Robotic Surgery and Prostate Cancer Treatment FAQs

The following information is provided by Dr. Abaza based upon his counseling of thousands of patients. The robotic surgery and prostate cancer treatment information below is meant to be a general overview, and you will learn more during your visit with Dr. Abaza. Information about alternative treatment methods is not meant to be a substitute for medical advice, and as always, Dr. Abaza recommends obtaining consultation with specialists such as radiation oncologists if you are considering such treatments.

What are the treatment options for prostate cancer?

There are five options for treatment of prostate cancer:
  • Watchful Waiting or Active Surveillance:

    Those patients who choose not to treat their cancer can be followed with the hope that their cancer may not progress. Surveillance usually consists of PSA monitoring and periodic biopsies every 1-2 years or so. This option is more appropriate for older men, men with less than a 10-year life expectancy, men with medical problems making treatment unsafe and men with less aggressive cancers that are less likely to progress. Some men may pass away from other medical conditions before their prostate cancer needs treatment, and most cancers that progress and become more aggressive can still be cured as long as the cancer has not yet spread.
  • Surgery:

    This is removal of the prostate, which Dr. Abaza performs in minimally-invasive fashion using robotic surgery. Only with surgery can the prostate and cancer be removed from the body entirely. Because prostate cancer is usually multifocal and biopsies can miss small areas of cancer, the entire prostate is always removed to ensure that no cancer is left behind. The function of the prostate is to make a portion of the fluid in semen for reproduction, so men who are not planning to have more children do not need the prostate, and no hormone replacement is needed after the prostate is removed as it does not make hormones. After removal of the prostate, there is no fluid expressed at orgasm (ejaculation).
  • Radiation:

    This is performed by a radiation oncologist. Radiation can be delivered to the prostate using external beam radiation on a daily basis for 6-8 weeks or by surgically placing radioactive seeds in the prostate (brachytherapy) that give off radiation over weeks to months. Leading edge modalities of radiation therapy, including brachytherapy, are provided at several OhioHealth Cancer Care locations.
  • Hormonal therapy:

    This treatment is not curative but instead will typically put prostate cancer into remission for some period of time. This is typically reserved for those whose cancer has already spread and cannot be cured by surgery or radiation or for those who do not want any of the curative treatments. Hormonal therapy is also commonly used in men who have prostate cancer that has already spread to other parts of the body and cannot be cured by surgery or radiation.
  • Experimental therapies:

    There are treatments for prostate cancer that have yet to be proven such as high-intensity focused ultrasound (HIFU), cryotherapy (freezing) and proton therapy. Patients interested in these options can be referred to expert physicians within OhioHealth Cancer Care who have access to a wide variety of clinical trials.

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What factors could I consider when deciding to choose between radiation and surgery?

Both surgery and radiation are reasonable options for most men, and for many, the decision is more personal than medical.
  • Medical considerations include:

    • Brachytherapy is not an option for some of the more severe cancers. Some prostates are too large for any type of radiation while this is not a limitation for surgery.
    • Some men have urinary symptoms due to an enlarged prostate that can make surgery a better option as radiation will temporarily make urinary symptoms worse and rarely can even lead some men to be unable to urinate. Removal of the prostate in men with enlargement of the prostate will often relieve some but not all urinary symptoms.
    • Some men have too many medical problems to be able to safely undergo surgery. There is no age limit for surgery as this depends more on health than chronological age.
    • Many men ask what options they have if surgery or radiation should fail. Both treatments will fail if patients have cancer that has already spread to somewhere else in the body, in which case they would have the option of hormonal therapy as a common first therapy.
    • If radiation fails locally (not all the cancer in the prostate is destroyed), more radiation cannot be given, and the surgery to remove the prostate is rarely performed due to the severe complications and side effects from scarring around the prostate after radiation. While younger men are usually more concerned about this possibility of radiation failure from a few cancer cells surviving and growing during the next 20 years of their life, this should not be a major consideration for most men as most cancers seem to respond to radiation with a low rate of recurrence at 10-15yrs post therapy.
    • If surgery fails locally (microscopic cancer comes back where the prostate used to be), radiation can still be given. Many men feel more comfortable choosing surgery as primary therapy knowing that after surgery they can still receive radiation if they need it as opposed to the more difficult problem of radiation failure when it occurs, but again, most cancers will not need secondary treatment (radiation after surgery or surgery after radiation) unless they are more aggressive or advanced cancers.
  • Personal considerations include:

    • Some men do not like idea of surgery and prefer radiation to avoid general anesthesia (going to sleep), although this is still a part of brachytherapy (seeds).
    • Some men do not like the idea of surgery because of the scars and pain involved even though this is typically mild with robotic surgery.
    • Some men feel better knowing that the cancer has been physically removed from the body, which can only be done with surgery.
    • Also, the lymph nodes are removed with surgery to detect microscopic spread of cancer as the lymph nodes are typically the first place that prostate cancer spreads.
    • Some men prefer to know this after surgery since the lymph nodes cannot be removed and analyzed microscopically with radiation.
    • Some men prefer to have all the side effects of treatment up front so that they know they will just get better from there while others prefer that the side effects come slowly so that they can adjust with them. The side effects of surgery are immediate after surgery while with radiation they tend to come weeks to months later with varying severity and duration from person to person.
    • Some men want a treatment where they will have more immediate feedback on the success of the therapy. While radiation may take a year or longer before success can be determined due to the slow way that radiation works on the prostate, the PSA should be undetectable by 3 months after surgery, and the prostate and lymph nodes will be reviewed microscopically as well.
    • Some men are more comfortable with bowel side effects and some are more comfortable with bladder side effects. There is more risk of bowel side effects with radiation (see below) whereas with surgery most men will experience at least temporary incontinence (leakage of urine).

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What are the possible side effects of radiation?

To effectively radiate the entire prostate and kill all cancer cells, some dose of radiation will reach the tissues and organs around the prostate. This includes the nerves that allow erections for sexual function such that impotence occurs after radiation with approximately the same frequency as surgery. Also included are the organs closest to the prostate, which are the bladder and rectum. Side effects from radiation to the bladder and rectum can include, urgency of urination, burning with urination, blood in the urine, diarrhea, painful bowel movements or blood in the stool. The severity and duration of side effects depend on the radiation delivery technique and sensitivity of the individual patient to radiation. Some patients have mild side effects for a couple weeks while rarely some can develop severe inflammation and scarring that can lasts months to years or require surgical intervention.

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What are the possible side effects of surgery?

The two major possible side effects are:
  • Impotence due to the effect on the same nerves affected by radiation that allow erections
    • Erections: The difficulty with erections for sexual function typically lasts 6 to 12 months and is permanent in some men as with radiation.
  • Incontinence or leakage of urine.
    • Incontinence: The leakage of urine is typically dribbling between urinations especially with coughing or sneezing similar to what many women experience after having children. Most men will wear a pad in their underpants to catch any urine that leaks until they regain complete control. This typically takes 1 to 3 months but can take longer or can be immediate in some men. Kegel exercises are recommended and will speed recovery of control if done as recommended.

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What is “nerve-sparing,” and what affect does it have on sexual function?

“Nerve sparing” refers to the nerves that travel along the prostate to the penis and are necessary for erections. If the nerves are spared, men will undergo erectile rehabilitation starting the week after surgery to maximize return of function of these nerves, although it will typically take several months for erections to be good enough for sexual activity. Even with nerve-sparing, some men will not regain erections that are as good as before surgery or may need Viagra, but most men will achieve erections adequate for sex. Younger men and men with good erectile function before surgery typically have better results after surgery, while men already needing Viagra, for example, before surgery typically have a lower chance of regaining erections they can use.

Some men will choose not to have a nerve-sparing surgery. Because the nerves responsible for erections course very closely to the capsule or edge of the prostate, saving the nerves involves a “close shave” on the edge of the prostate that risks leaving microscopic cancer behind if the cancer is close to the edge or growing through the capsule or “peel” of the prostate. Men who are already impotent typically choose non-nerve sparing surgery as this allows for a wider resection of tissue around the prostate and improves the chances of getting all of the cancer out. Men who have severe cancers will typically choose not to spare the nerves unless they are willing to take more risk of not being cured by the surgery to maintain sexual function. For example, a man with a favorable risk cancer and only a 10% risk of having invasive cancer might be comfortable choosing nerve-sparing, while a man with a more severe cancer and 50% risk of invasive disease might decide not to take the risk and choose non-nerve-sparing.

