The role of surgery in the treatment of prostate cancer

S e m i n a r s in O n t o l o g y Nursing, Vol 17, No 2 (May), 2001: pp 85-89

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OBJ-ECTI~_,S;

To describe the role of a~r~'ry in the treatment of organ-cxmfined prostate cancer and advanced

THE ROLE OF

p r o s t a t e ¢~.noer.

DATA SOURCES: J(ntrnals, textbooks, and personal comnl univation.

CONCLUSIONS: possible role in curing those patients with disease cdnfi~wzI to the prostate. P,ila&ral orchiectomy p/ays a pa//iative r01efor pat/ents with advanced 'disease.

iMPLiChTIONSFOR~:NuRstNa PRACTICE: This article:provides nurses with the k:rurwled~ needed to teach patients at~,ut how the S~urgety is performed, the assocqated eompli-. cations, and the likelilmod of cancer control.

From the l)epartn~om ~f l_:rolo~,: Johns llopkins Scho[~l of Medicine, Baltimore, MD. . . Pcnny 8. Marschke, 1k'q,PhD- Clinical Research Program Maturer. Department of Urology, Johns ltopkins School of Medicine. Baltimore,-MD. ...... Address reprint requests to Penny S. bfarschke~ RN, PhD. Deparcm~t of Urology, Johns tlopkirLs Sclmol of Modicqne, iJHOC---4th Floor Uiolof~', 601 N Caroline St, Bahinmre. All) 21287-0850.

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SURGERY IN THE TREATMENT OF

PROSTATE CANCER PENarr S. Ma~C/-/KE

T

HE American Cancer Society estimates 198,100 new eases of prostate cancer will be diagnosed in 2001 and an estimated 31,500 caneer deaths will be attributed to prostate cancer. 1 In the late 1980s the development of prostate-speeific antigen testing for early cancer detection made it possible to identify prostate cancer at a curable stage? The most frequently asked question by newly diagnosed prostate cancer patients is, "Can I be cured?" The urologist's answer will depend on the stage of the prostate cancer, the Gleason score, and the prostate-specific antigen level. Surgery (radical prostateetomy) plays a role in curing those patients with disease confined to the prostate. Surgery (bilateral orehieetomy) plays a palliative role for those patients with advanced disease) This article will focus on the role of surgery in prostate cancer, specifically radical prostateetomy for low-stage disease and orehieetomy for advanced-stage prostate cancer. PROSTATECTOMY n 1904, a procedure to remove the prostate as a treatment for

I .eaneer was first performed by Hugh Hampton Young at the Johns Hopkins Hospital. 4 This was the first radieal perineal pros-

tateetomy. Another approach, retropubie prostateetomy, was introdueed in the 1940s. s One of the downsides to this approach was exeessive bleeding. Following both approaehes all men were impotent after surgery and many had significant problems with urinary eontrol. By the late 1970s the anatomy of the venous system surrounding the prostate was understood and new surgical methods evolved to lessen blood loss. 5 With less blood obstrueting the view of the surgieal field, more preeise dissection and reconstruetion redueed the likelihood of urinary ineontinenee. 5 In 1982, Patrick Craig Walsh at the Johns Hopkins Hospital introdueed a refined teehnique for performing radical retropubie prostatee-

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P E N N Y S. M A R S C H K E

tomy, called the a n a t o m i c or n e r v e - s p a r i n g radical prostateetomy. 6 Unsurpassed by any other treatment for clinically localized prostate cancer, radical prostatectomy is considered by some to be the gold standard for the treatment for early stage disease in otherwise healthy men with localized diseaseJ Today, radical prostatectomy can be safely and effectively performed via either a perineal or retropubie approach. The laparoseopic approach is currently being investigated. Three types of prostatectomies suitable for potentially curing low-stage prostate cancer will be discussed. These include the perineal, retropubie, and laparoseopic prostatectomy. Descriptions will include information about how the surgery is performed, the associated complications, and the likelihood of cancer control. Each of these approaches is associated with urinary incontinence and erectile dysfunction to varying degrees. The goals of prostatectomy, regardless of surgical approach, are (1) cancer control by removing all the visible tumor, (2) the preservation of urinary continence, and (3) the preservation of erectile function.

