Prostate cancer is a malignant tumor that forms in the prostate gland of the male reproductive system. It is one of the most common types of cancer diagnosed in American men, over the age of 50. More than 200,000 new cases are diagnosed each year in the United States. As with most cancers, prostate cancer is not contagious. Recently, the overall 5-year survival rates for all stages of prostate cancer have increased from 69% to nearly 100%. This change is a result of early detection and better treatment methods, in particular minimally invasive robotic surgery. The main function of the prostate is to produce semen, which transports sperm during ejaculation. Normally, the prostate is small, about the size and shape of a walnut. The prostate gland is located below the bladder, encircles the urethra, and is in front of the rectum.
Theoretically, all men are at risk for developing prostate cancer. The likelihood of getting this form of cancer increases with age, with 50 years as a good time to get screened. For African American men, or those genetically predisposed to the cancer, screening should begin at age 45, or earlier, depending on the circumstances.
There is no single cause for prostate cancer; therefore, a preventative strategy hasn’t been developed. You are at risk if a close relative (your father or brother) has the disease which means there is a genetic component to prostate cancer. Diet may play a role so we recommend eating food with high nutritional value. Typically, this list includes whole fruits, fresh vegetables, grains, and protein that is low in fat. Obviously, getting regular exercise is important. Yearly screening for prostate cancer is advised, because, if caught early, the chances of ridding it are high.
If all is well—great—but remember to get tested for prostate cancer every year after, as part of a comprehensive physical examination. Typically, my office initially performs a quick and simple manual test called a Digital Rectal Exam (DRE). The DRE allows us to feel the shape and texture of the prostate with our finger. If there is an abnormality, for example, a firm ridge, then the second step is to check the level of Prostate Specific Antigen (PSA) in your body. Blood is drawn and a measurement is made. Normal PSA levels go from 0.0 to 4.0 nanograms/milliliter; however, approximately 25% of men with prostate cancer have a number below 4.0 ng/mL. A high level of PSA in the bloodstream is a warning sign that the prostate might be cancerous. It’s possible that a high reading of PSA is not prostate cancer; it could be a benign enlargement of the prostate called Benign Prostatic Hyperplasia (BPH). In either case, you will need to be evaluated further to see if prostate cancer exists and treatment is necessary. A biopsy of the prostate tissue is usually the next course of action to complete the diagnosis. A needle is used to remove a small amount of tissue from the prostate. The tissue cells are analyzed under a microscope to determine the presence of cancer cells.
If a biopsy shows the cells to be cancerous, then we talk to you about staging and treatment for prostate cancer. Staging assesses the size and location of the tumor. The larger the size and the greater the spreading means a more advanced stage and the need for immediate treatment. Several options are available to you for the treatment of prostate cancer. We carefully go over each of the choices with you and your loved ones. There are different approaches to prostate surgery: open, laparoscopic, and da Vinci Prostatectomy, as well as several non-surgical therapies: radiation, chemical, and hormonal. In most cases, robotic surgery using the da Vinci system eliminates the need for post-operative therapies and is the preferred treatment method.
Surgical techniques have improved in recent years; however, each approach has benefits and risks. Patients need to take an active role with me and my medical team to determine which surgery is best for them. As always, the goal of any surgery is to remove all of the cancer and to prevent its reoccurrence.
There are very few warning signs for the onset of prostate cancer. The gold standards are the Digital Rectal Exam and the Prostate-Specific Antigen test. If caught early, the chances of a cure are high. I define a cure as eliminating and managing cancer cells for the life of the patient.
