Prostate Cancer Surgery in Turkey

Prostate cancer surgery (radical prostatectomy) is the surgical removal of the prostate gland, the surrounding capsule, and the seminal vesicles as a whole in order to completely remove cancerous cells from the body. Considered the gold standard in the treatment of localized tumors, meaning tumors that have not spread beyond the prostate, this operation aims to permanently halt the progression of the disease. This contemporary surgical approach does not focus solely on removing malignant tissue; it also reconstructs the anatomical structure of the urinary tract and reproductive system in accordance with oncological principles. In cases diagnosed at an early stage, this treatment is a critical medical step that secures long-term health by combining the expectation of complete recovery from cancer with the quality of daily life.

Through Which Stages Is the Decision for Prostate Cancer Surgery Made?

The prostate is a gland approximately the size of a walnut, located just below the urinary bladder, forming part of the male reproductive system and surrounding the urinary canal like a ring. With advancing age, uncontrolled proliferation may occasionally occur in the cells of this gland. Diagnosis of the disease and the decision to proceed with surgery generally occur as a result of meticulous, sequential evaluations. The process most often begins when the Prostate Specific Antigen, or PSA, value measured in the blood during routine health checkups is found to be elevated. PSA is a protein produced by prostate cells, and its presence in the blood above a certain level may indicate activity within the prostate.

However, not every elevated PSA value directly means cancer; benign conditions such as prostate enlargement or prostatitis can also increase this value. Therefore, in suspicious cases, the next step in the medical process is a physical examination known as a digital rectal examination. Because the back surface of the prostate gland is adjacent to the large intestine, any possible hardness or irregularity on the surface of the prostate can be easily felt during this examination. If suspicion continues after the tests and examinations, small tissue samples are taken from the prostate gland through a biopsy procedure and examined in the laboratory.

The decision for surgery comes to the fore when the presence of cancer cells is confirmed in the laboratory results. At this stage, the patient’s general health condition, other accompanying chronic diseases, and physical condition are reviewed in detail. Surgical intervention is generally considered the first and strongest treatment option in individuals who have a long life expectancy and whose disease is assessed to be confined only to the prostate. In some cases, even if cancer cells have approached the capsule of the prostate, surgery may be combined with other medical treatments and form the main backbone of a comprehensive recovery plan.

Which Imaging Methods and Tests Are Used Before Prostate Cancer Surgery?

Before surgical intervention, understanding the exact location, volume, and relationship of the cancerous tissue with surrounding tissues is of great importance for planning the operation safely. For this purpose, advanced technological tools offered by modern medicine are used.

Methods frequently used in preoperative evaluation include:

• Blood tests
• PSA measurement
• Urine tests
• Prostate examination
• Multiparametric MRI
• Fusion biopsy
• PSMA PET scan

Among these methods, multiparametric prostate MRI is particularly effective in mapping the internal structure of the prostate. Unlike standard MRI scans, this method examines prostate tissue using different parameters and shows the density and boundaries of suspicious areas, as well as how close the cancer is to the outer capsule of the prostate, with considerable clarity. When a suspicious focus is detected on MRI images, these images are transferred to the ultrasound device and a targeted fusion biopsy is performed. This procedure works much like a navigation system, helping to take samples directly from millimetric points carrying a cancer risk instead of obtaining tissue blindly.

In cases with higher risk or where there is a possibility that the disease has spread to the lymph nodes or other organs, a PSMA PET scan is used. In this scanning method, the entire body is scanned using a special substance that binds to prostate cancer cells. In this way, whether the cancer has spread beyond the prostate is largely clarified, and the surgical strategy takes its final form in light of this information.

What Are the Main Surgical Methods Used for Prostate Cancer Surgery?

As a reflection of medical developments, radical prostatectomy operations have undergone major evolution over the years. Although the objective has remained the same, the way of reaching that objective has changed, and these methods are selected according to the patient’s anatomical characteristics and medical requirements.

The surgical approaches that may be preferred in current medical practice include:

• Open surgery
• Laparoscopic surgery
• Robotic surgery

Open surgery is a traditional method performed through a vertical incision extending from below the belly button toward the groin. In this method, which has been practiced for many years, the prostate located deep within the pelvic bone is reached directly with hand and visual contact. However, because the pelvic cavity is quite narrow and the prostate is surrounded by a dense network of blood vessels, this method may increase the risk of bleeding. In addition, the large incision in the abdominal wall may somewhat prolong the postoperative recovery period and the time required to return to normal life.

