My Penis Stuff

Prostate cancer is the most common non-skin cancer among American men. Public health records indicate that one in six American men will be faced with the diagnosis of prostate cancer during their lifetime. On average, about 189,000 men are diagnosed with prostate cancer each year with about 32,000 cases being fatal.

Prostate-specific antigen (PSA) is a protein almost exclusively produced by the prostate. Initially approved by the Food and Drug Administration for the purpose of monitoring the status of prostate cancer in 1986, PSA has become an integral part of prostate cancer screening along with a digital rectal examination (DRE). Men with prostate cancer often have elevated levels of serum PSA which correlate with the extent of cancer spread. With the introduction of PSA screening in the late 1980s, there has been a dramatic rise in the number of men diagnosed with localized prostate cancer; approximately 80 percent of newly diagnosed men are considered to have a clinically organ-confined disease that is potentially amenable to cure.

Once diagnosed, men with localized prostate cancer face a difficulty choosing amongst various treatment options. Several factors come into play when selecting an appropriate therapy. The stage (extent of local spread) and grade (aggressiveness) of prostate cancer, as well as competing medical co-morbidities and age at diagnosis, can all influence the decision regarding the choice of therapeutic intervention.

What are the current treatment options for men with localized prostate cancer?

Surgery (Radical Prostatectomy)

Surgery remains the primary option for many men with localized prostate cancer. Compared to other treatment methods such as radiotherapy and cryotherapy, a radical prostatectomy has an advantage of providing accurate local staging as well as assessment of pelvic lymph nodes through a detailed pathologic analysis. For patients with prostate cancer pathologically confined to the prostate, the chance of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. The risk of cancer progression in men with extracapsular disease (cancer beyond the capsule of the prostate gland) and/or positive surgical margins is much higher ranging from 30 to 50 percent, and these patients may benefit from additional therapy such as external radiotherapy or androgen ablation. Although the incidence of surgical complications is quite low, the main postoperative issues remain urinary incontinence (5 percent) and erectile dysfunction (20 to 50 percent).

Open Radical Prostatectomy: In radical prostatectomy, the entire prostate gland is removed as a unit with the seminal vesicles and the nearest portions of the vas deferens. There are several different surgical techniques in performing a radical prostatectomy. The retropubic approach utilizes a midline incision below the umbilicus and allows simultaneous access to the prostate and pelvic lymph nodes. Based on precise anatomical delineation, the prostate gland can be safely removed with limited blood loss and preservation of the neurovascular bundles, which are responsible for maintaining erectile function. With the surgical steps clearly defined, the retropubic approach remains the most popular technique used by practicing urologists.

In perineal approach, the prostate is removed through a small semi-lunar incision in the perineum. By avoiding the pelvic vein complex, which can lead to significant bleeding in the retropubic approach, bleeding is usually minimal. Other advantages include precise urethra-vesical anastomosis (re-attaching the urethra to the bladder), a smaller incision, a shorter hospital stay and faster overall recovery. The main disadvantages are a higher incidence of rectal injury, difficulty of preserving the neurovascular bundles and a separate incision for pelvic lymphadenectomy. Typically, the perineal approach is preferred in obese individuals or those with prior lower abdominal surgery.

Robotic Assisted Laparoscopic Radical Prostatectomy: With recent advances in minimally invasive surgery and computer technology, the prostate gland can now be removed through a small one- to two-inch incision in the patient’s abdomen. Introduced in 2001, robotic prostatectomy utilizes a surgical robotic system—named the da Vinci Robot (Intuitive Surgical, Inc., Sunnyvale, CA)—to remove the prostate gland through laparoscopic access in which surgeons make keyhole openings rather than a single 6 to 8-inch midline incision. The da Vinci Surgical System is the first surgical robotic system approved by the Food and Drug Administration for performing robotically assisted, minimally invasive surgery.

The system incorporates a surgeon’s console and four interactive, robotic arms equipped with a camera and miniaturized surgical instruments. A surgeon controls the da Vinci’s arms from a remote console that precisely translates his hand, wrist and finger movements to the robotic arms inside the patient’s body while providing a three-dimensional view of those movements; the enhanced views offered by the da Vinci mean less chance of damaging surrounding nerves and tissue and a reduced risk of scarring. As a result, the incidence of postoperative erectile dysfunction and urinary incontinence appear to be much less than that of open radical prostatectomy. Furthermore, these small skin incisions result in less pain, less blood loss, faster catheter removal and a shorter hospital stay, with some patients returning to work as early as two weeks after the procedure. Patients who undergo this surgery generally leave the hospital the next day, and their overall recuperation time is reduced by half compared to that of standard open radical prostatectomy.

