SPECIAL REPORT

T H E P R O S TAT E B U L L E T I N

THE RADICAL PROSTATECTOMY

A
JACEK L. MOSTWIN, M.D., s men pass into their 40s, the prostate gland gradually
enlarges, sometimes interfering with urination and causing
D. Phil. (Oxon), pro-
bladder or kidney problems. The most serious concern, how-
fessor of urology at Johns ever, is the tendency of the prostate to develop malignant tumors,
Hopkins, is head of the which may spread to the lymph nodes and bones, eventually causing
Division of Reconstruc- death.
tive and Neurological
Prostate cancer is the second most common form of cancer in men
Urology. Dr. Mostwin,
(after skin cancer) and the second most common cause of cancer
who has performed more death (after lung cancer). An American boy born today has a 16 per-
than 2,300 radical cent chance of developing prostate cancer in his lifetime and about a
prostatectomies over the 3 percent risk of dying from it. While prostate cancer may progress
years, is the medical so slowly that some patients live with it for years and end up dying of
something else, once it spreads it is incurable.
editor of the Johns
Hopkins Prostate The risk factors for prostate cancer include age, race, and family his-
Bulletin. tory—three factors you cannot control. Age is a major determinant;
the incidence of cancer is 1 in 53 for men in their 40s and 50s, but
jumps significantly to 1 in 7 for men 60 to 79. People with a family his-
tory of the disease are at higher risk: If your brother or father had
prostate cancer, your risk is twice as great. African-Americans are at
tremendous risk, for unknown reasons, and they have the highest rate
of prostate cancer of any ethnic group in the world.

Still, deaths from prostate cancer have been on a steady decline over
the past decade, directly attributable to better diagnosis with DRE
(digital rectal examination) and PSA (prostatic specific antigen) test-
ing and follow-up treatment. The American Cancer Society estimates
that there will be about 232,090 new cases of prostate cancer in the
United States in 2005, with about 30,350 men dying from the disease
this year.

Q. What is the best treatment for prostate cancer?

A. I’m asked this question by just about every man with the disease
who comes to see me for a consultation. It’s a question with several

1 Visit us at www.prostatebulletin.com
 SPECIAL REPORT
Radical Prostatectomy
The removal of the prostate
through conventional open
surgery—the radical prostatec-
tomy—remains the gold standard
against which other treatments
must still be measured.
2 Visit us at www.prostatebulletin.com
possible answers because many factors have to be considered in
choosing a procedure that is just right for each person.
I can say this, however: The removal of the prostate through con-
ventional open surgery—the radical prostatectomy—remains the gold
standard against which other treatments must still be measured. On
average, a cancerous prostate contains seven distinct tumors, and
there’s no more certain way to eliminate a cancer that’s confined to
the prostate than total removal of the gland. In younger men, with a
greater life expectancy, the odds of survival increase if they undergo
surgery to remove the prostate.
Q. When searching for a prostate cancer surgeon, is the
number of surgeries performed annually a good indicator of
surgical competency?
A. Studies have shown that surgeons who perform fewer than 50
procedures a year have a much higher rate of complications. The
majority of practitioners who are very active and skilled are probably
going to be doing at least 100 to 120 surgeries a year. I have been per-
forming between 170 and 180 radical prostatectomies annually for the
past decade and several of my colleagues in the department perform
even more. I think this is more likely in a large academic center like
ours.
Q. Do you encourage men to get a second opinion about their
prostate cancer options?
A. In our surgical practice at Johns Hopkins, the majority of patients
we counsel have already made up their minds that they wish to have
an operation performed at Hopkins. Of those who have come to Hop-
kins from somewhere else for a second opinion, two-thirds end up
having the surgery performed here.
This is not always the case at other hospitals, and I would encourage
men to seek a second opinion in most cases. It would be wise to speak
to both a surgeon and a radiation therapist, unless you already have a
clear-cut idea of what you want to do about your cancer. Be wary of
anyone who rushes you into any form of treatment. Prostate cancer
is a slow growing disease and you have plenty of time to make a deci-
sion. Besides, you need that extra time for the biopsy site to heal
before surgery (we recommend six weeks).
 SPECIAL REPORT
Radical Prostatectomy

Q. How is the radical retropubic prostatectomy surger y performed?

A. A radical retropubic prostatectomy performed by an experienced surgeon in our hospi-
tal usually takes from 90 minutes to 120 minutes. Fifteen years ago, before the era of early
detection due to PSA, the operation could take more than three hours, and in some hospi-
tals it still can. That’s the difference experience has made.

