Patients with early-stage prostate cancer have several treatment options. The treatment selected may be influenced by the patient’s age, concurrent health problems, the patient’s goals of treatment, and the bias of the treating physician. Treatment options include hormone therapy, surgery, radiation, combinations of therapy and “watchful waiting.” It is important to obtain as much information as possible about the results of each treatment and obtain more than one opinion, especially when deciding on surgery versus radiation therapy. A surgeon who specializes in treatment of disorders of the male genital tract, including prostate cancer, is known as a urologist. A urologist plays an important role in the diagnosis and treatment of prostate cancer. The common surgical procedures and their side effects are described below.
Prostate Biopsy: If laboratory tests or examination results suggest that cancer may be present, the patient will need to have a prostate biopsy. A biopsy is the only way to know for sure whether a patient has cancer. During a biopsy, a needle is used to remove several small pieces of prostate tissue through the rectum. These pieces of prostate tissue are examined under the microscope to determine whether cancer cells are present. If cancer cells are present, assessment of how aggressive or abnormal the cancer appears is performed. A number, called the Gleason score, is assigned to the cancer, with higher numbers representing faster growing and faster spreading cancers.
Transurethral Resection of the Prostate (TURP): In this procedure, the cancer is cut out of the prostate gland using a small tool that can be inserted into the prostate through the urethra.
Prostatectomy and Lymph Node Dissection: Surgery is a common treatment of Stage I, II, and sometimes Stage III cancer of the prostate. The operation used to remove the prostate cancer is called a radical prostatectomy. Radical prostatectomy is most effective if the staging evaluation shows that the cancer has not spread outside the prostate. This is because surgery cannot remove cancer that has already spread away from the prostate gland. Some patients will have small amounts of cancer that have spread outside the prostate into the pelvic lymph nodes or other distant locations. In general, the higher the stage, the more likely the cancer will have spread away from the prostate.
Before a prostatectomy is performed, the urologist may perform surgery to take out lymph nodes to see if they contain cancer. This is called a pelvic lymph node dissection. If the lymph nodes contain cancer, usually the urologist will not proceed with a radical prostatectomy. Another form of treatment, usually hormone therapy and/or radiation therapy, is generally recommended.
A pelvic lymph node dissection is most useful when it prevents an unnecessary prostatectomy from being performed. It is typically recommended for patients with clinical Stage III cancer or those with higher risk Stage I or II cancer who are considering surgical treatment. Studies indicate that pelvic lymph node dissection may not be necessary for patients with Stage I-II cancer if the total Gleason score is less than 5 and PSA is less than 4.0 ng/mL. Since the complications of pelvic lymph node dissection are minimal and identification of cancer in the lymph node can prevent performing an unnecessary prostatectomy, bilateral pelvic lymph node dissection may be indicated.
Radical Prostatectomy: Candidates for radical prostatectomy should be young and healthy enough to have a 10-20 year life expectancy. During a radical prostatectomy, the entire prostate gland with the cancer and a rim of normal tissue around it is removed. Removing a part of the prostate is not recommended because most prostate cancers have multiple areas of involvement. With a radical prostatectomy, a portion of the urethra, or tube that empties the bladder through the penis, is removed and the cut ends are re-attached. To help with the healing of the urethra, the patient will go home with a catheter into the bladder for a couple of weeks. Radical prostatectomy can be performed through a low abdominal incision (retropubic) or through the perineum, the area between the scrotum and the anus (perineal prostatectomy). With the perineal approach, one cannot simultaneously remove the lymph nodes. Removal of lymph nodes is important for staging, but studies now indicate that pelvic lymph node evaluation is probably not necessary for most patients with Stage I-II cancers.
Radical prostatectomy can also be performed by laparoscopy (sometimes called “minimally invasive surgery”), in which several small incisions are made. During laparoscopy, the surgeon inserts a small video camera through one of the incisions in order to see inside the abdomen. In a variant of laparoscopic surgery known as robotic-assisted laparoscopic surgery, the surgeon sits at a console near the operating table and performs the surgery by controlling robotic arms that hold the surgical instruments. Studies suggest that conventional open surgery and laparoscopic surgery produce similar results and rates of complications. Laparoscopic surgery may, however, result in a shorter hospitalization.
