Prostatectomy (Surgery)

A surgical approach toward the treatment of prostate cancer can be used to remove all or part of the prostate. Typically, men with early-stage disease or cancer that is confined to the prostate will undergo radical prostatectomy, or surgical removal of the entire prostate gland plus some surrounding tissue. This procedure is described below. Other surgical procedures may be performed on men with advanced or recurrent disease.

In the most common type of prostatectomy, known as radical retropubic prostatectomy, an incision is made in the abdomen and the prostate is cut out from behind the pubic bone. After removing the prostate, the surgeon stitches the urethra directly to the bladder so urine is able to flow. (Review the roles of the prostate and the surrounding organs in the About the Prostate section.)

Because it typically takes a few days for the body to get used to this new setup, the surgeon will insert a catheter, or tube, into the bladder. With this in place, urine flows automatically out of the bladder, down the urethra, and into a collection bag without the need for conscious control of the sphincter. The catheter is usually kept in place for about a week to 10 days.

Another type of surgery, known as radical perineal prostatectomy, is performed less frequently these days. In this approach, the surgeon makes the incision in the perineum, or the space between the scrotum and the anus, and the prostate is removed from behind.

Surgical Techniques


In a nerve-sparing prostatectomy, the surgeon cuts to the very edges of the prostate, taking care to spare the erectile nerves that run alongside the prostate. In cases when the nerves cannot be spared because the cancer extends beyond the prostate, surgically attaching, or grafting, nerves from other parts of the body to the ends of the cut erectile nerves might be possible.

In laparoscopic surgery, very small incisions are made in the abdomen, into which the surgeon inserts narrow instruments fitted with cameras and/or surgical tools, allowing the surgeon to visualize and operate on the internal structures without cutting open the entire abdomen. With a robotic interface, the surgeon maneuvers the robotís arms, which in turn control the cameras and instruments inserted in the abdomen.

The Importance of Surgical Skill


Prostatectomy, like many surgical procedures, is very delicate work, and the difference between a good surgeon and a great surgeon can affect outcomes. When choosing a surgeon, at a minimum, ensure that he or she is someone in whom you have confidence, and someone who has enough experience to not only perform the operation, but to also make an informed clinical judgment and change course should the need arise.

Radiation Therapy

Radiation involves the killing of cancer cells and surrounding tissues with directed radioactive exposure. (Review the roles of the prostate and the surrounding organs in the About the Prostate section.)

The use of radiation therapy as an initial treatment for prostate cancer is described below. Some forms of radiation therapy can also be used in men with advanced or recurrent prostate cancer.

External Beam Radiation Therapy


The most common type of radiation therapy is external beam radiotherapy. CT scans and MRIs are used to map out the location of the tumor cells, and x-rays are targeted to those areas. With 3D conformal radiotherapy, a computerized program maps out the exact location of the prostate tumors so that the highest dose of radiation can reach the cancer cells within the gland.

Intensity-modulated radiation therapy (IMRT) allows oncologists to modulate, or change, the intensity of the doses and radiation beams to better target the radiation delivered to the prostate, while at the same time delivering lower doses to the tumor cells that are immediately adjacent to the bladder and rectal tissue. In some centers, proton-based therapy is used during IMRT rather than the more traditional photon-based therapy. Although early studies have shown that oncologists may be able to manipulate these beams even more precisely, this technology is not yet widely available.

Because the treatment planning with these types of radiation therapy are far more precise, higheróand more effectiveódoses of radiation can be used with less chance of damaging surrounding tissue.

Regardless of the form of external radiation therapy, treatment courses usually run five days a week for about seven or eight weeks, and are typically done on an outpatient basis.

Brachytherapy


With brachytherapy, tiny little metal pellets containing radioactive iodine or palladium are inserted into the prostate via needles that enter through the skin behind the testicles. As with 3D conformal radiation therapy, careful and precise maps are used to ensure that the seeds are placed in the proper locations.

Over the course of several months, the seeds give off radiation to the immediate surrounding area, killing the prostate cancer cells. By the end of the year, the radioactive material degrades, and the seeds that remains are harmless.

