Role of Surgery in Prostate Cancer

Nearly all patients with prostate cancer will have some kind of surgery. Surgery may be used to perform a biopsy in order to obtain a specimen for determining an accurate diagnosis, provide local treatment of the cancer, and obtain other information to help determine whether additional treatment is necessary. Surgical techniques continue to improve, and surgeries are now less invasive and often performed on an outpatient basis.

A surgeon who specializes in treatment of disorders of the male genital tract, including prostate cancer, is known as a urologist. A urologist plays an important role in the diagnosis and treatment of prostate cancer.  Individuals with early-stage prostate cancer have several treatment options including surgery, which may be used alone or in combination with other therapies.

Prostate Biopsy

If laboratory tests or physical examination results suggest that prostate cancer may be present, you will need to have a prostate biopsy. A biopsy is the only way to know for sure whether an individual has cancer. During a biopsy, a needle is used to remove several small pieces of prostate tissue through the rectum. These pieces of prostate tissue are examined under the microscope to determine whether cancer cells are present. If cancer cells are present, an assessment of how aggressive or abnormal the cancer appears is performed. 

Radical Prostatectomy and Lymph Node Dissection

Surgery is a common treatment of Stage I, II, and sometimes Stage III cancer of the prostate. The operation used to remove the prostate cancer is called a radical prostatectomy. During a radical prostatectomy, the entire prostate gland with the cancer and a rim of normal tissue around it is removed. With a radical prostatectomy, a portion of the urethra, or tube that empties the bladder through the penis, is removed and the cut ends are re-attached. To help with the healing of the urethra, the patient will go home with a catheter into the bladder for a couple of weeks.

Radical prostatectomy is most effective if the staging evaluation shows that the cancer has not spread outside the prostate. This is because surgery cannot remove cancer that has already spread away from the prostate gland. Some patients will have small amounts of cancer that have spread outside the prostate into the pelvic lymph nodes or other distant locations. In general, the higher the stage, the more likely the cancer will have spread away from the prostate.

Before a prostatectomy is performed, the urologist may perform surgery to take out lymph nodes to see if they contain cancer. This is called a pelvic lymph node dissection. If the lymph nodes contain cancer, usually the urologist will not proceed with a radical prostatectomy. Another form of treatment, usually hormone therapy and/or radiation therapy, is generally recommended. A pelvic lymph node dissection is most useful when it prevents an unnecessary prostatectomy from being performed. It is typically recommended for patients with clinical Stage III cancer or those with higher risk Stage I or II cancer who are considering surgical treatment.

A surgeon can perform a radical prostatectomy using different techniques including the following. Make sure you discuss the advantages and disadvantages of each technique, as well as your preferences, to determine which approach is best for you.1, 2, 3, 4

Open Radical Prostatectomy

Radical prostatectomy can be performed through a low abdominal incision (retropubic) or through the perineum, the area between the scrotum and the anus (perineal prostatectomy). With the perineal approach, one cannot simultaneously remove the lymph nodes.

Minimally Invasive Surgery

Several recent studies suggest that minimally-invasive radical prostatectomy (MIRP) may be produce better outcomes than traditional open surgery—resulting in fewer post-surgical complications, fewer blood transfusions, and shorter hospital stays. Men with prostate cancer should speak with their physician to safely evaluate the risks and benefits of the different surgical procedures.2, 3

Robotic-assisted Radical Prostatectomy (daVinci):

During Robot-assisted surgery the surgeon sits at a console near the operating table and performs the surgery by controlling robotic arms that hold the surgical instruments and a camera.  Several small incisions are made in the lower abdomen. The instruments and camera are inserted into the patient’s body through these small incisions. The magnified, three-dimensional view provided by the camera, in combination with very small surgical instruments and highly maneuverable robotic arms, allow trained surgeons to work with precision. The ability to operate with increased precision can provide important benefits in urologic surgery. Organs such as the prostate are in a tightly confined area, and are close to nerves that affect urinary and sexual function. Avoiding damage to neighboring organs and structures is an important goal of surgery.2, 3, 4