Possible long-term side effects of prostatectomy include incontinence (lack of bladder control) and impotence (inability to have an erection). Approximately 50-75% of men become impotent following prostatectomy and approximately 0-5% experience permanent incontinence. Injury to the rectum can also occur in men treated with surgery. In-hospital death occurs after radical prostatectomy in less than 1% of cases. Complications from radical prostatectomy tend to be less frequent in younger patients. Severe complications from radical prostatectomy are relatively uncommon. Ask your physician to provide you with the risks of these complications in his/her institution.
Nerve-Sparing Prostatectomy: Some urologists perform a newer surgical technique referred to as nerve-sparing prostatectomy. This approach may prevent permanent injury to the nerves that control erection and the bladder. When this surgery is fully successful, impotence and urinary incontinence are only temporary. Nerve-sparing surgery preserves potency in 60-75% of patients and less than 10% have urinary stress incontinence when the operation is performed by an experienced surgeon.
Cryosurgery: Cryosurgery is a technique that kills cancer cells by freezing them with sub-zero temperatures. During this procedure, hollow steel probes, guided by ultrasound, are placed inside and surrounding the cancer. Liquid nitrogen is then circulated through the probes, freezing the cancer cells and creating a ball of ice that surrounds the cancer. Once an adequate ice ball is formed, heated nitrogen is circulated through the probes. This process is then repeated. A heated probe is placed near the urethra throughout the freezing process so that the urethra is protected during the entire procedure. It is believed that cryosurgery creates cancer-killing effects through three distinct processes. First, ice crystals formed within cells are known to be lethal to nearly all cells. Second, when the ice forms around the cell, it draws water out of the cell, which collapses many of the walls or membranes within the cell. Third, when the ice surrounding the cells melts through the heating process, the water rushes back into the shrunken cell and causes it to burst.
This procedure has some compelling advantages, such as out-patient treatment, less pain, less blood loss, and faster recovery times. Since healthy tissue is preserved in the cancer-involved organ, the procedure can be repeated if the cancer returns.
The most serious complication associated with cryosurgery is when the rectal tissue is mistakenly frozen along with the prostate cancer. This complication has been reported in less than 1% of patients in several large studies. However, it is more likely to occur with a less experienced surgeon. The repair of this complication may require a temporary colostomy and additional surgery to close the hole between the rectum and the urethra. In one clinical trial, approximately 50% of the patients who had undergone cryosurgery were still impotent one year following surgery. The patients who may be the most appropriate candidates include older men over 70 years of age; patients who might have medical problems that would increase their risks of undergoing major surgery; or patients who have failed radiation therapy and have no other options.
Orchiectomy: Prostate cancer cells need male hormones (especially testosterone) in order to grow. Hormone therapy decreases the level of male hormones in the blood, which causes prostate cancer cells to die. Because hormone therapy can affect prostate cancer cells everywhere in the body, this treatment is used when cancer cells have escaped the prostate to other areas of the body. Prostate cancer that has spread to other areas of the body usually can be controlled with hormone therapy for a period of time, often several years. Eventually, however, most prostate cancers are able to grow despite the hormone therapy.
Bilateral orchiectomy (castration) is an operation to remove the testicles. By removing the testicles, the main source of male hormones is removed and hormone levels decrease. Orchiectomy is a common treatment for patients with metastatic (Stage IV) prostate cancer who will likely require hormone therapy for life. Patients may experience a benefit in symptoms in a matter of days following surgery.
Orchiectomy can cause side effects such as loss of sexual desire, impotence, hot flashes, and weight gain. The operation itself is relatively safe and not associated with severe complications. Because it is a one-time procedure, orchiectomy is a convenient and less costly method of hormone therapy.
Strategies to Improve Treatment
Neoadjuvant Hormonal Therapy: Some urologists are trying to make radical prostatectomy more successful for Stage II or Stage III prostate cancer by shrinking the cancer prior to surgery with hormone therapy. Hormone therapy deprives a man’s body of male hormones necessary for prostate cancer to grow. By administering hormone therapy for several months before the operation (neoadjuvant therapy), the prostate cancer may shrink enough to permit successful surgery. The use of neoadjuvant hormone therapy prior to radical prostatectomy is being evaluated in clinical studies.
Lowrance WT, Elkin EB, Jacks LM, et al. Comparative effectiveness of prostate cancer surgical treatments: A population based analysis of postoperative outcomes. Journal of Urology
. 2010 Apr;183(4):1366-72