Compared with external radiation therapy, brachytherapy is less commonly used, but it is rapidly gaining ground, primarily because it doesnít require daily visits to the treatment center.

The Importance of Dose Planning


Just as surgical skill can play an important role in determining outcomes from prostatectomy, technical skill and manual dexterity can play an important role in determining outcomes from radiation therapy. The use of computer software to assist with the dose planning and target prostate tissue helps greatly, but, in the end, the skill and experience of the radiation oncologist will make the biggest difference.

When choosing a radiation oncologist, at a minimum, make sure he or she has broad experience with an assortment of approaches and can objectively help to decide on the best course of treatment.

Hormone Therapy

Prostate cancer cells are just like all other living organismsóthey need fuel to grow and survive. Because the hormone testosterone serves as the main fuel for prostate cancer cell growth, it is a common target for therapeutic intervention in men with prostate cancer.

Hormone therapy, also known as androgen-deprivation therapy or ADT, is designed to stop testosterone from being released or to prevent the hormone from acting on the prostate cells. Although hormone therapy plays an important role in men with advancing prostate cancer, it is increasingly being used before, during, or after local treatment as well.

The majority of cells in prostate cancer tumors respond to the removal of testosterone. But some cells grow independent of testosterone, and therefore remain unaffected by hormone therapy. As these hormone-independent cells continue to grow unchecked, over time, hormone therapies have less and less of an effect on the growth of the tumor.

Hormone therapy is therefore not a perfect strategy in the fight against prostate cancer, and does not cure the disease. But it remains an important step in the process of managing advancing disease, and will likely be a part of every manís therapeutic regimen at some point during his fight against recurrent or advanced prostate cancer.

The most common types of hormone therapy are described below. Although each of these therapeutic options is effective at controlling prostate cancer growth, the loss of testosterone confers significant side effects in nearly all men. (A review of how best to manage side effects from testosterone loss can be found in the Side Effects section.)

Orchiectomy


Because about 90% of testosterone is produced by the testicles, surgical removal of the testicles, or orchiectomy, is an effective solution to blocking testosterone release. This approach has been used successfully since the 1940s, but because itís a permanent and irreversible surgical solution, most men opt for drug therapy instead.

For men who choose this option, the procedure is typically done on an outpatient basis in the urologistís office. Recovery tends to be rather quick and no further hormone therapy is needed, making orchiectomy a very attractive choice for someone who prefers a low-cost, one-time procedure.

LHRH Agonists


LHRH, or luteinizing-hormone releasing hormone, is one of the key hormones released by the body before testosterone is produced. (Note that LHRH is sometimes called GnRH, or gonadotropin-releasing hormone.) Blocking the release of LHRH through the use of LHRH agonists or LHRH analogues is one of the most common hormone therapies used in men with prostate cancer.

Drugs in this class, including leuprolide (Eligard, Lupron, and Viadur), goserelin (Zoladex), and triptorelin (Trelstar), are given in the form of regular shots: once a month, once every three months, once every four months, or once per year.

Chemotherapy

The term "chemotherapy" refers to any type of therapy that uses chemicals to kill or halt the growth of cancer cells. The drugs work in a variety of ways, but are all based on the same simple principle: stop the cells from dividing and you stop the growth and spread of the tumor.

Until recently, chemotherapy was used only to relieve symptoms associated with very advanced or metastatic disease. With the publication of two studies in 2004 showing that the use of docetaxel (Taxotere) can prolong the lives of men with prostate cancer that no longer responds to hormone therapy, more and more doctors are recognizing the potential benefits of chemotherapy for the men they treat with advanced prostate cancer.

Building on these successes, there are now dozens of clinical trials studying various combinations of chemotherapy drugs, some using new mixes of older drugs and some using newer drugs. Some trials are looking to find a chemotherapy regimen thatís more tolerable or more effective than docetaxel in men with metastatic disease, others are looking to find a chemotherapy regimen that can delay the onset of metastases, and still others are seeking to improve upon the results with docetaxel by adding to it other novel agents and testing the combination.