Anatomic, Radical Retropubic Prostatectomy The anatomic, radical retropubie prostatectomy involves removing the prostate with controlled hemostasis and clearer visualization of the neurovascular bundles that innervate the corpora eavernosa of the penis. 7 Under either spinal or epidural anesthesia, the surgery begins with an incision that extends from the umbilicus to the pubis. A staging pelvic lymphadeneetomy is then performed. If the lymph nodes are cancer free, the surgery continues. This surgery involves maintaining a bloodless field while removing the prostate gland and all visible cancer cells without damaging the urethral sphincter responsible for urinary continence or the neurovaseular bundles located on both sides of the prostate, which are responsible for erections, s Occasionally, it is necessary to remove one or both neurovascular bundles to ensure cancer control. This surgical approach allows clear visualization of the tumor for more precise dissection. Once the prostate gland, seminal vesicles, and vas deferens are removed, the bladder neck is reconstructed and anastomosed to the urethra, s Two pelvic drains will remain in place for approximately 3 days to evacuate any urine leaking from the anastomosis. A Foley catheter will remain in place from 10 to 21 days to allow the reconstructed urinary tract to

heal. s-l° The patient can be discharged from the hospital on the second or third postoperative day. ~1 Postoperative complications can include urinary incontinence and erectile dysfunction. Generally, patients consider urinary incontinence more bothersome than erectile dysfunction. Wei et al ~2 reported that the significant predictors of continence outcome in the radical retropubie prostateetomy were preoperative continence, patient age, and the nerve-sparing approach. At centers of excellence for prostate cancer, approximately 50% of patients will have recovery of urinary control immediately after catheter removal. 7 Most of the remaining patients will recover continence within the next 3 months. Some patients experience a slower recovery of urinary incontinence, but generally recover within 12 to 18 months. Very few patients (2%) experience incontinence severe enough to require collagen injections or the implantation of an artificial sphineterJ A review of all the men in the Medicare population who underwent radical retropubie prostateetomy in 1991 revealed a morbidity rate that was slightly higher than that reported by major health centers. 13 Recovery of erectile function takes longer than continence. Determinants in the return of erectile function after this surgery include age of the patient, clinical and pathologic stage of the disease, and surgical technique. 14,15 Among patients who have been monitored for 18 months after surgery, potency rates of 60% to 90% have been reported at high-volume academic centers. 16 The higher rates have been reported recently in younger men who have used sildenafil citrate. For sildenafil citrate to be effective, however, the nerves innervating the corpora eavernosa of the penis must be intact (P.C. Walsh, personal communication, May 2000). P e r i n e a l Prostatectomy

In high-risk patients, before the perineal prostatectomy, an open or laparoscopie lymph node dissection is performed to identify positive nodes before the perineal prostateetomy. Positive lymph nodes would indicate that cancer has spread outside of the prostatic capsule. 17 Using epidural or spinal anesthesia, an incision is made from one isehial tuberosity to the other with the apex of the incision approximately 1.5 cm above the anus. 17 The prostate is teased away from the rectum, bladder, urethra, and vas deferens. Seminal vesicles are then removed with the prostate. Finally, the urethra is anastomosed to the anterior bladder neck. A Penrose drain is placed on each side of the