Laparoscopic, or standard minimally invasive surgery, is performed through small holes using a camera and long, thin instruments placed inside the abdomen instead of making a large incision. The abdomen is inflated with a special gas to create a working space. The pressure generated by this gas significantly suppresses the possibility of bleeding from small vessels. However, because the instruments used in laparoscopic surgery are shaped like straight rods and cannot bend, performing delicate procedures in a narrow area can be difficult. To overcome these limitations, the most advanced systems are generally used today.

What Is the Role of Robotic Technology in Prostate Cancer Surgery?

Robot-assisted laparoscopic prostatectomy is considered one of the most advanced points reached in the field of surgery. This system was designed to overcome the limitations of open surgery and standard minimally invasive surgery. In robotic surgery, the patient’s abdomen is again entered through small holes, but the instruments working inside are controlled not directly by the surgeon’s hands, but through a control console located in another part of the room.

The surgeon sits at this console and views the surgical area in high resolution and three dimensions with magnification many times greater than what the naked eye can see. Thanks to this detailed imaging, prostate tissue, fine capillaries around it, nerve networks, and the muscles responsible for urinary continence can be distinguished very clearly. The surgical instruments located at the tips of the robot’s arms have a range of motion that exceeds the anatomical limits of the human hand. These instruments, which can rotate around their own axis at wide angles, provide the ability to place sutures, separate tissues, and control bleeding with high precision in deep and narrow areas.

In addition, the system filters out even the slightest natural tremors that may occur in the surgeon’s hands and transfers the movements smoothly to the robotic arms. In this way, tissue damage is kept to a minimum. Thanks to the precise approach provided by the robotic system, blood loss is reduced, postoperative pain is experienced less, and the patient’s hospital stay may be significantly shortened.

How Is It Evaluated Whether Cancerous Tissues Have Been Removed During Prostate Cancer Surgery?

The primary oncological objective of the operation is to remove cancerous tissues from the body without leaving behind any suspicious cells. The prostate tissue, surrounding membranes, and vesicles removed during the operation are sent to the pathology laboratory for detailed cellular examination after surgery.

The main factors considered in the pathology examination are:

• Stage of the tumor
• Degree of cellular aggressiveness
• Status of the surgical margins
• Status of the lymph nodes
• Extracapsular spread

Pathologists mark the outermost surface of the removed tissue with special dyes and examine it under a microscope. Whether cancer cells have reached this stained area, namely the surgical margin, is checked with great care. If the cancer cells have not reached the surgical margin, this is interpreted as a negative surgical margin and is considered a strong indication that the tissue has been successfully removed.

In cases where the disease is aggressive or carries a risk of spreading to other parts of the body, not only the prostate gland is removed during surgery; the lymph nodes extending along the main vessels around the prostate are also removed. This procedure, called extended lymph node dissection, is of great importance for removing microscopic cancer cells that may have infiltrated the lymphatic channels. These removed lymph nodes also undergo the same laboratory process, allowing a clear and comprehensive report on the status of the disease to be prepared.

How Is Urinary Continence Preserved After Prostate Cancer Surgery?

In the human body, urinary control is provided by the sphincter muscle located just below the urinary bladder and surrounding the urinary canal called the urethra. Since the prostate gland is also located in this region, removing the gland requires working very close to the sphincter muscle. Concern about urinary leakage is an issue frequently emphasized by individuals deciding on surgery. However, thanks to advanced surgical techniques, preservation of this function can largely be targeted.

Some factors affecting the recovery process of urinary control include:

• Anatomy of the urinary continence muscle
• Preservation of urethral length
• Support structure of the pelvic floor
• The patient’s preoperative condition

During surgery, when the prostate is cut and removed, great care is taken not to disrupt the integrity of the sphincter muscle and to leave the remaining urinary canal as long as possible. After the prostate is removed, the urinary bladder remaining in the empty space is brought downward and sutured again to the urinary canal in a watertight manner. A urinary catheter must be used for a period of time so that this new connection point can heal securely. In the early period after the catheter is removed, temporary urinary leakage due to weakening of the pelvic floor muscles is a natural part of the process. Pelvic floor exercises are started to strengthen these muscles and support a much faster return of urinary control to its previous form. As the muscles become stronger, the capacity to hold urine gradually increases over the course of months.

How Are Sexual Functions Preserved After Prostate Cancer Surgery?

The structures that enable erection in the male body are millimetric nerve and vessel bundles that extend like a network along the right and left posterior surfaces of the prostate gland. These nerve networks are located immediately adjacent to the outer capsule of the prostate. In individuals where the cancer is not close to these nerves and the disease is assessed as belonging to a low-risk group, preservation of these nerves is planned during surgery.

