Prostate Cancer & Treatment

What is the Prostate?

The prostate is a small gland that sits underneath the urinary bladder, and surrounds the urethra, the channel through which you urinate. The prostate is about the size of a walnut, and usually begins to enlarge after age forty.  The function of the prostate is to make semen, or the fluid that the sperm swim in.

What is prostate cancer?

Prostate cancer is the abnormal growth of prostate cells, whereby the cells grow out of control. Prostate cancer comes is various types, from a very slow growing type to very fast growing type (Gleason Grades 2 to 10).   

How do I know if I have Prostate Cancer?

A Prostate Biopsy, performed under ultrasound guidance, establishes the diagnosis of Prostate Cancer.  The indications for a prostate biopsy are:  
1)    Elevated PSA (Prostate Specific Antigen) blood test.
2)    Elevated PSA Velocity (too rapid a rise in the PSA).
3)    An abnormal digital rectal examination of the prostate (prostate nodule).  

Prostate biopsies are performed through the rectum, using an ultrasound probe shaped like a finger.  Local anesthetic is administered before taking the biopsy, so the biopsy itself is almost painless. Antibiotics are given to prevent infection. The prostate biopsy specimen is sent to the pathologist for examination. The biopsy procedure is performed in our office and only takes about 10 minutes.  

The pathologist looks at the biopsy specimen, and if Prostate Cancer is present, the pathologist assigns the cancer a Gleason Score, from 2 to 10, depending on how aggressive it appears under the microscope.  The Gleason Score (or Gleason Grade) is a measure of biological aggressiveness, where Gleason Grades 2-6 are all lumped together as the slowest growing types, Gleason 7 is more aggressive, and Gleason 8-10 are the fastest growing types.  

Once the grade is known, the Urologist establishes its Stage, which is a determination of its extent. 

• Stage T1: Cancer confined to the prostate, elevated PSA, but normal digital rectal exam.
• Stage T2: Cancer confined to the prostate with an abnormal digital rectal exam (prostate nodule confined to the borders of the prostate).
• Stage T3: Cancer extending beyond the borders of the prostate, but no evidence of spread to other locations.
• Stage T4: Cancer spread to other organs

In the modern era, over 90% of Prostate Cancers are detected at potentially curable stages (T1, T2, and some T3's).  For prostate cancer of low Grade (Gleason score 6 or less), low Stage (T1 and T2), and low PSA (PSA less than 10), often no additional testing is necessary.  For higher Grade, higher Stage, or higher PSA cancers, usually tests are necessary to determine if the cancer is still confined to the prostate, or if it has spread to other regions of the body.  Common tests are a Bone Scan, Chest X-Ray, CT scan of the abdomen and pelvis, and MRI.  Your urologist will advise you if any of these tests are necessary.  

Treatment of Prostate Cancer

Once the Gleason Score (Gleason Grade) and Stage are known, your urologist will discuss all the treatment options. The treatment options for prostate cancer include:
1)    Active Surveillance (watchful waiting)
2)    Radical Prostatectomy (da Vinci Robotic Radical Prostatectomy): total removal of the prostate
3)    Radiation Therapy (External Beam Radiation Therapy, Interstitial Brachytherapy (Seeds), High Dose Rate Brachytherapy (HDR) or combinations of the above (e.g. Seeds plus external Beam).
4)    Cryotherapy (freezing the prostate).
5)    Androgen Deprivation Therapy (Treatment to lower the Testosterone).

Healthy men, with a life expectancy greater than ten years, and Stage T1 or T2 prostate caner, are good candidates for the da Vinci Robotic Radical Prostatectomy, or total removal of the prostate.  Some men are not healthy enough for surgery and some men prefer alternate treatment options, such as Active Surveillance (Watchful Waiting) External Beam Radiation Therapy, Interstitial Brachytherapy (Seeds) or Hormone Therapy (Androgen Deprivation Therapy). 

There are advantages and disadvantages with each of these approaches and your urologist will discuss each appropriate treatment option with you, based on the Gleason Grade, Stage, your age, general health, life expectancy, and your particular needs.  

Radical Prostatectomy

Radical Prostatectomy involves the total removal of the prostate and seminal vesicles.  Ideal candidates for Radical Prostatectomy are healthy men with a long life expectancy, Stage T1 or T2, and any Gleason score. If the disease is detected at early stages and if men are sexually active, then a Nerve Sparing Radical Prostatectomy can be performed to preserve sexual function. 

For patients with Gleason Score of 7 or higher, or PSA greater than 10, usually the lymph nodes draining the prostate are also removed (Pelvic Lymphadenectomy) to make sure there has been no spread of the cancer to the lymph nodes. The advantage of a total prostatectomy is that the whole gland is removed for pathologic evaluation, and it cannot recur inside the prostate (which is a risk with alternative treatments).

Once the entire prostate is out, the pathologist examines the prostate under the microscope to determine if the cancer is totally confined to the prostate, or has migrated out.  Additional treatment can always be given, such as radiation therapy or hormones, based on the pathologic findings.  Also, follow up is relatively easy after a Radical Prostatectomy.  The only test needed is a PSA blood test, which should be at undetectable levels. 

A Radical Prostatectomy can be performed through an open incision or laparoscopically utilizing the da Vinci Robot. The open radical prostatectomy has been developed and modified through the past 30 years, and has "passed the test of time".  The cancer control rate is well established, because we have almost thirty years of data with current techniques.  An Open Radical Retropubic Prostatectomy involves an incision from the navel to the pubic bone, 2 or 3 nights in the hospital, 10 to 21 days of catheter time, and 6 to eight weeks to heal and resume normal activity.  There is slow recovery of bladder control and slow return of erectile function.  

Da Vinci Robotic Radical Prostatectomy

The da Vinci Robotic Radical Prostatectomy is now the most frequent type of surgery for treatment of prostate cancer performed by the physicians at Pacific Urology. The first Robotic Assisted Laparoscopic Radical Prostatectomy was performed at John Muir Concord Campus in 2002, and (as of 2009) the Pacific Urology physicians have performed in excess of 500 of them. 

The da Vinci Robotic Radical Prostatectomy has essentially replaced the open technique for 99% of our patients.  The robotic surgery attempts to mimic the open procedure, but by a minimally invasive method.  This results in a faster recuperation, shorter catheterization times, more rapid return of good bladder control, more rapid return of normal sexual function, more rapid return to normal activities, etc. 

Long-term data on cancer control rates is lacking, as the technique is so new that we do not yet have ten or fifteen years of data, as we do for the Open Radical Prostatectomy.  However, most urologists who are performing the Robotic Radical Prostatectomy feel confident that the long-term data will eventually show no difference between to open and robotic techniques.  Intermediate endpoints, such as PSA recurrence rates and "Positive Surgical Margins" show no difference between the two techniques.