Surgical Procedures: Surgery and Staging for Prostate Cancer

When there are cancer cells in the prostate gland, it is called prostate cancer. The prostate gland is about the size of a walnut. It surrounds the urethra (tube that drains urine) and 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 done?

Staging is a way to find out if and how far cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. Some of these tests are:

• Physical Exam: This is an 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 nearby tissue to check for any changes or abnormalities.
• Imaging: Radiology tests can look inside your body to see if the cancer has spread. Some imaging tests are:
  • Bone scan.
  • Transrectal ultrasound (TRUS).
  • CAT scan (CT scan).
  • Magnetic Resonance Imaging (MRI).
  • ProstaScint scan.
• Transrectal or transperineal biopsy: A needle is placed through the rectum or perineum (area between the anus and scrotum) to remove tissue that will be tested for cancer cells (called a biopsy).
• Pelvic Lymphadenectomy: Lymph nodes are removed from the pelvis and tested for cancer cells.
• Seminal Vesicle Biopsy: A thin needle removes cells from the seminal vesicle to be tested for cancer. Seminal vesicles are tubes that make fluid that becomes semen.
• Serum PSA: This is a blood test that measures your PSA (prostate specific antigen) level. PSA levels are often higher if you have prostate cancer. However, PSA can also be high because of infection or inflammation.

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

• Clinical staging is based on the exam findings, blood test results, imaging, and biopsy.
• Pathologic stage is decided after surgery, allowing for a more complete understanding of the tumor.
• These two stages are often different. Pathologic staging is more accurate because it looks at the whole prostate, but can only be done if you have surgery. Clinical staging is used when surgery may not be an option.

Clinical staging for prostate cancer is based on 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 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 are. The TNM and Gleason score are combined to give a stage of I (1) through IV (4).

Surgical Procedures Used to Treat Prostate Cancer

Surgery can be used to treat prostate cancer. The type of surgery depends on the stage and extent of the cancer. The types of surgery used for prostate cancer are:

• Radical Prostatectomy: The prostate, nearby tissue, and seminal vesicles are removed. There are two ways this is done:
  • Retropubic Prostatectomy: An incision (cut) is made in the abdomen (belly) to remove the prostate. Lymph nodes may also be removed.
  • Perineal Prostatectomy: The prostate is removed through an incision made in the perineum. An incision in the belly may be needed if lymph nodes are removed.
• Pelvic Lymphadenectomy: Pelvic lymph nodes are removed and tested for cancer cells.
• Transurethral Resection of the Prostate (TURP): Some prostate tissue is removed 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.

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

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

What are the risks of 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, to not remember it, and to help with pain. Reactions can include wheezing, rash, swelling, and low blood pressure.)
• Bleeding that requires blood transfusions.
• Blood in the urine.
• Infection.
• Injury to nearby 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 is released).
• Changes in the ability to father a child.
• Inability to hold your urine and/or stool.
• The penis can become shorter by about 1-2 centimeters (cm).
• Inguinal hernia (When tissue pushes through muscle. It looks like a lump and can be painful to the touch).

What is recovery like?

Recovery from prostate surgery depends on the procedure you 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 told how to care for your catheter if it will stay in when you go home.

Your care 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 changes you might need to make to your activity level.

When should I call my provider?

• Fever. Your provider will tell you at what temperature you should call the office.
• 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.