Preserving fertility after radical prostatectomy

Dear Dr G,

I read your response to a reader who asked about nerve-sparing radical prostatectomy, but you did not mention another complication which could render someone infertile.

(A radical prostatectomy is a surgical procedure to partially or completely remove the prostate gland.)

I am 50 years old and there is a history of breast cancer in the family. I went for a routine prostate-specific antigen (PSA) blood test three years ago and the biopsy revealed I had prostate cancer.

I was lucky enough to undergo robotic radical prostatectomy at the Kuala Lumpur General Hospital soon after the diagnosis and the cancer has been under control since.

I have since entered into a relationship with a younger partner and we want to get married and start a family.

However, we are saddened that I have lost my ability to father a child.

To put Dr G on the spot, can men still retain reproductive function after a prostate cancer operation?

Thanks in advance

Infertile Ian

Prostate cancer is a common cancer, affecting up to one in six men. The number of men diagnosed with this is rising, perhaps due to widespread diagnostic PSA tests and increasing life expectancy.

Although prostate cancer is generally associated with men of advanced age, the detection of the cancer in younger men is becoming more common. Such observation is thought to be linked to family history of breast cancer and such individuals are more at risk with a sedentary lifestyle.

The most effective mode to eradicate early-stage prostate cancer is radical prostatectomy. Such surgical intervention is traditionally performed with open or keyhole approaches. Recent advancements in robotic-assisted removal of the prostate is also performed to minimise complications.

As part of the male reproductive system, the prostate gland’s primary function is to secrete a slightly alkaline liquid that forms part of seminal fluid. As this surgery completely removes the prostate gland – including healthy tissue – sexual and reproductive health will be affected.

Before the radical prostatectomy, all men are counselled about the potential incontinence, erectile dysfunction and sterility. Although intra-operative care can be ensured to preserve the nerves that are responsible for continence and erections, preserving fertility in men is impossible.

Radical prostatectomy severs the connection between the testicle and the urethra, which is technically equivalent to a vasectomy. This results in the inability to provide sperm through natural ejaculation. A man may be able to have dry orgasm but all men who undergo the operation will be rendered sterile.

For men who want to father a child may consider freezing their sperm. On the other hand, the advent of artificial reproductive technology now allows the direct retrieval of sperm from the source. Operations such as percutaneous epididymal sperm aspiration (Pesa), microscopic epididymal sperm aspiration (Mesa) or testicular exploration and sperm extraction (Tesa) can be carried out for men who still wish to father a child after radical prostatectomy.