Prostate Cancer (cont.)
Kevin C. Zorn, MD, FRCSC, FACS
Gagan Gautam, MD, MCh
William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Dennis Lee, MD
Dennis Lee, MD
Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
In this Article
What are the treatment options for prostate cancer?
Deciding on treatment can be difficult, partly because the options for treatment today are far better than they were 10 years ago but also because not enough reliable data are available on which to base the decisions. Accordingly, scientifically controlled, long-term studies are still needed to compare the benefits and risks of the various treatments.
To decide on treatment for an individual patient, doctors categorize prostate cancers as organ-confined (localized to the gland), locally advanced (a large prostate tumor or one that has spread only locally), or metastatic (spread distantly or widely). The treatment options for organ-confined prostate cancer or locally advanced prostate cancer usually include surgery, radiation therapy, hormonal therapy, cryotherapy, combinations of some of these treatments, and watchful waiting. A cure for metastatic prostate cancer is, unfortunately, unattainable at the present time. The treatments for metastatic prostate cancer, which include hormonal therapy and chemotherapy, therefore, are considered palliative. By definition, the aims of palliative treatments are, at best, to slow the growth of the tumor and relieve the symptoms of the patient.
What about prostate cancer surgery?
The surgical treatment for prostate cancer is commonly referred to as a radical prostatectomy, which is the removal of the entire prostate gland. The entire prostate, seminal vesicles, and ampulla of the vas deferens are removed, and the bladder is connected to the membranous urethra to allow free urination.
The radical prostatectomy is the most common treatment for organ confined or localized prostate cancer in the United States. This operation is currently performed in about 36% of patients with organ-confined (localized) prostate cancer. The American Cancer Society estimates a 90% cure rate nationwide when the disease is confined to the prostate and the entire gland is removed. The potential complications of a radical prostatectomy include the risks of anesthesia, local bleeding, impotence (loss of sexual function) in 30%-70% of patients, and incontinence (loss of control of urination) in 3%-10% of patients.
Great strides have been made in lowering the frequency of the complications of radical prostatectomy. These advances have been accomplished largely through improved anesthesia and surgical techniques. The improved surgical techniques, in turn, stem from a better understanding of the key anatomy and physiology of sexual potency and urinary continence. Specifically, the recent introduction of nerve-sparing techniques for the prostatectomy has helped to reduce the frequency of impotence and incontinence. Of men who undergo these newer techniques, 98% are continent, and 60% are able to have an erection.
Radical prostatectomy can be performed by open surgery, laparoscopic surgery, or by robotic surgery (robotic assisted radical prostatectomy). Currently, almost 70% of radical prostatectomy surgeries in the U.S. are performed using the of the Da Vinci robotic system. For robot-assisted surgery, five small incisions are made in the abdomen through which the surgeon inserts tube-like instruments, including a small camera. This creates a magnified three-dimensional view of the surgical area. The instruments are attached to a mechanical device, and the surgeon sits at a console and guides the instruments through a viewing device to perform the surgery. The instrument tips can be moved in a variety of ways under the control of the surgeon to achieve greater precision in surgery. So far, studies show that traditional open prostatectomy and robotic prostatectomy have had similar outcomes related to cancer-free survival rates, urinary continence, and sexual function. However, in terms of blood loss during surgery and pain and recovery after the procedure, robotic surgery has been shown to have a significant advantage.
If post-treatment impotence does occur, it can be treated by sildenafil (Viagra) tablets, injections of such medications as alprostadil (Caverject) into the penis, various devices to pump up or stiffen the penis, or a penile prosthesis (an artificial penis). Incontinence after treatment often improves with time, special exercises, and medications to improve the control of urination. Occasionally, however, incontinence requires implanting an artificial sphincter around the urethra. The artificial sphincter is made up of muscle or other material and is designed to control the flow of urine through the urethra.
Transurethral resection of the prostate (TURP) involves the removal of a part of the prostate by an instrument inserted through the urethra. It is used as an alternative to prostatectomy in patients with extensive disease or those who are not fit enough to undergo radical prostatectomy to remove tissue that is blocking urine flow. This is often referred to as a channel TURP.
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