August 29, 2016
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Prostate Cancer (cont.)

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Watchful waiting

This does NOT mean doing nothing about your prostate cancer. It means that rather than having the patient undergo aggressive treatments -- usually surgery or radiation therapy -- the urologist and the patient commit to a scheduled program of follow-up examinations, blood tests including PSAs, and repeat prostate biopsies at regular intervals. If the cancer shows signs of progression in the prostate gland, or the PSA starts to rise substantially, treatments are reconsidered.

This approach is appropriate for patients with smaller amounts of low-grade prostate cancer. It is also appropriate in patients in whom other medical conditions, or age, or both, suggest an excessively high risk of potentially serious problems developing were aggressive therapy attempted.


The removal of the entire prostate gland and the attached seminal vesicles is referred to as a radical prostatectomy. This is usually done through an incision or incisions made over the front of the lower abdominal wall with the procedure, taking place behind the pubic bones at the front of the pelvis (a retropubic approach). Today the main choice is between a standard open radical prostatectomy and the use of a robotic system for performance of the procedure through smaller incisions. The former allows the surgeon to feel the tissues and make the cuts themselves. The latter uses an operating system robot, which the surgeon guides. The former takes longer to recover from, and has more risk of blood loss associated with it. The latter results in a more rapid recovery and less blood loss generally.

Intact pelvic nerve bundles on either side of the prostate in the pelvis are essential for a man to be able to have an erection. Impotence -- or the inability to have and sustain an erection of a quality sufficient for successful intercourse -- can occur after this operation. The likelihood of impotence is primarily dependent on whether or not the necessary nerves can be preserved during surgery, AND the patient's true preoperative ability to still have an erection. Nerve-sparing surgical technique is desirable and the surgeon should plan to do this, if possible. These important pelvic nerve bundles may need to be sacrificed if they are too close to or are involved with the cancer. The objective of the surgery is to cure the patient of the prostate cancer with the least number of problems afterward as possible, but the performance of a potentially curative procedure must remain the primary objective of the surgeon.

The radical prostatectomy involves the removal of a portion of the urethra. The urethra is the tube that runs from the bladder to the outside through the penis. It runs through the prostate gland. The procedure can disrupt the sphincter or valve, which controls urine flow from the bladder. The surgeon reconnects the urethra to the bladder after the prostate is out. The more careful and experienced the surgeon, the less the risk of long-term inability to control the flow of urine (incontinence).

The risks of an operation lasting several hours also remain substantial and include heart problems, blood loss, as well as a risk of infection, blood clots, and rarely death. Such operations are appropriate for patients whose cancer appears to be confined to the prostate gland.

If a preoperative nomogram in a patient with a T1 or T2 tumor suggests a 2% or greater risk of lymph node metastases, then a pelvic lymph node dissection may be performed in addition to the radical prostatectomy. Pelvic lymph node dissection is unnecessary in almost half of patients undergoing radical prostatectomy.

Medically Reviewed by a Doctor on 11/12/2015



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