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anastomosis. A Foley catheter is placed and taped to the midline of the abdomen. The patient can be discharged on the second postoperative day. is The perineal prostatectomy offers the major advantage of less blood loss because the dorsal vein complex is not removed with the prostate. 5 However, this also means that the surgeons are not able to remove as much tissue; therefore, positive surgical margins are more likely in men who have capsular penetration. The incidence of postoperative erectile dysfunction and rectal injury are greater in comparison to the retropubie approach.3, z9 Laparoscopic Prostatectomy Under general anesthesia, a 12-ram trocar is placed through a minilaparotomy incision just below the umbilicus. Insufflation, the process of injecting carbon dioxide into the peritoneum to achieve exposure during laparoseopie surgery, is then begun and the secondary troears are placed under visual control. Through the trocars, visualization of the field (including the neurovaseular bundles) is maintained. The prostate gland is dissected out and removed in an Endocateh (US Surgical, Norwalk, CT) through the umbilical port site. The bladder neck is anastomosed to the urethra and a Foley catheter is inserted into the bladder. A small suction-drain is inserted and left in place for 48 hours. Depending on the experience level of the surgeon, this surgery can take from 7 hours without lymphadenectomy to 8.6 hours with lymphadenectomy.2°-22 Abbou et al ~° reported that once the learning curve (for the procedure) was completed, 50% of patients left the hospital without a Foley catheter within 5 days. The major advantage of the laparoseopic approach is that it is minimally invasive; in theory, allowing patients to resume activities of daily living earlier than those undergoing open surgery. Reports from experienced laparoseopic surgeons indicate that the incidence of urinary incontinence and erectile dysfunction is comparable to the retropubie approach or gold standard. 2° However, the data are too preliminary to make any meaningful comparisons at this time. Furthermore, data on cancer control are too immature for comparison. Although laparoseopie prostateetomy is gaining tremendous publicity because of its minimal invasiveness and potential for a briefer recovery period, Sehulam 23 offers the caveat that any compelling benefit for the laparoseopie procedure over

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the radical retropubie prostateetomy remains to be determined. A systematic comparison of technical advantage, morbidity, and long-term functional outcomes is necessary. Guilloneau and Vallaneien 24 note that the laparoseopic approach could be a major technical improvement over radical prostatectomy if long-term oneologic results are confirmed and if improvement of intraoperative vision improves the functional results of this procedure. Until laparoseopic prostateetomy is demonstrated to be as effective as radical retropubic prostateetomy in cancer control, the radical retropubie prostateetomy should remain the preferred approach for men with low-stage prostate cancer who have a life expectaney longer than 10 years. 7

ORCHIECTOMY O

rehieetomy is the surgical removal of the testes. For advanced stages of prostate cancer that has spread to the lymph nodes and bone, orehieetomy or surgical castration is one possible approach to cancer control, s After removing the testes testosterone will not be produced, resulting in a shutdown of hormonal stimulation to the prostate, which sustains cancer growth. Prostate growth is controlled by testosterone, which is made in the testicles. Testosterone circulates in the blood and enters the prostate where it is transformed into dihydrotestosterone, the active hormone within the prostate, s This hormone chain is initiated in the hypothalamus where gonadotropin-releasing hormone (luteinizing hormonereleasing hormone) is produced and released. This sends a chemical signal to the pituitary gland to produce and release luteinizing hormone. Luteinizing hormone in turn signals the testicles to produce testosterone. The major goal for orehieetomy (surgical castration) or hormone therapy is to reduce testosterone, which stimulates the prostate tumor. Within approximately 3 hours after orehieetomy, the testosterone levels begin to plummet to a level called the castrate range. 5 Castration reduces the body's amount of testosterone by 95% almost immediately and permanently. 5 A simple orehiectomy is performed with the patient under spinal or local anesthesia. A longitudinal incision is made in the midline serotal raphe, which provides exposure of the testicles. The surgical field is bloodless. Each testicle is brought out individually through the opening. The

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Possible Side Effects

Type of Surgery

Stage of Prostate Cancer

Anatom c, radical retropubic prostatectomy Perineal radical prostatectomy Laparoscopic radical prostatectomy Bilateral orchiectomy

Low stage, confined to the prostate

Urinary incontinence, erectile dysfunction

Low stage, conf ned to the prostate

Rectal injury, erectile dysfunction, urinary incontinence Urinary incontinence, erectile dysfunction

