Overview: Reviewed options of watchful waiting, radiation (brachytherapy, external beam, combination brachytherapy and external beam), cryotherapy, hormonal therapy and surgery.

Watchful waiting. Usually inadvisable in an otherwise healthy man with a greater than 10 year life expectancy. Prostate cancer that is found early and has a low Gleason (2-6) may grow slowly and may be monitored rather than treated.

Advantages- No side effects from therapy.

Disadvantages- Cancer eventually may spread and be incurable.

Hormonal therapy. Prostate cells need testosterone to maintain themselves. Removing a man’s testosterone may slow down the growth of prostate cancer cells. Usually inappropriate for long term therapy of localized disease. There is evidence that the cancer can spread even during long term hormonal therapy. Hormonal therapy is not curative. Hormonal therapy may be given prior to radiation.

Disadvantages- Hot flashes, osteoporosis, etc.

Radiation: High energy x-rays are used to kill cancer cells.

Brachytherapy.

Procedure: Performed as outpatient, under anesthesia. Places radioactive seeds into the prostate to burnout the cancer from within.

Concerns: Seeds may migrate during placement leading to over or under treatment of certain areas of the prostate (and cancer). Therefore, as a sole modality, may be less effective than external beam or combination radiation therapy.

Side effects: Radiation cystitis and proctitis (probably will be worse than other forms of radiation); erectile dysfunction (may be less so than external beam or combination radiation therapy).

Advantages: Short duration of therapy. Few side effects up front if the prostate is small.

Disadvantages: Least effective treatment,. Side effects can occur even years after therapy and may be underappreciated by some radiation oncologists. Bladder outlet obstruction can occur and be difficult to treat, especially if the prostate is enlarges.

MAY NEED OTHER FORMS OF THERAPY TO SHRINK THE PROSTATE.

 

External Beam:

Procedure: Cast is made of the body. Radiation is applied to the prostate through many ports, 5d/week for 7-8 weeks. Each session lasts about 20 minutes.

Side effects: Radiation cystitis, proctitis, and erectile dysfunction.

Advantages- Cure rates similar to surgery at 10-15 years with hormones added

Disadvantages- Daily therapy for 2 months causes a systemic effect. Side effects can happen later. Radiation effect in long term is unknown- new study shows a 70% higher rate of rectal cancer after XRT.

Combination External Beam and Brachytherapy

Combination of above, but external beam will only last about 5 weeks. Same Side effect profile and cure rate as external beam alone.

 

 

 

 

Surgery:

Procedure involves removal of the entire prostate and seminal vesicles. The goal of this procedure is to completely remove the cancer while it is contained within the prostate. Surgery is typically about 3 hours long, and is considered major surgery. Average blood loss is 2 units, but may be higher. Patients are usually asked to bank blood for themselves prior to surgery (“autologous blood”). Average hospital stay is about 3 days. A catheter remains in the bladder for about 1-2 weeks. Back to work is usually no sooner than 1 month after surgery.

Small risks of injury to rectum or ureters, blood vessels, nerves.

Side effects: Incontinence, usually lasting a few months. Erectile dysfunction.

Advantages: We can more accurately predict your prognosis. Best long term cure rates. Least amount of bladder outlet obstruction.

Disadvantages: Major surgery with blood loss and recovery.

 

Robotic Prostatectomy:

The Robotic Radical Prostatectomy represents a quantum leap forward in prostate cancer surgery. The da Vinci Surgical System enables urologic surgeons to perform a radical prostatectomy with similar, or improved technique when compared to the standard open procedure, while maintaining all the advantages of minimally invasive surgery.

 

The robot controls tiny jointed instruments, which can move at the tip like the human hand. Unlike conventional laparoscopy and its two dimensional image, the da Vinci camera has two lenses that combine to provide the surgeon a true 3-D image with 10x magnification. Also, any position or movement of the surgeon’s hands is enhanced with scaling and tremor reduction and is mirrored in real time.

 

Advantages of the minimally invasive procedure may include reduced pain, scarring, risk of infection, and less operative blood loss. Additionally, these benefits have translated into shorter hospital stays, faster recovery times, and a quicker return to employment and recreational activities.

 

The robotic radical prostatectomy can be performed with minimal blood loss and patients are no longer advised to donate blood for their operation. Patients typically go home after one night and can return to work within one to two weeks. The urinary catheter remains in place for approximately six days and continence is achieved more quickly and completely than with the other surgical techniques. Erectile function is regained more quickly and with greater frequency.

Advantages: Best therapy available with least amount of side effects overall in experienced hands.

Disadvantages: Blood loss is still possible, as are other side effects of surgery. Surgery can be longer than open for inexperienced surgeons.

Requires a general anesthetic.

Learning curve is longer than open surgery.

Cryosurgery: Involves the use of liquid nitrogen to freeze and destroy cancer cells. Its main use currently is for the control of local disease if primary therapy is unsuccessful. Long term results using current technology are still not known.

HIFU:

Similar to cryosurgery except we are heating up the prostate with a focused ultrasound probe instead of icing the prostate.

Advantages: Probably least amount of side effects overall.

Disadvantages: It is currently experimental in the US and available in Canada and Europe.

The worst cure rates at the current time.