Cryosurgery

Cryosurgery is a technique that kills cancer cells by freezing them with sub-zero temperatures. During this procedure, hollow steel probes, guided by ultrasound, are placed inside and surrounding the cancer. Liquid nitrogen is then circulated through the probes, freezing the cancer cells and creating a ball of ice that surrounds the cancer. Once an adequate ice ball is formed, heated nitrogen is circulated through the probes. This process is then repeated. A heated probe is placed near the urethra throughout the freezing process so that the urethra is protected during the entire procedure. It is believed that cryosurgery creates cancer-killing effects through three distinct processes. First, ice crystals formed within cells are known to be lethal to nearly all cells. Second, when the ice forms around the cell, it draws water out of the cell, which collapses many of the walls or membranes within the cell. Third, when the ice surrounding the cells melts through the heating process, the water rushes back into the shrunken cell and causes it to burst.

This procedure has some compelling advantages, such as out-patient treatment, less pain, less blood loss, and faster recovery times. Since healthy tissue is preserved in the cancer-involved organ, the procedure can be repeated if the cancer returns.

The most serious complication associated with cryosurgery is when the rectal tissue is mistakenly frozen along with the prostate cancer. This complication has been reported in less than 1% of patients in several large studies. However, it is more likely to occur with a less experienced surgeon. The repair of this complication may require a temporary colostomy and additional surgery to close the hole between the rectum and the urethra. In one clinical trial, approximately 50% of the patients who had undergone cryosurgery were still impotent one year following surgery. The patients who may be the most appropriate candidates include older men over 70 years of age; patients who might have medical problems that would increase their risks of undergoing major surgery; or patients who have failed radiation therapy and have no other options.5

Orchiectomy

Prostate cancer cells need male hormones (especially testosterone) in order to grow. Hormone therapy decreases the level of male hormones in the blood, which causes prostate cancer cells to die. Because hormone therapy can affect prostate cancer cells everywhere in the body, this treatment is used when cancer cells have escaped the prostate to other areas of the body. Prostate cancer that has spread to other areas of the body usually can be controlled with hormone therapy for a period of time, often several years. Eventually, however, most prostate cancers are able to grow despite the hormone therapy.

Bilateral orchiectomy (castration) is an operation to remove the testicles. By removing the testicles, the main source of male hormones is removed and hormone levels decrease. Orchiectomy is a common treatment for patients with metastatic (Stage IV) prostate cancer who will likely require hormone therapy for life. Patients may experience a benefit in symptoms in a matter of days following surgery.

Orchiectomy can cause side effects such as loss of sexual desire, impotence, hot flashes, and weight gain. The operation itself is relatively safe and not associated with severe complications. Because it is a one-time procedure, orchiectomy is a convenient and less costly method of hormone therapy.4

Transurethral Resection of the Prostate (TURP)

Transurethral resection of the prostate (TURP) is a type of prostate surgery done to relieve moderate to severe urinary symptoms caused by an enlarged prostate, a condition known as benign prostatic hyperplasia (BPH). In this procedure, the cancer is cut out of the prostate gland using a small tool that can be inserted into the prostate through the urethra.

During TURP, a combined visual and surgical instrument (resectoscope) is inserted through the tip of your penis and into the tube that carries urine from your bladder (urethra). The urethra is surrounded by the prostate. Using the resectoscope, your doctor trims away excess prostate tissue that’s blocking urine flow and increases the size of the channel that allows you to empty your bladder.

The following sections may answer additional questions that you have about undergoing surgery.

References:

1 Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. New England Journal of Medicine. 2014; 370:932-942.

2 Kowalczyk KJ, Levy JM, Caplan CF, et al. Temporal national trends of minimally invasive and retropubic radical prostatectomy outcomes from 2003 to 2007: Results from the 100% Medicare Sample. European Urology. 2012; 61: 803-809.

3 Lowrance WT, Elkin EB, Jacks LM, et al. Comparative effectiveness of prostate cancer surgical treatments: A population based analysis of postoperative outcomes. Journal of Urology. 2010 Apr;183(4):1366-72

4 http://www.auanet.org/education/guidelines/prostate-cancer.cfm

5 Prepelica K, Okeke Z, Murphy A, et al. Cryosurgical ablation of the prostate: High-risk patient outcomes. Cancer. 2005; 103: 1625-1630.

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