First, let’s review the territory. For a surgeon, this is precarious terrain indeed: The prostate is located deep in the pelvis, surrounded by structures that are fragile and vulnerable to injury—the rectum, the bladder, the sphincter responsible for urinary control, some large blood vessels, and the bundles of nerves that are responsible for erection.
The operation begins with an incision through skin and muscle in the abdomen that extends from the pubic area to the navel. Almost immediately, before the prostate is ever reached, the surgeon removes a triangle of tissue on each side of the bladder; these triangles contain important lymph nodes. This is called a staging pelvic lymphadenectomy—dissection of the pelvic lymph nodes, to make sure they’re free of cancer. These lymph nodes are removed, then rushed to a pathologist for what’s called frozen-section analysis to check for cancer; the tissue is frozen, then sliced into very thin sections to be examined under the microscope.
(Note: Some doctors only have frozen-section analysis done if a man’s Gleason score is 8 or higher. One reason for this is that with lower-grade, well-to moderately well-differentiated tumors—Gleason 7 or less—the long-term prognosis of patients is different than for men with high-grade, poorly differentiated tumors. Most men with Gleason scores of 8 or higher will have metastases to bone within the first four years after surgery; therefore, removing the prostate ultimately does not benefit these men. But with Gleason scores of 7 or lower—even when there is a tiny bit of cancer in a lymph node—60 percent of men have no sign of metastases on bone scans ten years later. This doesn’t mean the cancer won’t eventually come back in these men, but that it can take years longer to return when the tumor is of a lower, better-differentiated grade. So, because these men can live for many years, they often benefit from having their prostate removed. And removing it now will help them avoid problems with urinary tract obstruction and bleeding later, when the cancer does return.) If the cancer has spread massively to the lymph nodes, the surgeon will stop the operation at this point, because surgery won’t help the situation. But if the
Next, the major vein system that overlies the prostate and urethra (this is called the dorsal vein complex) is cut. Blood loss must be kept to a minimum so that the operation can be performed in a “bloodless field.” This is a crucial step; control of these veins makes a huge difference in the surgeon’s ability to see what’s happening, and it’s particularly significant for what happens next—cutting through the urethra. If the urethra is cut too close to the prostate, some cancer might be left behind; but if it’s cut too far away from the prostate, the urethral sphincter might be damaged—and such an injury can make a man incontinent.
Next, depending on the degree of cancer, the surgeon must make a decision that will affect the patient’s potency—to leave intact the neurovascular bundles, the wafer-thin packets of nerves that sit on either side of the prostate, or to remove one or both along with the prostate. These are the nerve bundles responsible for erection.
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