Limitations of surgery:
cancer operations are those that seek to remove cancerous material from the body by removing a tumor and as much surrounding
normal tissue as possible. The tenants of cancer operations are to avoid cutting through actual tumor and to avoid exposing
the actual cancer to the naked eye. In other words, by removing much of the normal tissues surrounding a tumor, the cancer
itself never has to be exposed. With this approach, the risk of cutting through tumor and/or spilling tumor cells into the
operative field is reduced. Unfortunately, due to the prostate's close proximity to the nerves that control erections, the
rectum and the bladder, this type of cancer operation can not be performed. Hence, the risk of leaving cancer behind in the
body or spilling cells into the blood stream is relatively high. This is especially true in higher risk prostate cancer (ie.
Those with higher PSAs and Gleason scores) I wrote an editorial on this topic for the journal " Brachytherapy" To
read this article please CLICK HERE
Side effects of surgery
One of the major
side effects of radical prostatectomy is the development of urinary incontinence. In order to understand why this happens,
it is important to understand the normal mechanisms by which the body maintains continence. The bladder is a bag like structure
that fills with urine that is produced by the kidneys. The bladder funnels into the prostatic urethra which is a straw like
structure which runs through the center of the prostate. The bladder neck is the junction point between the bladder and the
prostate. In the normal state, the involuntary muscles of the bladder neck keep the opening of the bladder closed and keeps
urine from leaking out. The second mechanism for keeping continence is the genito-urinary diaphragm , which is the muscular
floor which sits beneath the prostate . This structure usually stays closed and keeps urine from leaking out through the penis.
It can also can be control by the individual by squeezing the muscles of the pelvic floor. By cutting through the muscular
fibers of the bladder neck to separate the prostate from the bladder and by cutting muscular fibers of the urogenital diaphragm
the surgeon can cause urinary leakage known as stress incontinence. This can occur in up to 30% of patients and results in
the patient needing to were pads or diapers.
In addition to, there is a high risk of erectile dysfunction following
surgery. This is due to the close proximity of the neurovascular bundles which are collections of fine nerves and blood vessels
that run adjacent to the prostate gland both on the right and left side and are believed to be responsible for achieving and
maintaining an erection. Usually the bundles or nerve fibers emerging from these bundles are cut during surgery despite the
surgeons attempt to spare as much of the nerves as possible. It is for this reason that erectile dysfunction still remains
one of the more common side effects of surgery.
In a recent prospective trial , known as the SPIRIT trial which was
run by the American College of Surgeons and the American Urologic Association, patients were either randomly assigned to receive
seed implantation or radical prostatectomy or choose their own treatment. Quality of life tools were filled out by patients
prior to and after their treatment. The results after treatment demonstrated that patients treated with surgery had a much
greater likelihood of being impotent and incontinent compared with seed implantation (click on link to see article).