What is a nerve-sparing radical prostatectomy?

The nerves responsible for erectile function run along each side of the prostate and along each side of the urethra before passing out of the pelvis into the penis. These nerves travel along with blood vessels, and the group is called the neurovascular bundle, which lies outside of the prostate capsule. These nerves are not responsible for control of urine, only erectile function. During a nervesparing prostatectomy^[1], the urologist attempts to dissect^[2] the neurovascular bundle from the prostate and the urethra. The surgeon may perform a bilateral nervesparing radical prostatectomy, in which the neurovascular bundle on each side is spared, or a unilateral nervesparing prostatectomy, in which one neurovascular bundle is removed with the prostate. The decision of whether or not to perform a nerve-sparing radical prostatectomy depends on many issues, one of which is your erectile function. If you already have erectile dysfunction, then sparing the nerves is not an issue. Other considerations include the amount of tumor present in your biopsy specimen, the location of the tumor (whether it is in both sides of the prostate), and the Gleason score. Remember that a radical prostatectomy is a cancer operation, and the goal of the procedure is to try to remove all of the cancer. Therefore, if you are at high risk for having cancer at the edge of the prostate, it is better to remove the neurovascular bundle(s) and surrounding tissue on that side in hopes of removing all of the cancer. A bilateral nerve-sparing radical prostatectomy does not guarantee that you will have normal erectile function after the surgery. You should consider this fact and decide before surgery how much of an impact postoperative erectile dysfunction would have on your life.

What is the success rate of radical prostatectomy?

In general, more than 70% of properly selected patients (i.e., men who are believed to have prostate cancer that is clinically confined to the prostate) remain free of tumor for more than 7 to 10 years. If one has a T2 tumor, the probability of remaining free from PSA elevation can be as high as 90% if there were no positive margins. However, it is hard to predict before surgery who is the best candidate for surgery because 30 to 40% of patients are diagnosed with a higher stage or grade of cancer when the surgical specimen is reviewed by the pathologist. Positive surgical margins are found in 14 to 41% of men undergoing radical prostatectomy, and in those men with positive margins, there is an almost 50% chance that the PSA will increase within 5 years after surgery. This varies with the amount of tumor at the margin and the location of the positive margin. Your urologist would discuss whether additional therapy is indicated if the margin is positive. Men with negative margins have only an 18% chance of the PSA rising at 5 years after surgery. Initially after surgery, you will have your PSA level checked every 3 months. Depending on the lab that your physician uses, a PSA level < 0.1 ng/mL or a PSA level < .02 ng/mL may be reported as undetectable. The numbers vary because the sensitivity^[3] in PSA testing varies from lab to lab. If the PSA remains undetectable after 1 year, then your urologist may order PSA testing every 6 months for about 1 year, after which you will continue with yearly PSA tests. Depending on your pathology report and your urologist's preference, you may also have a digital rectal examination at the time of your PSA.

Cliff's comment:

The first PSA test after surgery is the most suspenseful. Even though your urologist may tell you that your pathology specimen from surgery looks good and that there are no cancer cells at the the edges of the tissue, you are still anxious to hear what the PSA is. You want it to be undetectable—want it to indicate that the cancer has been caught and removed. You get your blood drawn and then you wait to meet with your urologist or for the phone call regarding your results. I remember how happy I felt when I got my first PSA report after the surgery. Now, 21/2 years later, I am still slightly anxious when I have my PSA drawn, although as each year goes by the anxiety is decreasing. With each good PSA result, I start to believe that they've gotten it all. I can technically say that I am cured, but each year that goes by that I am healthy and the PSA remains undetectable is another year enjoyed and another closer to that goal.

Who is a candidate for radical prostatectomy?

The ideal candidate for a radical prostatectomy is a man who is believed to have prostate cancer that is confined to the prostate gland, is healthy enough to withstand the general anesthesia and the surgical procedure, and is expected to live for at least an additional 7 to 10 years so that he will benefit from the surgery. It is difficult to determine who really has organ-confined disease, which is cancer that is apparently confined to the prostate. Tables may help estimate the risks of having tumor outside of the prostate, but these are only part of the decision making process. Approximately 20 to 60% of men undergoing radical prostatectomy have a higher stage of prostate cancer when the pathologist reviews the surgical specimen.

Just because you are a candidate for a radical prostatectomy does not mean that this is the best form of treatment for you. You must look carefully at your lifestyle, the risks of the surgery, and what is most important to you regarding your quality of life before making a decision. If, for example, the possibility of urinary incontinence would be devastating to you, then maybe surgery is not the best therapy for you. On the other hand, if the idea of leaving your prostate in place will constantly worry you, then perhaps surgery is best for you.

• [1] Form of radical prostatectomy whereby an attempt is made to spare the nerves involved in erectile function.
• [2] The surgical removal of tissue.
• [3] The probability that a diagnostic test can correctly identify the presence of a particular disease.