Paramount in all researchersí minds is a way to maximize benefit while minimizing side effects. Chemotherapy, like all powerful drugs, can take a toll on the body. A review of how to best manage the side effects of chemotherapy can be found in the Side Effects section.

Off-Label Chemotherapy Use


Strictly speaking, few chemotherapy agents have been approved by the FDA for use in prostate cancer. But over the years, doctors have found that some medications that are regularly used in other types of cancers can be used rather effectively in men with prostate cancer.

Off label use of a drug means that the drug is approved by the FDA for use in one disease but is being used in another. The drug is known to be safe overall, and has been proven effective for the disease in which itís approved. That doesnít mean itís not effective in prostate cancer as well; it just means that the drug hasnít been rigorously tested in prostate cancer, so thereís no formal "proof" that itís effective. Nevertheless, off-label use of chemotherapy is common, and its use is often found to be beneficial in men with prostate cancer.

Because very few drugs will score a home run in every person, second-line chemotherapy has a long and valued tradition in the treatment of cancer. In this setting, off-label drugs are common, and are chosen specifically because they work somewhat differently than what was used first, providing another chance to see a benefit.

 

Other Treatment Options

Surgery and radiation therapy remain the standard treatment for localized prostate cancer, but other, less popular treatment options might be beneficial as well. As time goes on and the benefits of these treatment options are further explored, itís possible that they will move more into the mainstream. For now, though, none are seen as standard treatments for localized prostate cancer.

Cryotherapy


Cryotherapy, also known as cryosurgery or cryoablation, has been around for years, but until a few years ago, it was rarely used. With this approach, probes are inserted into the prostate through the perineum (the space between the scrotum and the anus), and argon gas or liquid nitrogen is delivered to the prostate, literally freezing to death the prostate cells and any prostate tumors. (Review the roles of the prostate and the surrounding organs in the About the Prostate section.)

Over the years, a number of modifications were made to avoid freezing damage to the nearby structures, but the rates for both erectile and urinary dysfunction remain high, and data on long-term outcomes are limited.

Cryotherapy is also used as a secondary local therapy in men who underwent radiation therapy as initial treatment for early-stage prostate cancer. Note that men with more well-confined disease tend to fare better, while those who received hormone therapy in addition to radiation therapy tend to fare worse.

High-Intensity Focused Ultrasound


High-intensity focused ultrasound, or HIFU, works in exactly the opposite way compared with cryotherapy: with HIFU, the prostate cells are heated to death. A probe is inserted into the rectum, from which very high-intensity ultrasound waves are delivered to the target area. Although this technique remains experimental in the United States, itís been used in Europe for a number of years with a fair amount of success.

Primary Hormone Therapy


Hormone therapy, also known as androgen-deprivation therapy or ADT, is designed to stop testosterone from being released or to prevent the hormone from acting on the prostate cells. (A review of common hormone therapy strategies can be found in the Hormone Therapy section.)

Although there is little, if any, data to show that hormone therapy alone is an effective treatment strategy for men with localized prostate cancer, it is increasingly being used in this setting. Because it is not invasive, it is possible that the therapy is seen as a middle ground between active surveillance and local therapy.

 

Emerging Therapies

In labs around the world, researchers are busy identifying new drugs, new regimens, and new treatment approaches that might prove beneficial to men with prostate cancer. Most of these investigational agents are being tested in men with advanced prostate cancer: Therapy options for men at this stage of disease are often not effective enough to halt progression of the disease, and men are typically affected by side effects from the disease and/or the medications that theyíre taking. Itís therefore the perfect stage at which to test out new drugs because any improvement will likely be rapidly noticed and much appreciated.

The Goal of Targeted Therapies


Chemotherapy drugs can play an important role in improving the lives of men with advanced prostate cancer, but they often donít distinguish between tumor cells and healthy cells and can kill off some normal cells along the way. So-called targeted therapies, by contrast, are drugs that are specifically designed to interfere with the way cancer cells grow, with the way cancer cells interact with each other, and/or with the way that the immune system interact with the cancer.

