Can a patient with a potential diagnosis of prostate cancer, considering their age, overall health, and medical history, remove their prostate?

Can a Patient Remove Their Prostate?

Yes, radical prostatectomy (removal of the prostate) is an appropriate and effective treatment option for patients with clinically localized prostate cancer who have a life expectancy of ≥10 years and no serious comorbidities that would contraindicate elective surgery. 1

Eligibility Criteria for Radical Prostatectomy

The decision to proceed with prostate removal depends on several critical factors that must be evaluated systematically:

Life Expectancy and Age

• Patients must have a life expectancy of at least 10 years to benefit from radical prostatectomy, as prostate cancer typically progresses slowly and the survival benefit from surgery takes years to manifest 1, 2
• Age alone should not be the sole determining factor—an 81-year-old patient in excellent health may still be a candidate, though careful consideration of comorbidities is essential 3
• The median age at prostate cancer diagnosis is 67 years, and surgery has been performed successfully in patients up to age 79 4, 5

Disease Stage and Risk Category

Radical prostatectomy is most appropriate for:

• Localized disease (clinical stage T1-T2): This represents approximately 75% of newly diagnosed cases and is associated with nearly 100% 5-year survival 1, 4
• Selected T3 disease: May be considered as an option, though outcomes are less favorable 1
• Very low to high-risk categories: Surgery is appropriate across risk categories when life expectancy criteria are met 2, 6

Radical prostatectomy is NOT recommended for:

• Patients with confirmed lymph node metastases (pN1) and high-grade tumors (Gleason score ≥7) 1
• Patients with distant metastases (M1 disease) 4
• Patients with life expectancy <10 years 1, 2

Medical Fitness for Surgery

The patient must be able to tolerate an elective major operation, meaning:

• No serious comorbid conditions that would create unacceptable surgical risk 1
• Adequate cardiac, pulmonary, and overall physiologic reserve 1
• Most successful candidates have a low Charlson comorbidity index 5

Surgical Approach Options

Modern radical prostatectomy can be performed using three techniques, all with comparable oncologic outcomes in experienced hands:

• Open retropubic approach 1
• Laparoscopic approach 1
• Robot-assisted laparoscopic approach (most common currently) 1, 6

Critical caveat: High-volume surgeons in high-volume centers provide significantly better outcomes, particularly regarding functional results (continence and potency) 1

Expected Outcomes and Complications

Oncologic Efficacy

Long-term data demonstrates excellent cancer control:

• 10-year cause-specific survival: 90% 5
• 15-year cause-specific survival: 83% 5
• 10-year metastasis-free survival: 83% 5
• PSA should become undetectable (<0.2 ng/mL) within 2 months after surgery 2, 6

Functional Side Effects

Patients must understand and accept potential complications:

Urinary incontinence:

• Severe incontinence occurs in approximately 1.4% of patients with modern techniques 5
• Risk increases with age and can be minimized by preserving urethral length beyond the prostatic apex and avoiding damage to the distal sphincter mechanism 1
• Bladder neck preservation may decrease incontinence risk 1
• Older men experience higher rates compared to younger men 2

Erectile dysfunction:

• Recovery of erectile function directly relates to: patient age at surgery, preoperative erectile function, and degree of cavernous nerve preservation 1
• Nerve-sparing techniques can preserve potency in appropriate candidates, but this may not be possible if cancer extends to the neurovascular bundles 1
• Older men have significantly higher rates of permanent erectile dysfunction 2

Other complications:

• Hospital mortality has decreased to essentially 0% in modern series 5
• Blood loss can be substantial but is reduced with careful surgical technique 1
• Anastomotic strictures increase long-term incontinence risk 1

Alternative Treatment Options to Consider

Before proceeding with surgery, patients should understand competing options:

Active Surveillance

• Appropriate for very low/low-risk disease with life expectancy 10-20 years 2
• Involves PSA monitoring every 6 months, DRE every 12 months, and repeat biopsy every 12 months 2, 6
• Allows deferral of treatment side effects while maintaining curative option if disease progresses 1, 6

Radiation Therapy

• External beam radiation therapy (EBRT) or brachytherapy provide equivalent cancer-specific survival to surgery for localized disease 6
• May be preferable for patients with significant comorbidities who cannot tolerate surgery 6
• Different side effect profile: less incontinence, but more bowel symptoms and similar erectile dysfunction rates 2

Observation (Watchful Waiting)

• Appropriate for patients with life expectancy <10 years 2, 6
• Involves monitoring without curative intent, with palliative hormone therapy if symptoms develop 1, 7

Critical Decision-Making Algorithm

Step 1: Assess life expectancy

• If <10 years → Observation or watchful waiting 2, 6
• If ≥10 years → Proceed to Step 2

Step 2: Determine disease stage and risk category

• If metastatic (M1) → Surgery not indicated; androgen deprivation therapy 4
• If localized (T1-T2) → Proceed to Step 3
• If locally advanced (T3) → Consider as option but discuss limitations 1

Step 3: Evaluate surgical fitness

• If serious comorbidities present → Consider radiation therapy instead 1
• If medically fit → Proceed to Step 4

Step 4: Assess patient preferences regarding side effects

• Discuss incontinence risk (1.4%), erectile dysfunction risk (variable), and recovery time 5, 2
• Compare with radiation therapy side effect profile 6
• Patient must accept these risks to proceed with surgery 8, 9

Step 5: Ensure access to high-volume surgeon/center

• Outcomes are significantly better with experienced surgeons 1

Common Pitfalls to Avoid

• Do not perform radical prostatectomy in patients with life expectancy <10 years—they will not live long enough to benefit and will only experience treatment-related morbidity 1, 2
• Do not use neoadjuvant androgen deprivation therapy before radical prostatectomy—this is strongly discouraged and does not improve outcomes 1
• Do not assume all patients want aggressive treatment—fear of future consequences drives many decisions, but some patients prefer observation when fully informed 8, 9
• Do not proceed without discussing functional outcomes—patients often focus on cancer cure and underestimate the impact of incontinence and erectile dysfunction on quality of life 8
• Avoid surgery in patients with pN1 disease and Gleason score ≥7—outcomes are poor and alternative treatments are preferred 1