Surgery has proved to be a very effective treatment for prostate cancer. One of the standard therapies for men with this disease is radical prostatectomy, a procedure that removes the entire prostate gland along with some surrounding tissue.
This operation is very complex, however, and requires a high level of technical precision, as the prostate is surrounded by nerves and structures important to normal urinary and sexual function. Many prostate cancer patients are understandably concerned about the possibility of complications that may occur as a result of this surgery.
James Eastham, Chief of Memorial Sloan Kettering’s Urology Service, has performed approximately 3,000 radical prostatectomies in his surgical career. Here, he explains the side effects of prostate cancer surgery and clarifies how a number of factors specific to each patient affect his overall risk of complications.
When you meet with patients who have opted for prostate cancer surgery, what complications seem to cause the most anxiety?
Patients are usually concerned about longer-term quality-of-life issues, such as urinary control — also called urinary continence — and changes in sexual function. Prostate cancer surgery does sometimes have a negative impact on these functions, although the likelihood depends on a variety of factors, including age, the extent of the cancer, and baseline function, or how well everything worked before the procedure.
The outcomes for urinary continence at MSK are what I would consider to be excellent. More than 90 percent of our patients will regain urinary control, although they may go through a period — perhaps several months or a year after surgery — in which they do not have complete control.
For sexual function, the extent of recovery is especially affected by the nature of the cancer. Unfortunately, the nerve tissue that allows a man to get an erection is right up against the prostate. We obviously want to remove all the disease, and if the cancer extends outside the prostate at all, it’s not wise for us to try to preserve the nerve tissue because we might leave some cancer behind.
You often see claims made by institutions or surgeons that the patients they treat recover their erectile function in 90 percent of cases. That’s true only for a very select group of patients, usually those who are younger and had full erections prior to surgery.
What typically increases the risk of complications from prostate cancer surgery?
Complication risks can be increased if prior surgery for unrelated reasons was done in the area or if we have to do extensive surgery to remove the cancer. But complication rates also go up dramatically when we do surgery on patients who have failed other prostate cancer treatments, such as radiation therapy.
Radiation is a very effective treatment for prostate cancer, but it doesn’t work for everyone. In these patients, we often believe the cancer has recurred or persisted in the prostate without spreading, so removing the prostate following failed radiation treatment — a procedure called salvage prostatectomy — is potentially curative.
Salvage prostatectomy is more technically challenging than radical prostatectomy. Patients who have already had radiation therapy often have scarring in and around the prostate, which can make tissue in the area very difficult to separate while performing the operation. As a result, patients undergoing salvage prostatectomy have a much higher risk of urinary incontinence, and a higher rate of developing more scar tissue, strictures — which is a narrowing of the urethra that blocks urine flow — or injury to adjacent structures like the rectum.
MSK is a referral center for many patients whose radiation therapy did not work. Patients know that we have a high level of expertise in salvage prostatectomy, so this procedure makes up a significant portion of prostate surgeries at MSK compared with some hospitals. I treat a large number of these difficult cases — as do my colleagues here — and this can result in complication rates that are higher than if we had a more typical patient population.
What is a common misconception you find in patients regarding complications that might occur after prostate cancer surgery?
I have found that patients often misunderstand the real meaning of percentages doctors give them about the likelihood of recovering their function. A patient might be told that their chance for recovery of erections is 75 percent. A lot of patients interpret that as meaning, “I have a 75 percent chance of returning to my baseline function.” It actually means 75 percent of patients will be able to get a functional erection, often with the aid of a pill. Unless the doctor makes this clear to them, many patients will be disappointed. When a percentage is quoted, patients should ask their surgeons what it actually means because — as is usually the case — the devil’s in the details.
What advice would you give to a patient who wants to keep the risk of surgical complications as low as possible?
There are some things that patients can’t control, such as their age, their baseline functionality, or the nature of their cancer. But they can control the treatment choices they make. Patients should be aware that some cancers are found so early that immediate treatment is not necessary, and these tumors can be monitored closely through an approach called active surveillance — a method we’ve pioneered very successfully here at MSK.
For patients opting to undergo radiation therapy or surgery, it’s critical to know the outcomes of the individual doctor. It’s well established that surgeons or radiation oncologists who specialize in a specific treatment and do a high number of procedures have better outcomes.
These therapies are very effective. It’s always a balance between removing the cancer and trying to preserve function, and the balance is different for each person because each cancer is different. One of the benefits of places like MSK is that we have experts who can help guide patients in regaining urinary and erectile function.
Ultimately it’s all about finding a surgeon or a radiation oncologist with whom you feel comfortable — someone who sets realistic expectations based on your situation as a patient.