After anesthesia is administered, a catheter is inserted into the bladder to drain urine and
help identify the urethra. An incision is made through the skin, starting from a few inches
below the navel to the pubic area. The abdominal muscles are separated and spread. (They
are not cut, so there is no weakness or damage to the muscles, and post-operative pain is
minimized.)

Pelvic lymph nodes are removed from nearby the prostate. After surgery, these nodes, along
with the prostate, are sent to the pathologist to be examined for the presence and extent of
any cancer and to issue a final pathological stage. This is different from the clinical stage the
tumor was previously given, as that stage was based on the surgeon’s initial examination
before surgery.

Next, the dorsal vein complex, the major vein system that overlies the prostate and urethra,
is controlled to minimize the flow of blood, allowing the surgeon a cleaner field in which to
operate.

The junction of the urethra and the prostate is now identified. The urethra is separated from
the prostate at a natural division point, beyond any cancer-containing prostatic tissue. If the
division is too close to the prostate, some cancer may be left behind; if the division is too far
away, the urethral sphincter may be damaged and future urinary continence severely com-
promised.

If there is much cancer in the prostate, the surgeon must decide whether to remove one or
both neurovascular bundles, the nerves that lie against the sides of the prostate. Removing
one is very uncommon; removing both is exceptionally rare. Removing both will mean a per-
manent end to natural erections. If I am able to leave one bundle, the chances for erections
remain good if the man was having erections before the surgery. The decision to remove a
nerve bundle is never undertaken lightly. A good estimate of the need to do so can be made
before surgery by careful digital examination of the prostate and a review of the biopsy report
and PSA level.

Even if both nerve bundles have to be removed, men will still have a similar sex drive, nor-
mal sensation during sexual activity, and orgasm. The nerves controlling orgasm are not in
the surgical field. Erections can be restored by other means, including oral medication, vac-
uum erection devices, and injectable medications. Since the prostate is removed, orgasms
will be almost completely “dry”—minimal fluids will be expelled, usually small amounts of
lubricating fluid from the urethra and a few drops of urine, one of the cleanest fluids in the

3 Visit us at www.prostatebulletin.com
 SPECIAL REPORT
Radical Prostatectomy

body. A “dry” ejaculation is an expected outcome of a radical prosta-

tectomy. Semen is not expelled out of the urethra at sexual climax
because the major sources of fluid have been removed.

For men who still hope to father children (using their own sperm
cells) in the future, I recommend banking sperm before surger y.
Although not a natural means of reproduction, it is still effective and
allows the two partners who wish to conceive to join their genetic
materials.

Now, some good news: Since prostate cancer is being detected much
earlier, the nerves are preserved in the great majority of men so erec-
tions can return, even though fertility will not.

Before surgery, one can make a preliminary estimate regarding the

likelihood of preserving the nerves. During the surgery, when I’m
actually looking at the prostate, I can make the final decision. When
significant hard cancer is felt on the edge of the prostate, the neu-
rovascular bundle is generally removed, because the cancer may have
already penetrated the nerve bundle. This procedure, known as a wide
excision, is performed to cut out additional tissue surrounding the
prostate, to make sure every bit of cancer is removed. Remember:
The primary object of the surgery is to remove all cancer cells while
preserving erection capabilities whenever possible. Since prostate cancer is
being detected much
When no cancer is felt at the edges, and the nerve bundle easily falls earlier, the nerves are
away from the gland as it’s being removed, it’s a sign that the cancer preserved in the great
is more likely to be contained within the gland.
majority of men so
After the nerve bundles have been separated, the prostate remains erections can return, even
attached to the urinary tract only at its junction to the bladder. I will though fertility will not.
then separate it at the bladder neck, which connects the prostate to
the bladder. The goal is to take away all prostatic tissue while pre-
serving the natural muscle fibers of this portion of the bladder. The
seminal vesicles (glands that, like the prostate, support male repro-
duction; fluid secreted by these glands regulates the consistency of
semen) and the two vas deferens (the hard muscular cord that helps
form the ejaculatory duct) are divided at this time.

The prostate is now removed and inspected to satisfy the surgeon that
all cancer appears to have been removed, that there are no questions
regarding the margins of the specimen. With the prostate out, I recon-
nect the urinary tract, something that happens more naturally than
would seem. You see, when you were very young, the bladder and

4 Visit us at www.prostatebulletin.com
 SPECIAL REPORT
Radical Prostatectomy

the urethra were ver y close to each other, as they are in women
throughout life. But as the prostate grows, it displaces the bladder
upwards, out of this initial position.

With the prostate removed, the bladder falls back into its original posi-
tion and this should happen without any tension at all. The bladder
neck is reduced in diameter with a few small sutures, then re-attached
to the urethra over a new catheter inserted in the penis and anchored
by a tiny balloon in the bladder. The catheter will be left in place after
the procedure to drain urine over the course of the next 8 to 14 days,
until the connection(anastomosis) has securely healed.

