Surgery to Treat Prostate Cancer
Good candidates for surgery to treat prostate cancer have one or more of the following characteristics:
- Good health
- No spread of cancer to bone
- Tumor confined to the prostate gland (stage T1 and T2)
- Under the age of 70
- Expected to live another 10 years or longer
Depending on the extent of the disease, there are several surgical options for prostate cancer.
This minimally invasive outpatient procedure, also called cryoablation, destroys cancer cells by twice rapidly freezing and thawing cancerous tissue. It is recommended for patients who
- cannot tolerate surgery or radiation,
- have prostate-confined tumors (stage T3 or lower),
- do not respond to radiation (both external-beam and brachytherapy), and
- are elderly.
Transrectal ultrasound and prostate biopsy are performed prior to cryosurgery to determine the exact size and location of the tumor(s). The procedure is performed under regional (e.g., epidural nerve block) or general anesthesia.
With the man on his back, the surgeon inserts a warming catheter into the urethra to protect it from freezing temperatures. An ultrasound transducer is inserted into the rectum, so the surgeon can see the prostate and surrounding tissue and monitor placement of the cryoprobes. The surgeon then makes 5 to 8 needle punctures in the perineum and advances the needles to preselected locations in the prostate tumor. Liquid nitrogen or argon gas circulates through the probes and freezes cancer cells to -40ºC.
The temperature in and around the prostate is monitored with thermosensors, also inserted through the perineum. Once the spheres of tissue surrounding the cryoprobes are covered with ice, the liquid nitrogen or argon circulation is stopped and the area is allowed to thaw. The freeze-thaw cycle is repeated and then the instruments are removed. The procedure takes about 2 hours.
Patients usually go home the same day or the day after the procedure. A catheter is necessary for about 3 weeks. Most patients report very little discomfort and often recover fully within days.
Recent studies show that 97% of cryosurgery patients are cancer free at 1 year and 82% are cancer free at 5 years following surgery. Cryosurgery usually can be repeated safely if cancer returns.
The urethral warming device causes incontinence or urethral obstruction in about 1% of patients. There is an 85% chance that freezing will result in nerve damage and cause impotence (erectile dysfunction). However, nerve-sparing techniques are being developed to help reduce that risk.
High Intensity Focused Ultrasound (HIFU)
High intensity focused ultrasound (HIFU) is currently undergoing clinical trials in the United States. HIFU is a noninvasive treatment that uses precision-focused ultrasound waves to heat and destroy (ablate) targeted prostatic tissue without affecting healthy surrounding tissue. It has been shown to effectively treat localized prostate cancer as well as benign prostatic hyperplasia (BPH). The Food and Drug Administration (FDA) has not yet approved this treatment in the United States.
In clinical trials, HIFU is performed on an outpatient basis, under anesthesia. HIFU can be repeated as necessary, and each treatment takes 13 hours. Following treatment, a catheter is necessary for about 1 week and most patients are able to resume regular activities within days. Impotence occurs in 17% of patients.
Radical prostatectomy is the surgical removal of the prostate gland and surrounding tissues, including the seminal vesicles and the pelvic lymph nodes. Surgeons use one of two surgical techniques, retropubic prostatectomy or perineal prostatectomy. General anesthesia is used in both procedures.
In retropubic prostatectomy, an incision is made in the lower abdomen. This gives the surgeon access to the prostate gland, seminal vesicles, and the pelvic lymph nodes. In perineal prostatectomy, the incision is made in the perineum, the space between the scrotum and the rectum. With perineal prostatectomy, a second procedure is required to remove the pelvic lymph nodes (lymphadenectomy).
Radical Prostatectomy Recovery
Typically, patients remain in the hospital for 3 to 7 days after radical prostatectomy surgery and are catheterized for 2 to 3 weeks.
The 10-year survival rate after radical prostatectomy ranges from 75% to 97% for patients with well and moderately differentiated cancers (containing normal-appearing and slightly abnormal cells) and 60% to 86% for patients with poorly differentiated cancers (containing very abnormal cells).
Following prostatectomy, an imaging tested called ProstaScint® may be used to locate recurrent prostate cancer (indicated by PSA levels) earlier than CT scans and bone scans. This test can be used to help determine whether the patient should undergo pelvic radiation therapy.
In the ProstaScint® test, antibodies (immune system proteins) are injected into the body and attach to remaining prostate cells. Radioactive particles on the antibodies can then be detected during imaging, allowing the prostate cells to be located. Additional studies are needed to determine the effectiveness of this test.
Prostate Px is a new diagnostic test that may be appropriately used to help predict the risk for prostate cancer recurrence in high-risk patients who have undergone prostatectomy.
In this test, which is produced by Aureon Laboratories, a small piece of prostatic tissue removed during prostatectomy is analyzed and a report outlining factors that affect risk is submitted to the physician for review. While this test may be clinically helpful, Prostate Px is not 100% accurate, is not currently available everywhere, and is not inexpensive.
Radical Prostatectomy Complications
Urinary leakage (incontinence) is common after surgery, but most men eventually regain urinary control. Surgeons try to avoid removing or cutting the nerves that control the ability to achieve an erection. Depending on the patient's age and the stage of the tumor, these nerve-sparing techniques enable about 40% to 65% of men who were sexually potent before surgery to remain so. There is also a risk for blood clots, which can cause heart failure. Radiation therapy may be recommended if cancer returns.
Laparoscopic Radical Prostatectomy
Laparoscopic radical prostatectomy is performed through several small incisions. A device consisting of a tube and an optical system (laparoscope) is inserted into one incision and is used to guide the procedure. Surgical instruments are inserted through the other incisions. This procedure is not available in all areas, and not all surgical patients are good candidates for the laparoscopic approach.
Robotic Laparoscopic Radical Prostatectomy
In some cases, a computer-enhanced robotic surgical system is used to perform laparoscopic radical prostatectomy. In this procedure, a robotic surgical system (e.g., da Vinci® surgical system) is used to perform laparoscopic radical prostatectomy.
The robotic surgical system is comprised of 3 major components, including a vision system to provide the surgeon with a high magnification and high resolution view of the operative field, robotic arms and instruments used by the surgeon to perform the procedure, and a console to allow the surgeon to view the operative field and control the instruments.
Laparoscopic radical prostatectomy causes less bleeding and less postoperative pain and results in a shorter hospital stay and recovery period. Catheterization is required for approximately 3 days following the procedure.
Prostate cancer usually spreads first to the lymph nodes in the pelvis. The physician assesses the likelihood of spread based on the biopsy results, PSA tests, and the size of the tumor. Lymphadenectomy is the surgical removal of lymph nodes. There are two types of lymphadenectomy, open and laparoscopic. General anesthesia is used in both procedures.
In an open lymphadenectomy, the lymph nodes are removed through an incision in the lower abdomen. Laparoscopic lymphadenectomy is performed with a laparoscope, a miniature telescopic device connected to a monitor. The laparoscope and other microinstruments are inserted through four small incisions in the lower abdomen. This procedure allows the patient to recover more quickly than open lymphadenectomy.
Prostate Cancer Prognosis
When cancer is confined to the prostate gland, the disease is usually curable. A number of patients with locally spread cancer die within 5 years. Once cancer has spread to distant organs, life expectancy is usually less than 3 years.
Prostate Cancer Prevention
While prostate cancer cannot be prevented, measures can be taken to prevent progression of the disease. It is important for men over 40 to have an annual prostate examination. When identified and treated early, prostate cancer has a high cure rate.