Those who choose not to save the nerves will not be able to have natural erections, but sensation to the penis and ability to have orgasms will not be affected as a separate set of nerves are responsible for this. There are other treatments available to these men to resume sexual activity even if natural erections cannot be achieved (Viagra will not work, but injections or a vacuum pump can be used, for example).

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What is the typical course for a man having robotic surgery?

Men choosing robotic surgery will come to the hospital on the day of surgery. The surgery lasts about 2 hours but can take longer in overweight men or those with scarring from previous surgery. Men will stay overnight in the hospital. They will be walking the night of surgery and start by drinking liquids. Regular food is allowed the night of surgery but not required as some men will still feel the effects of the anesthesia drugs until the next morning. Men go home after eating breakfast and walking the next morning. A catheter is left in the bladder to drain the urine until the bladder heals from the removal of the prostate; it will be removed after an Xray to confirm healing the week after surgery (typically about a week after surgery).

Activity at home is not limited in terms of walking or using stairs, but men should not be involved in any strenuous activity for 6 weeks after surgery to allow healing, which includes lifting anything over 10lbs. Many men may want to stay home during the first week while they have a catheter, but they don’t necessarily have to do so as they will have a leg bag that can be worn under pants and is undetectable. Men with sedentary jobs (desk job) can work from home right away or go back to work after the first week if feeling able, but men with physically challenging jobs such as construction, landscaping, or factory work, are asked to take six weeks off. If you have questions about going back to work part time or on light duty sooner please ask Dr. Abaza.

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If I choose surgery, what will happen after my office visit with Dr. Abaza?

If you decide to proceed with surgery after your visit with Dr. Abaza, the office staff will promptly schedule your surgery. If possible, you may also be able to complete your preoperative testing the same day including blood work, EKG and meeting with the anesthesia staff to make sure you are safe to have surgery. Once you complete this testing, you will not need to return until the day of surgery.

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What will my follow up visits be like after surgery?

Typical follow-up visits:
  • About 1 week after surgery: catheter is removed
  • 3 weeks later: visit with Dr. Abaza to review the pathology report from surgery
  • 3 months later: visit after surgery with Dr. Abaza to review your first PSA blood test
  • 6 months later and beyond: You will have a PSA blood test every 3 months for the first year after surgery and then less frequently, but you will not need to see Dr. Abaza indefinitely. In most cases, when patients are doing well with cancer control, urine control and sexual function, they will be released to follow up with their local urologist after the 3 month visit with Dr. Abaza . Dr. Abaza works closely with your local urologist and our main goal is to get you back to them as quickly as possible. Dr. Abaza will be available if needed any time afterwards. For patients traveling by plane for their surgery, coordination with your local urologist will be arranged for followup so that you will likely not need to return to Ohio after the catheter is removed at one week.

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How many robotic surgeries has Dr. Abaza performed?

Dr. Abaza’s practice is limited to only robotic surgery. He has performed robotic surgery since 2006 and exclusively since 2008. He has performed over 4,000 robotic procedures, including over 450 in the last year. Dr. Abaza offers robotic prostatectomy to all men regardless of weight, previous surgery, prostate anatomy or severity of cancer. Although Dr. Abaza is fully trained in open prostatectomy, he has not had to perform this procedure in his practice and has never had to convert a robotic procedure to open surgery due to inability to complete the procedure or for complications. Many men who have been denied robotic surgery elsewhere have successfully undergone robotic surgery with Dr.Abaza, so even men who have been told they cannot have robotic surgery should discuss this with Dr.Abaza before making a treatment decision.

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Where will Dr. Abaza perform my surgery?

Dr. Abaza performs robotic urologic surgery at OhioHealth Dublin Methodist Hospital. Map and directions.

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Who is Dr. Abaza’s surgery team?

Dr. Abaza has built a team of nurses and other surgical assistants at OhioHealth Dublin Methodist Hospital who have worked with him in performing hundreds of robotic surgical procedures.  These team members specialize in robotic surgery just as Dr. Abaza does, including Renee Lewis, RN, PA who is Dr. Abaza’s bedside assistant for every robotic procedure he performs and has performed over 2,000 procedures with him.

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