The aim of nerve-sparing approaches is to slowly separate the prostate tissue from this fine nerve network without damaging it. During this process, even the smallest blood vessels are attempted to be preserved. However, in cases considered high risk due to the nature of the cancer or where the disease is thought to have extended beyond the prostate capsule, oncological safety is always prioritized. In such cases, it may be necessary to abandon the idea of preserving the nerves and remove a wider area of tissue in order not to endanger the patient’s general health.

Even if both nerves have been anatomically preserved successfully during surgical planning, experiencing erectile dysfunction in the early period is a physiological expectation. This condition is called “neuropraxia,” which refers to a temporary shock experienced by the nerves due to traction or heat during surgery. The recovery, reawakening, and restoration of the previous conduction strength of these dormant nerve networks is a slow healing process that takes time and may last, on average, from several months up to two years.

What Steps Are Taken Against Erectile Dysfunction During the Recovery Period After Prostate Cancer Surgery?

During the long recovery period spent waiting for the nerves to recover, it is very important that the spongy structures in the penile tissue do not lose their elasticity due to lack of oxygen. In a healthy man, natural erections that occur during sleep provide oxygenation of these tissues. Since this natural mechanism is interrupted while the nerves are dormant after surgery, support may need to be provided to the tissues.

Some methods used to support erectile function include:

• Low-dose pills
• Special creams
• Vacuum devices
• Injection treatments
• Shock wave therapies
• Penile prostheses

This support process is called penile rehabilitation. Beginning immediately after the urinary catheter is removed, the aim of this process is to provide blood flow to the penile tissue through external support and help the cells receive oxygen, even if a natural erection has not yet occurred. While low-dose oral medications contribute to relaxation of the blood vessels, vacuum devices support the mechanical drawing of blood into the tissues. When deemed necessary, shock wave treatments that encourage the formation of new blood vessels through low-intensity sound waves directed at the penis may also be added to the process. In individuals who do not achieve sufficient functional recovery despite completion of the healing process, penile prosthesis surgery, which offers a permanent and natural solution, may be considered a highly effective alternative.

How Does the Recovery Process Progress in the Hospital and at Home After Prostate Cancer Surgery?

After the operation is completed, patients are taken to their rooms and begin resting under close medical observation. Because tissue damage is lower with the advantages offered by minimally invasive and robotic methods, the hospital stay is usually limited to a few days. On the day after the operation, the patient is expected to begin consuming liquid foods and to get up and walk around the room. Early mobility accelerates the return of bowel movements to normal while at the same time greatly reducing the risk of blood clot formation in the legs.

Some habits recommended to be included in daily life during the discharge period include:

• Frequent short walks
• Adequate water consumption
• Fiber-rich nutrition to prevent constipation
• Avoiding lifting heavy loads
• Regular rest breaks

When the patient is discharged from the hospital, the catheter placed to protect the healing urinary canal goes home with the patient. This catheter is usually removed one or two weeks later with a short and painless procedure. Once the catheter is removed, the patient’s urinary tract becomes completely free, and pelvic floor exercises are intensified at this point. During the recovery process at home, it is very important for the patient to avoid sudden straining and to pay attention to nutrition to prevent problems such as constipation that may cause straining, in order to protect the sutures. Generally, within a few weeks, individuals can comfortably return to desk jobs and their normal daily routines.

How Is Long-Term Follow-Up Planned After Prostate Cancer Surgery?

Once recovery is complete after prostate surgery, a structured follow-up program is started to ensure that the cancer has been completely left behind and to protect the patient’s health for many years. Since the prostate gland has been completely removed through surgery, there is no tissue left in the body to produce the PSA protein. Therefore, during follow-up, it is desired that the PSA value measured in the blood be so low that it is undetectable, close to zero.

Some steps used in long-term follow-up include:

• Blood tests at regular intervals
• Regular medical evaluations
• PSA measurements
• Additional imaging when necessary

The follow-up program is generally carried out every few months during the first years after surgery, while as the years pass, these intervals are extended and eventually become once a year. If the PSA level in blood tests begins to rise above the expected values, this condition is medically called biochemical recurrence. In such a case, the disease may have become active again at a microscopic level. There is no need to panic when recurrence is detected, because modern oncology practice offers a very wide range of options for these situations. Depending on the patient’s age and the characteristics of the disease, radiation treatments that can be applied to the prostate bed, medications that regulate hormones, or different systemic treatment approaches can largely keep the disease under control and allow the patient to maintain a healthy life for many years.