Despite its promising clinical results of robotic prostatectomy, the main caveat of this procedure is a steep learning curve in acquiring the surgical skills by the practicing urologists. It is estimated that the surgeon typically needs to perform 50 to 100 robotic prostatectomies before becoming facile with this approach.

Radiotherapy

Traditionally, radiotherapy has been reserved for an elderly population (over 70 years), men with locally advanced prostate cancer, and those with a short life expectancy (less than 15 years). Recent retrospective studies have shown that radiotherapy and surgery can offer comparable long-term outcomes up to 10 years, and as a result, the applicability of radiotherapy is no longer limited to the traditional indications. It is estimated that an equal number of patients undergo radical prostatectomy and radiotherapy at the present time.

Radiotherapy for prostate cancer can be divided into two modalities: external beam radiation (EBRT) and brachytherapy (PB). In external beam radiotherapy, a small amount of radiation is delivered incrementally to the prostate over a course of 6 to 7 weeks. The total radiation dose received is usually over 70 Gy. Currently, three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) is used to deliver high-dose radiation to the prostate while minimizing toxicity to the surrounding normal structures such as the bladder and rectum.

Prostate brachytherapy is a method in which radioactive seeds are implanted directly into the prostate. The seeds are delivered percutaneously into the prostate via the specially designed needles under real time ultrasound imaging. Both low-dose rate (but high-dose) permanent prostate seeds and high dose rate (HDR) temporary implants can be used to treat the gland successfully. PB is typically performed in an outpatient setting under either general or regional anesthesia. The procedure is usually well tolerated with minimal perioperative morbidity.

The relative effectiveness of EBRT and PB appear to be similar for early stage prostate cancer. Some patients are offered the combination therapy in which both EBRT and PB are utilized. For those with locally advanced cancer and/or highly aggressive cancer, androgen deprivation is also added to optimize cancer control.

The main side effects of radiotherapy include bladder and rectal toxicities which can result in urinary and bowel dysfunction. The incidence of erectile dysfunction also appears to be similar to that of surgery, ranging in 20 to 50%. The long-term effects of radiation to normal tissues remain unknown though an incidence of secondary malignancy appears to be higher in this population.

Cryotherapy

Cryoablation of the prostate is a treatment in which prostate cancer is eradicated by freezing the prostate gland. Cryotherapy has a similar setup to that of prostate brachytherapy in that special needles called “cryoprobes” are placed into the prostate transperineally under the guidance of transrectal ultrasound. Argon gas is then used to create an “iceball” which results in instant cell death within the predefined area. Real time ultrasound monitoring of cryoablation combined with the use of thermocouples prevents cryo injuries to the surrounding normal tissues. Although prostate cryotherapy is most commonly offered after failed radiotherapy, there is emerging data supporting its use as a single treatment option in men with newly diagnosed prostate cancer. Cryotherapy currently has a limited role as an initial therapy in newly diagnosed men. In addition, cryotherapy should only be employed in men with erectile dysfuction as virtually all patients experience impotence following cryotherapy.

Androgen Ablation Therapy

Prostate cancer is androgen sensitive in early stages. As such, androgen ablation can result in a dramatic reduction in cancer burden in the vast majority of cases. Unfortunately, most prostate cancers eventually progress despite effective medical or surgical castration and become androgen independent. In the management of localized prostate cancer, the role of androgen ablation is usually limited to a neoadjuvant or adjuvant setting. Two most common scenarios are 1) to reduce the prostate size prior to prostate brachytherapy and 2) to sensitize malignant cells to radiation during EBRT. For patients who are at high risk for cancer recurrence, a prolonged use of androgen ablation (up to 3 years) combined with EBRT has resulted in improved survival compared to EBRT alone.

Watchful Wait or Expectant Management

Prostate cancer is often a slowly progressive disease, and many men with prostate cancer will die from causes other than prostate cancer. Several nomograms (decision charts) have been established in order to distinguish men with clinically significant cancers from those with clinically indolent tumors. In general, older men with a limited life expectancy and those with low-grade, small-volume disease may benefit from expectant management, and a therapeutic intervention should be reserved for those demonstrating clinical progression.