Q. What is the impact of surger y on urinar y continence?

A. Urinary function is always an issue, regardless of the form of treat-
ment. With external radiation therapy the problem is fibrosis of the
bladder; with brachytherapy (“seed therapy”) it is fibrosis or irrita-
tion of the urethra; with surgery it is injury to the sphincter. The good The good news is that all
news is that all of the centers of excellence report better than ninety
of the centers of excellence
percent urinary continence after surgery.
report better than ninety
Remember, however, that urinary continence is defined as either being percent urinary conti-
totally dry or else having to wear one small absorbent pad a day. A nence after surgery.
small pad is something like a woman’s sanitary napkin, the kind of
thing that could be inserted into a pair of undershorts and forgotten
for the rest of the day. For all practical purposes, most men rarely have
any leakage; if they do, it’s just a drop or two when they exert them-
selves getting out of a car or swinging a golf club. However, if at all
other times and at night they are dry—they don’t need to wear a pad
to bed.

The chances of being severely incontinent—which means requiring an

artificial sphincter—are probably 1 to 2 percent at most. The chances
of being moderately incontinent—which means that medication or
collagen injections may be needed to bulk up the sphincter—are prob-
ably in the range of 5 to 8 percent.

Q. When is a PSA test performed after surger y?

A. The PSA level can be tested six weeks after surgery. If all cancer
has been removed along with the prostate gland, the PSA should be
undetectable, which is generally considered less than 0.05 ng/ml or
less than 0.1 ng/ml, depending on the pathology laboratory your sur-
geon uses.

5 Visit us at www.prostatebulletin.com
 SPECIAL REPORT
Radical Prostatectomy

When PSA is undetectable, the next test is given three months later,
and then every six months for years two through five. The PSA is then
performed annually. The frequency of PSA testing can be modified
based on the Gleason score and the overall surgical pathology report.

Q. Will a man be able to have an erection suitable for inter-

By removing this disease
from a man’s body and
removing it from the
remainder of his life, I am
able to offer the man not
only an improved quality
of life, but hopefully years
more of good health.
course after a radical prostatectomy?
A. It depends on the man’s age and his level of erectile strength
before surgery. A good way to assess this is with the SHIM (Sexual
Health Inventory for Men) questionnaire. This simple quiz provides
a good indication of future possibilities. If the man’s score is 21 or
lower, or if he is already using Viagra, Cialis, or Levitra, I think he has
to be realistic in understanding that his erection capabilities will be
even more diminished following surgery.
In the hands of the most skilled surgeon, if both neurovascular bun-
dles are preserved during surgery, erections should return in at least
80 percent of men in their forties and fifties, and 60 percent of men in
their sixties. Only about 25 percent of men over age 70 will have suit-
able erections following surgery.

Q. Looking back at your surgical career, and as one who has

performed and continues to perform many radical prostatec-
tomies, what are your overall thoughts on the procedure?

The information contained in this Prostate

Bulletin Special Report is not intended as a A. I believe that I have saved men’s lives by performing this opera-
substitute for the advice of a physician. tion, and I sincerely believe that they would not have been saved by
Readers who suspect they may have specific other forms of treatment. I believe that the operation can be performed
medical problems should consult a physician
about any suggestions made.
very safely in the overwhelming majority of carefully selected patients.
My experience has reinforced in me the desire to offer this operation
* * *
JACEK L. MOSTWIN, M.D., D.PHL (OXON) to men at any age where I feel there is a realistic chance of being cured
Medical Editor
and they are in good enough health to expect a good outcome.
Copyright ©2006 Medletter Associates, LLC

All rights reserved.

No part of the Prostate Bulletin Special Report may be
By removing this disease from a man’s body and removing it from the
reproduced or transmitted in any form or by any means remainder of his life, I am able to offer the man not only an improved
electronic, mechanical, photocopying, recording, or other-
wise, without the prior written permission of the publisher.
quality of life, but hopefully years more of good health.
For subscription inquiries or problems, please write to:
The Prostate Bulletin, Customer Service, PO Box 420235,
Palm Coast, FL 32142; or call: (800) 829-0422 (US only)
or (386) 447-6313 (outside US). For all bulk orders,
inquiries, and permission to reproduce sections of this
Bulletin write to: The Johns Hopkins Prostate Bulletin,
Medletter Associates, LLC,
6 Trowbridge Drive, Bethel, CT 06801
Printed in the United States of America

PBSR2-1

6 Visit us at www.prostatebulletin.com