Prostatectomy (surgical prostate removal) is the most common treatment for prostate cancer. Innovative surgical techniques have provided more options for men who desire complete cancer control with minimal impact on quality of life.
There are two types of "open" prostatectomy:
Retropubic: An incision is made between the navel and pubic bone. The surgeon removes the prostate and any affected lymph nodes and then sews the urethra and bladder back together. Retropubic prostatectomy provides the best chance of sparing the urethra to preserve urinary continence, as well as the neurovascular bundles responsible for erection. The procedure takes 2.5 to 3 hours if nerves are not spared; 3.5 to 4 hours if nerves are spared. It is the most common type of prostatectomy.
Perineal: The incision is made between the scrotum and rectum, and the prostate is approached from the bottom. Perineal surgery is less invasive than retropubic, with a faster recovery time and fewer days on a catheter, but it is seldom used today and few surgeons are trained on this approach. Perineal prostatectomies are best for low-grade and/or early stage tumors with no lymph node involvement, or for very obese patients.
Nerve-sparing surgery is performed during a prostatectomy in order to preserve the two neurovascular bundles next to the prostate that are responsible for erections. Before 1980, these nerves were routinely taken to make sure all cancer cells were removed, but the unfortunate result was sexual impotence.
Today, surgical and diagnostic advances have allowed MD Anderson surgeons to spare one or both nerves in about 75% of prostatectomies, giving the patient a better chance of retaining sexual function. If both nerves are spared (bilateral), the patient has an 80% chance of maintaining sexual potency; if one nerve is spared (unilateral), the potency rate is about 30%.
The decision for nerve-sparing surgery is largely up to the patient, but controlling the cancer is the surgeon's primary goal. The best candidates for nerve-sparing surgery are men with:
- Localized tumors
- A PSA level of 10 or less
- A Gleason score of 6 to 7 or less
- No prior use of erectile dysfunction (ED) drugs
Nerve-sparing surgery is not recommended for men with large tumors or high-grade disease, or for those who have pre-existing erectile dysfunction unrelated to cancer treatment.
Sural Nerve Graft
This surgery is generally performed on patients who are not eligible for nerve-sparing, but had normal erections before surgery. The sural nerve, which is located in the calf, is removed and then used to replace either one or both of the nerve bundles alongside the prostate.
Sural nerve graft was developed in the late 1990s and is still considered experimental. Its role in preserving sexual function has diminished as nerve-sparing techniques have improved. However, for young, potent men with locally advanced disease, this may be an option.
Laparoscopic Radical Prostatectomy (LRP)
Minimally invasive surgery is quickly becoming an alternative to standard "open" surgery for treating prostate cancer. A laparoscopic radical prostatectomy (LRP) involves the use of a laparoscope, which is a thin tube with a tiny camera. An incision less than an inch long is made at the navel and the laparoscope is inserted so that surgeons can view the treatment area on a monitor. Four other tiny incisions are made for miniature surgical instruments that can remove the entire prostate.
Although LRP is more complicated than traditional surgery and may take longer, there are many benefits for the patient:
- Less blood loss during surgery
- Shorter hospital stay
- Decreased recovery time
- Decreased reliance on narcotic pain medications
- Less fluid buildup
- Fewer days with a urinary catheter
Other benefits may include a decreased risk of post-surgery bladder and bowel continence. Outcomes appear to be similar to standard surgery.
The best candidates for LRP are men with low to intermediate grade prostate cancer who have no prior pelvic radiation or surgery. Age is not a factor, but generally, surgery is not offered to men over age 70.
Side effects of prostatectomy: Urinary incontinence (stress and total), erectile dysfunction (ED), typical post-operative complications.
Radiation therapy is a primary treatment option for both localized and locally advanced prostate cancer. For early-stage disease, patients often have a choice between surgery and radiation, with similar outcomes. For larger or more aggressive tumors, radiation therapy may be used in combination with hormone therapy.
The following technological means and type of radiation therapy are used with this disease:
- Virtual CT simulation
- Intensity modulated radiation therapy (IMRT)
- Volumetric Modulated Arc Therapy (VMAT)
- Stereotactic body radiation therapy (SBRT): Extracranial radiosurgeryconsists of delivering high-dose radiation in just a few sessions, between 1 and 5. It is used with small tumors and to minimize toxicityto healthy tissue, image guided radiation therapy (IGRT) is used to treat bone metastases.
