This is a general exam to look at your body and to talk about your past health issues.
• Rectal Exam: A provider will use a gloved finger to feel the prostate gland and surrounding tissue to check for any abnormalities.
• Imaging: Radiology tests can look inside your body to look at the cancer and determine if it has spread. These tests can include:
  • Bone scan.
  • Transrectal ultrasound (TRUS).
  • CAT scan (CT scan).
  • Magnetic Resonance Imaging (MRI).
  • ProstaScint scan.

• Transrectal or transperineal biopsy: A needle is inserted through the rectum or perineum to remove tissue to be tested for cancer cells (called a biopsy).
• Pelvic Lymphadenectomy: The removal of lymph nodes from the pelvis to be tested for cancer cells.
• Seminal Vesicle Biopsy: The use of a thin needle to remove cells from the seminal vesicle to be tested for cancer. Seminal vesicles are tubes that secrete fluid that becomes semen.
• Serum PSA: This is a blood test that measures your PSA (prostate specific antigen) level. It is often elevated when a man has prostate cancer. It can also be elevated due to infection and inflammation.

Prostate cancer spreads to other parts of the body through the tissue, lymph, and blood systems. The stage tells how extensive the cancer is, how far it has spread, and helps guide the treatment. For prostate cancer, two types of staging can be used: clinical and pathologic staging.

• Clinical staging is decided by your provider based on the exam findings, blood test results, imaging, and biopsy.
• Pathologic stage is decided after surgery, allowing for a more complete evaluation of the tumor.
• These two stages are often different. The pathologic staging is more accurate because it is able to examine the entire prostate, but can only be done if you have surgery. The clinical staging is used when surgery is not done and that is acceptable.

Providers will use the American Joint Committee on Cancer TNM staging system. This system uses information on the extent of the tumor (T), spread to the lymph nodes (N) and distant metastasis (spread) (M). You will also be given a Gleason Score, which describes how different the cancer cells look from normal cells. This score tells how aggressive the cells will behave. The TNM and Gleason score are combined to give a stage of I through IV.

Surgical Procedures Used in the Treatment of Prostate Cancer

Surgery can be used in the treatment of prostate cancer. The type of surgery will depend on the stage and extent of the cancer. Surgeries include:

• Radical Prostatectomy: Removal of the prostate, surrounding tissue, and seminal vesicles. There are two ways this is done:
  • Retropubic Prostatectomy: An incision (cut) is made in the belly (abdominal wall) to remove the prostate. Lymph nodes may also be removed.
  • Perineal Prostatectomy: The prostate is removed through an incision (cut) made in the perineum. The perineum is the space between the scrotum and anus. An incision in the belly may be needed if lymph nodes are removed.

Your surgeon will talk to you about the best type of surgery for you. They can include using an open (large incision), laparoscopic (many small incisions), or robotic approach. Each type of surgery has its own risks and benefits and your surgeon should explain them to you.

• Pelvic Lymphadenectomy: Removal of pelvic lymph nodes to be tested for cancer cells.
• Transurethral Resection of the Prostate (TURP): Removal of some prostate tissue that is done using a tool called a resectoscope. The resectoscope is placed through the urethra (tube that drains urine). It does not cure prostate cancer but can be used to treat symptoms of advanced prostate cancer, such as urinary complications.

Surgery to treat prostate cancer can lead to nerve damage that can stop a man from being able to have an erection. Nerve sparing surgery may be an option for some men. Your surgeon will talk to you about your surgery and options for nerve sparing.

What are the risks associated with prostate surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Reaction to anesthesia. (Anesthesia is the medication you are given to help you sleep through the surgery, not remember it and to manage pain. Reactions can include wheezing, rash, swelling, and low blood pressure.)
• Bleeding which may or may not require blood transfusions.
• Blood in the urine.
• Infection.
• Injury to the surrounding organs.
• Lymphocele. (A collection of fluid.)
• Lymphedema. (Swelling that can happen after lymph nodes have been removed.)
• Inability to have or maintain an erection.
• Changes in orgasm (can be “dry”, meaning no semen released).
• Changes in the ability to father a child.
• Inability to hold your urine and/or stool.
• The penis becoming shorter by about 1-2 cm.
• Inguinal hernia. (This is when tissue pushes through muscle. It looks like a lump and can be painful to the touch.)

What is recovery like?

Recovery from a prostate surgery will depend on the procedure you have had. You may have to stay in the hospital for a few days. You may have a temporary urinary catheter to drain urine from your bladder. You will be given instructions on catheter care if it will stay in when you go home.

Your medical team will talk to you about the medications you will be taking, such as those to prevent pain, blood clots, infection, constipation or other conditions.

Your provider will talk to you about any activity restrictions you will have.

When to call your provider?

• Fever. Ask your provider how high your fever should be before calling them.
• If you don’t have a catheter and you are unable to pee on your own.
• If you have a catheter and the flow of urine has stopped.
• Any new or worsening pain.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.