There are a number of different kinds of targeted therapies being investigated for prostate cancer. As of yet, none have been approved by the FDA for use in prostate cancer, but the excitement generated by some of the early studies have led many researchers to believe that itís only a matter of time before a targeted therapy is found that can result in better outcomes overall.

Interfering With Cancer Cell Growth


All cells in the body, including cancer cells, rely on a complex communication system to know when to grow, when to divide, and when to die. This system uses specialized proteins, fats, and other substances to tell the different cells or parts of cells how to act. Over the years, cancer researchers have been studying ways to interfere with the signaling system that regulates the growth of cancer cells.

So far, interfering with cellular signaling to halt cancer cell growth hasnít yet proven to be a very effective strategy in prostate cancer. But in the process of learning which drugs might work and why, researchers found that the strategy of adding a "targeted therapy" to other effective drugs in order to see better results than with either drug alone is an important part of cancer research. The idea is to exploit the synergy between the two drugs, or the ways in which the two drugs might work together to fight off the cancer.

Interfering With Cancer Cell Spread


As cancer cells divide and start to spread, new blood vessels sprout from the old ones to help supply the necessary nutrients to the new tumor site via a process called angiogenesis. If angiogenesis could be inhibited, researchers theorized, the new tumor cells would die and the cancerís growth would be halted.

In 2004, the angiogenesis inhibitor bevacizumab (Avastin) was approved by the FDA for use in colorectal cancer. Since then, it has been shown to improve outcomes in women with breast cancer, and is currently being studied in a number of other cancer types, including prostate cancer. Although no other drugs currently available were designed to specifically act as an angiogenesis inhibitor, researchers have found that the drug thalidomide (Thalomid) has some anti-angiogenic properties, and is also currently being tested in men with prostate cancer.


Harnessing the Immune System to Fight Off Cancer Cells


In order for the immune system to fight off foreign invaders, it has to learn to recognize whatís normal and whatís not normal. Unfortunately, because cancer cells start out as normal healthy cells, the immune system never has a chance to learn to distinguish between the normal cell and the cancer cell.

Unlike preventive vaccines, which are designed to teach the immune system to develop a way to fight off a specific virus should it come into contact with that same virus again, therapeutic vaccines stimulate the immune system to recognize and fight certain proteins specific to cancer cells. Each of the therapeutic vaccines currently being tested in men with advanced prostate cancer works in a slightly different fashion, but all are designed to harness the immune systemís ability to fight off disease and teach it to fight off prostate cancer cells.

 

Useful Resources

The Prostate Cancer Foundation has put together a comprehensive list of useful resources, including publications and links, to better educate and assist those individuals seeking additional information.

 

Prostate Cancer Guides

The Prostate Cancer Foundation has produced three prostate cancer guides that can be ordered or downloaded from this website:

An Introduction to Prostate Cancer
This brief introductory guide is designed to help men and their families and friends understand the risk factors for prostate cancer, find out how prostate cancer is diagnosed, and look at the different treatment options that can be used. (7 pages)
Order a free copy or download a copy in PDF format.

Report to the Nation: A Guide for Men and Their Families
This guide provides in-depth information about the diagnosis of prostate cancer, the available treatment options at each stage of the disease and more. The Guide highlights key issues that men with prostate cancer face at every step of the way, and includes a set of tear-out, wallet-sized cards with questions to ask their doctors at each stage of disease. (108 pages)
Read the Guide online, order a free paper copy by completing the registration form or download a copy in PDF format.

Nutrition and Prostate Cancer
The Nutrition and Prostate Cancer guide summarizes the "best of the best" data and information available in the research arena today, and is designed to help everyone affected by or at risk for prostate cancer understand how key nutritional strategies can be incorporated into everyday life. (92 pages)
Order a free paper copy by completing the registration form or download a copy in PDF format.

 

 

 

 

Glossary of Key Terms

FAQs About Prostate Cancer