c) Radical Prostatectomy

This very popular treatment is used for a number of patients with prostate cancer. It tends to be avoided when patient comorbidities would make anaesthetic and surgical complications more problematic.

Use in Low Risk Disease (T1-2, N0, M0, Gleason 6, PSA < 10)

This is controversial. Surgery definitely has good rates of cure, but so does active surveillance (Toronto observation study). Surgery is better than watchful waiting for patients with > 10 years life expectance (Scandinavian trial). Further results of randomised active surveillance trials are awaited. Additionally, surgery has not been compared directly with other curative options (radiotherapy).
10 year survival with radical prostatectomy is 95% and disease specific survival is 99% for this patient group.

Use in Intermediate and High Risk Disease

This is also controversial. Surgery is associated with poorer outcomes and up to 50% of patients will have adverse pathological features that suggest that adjuvant radiotherapy may be beneficial. There is no data on whether a combined modality approach (surgery + RT) is better than radiotherapy with androgen therapy, and there is definitely increased toxicity from combined treatment. Nevertheless, a number of patients undergo radical prostatectomy.
Patients with high risk disease have lower rates of organ confined disease and adjuvant therapy is more frequently recommended.

Side Effects

Surgical side effects are intra-operative and post-operative:

  • Peri-operative risks include myocardial infarction, pulmonary embolism and infection. Mortality rates are usually < 1% but higher for at risk individuals.
  • Post operative complications include:
    • Urethral stricture (10%)
    • Urinary incontinence (50% at 2 months, 15% at 2 years)
    • Impotence (variable, depends on age and nerve sparing operation, but between 20-60%)

These tend to compare favourably with radiotherapy, which also has much later side effects particularly in younger men.