Educated Patient® Prostate Cancer Summit Overview of Surgery Presentation: May 21, 2022

The ability and track record of a surgeon is of utmost importance when a patient with prostate cancer is selecting the team that may operate on them and potentially remove the organ, according to an expert.

Dr. Ganesh V. Raj, The Dr. Paul Peters Chair in Urology at UT Southwestern Medical Center in Dallas, Texas, recently discussed the role of surgery and active surveillance for prostate cancer during CURE®’s Educated Patient® Prostate Cancer Summit. Moreover, Raj highlighted how decisions to treat are made and how advances have been made over the years to ensure that patients retain their ability to get an erection and don’t experience incontinence.

Is the Prostate Cancer Localized?

Before a treatment decision is made, providers assess if the disease is localized to the prostate or if it has metastasized — or spread to other nearby organs or lymph nodes. Raj explained that if the cancer is localized to the prostate, then surgery, radiation or even active surveillance (routine follow-up and testing to ensure the disease isn’t growing) are all viable treatment options. However, if a patient has metastatic prostate cancer, then localized treatments — such as surgery — are not often possible. Instead, patients will often be treated with chemotherapy, immunotherapy or hormonal therapy.

Providers also often use disease staging and a Gleason score to identify which treatment options may be best suited for certain patients. For instance, Raj noted that stage 1, 2 and 3 prostate cancer is confined to the prostate. Whereas stage 4 disease has spread outside of the prostate. The Gleason score is used by providers as a grading system to essentially identify if patients fall into certain risk groups. For instance, a patient who is considered very low-risk, meaning their tumor(s) are likely to cause no harm to the patient, is recommended to undergo active surveillance.

Ultimately, Raj said, the decision to treat and how to treat is based on these risks. And that decision is broken down into three categories, according to Raj.

First, what is the risk of disease recurrence? If the risk is determined to be low, then is surgery really necessary? But, if the risk of recurrence is intermediate or high, then, he said, surgery provides more benefit than risk. Another way to look at the decision to treat with surgery or any other modality, he said, is to assess the patient’s life expectancy. If surgery, chemotherapy or even radiation provide the potential for the patient to live a long life and eventually die of a cause that is not the prostate cancer, then those treatments should be strongly considered.

The Evolution of Prostate Cancer Surgery

While many patients dread the idea of surgery, Raj explained that the procedure has drastically evolved since it was first performed in 1904 at Johns Hopkins Hospital in Baltimore.

At the time, surgeons cut into the perineum (which is the area between the scrotum and rectum) and removed the prostate. While this may have effectively treated the cancer, most patients were left incontinent and experienced declines in quality of life.

“Since we've understood how to do this better, now we do it robotically and a vast majority of patients undergoing the surgery have both potency (the ability to get and maintain an erection) and continence,” he explained.

‘The Hand of Man Meets the Hand of God’

For Raj, he explained that a well-performed radical prostatectomy (complete removal of the prostate) mimics the famous “The Creation of Adam” painting where “the hand of man meets the hand of God.”

He said that it “feels incredible” to perform a surgery that spares vital nerves and functions while also removing the cancer from the patient’s body.

This is all aided by a robotic surgical system known as da Vinci. Here, the surgeon sits at a console a few feet away from the patient. The system provides the surgeon with a 3D view of the patient’s abdomen. There are three pivotal advantages to performing a robotic prostatectomy, according to Raj.

The pros to this device include a reduction in the risk of bleeding in patients, as well as the removal of a surgeon’s potential hand tremors. One of the more important advantages, he explained, is the magnification for the surgeon.

“Imagine, if you will, I asked you to cut between two points that are about a millimeter apart,” he said. “And I asked you to cut between those. And I said if you went too close on one side, well, you could leave cancer behind, (and if) you went too close on the other side, you'd cut the nerve, and the guy would not have erectile function. That's hard to do. But imagine if I magnified that 100-fold. And I asked you to cut between two things that were (magnified). … That's a much easier operation.”

Timeline of Recovery After Surgery

For patients, one of the questions about surgery is how well it works. The answer, according to Raj, is that most patients achieve completely recovered continence. And if there hasn’t been a full return of that function, it likely will come back within 12 months.

In terms of erectile function, it all depends on what the patient’s ability to get and maintain an erection prior to surgery was. For instance, if a patient is older and has preexisting underlining erectile dysfunction, then they likely will not recover that ability.

“(However), a vast majority of patients in whom we are able to save the nerves and who had good erectile function preoperatively will have erectile function afterwards,” he said.

Parting Thoughts

Most patients with prostate cancer, Raj noted, will die with the disease and not because of it.

“So a vast majority of them will die of cardiovascular disease but not of prostate cancer,” he said.

Raj concluded by noting that patients should in fact pay attention to the quality of their surgeon. Oftentimes surgeons who have little experience performing the procedure may likely not be as well versed and patients may be at a greater risk for side effects such as incontinence and erectile dysfunction.

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