Low stage, confined to the prostate Advanced stage

surgeon then cuts the vas deferens and blood vessels that supply eaeh testicle and the testieles are removed. Strict hemostasis of the spermatie eord and skin edges is obtained using eautery. 2s 8ome surgeons perform a subeapsular orehieetomy, which involves opening the lining to the testicles and emptying the contents of each testicle. s The lining is sutured and the empty shell is placed back inside the scrotum, thereby producing the cosmetic appearance that the testicles have not been removed. Although this approach has great psychological benefits for the patient, some surgeons prefer not to perform the subeapsular orchieetomy because of concerns that testosterone-producing cells may remain, s Zhang et a126 studied 37 men who underwent total orehieetomy and 37 patients who underwent subcapsular orehiectomy for metastatic prostate cancer. They found that tumor response, survival, and clinical parameters were similar in the two groups and concluded that subcapsular orehieetomy is a viable option for treatment of metastatie prostate eaneer. After the orehieetomy is eompleted, a turban pressure dressing of gauze fluff and a serotal supporter are applied for 24 hours. The patient is usually discharged the day of surgery. The most frequent surgical complication is development of a serotal hematoma. If a hematoma oeeurs, it should be drained only if it becomes large, extremely tender, or infected. 13 Physieal side effects associated with orehieetomy include hot flashes, gynecomastia, loss of sex drive, and erectile dysfunction (Table 1). s Distressing vasomotor symptoms sueh as hot flushes and profuse sweating are related to the sudden withdrawal of sex steroids.27, 2s Karling et

Hot flashes, gynecomastia, loss of sexual drive, weight gain, loss of muscle mass, grief react on)depress on

a129 reported that contrary to general belief, hot flushes do not disappear with time. Among men in their sample, 40% experienced hot flushes 8 years after orehieetomy. Psyehologieally, men report that they do not feel "normal"; they may feel irritable and less aggressive. Weight gain, loss of muscle mass, and subtle ehanges in physical appearance can have profound effects on the man's psyche, s The psychological impact for men can include the grief reaction and/or depression. 3 Montgomery and Shanti 3° reported significant differences between preoperative and postoperative physieal self scores and identity scores as measured by the Tennessee Self-Concept Scale. Another problematie side effect associated with orehiectomy is osteoporosis. 31 Daniell et aP 2 found that surgieal castration of men with prostate cancer is usually followed by greatly aceelerated bone loss. These same researehers also noted that baseline bone mass and subsequent bone loss may be influenced by patient obesity, age, and exercise habits. Although an orchieetomy can accomplish the ablation of testosterone very effectively, the physieal and psychologieal effeets on the patient must be carefully assessed due to the permanence associated with this treatment modality. For this reason, most men today select chemical castration with a luteinizing hormone-releasing hormone agonist, s CONCLUSION urgery plays a role in the treatment of prostate caneer. The results of at least one reeent study Ssuggest that radical retropubie prostatectomy ean

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cure approximately 70% of patients with clinically localized disease. Cure rates are dependent on tumor grade, tumor stage, and the serum prostatespecific antigen level. Prospective randomized trials are needed before any conclusions can be

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reached regarding the benefits of laparoseopic radical prostatectomy. For patients with advanced prostate cancer there is rio curative therapy; however, orchiectomy is one approach to palliative care for this population.

