What every patient should know: there are TWO, not one prostate cancer operations

Mr Alan Doherty

By Alan Doherty, consultant urologist, BPC

In almost everything I read about prostate cancer, the discussion is about the operation for cancer of the prostate, medically termed the radical prostatectomy. In other words, a single, all encompassing operation for prostate cancer.

This is wholly different to the discussions I have with my patients. In these discussions, I talk about the difference between a radical prostatectomy and a total prostatectomy.

The main difference is that the total prostatectomy involves removing all the prostate and trying to leave the erectile nerves intact, (this is sometimes referred to as bilateral nerve sparing). The total prostatectomy also preserves the bladder neck and as much urethral length as possible; in other words, only the prostate is removed with an attempt not to damage surrounding tissues that are very unlikely to be involved with cancer.

It is such an important distinction: in fact, we are talking about two different operations in terms of intent, process and outcomes.

What I mean by a total prostatectomy with bilateral nerve sparring is this: the whole of the prostate is removed, with a primary aim of full cancer clearance. Priority is also given to reducing collateral damage to the nerves and tissue around the prostate.

The nerves which produce erections lie alongside the prostate (although they are not a part of the prostate itself). During the traditional radical prostatectomy, the process of removing the prostate often causes so much damage to the nerves that the patient is left with permanent erectile dysfunction. This damage is often intentional to provide a clear margin if the cancer is considered at a high risk of having spread outside the prostate.

Nerve-sparing refers to a deliberate process of peeling back the tissue which is stuck onto the side of the prostate gland, leaving the nerves underneath as undisturbed as possible. I sometimes describe this to patients as being like the nerves being held close to the prostate by a layer of cling film (fascia).

These layers are variable in their characteristics: if they are like domestic cling film, it is easy to cut, and the layers separate cleanly and easily. If it’s thick and more rigid like the commercial variety, it tends to stick to the prostate and is harder to divide cleanly in a single go. That’s one of the reasons that nerve sparing is not always successful.

This analogy is helpful because it helps me to describe the nerve-sparing process; to explain why I find open surgery is the best way of undertaking nerve-sparing and also to say it isn’t possible to fully predict how easy or difficult this aspect of the process will be until the surgery is taking place.

Bilateral, of course, refers to the fact that nerve-sparing can take place on both sides of the prostate, providing it is appropriate to do so from a cancer management perspective.

Sometimes the quality of nerve-sparing may be better on one side than on the other. I grade nerve sparing on each side, so I can be transparent with my patient about all aspects of the procedure and equally, when I audit the outcomes of each operation, I have a clear measure to evaluate future outcomes.

If the data indicates that providing nerve-sparing is medium to low quality on one side, providing the quality is high on the other side of the prostate, outcomes for erectile recovery are usually good.

A total prostatectomy with bilateral nerve-sparing is a procedure with several, complex aspects that requires a high level of surgical skill. A radical prostatectomy also requires strong surgical skill and remains the right operation when a patient has high risk disease because we know cancer is very close to or may have moved outside the prostate capsule.

Full cancer clearance is always the primary, over-riding priority and sometimes nerve-sparing is not possible or safe.

However, my main message would be: these are two different operations. This is important to bear in mind for two reasons – you may read studies and articles comparing a radical prostatectomy to other approaches to prostate cancer, such as active monitoring or focal therapy.

You may read about how outcomes from surgery compare poorly to other approaches, notably the functions of erections and continence. The problem here is that under surgery, there is no indication of what type of approach is used, who is included (low risk/high risk); all are placed together, making meaningful interpretation impossible.

In my own results, for a decade, I have differentiated patients by risk type and surgical approach. I would expect the post-op functions for each group to be different; I would be a poor surgeon if this was not the case. The results for continence and erectile recovery are much better after a ‘total’ prostatectomy.

In the conversations you have with your prostate cancer specialist, it may be helpful to see whether there is recognition of the two different types of operation undertaken, with their different aims, processes and outcomes. When you speak to a surgeon, this can be a useful way of understanding their personal approach and surgical philosophy (something which is perhaps not easy to establish but I would say is essential).

I would describe myself as a surgeon with an emphasis upon functional outcomes: I will treat your cancer, first and foremost, but I will be very focused on preserving your functions. We will talk about this, plan for it before surgery, monitor things very closely afterwards, both in the short, medium and the long term because once we have addressed your cancer, your functions will be very important for your lifestyle and well-being.