There is an alternative to extreme radiation therapy with IMRTrecommended for a selected group of patients with low-risk tumors (detected in the early stages): Prostate brachytherapy
Treatment side effects can be similar for all forms of radiation therapy, although many patients report fewer side effects with proton therapy treatment. Side effects may be more intense for brachytherapy. Overall, most patients will experience some side effects, but they generally are not severe and go away after treatment ends. The rectum and bladder are most likely to be affected in prostate cancer patients.
Possible side effects include:
- Irritation of the bladder, urethra and/or rectum
- Frequent urination, burning on urination, stronger urge to urinate
- Rectum soreness (may be accompanied by slight bleeding)
- More frequent bowel movements
Chemotherapy generally is not a standard treatment for prostate cancer. Since most tumors are slow-growing and occur in older men, the side effects from chemotherapy usually outweigh any benefit that treatment may provide.
However, chemotherapy may be an option for men with advanced or recurrent prostate cancer, or who have not responded to other treatments. Mitoxantrone and prednisone, two drugs used in combination, have had some effect in easing pain and improving quality of life in patients whose cancer has metastasized (spread) to bone, but with no significant change in overall survival.
The majority of prostate cancers are hormone-sensitive, which means they depend on the male hormone (testosterone) as fuel for tumorgrowth.
Hormone therapies work best on early-stage, high-grade tumors (Gleason score of 8 or higher). However, there is disagreement over the length and timing of hormone therapy. Most studies have shown that suppression of testosterone at an earlier stage has a significant effect on patient survival. There are differing opinions on length of therapy, but MD Anderson oncologists agree that therapy spanning three years produces the best results.
There are three types of hormone therapies for prostate cancer:
Androgen ablation blocks the ability of cancer cells to interact with testosterone at the cellular level. Flutamide and Casodex® are two types of androgen ablation drugs. They are taken orally on a daily basis for up to three years. Their effects are permanent in most patients.
The standard of care for early-stage, high-grade disease is androgen ablation given at least two months before radiation therapy. The drugs make the tumor more responsive to radiation treatment, and reduce the number of cancer cells to be treated.
LHRH agonists work by overstimulating the pituitary gland to release luteinizing hormone-releasing hormone (LHRH), which signals the testicles to suppress testosterone production. Zoladex and Leuprolide are LHRH agonist drugs, administered by regular injections ranging from once a month to once a year. A disadvantage of this therapy is that it causes a short spike in testosterone levels before suppression takes effect. However, its effects are not permanent, so patients who cannot cope with treatment side effects can be taken off the drug and can resume testosterone production.
Orchiectomy (surgical removal of the testicles) used to be the standard hormone therapy for prostate cancer. Because orchiectomy is an efficient, cost-effective and convenient method of reducing testosterone, it is still an option for certain patients, particularly elderly men.
Side effects of hormone therapies include:
- Impotency, loss of sex drive
- Loss of muscle mass, weakness
- Decreased bone mass (osteoporosis)
- Shrunken testicles
- Loss of self-esteem, aggressiveness/alertness and higher cognitive functions such as prioritizing or rationalization
The severity of side effects increases with the length of hormone therapy.
For men with advanced or metastatic prostate cancer, hormone therapies provide relief from pain and other cancer-related symptoms. In these patients, the symptoms of advancing cancer outweigh the side effects of hormone therapy.
Because not all prostate cancers will progress to threaten patients’ lives, MD Anderson does consider watchful waiting as a treatment option for very carefully selected patients with low-grade prostate cancer. These patients fall into two general categories:
For patients who believe the side effects of treatment (impotence, urinary incontinence) are excessive, watchful waiting would be considered for these men if they:
- Recognize there is no validated screening method for early detection of disease progression
- Have a low Gleason score
- Have low-volume disease
- Have a PSA level within the normal range (or accounted for by an enlarged prostate)
- Are willing to submit to follow-up with annual biopsies and quarterly PSA tests
For patients who believe the risk for cancer is less than the risk from unrelated, co-existing health conditions, watchful waiting would be considered acceptable if:
- Patients have a less than 10-year expected survival
- The Gleason score is low
- Patients have low-volume disease
- The PSA level is within the normal range
- Patients have an estimated survival of less than five years and a cancer judged not to be at risk during that time
- Patients are willing to submit to follow-up with quarterly PSA tests and annual biopsies
The challenge of watchful waiting is that oncologists still cannot anticipate progression of the disease in a timely enough fashion to avoid risky treatment delays, and there are still no reliable methods to select patients in whom cancer is unlikely to spread. As the ability to predict prostate cancer progression improves, the risks of watchful waiting can be minimized.