Some patients are better suited for surgery than others. In general, patients with widespread metastatic disease are also not good candidates for surgery, particularly if their cancer has spread beyond the prostate to areas like the liver, lungs, and bones.
In addition to an in-depth look at the role surgery plays in the treatment of prostate cancer, Dr. Mark Tyson, II, an associate professor of urology at the Mayo Clinic in Phoenix, Arizona, recently offered patients a glimpse into the future with an overview of up and coming procedures like focal therapy at CURE®’s Educated Patient® Prostate Cancer Summit.
Radical prostatectomy, or the complete removal of the prostate gland, surrounding tissues and seminal vesicles, is the main type of surgical treatment for prostate cancer in men whose disease is located solely in the prostate.
As Tyson explained, there are two ways to approach this procedure: robotic, which is how the vast majority of prostatectomies are done today in the United States, or open, which is a more traditional approach that involves a single long incision done by a surgeon.
Patients undergoing robotic surgery generally spend one night in the hospital, but Tyson noted that recovery time is shortening, with about half to three quarters of patients now going home on the same day. But while robotic surgery might be viewed as better by some, in areas where the technology is not yet available, open prostatectomy is an equally effective method.
“I do like to make the point with patients that open (prostatectomy) is just fine,” Tyson said during the presentation. “Aside from a little more pain and maybe another day or two in the hospital, there's really no difference. Long term outcomes like urinary incontinence and erectile dysfunction, and cancer control are about the same.”
When identifying candidates for surgery, Tyson explained, some patients are better suited for surgery than others. “In general, if somebody shows up in a wheelchair, on oxygen, that's a good sign that they're probably not healthy enough for surgery,” said Tyson. “We're also looking to make sure patients are going to live long enough to benefit from surgery.”
In general, patients with widespread metastatic disease are also not good candidates for surgery, particularly if their cancer has spread beyond the prostate to areas like the liver, lungs, and bones. For these individuals, Tyson recommends systemic therapy. However, individuals with limited metastatic disease could potentially be candidates for surgery in addition to other treatments like radiation, although this is a more controversial theory that is currently under investigation by the Southwest Oncology Group.
When undergoing prostatectomy, patients can expect to experience some side effects and complications, Tyson noted, though they are mostly rare. More common complications include incisional pain, nausea as a result of anesthesia, urinary tract burning and constipation.
More rare complications, according to Tyson, include infection of both the wound and the urinary tract, as well as urine leaks. “When you have patients with a catheter in for seven days, (who have) excised the prostate, you obviously injure the urinary tract, and so infections are not totally out of the ordinary,” Tyson said.
And while they are extremely rare, Tyson mentioned that injuries during surgery can occur to areas like the rectum, vasculature, bladder or even the lower extremities. “These are all really, really rare complications, but they're important to remember. In surgery, we take nothing for granted.”
In less than one percent, Tyson explained, lower extremity lymphedema is also a possible complication to consider, especially when pelvic lymph node dissection is involved. In these cases, plastic surgeons are then called in to restore microcirculation of the lymphatic system from the legs to the heart.
While the focus of his presentation was on surgery, Tyson briefly discussed the role of active surveillance in prostate cancer. “Not all cancers need to be treated,” he explained, citing data from a recent study that demonstrated the predicted probability of death to be “precisely the same” whether patients choose surgery, radiation or active surveillance.
“The reason why we often recommend active surveillance for patients with low and very low risk disease is because we cannot look you in the eye and tell you that treatment is going to materially alter your survival outcome.”
The first and most important goal of prostatectomy is curing the cancer. But with this goal in mind, the risk of failure is directly related to the risk of the disease, Tyson explained. In short, the more involvement the disease has with lymph nodes, surrounding tissue, and the higher a patient’s PSA is, the more likely it is they will need additional post-surgical treatment, such as hormone therapy or radiation.
“If a cancer is clinically localized to the prostate, and you have negative margins, and get the whole thing out and connect the bladder back down the penis and then the job is done, the cancer is cured and the patient will live the rest of their life without a problem,” Tyson said. “But that's not always the case.”
When it comes to hormone therapy, Tyson noted, while it is tolerated reasonably well by many men for the first year, some individuals experience side effects like fatigue, loss of libido, and erectile dysfunction, but that these are reversible once therapy is discontinued.
If the primary goal of surgery is to cure the cancer, Tyson added, the secondary goals are to avoid urinary incontinence and preserve erectile function.
While temporary urinary incontinence is common in patients who have undergone a radical prostatectomy, it is often temporary, lasting up to six months. It can be treated with Kegel exercises that can strengthen the pelvic floor muscles, and in more drastic cases where permanent incontinence is a concern, surgical procedures like slings or sphincters can help.
Erectile function is another area where patients may suffer as a result of surgery. The procedure itself is mostly to blame here, Tyson said, as patients lose ejaculatory function because those organs are removed during the surgery. However, this is usually treated with oral medications like Viagra (sildenafil citrate), and in more difficult cases, procedures involving mechanical pumps or surgical prosthetics are also an option.
When looking at where the field of prostate cancer surgery is headed, Tyson explained, focal therapies are likely to be used more and more in the future.
In cases where the cancer is localized to only one region of the prostate, patients often ask why the entire prostate must be removed. Here, focal therapies that are generally more non-invasive and only attack the cancer while leaving the rest of the gland intact, sparing normal tissue and protecting patients from many of the negative side effects of prostatectomy.
At the Mayo Clinic in Arizona where Tyson is located, he and his colleagues are using high intensity frequency ultrasound (HIFU) to perform MRI-assisted focal ablation of just one region of the prostate. This type of non-invasive procedure offers a number of advantages over surgery, including being a same-day treatment involving no incisions, and the side effects seem minimal at this time. Downsides, however, include the need for general anesthesia, a lack of research around the procedure, and the fact that it is not yet covered by many insurers.
“I think emerging surgical technologies like HIFU … will likely dominate the surgical landscape decades from now, but at the present time, it's a new surgical approach and it should be reserved for highly selective and well-informed patients,” Tyson concluded.
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