REFERENCES 1. Greenlee RT, Hill-Harmon MB, Murray T, et al: Cancer statistics: 2001. CA Caneer d Clin 51:15-36, 2001 2. Catalona WJ, Smith DS, Ratliff RL, et al: Measurement of prostate speeifie antigen in serum as a screening test for prostate caneer. N Engl J Med 324:1156-1161, 1991 3. Klimaszewski AD, Karlowiez KA: Caneer of the male genitalia, in Karlowiez KA (ed): Urologic Nursing Principles and Practice. Philadelphia, PA, Saunders, 1995, pp 271-308 4. Young HH: The early diagnosis and radieal care of carcinoma of the prostate: Being a study of 40 eases and presentation of a radieal operation which was carried out in four eases. Johns Hopkins Hosp Bull 16:315-321, 1905 5. Walsh PC, Worthington JF: The Prostate: A Guide for Men and the Women Who Love Them. Baltimore, MD, The Johns Hopkins University Press, 1995 6. Walsh PC, Donker PJ: Impotence following radical prostateetomy: Insight into etiology and prevention, d Urol 152: 492-497, 1982 7. Catalona WJ, Ramos CG, Carvahal GF: Contemporary results of anatomic radical prostateetomy. CA Cancer J Clin 49:282-296, 1999 8. Walsh PC: Anatomie Radical Retropubie Prostatectomy, in Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ (eds): Campbell's Urology (ed 7). Philadelphia, PA, Saunders, 1998, pp 2565-2587 9. Santis WF, Hoffman MA, DeWolf WC: Early eatheter removal in 100 consecutive patients undergoing retropubie prostateetomy. Br d Urol 85:1067-1068, 2000 10. DeMareo RT, Bihrle R, Foster RS: Early eatheter removal following radical retropubic prostateetomy. Semin Urol Oneol 18:57-59, 2000 11. Gardner TA, Bissonett EA, Petroni GR, et al: Surgieal and postoperative factors affecting length of hospital stay after radical prostateetomy. Cancer 89:424-430, 2000 12. Wei JT, Dunn RL, Marcovieh R, et al: Prospective assessment of patient reported urinary continence after radical prostatectomy. J Urol 114:744-748, 2000 13. Benoit RM, Naslund MJ, Cohen JK: Complications after radical retropubie prostatectomy in the Medicare population. Urology 56:116-120, 2000 14. Quinlan D, Epstein J, Carter B: Sexual funetion following radical prostatectomy: Influence of preservation of neurovascular bundles. J Urol 145:998-1002, 1991 15. Rabbani F, Stapleton AM, Kattan MW, et al: Factors predicting recovery of erections after radical prostateetomy. J Urol 164:1929-1934, 2000

16. Walsh PC, Marsehke P, Picker D, et al: Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 55:58-61, 2000 17. Gibbons RP: Radical perineal prostatectomy, in Walsh PC, Retik AB, Vaughnan ED Jr, Wein AJ (eds): Campbell's Urology, ed 7. Philadelphia, PA, Saunders, 1998, pp 2589-2604 18. Weldon VE, Tavel FR, Newirth H: Continenee, potency and morbidity after radical perineal prostatectomy. J Urol 158:1470-1475, 1997 19. Lassen Plvl, Kearse WS: Reetal injuries during radical perineal prostateetomy. Urology 45:266-269, 1995 20. Abbou CC, Salomon L, Hoznek A, et al: Laparoseopie radical prostatectomy: Preliminary results. Urology 55:630634, 2000 21. Jacob F, Salomon L, Hoznek A, et al: Laparoseopie radical prostateetomy results. Eur Urol 37:615-620, 2000 22. Guilloneau B, Vallancien G: Laparoscopie radical prostateetomy: The Montisouris experienee. J Urol 163:418-422, 2000 23. Sehulam PG: Laparoseopie radical prostatectomy. World J Urol 18:278-282, 2000 24. Guilloneau B, Vallancien G: Laparoscopic radical prostatectomy: Initial experience and preliminary assessment after 65 operations. Prostate 39:71-75, 1999 25. Wolfson BA, Railer J, Freedman A: Simple and radical orehiectomy, in Marshall FF (ed): Textbook of Operative Urology. Philadelphia, PA, Saunders, 1996, pp 630-633 26. Zhang XZ, Donovan MP, Williams BT, et al: Comparison of subeapsular and total orchieetomy for treatment of metastatic prostate cancer. Urology 47:402-404, 1996 27. Aubert J, Vigoromx V, Dore B: Hot flushes in men after surgical or pharmacologic eastration. Progr Urol 5:507-509, 1995 28. Bucholz NP, Mattarelli G, Bucholz MM: Post-orehieetomy hot flushes. Eur Urol 26:120-122, 1994 29. Karling P, Hammar M, Varenhorst E: Prevalence and duration of hot flushes after surgical or medical castration in men with prostate carcinoma. J Urol 152:1170-1173, 1994 30. Montgomery P, Shanti G: The influence of bilateral orehieetomy on self-concept: A pilot study. J Adv Nurs 24: 1249-1256, 1996 31. Daniell HW: Osteoporosis after orehiectomy for prostate cancer. J Urol 157:439-444, 1997 32. Daniell HW, Dunn SR, Ferguson DW, et al: Progressive osteoporosis during androgen deprivation therapy for prostate eaneer. J Urol 163:181-186, 2000