Radical prostatectomy is the surgical removal of the entire prostate gland. This is usually performed to remove early-stage prostate cancer that is contained in the prostate. Before this surgery, I may suggest hormonal therapy to reduce the size of the tumor so it can be removed more easily. Surgery can be performed using traditional open surgery or by minimally invasive laparoscopic surgery. The incision for open surgery runs from the navel to the pubic bone. This large opening allows the surgeon to see the entire site at once and to reach into the prostate with his hands and to remove the gland. This one-time procedure may cure prostate cancer in the early stages of development. The risks of open surgery are bleeding, nerve damage, a longer healing time, and possible infection along the incision. Impotence or Erectile Dysfunction (ED) is a unfortunate risk associated with radical prostatectomy. The nerves that control the blood supply to the penis lie along each side of the prostate may be cut or injured in the surgery.
The incidence of postoperative erectile dysfunction may be as low as 25% in men less than 60 years of age, or as high as 62% in men over 70. Many factors can affect ED after surgery, such as your age, the stage of your tumor, the extent of preservation of the nerves, and your normal erectile function before surgery. The good news is that it’s possible for ED to resolve itself a year or two after surgery. Also, after surgery, you have no ejaculate because the sources of the fluid are either removed or tied off during a radical prostatectomy. Nevertheless, you are still able to have sexual intercourse. (Click here to read more about sex after prostate surgery)
Urinary incontinence is another risk of open or laparoscopic radical prostatectomy. The inability to hold urine voluntarily may vary depending on the individual, from a small percentage to more than 50% in some cases. Needless to say, the thought of being 60 years old, and wearing diapers is not something to look forward to. There are options available for the treatment of urinary incontinence after radical prostatectomy. They include Kegel exercises, a penile clamp, collagen injection, an artificial sphincter, and a male urethral sling. You should report to me any situations or activities that trigger the uncontrolled loss of urine.
Laparoscopic radical prostatectomy is a relatively new surgical procedure with many benefits to the patient. This surgery uses several small abdominal incisions as opposed to the longer midline cut in open surgery. A small telescoping instrument is inserted in one of the openings and the fine surgical instruments are fed into another opening. The surgeon’s hands remain outside of the patient and are controlled with extensions coming from the instruments. The obvious advantages are less pain and quicker recovery time. The scars are hardly noticeable and the risk of infection is greatly reduced. The disadvantage of this procedure is, with the small opening, the surgeon may have difficulty viewing the gland and removing it in its entirety.
da Vinci Robotic Prostatectomy is the latest in minimally invasive surgery, offering the most recent advances in robotics and computer technology for a patient with prostate cancer. We prefer this method over all others because it has the most important advantages for you, the patient. Here are some of the benefits:
This system allows surgeons to be even more precise with ridding cancer from the prostrate.
Radiation therapy uses high-energy waves to kill cancer cells. This therapy is suggested in place of surgery if the cancer is localized or if it has spread to the surrounding tissue. Radiation can be as effective as surgery in stopping early-stage prostate cancer. But, the chances of post operative incontinence and impotence are higher. Radiation can also reduce the size of the tumor and alleviate symptoms in the advanced stages of this disease.
Watchful waiting is an option whereby nothing is done to treat prostate cancer at the time of diagnosis. Our team of medical experts monitors the cancer to see if it progresses. Typically, the PSA value is assessed at regular intervals to see whether it is increasing and at what rate. This is called the PSA velocity. Until a certain threshold is reached with PSA value or the onset of bone pain occurs, any treatment is on hold. Watchful waiting is ideally suited for individuals with other life-threatening medical conditions and older patients whose bodies would not be able to handle the trauma of surgery or vigorous therapies. Obviously, if the PSA velocity increases rapidly, then a course of treatment needs to be put in place as soon as possible, regardless of age or health.
Brachytherapy is a treatment for prostate cancer using “seeds”. Under anesthesia, we insert small radioactive rods directly into the tumor. The radioactive material emits a continuous dose of radiation into the tumor for several days until it has gone through many half-lives and is on its way to becoming a stable element. Radioactive treatments are highly effective for small scale tumors and in most cases leave the patient with bladder control and virility.
This treatment relies on sound waves to heat and to destroy malignant cells in the prostrate. The waves are focused to a precise location in the prostate so there is minimal risk to the surrounding non-cancerous tissue. Because of the exact nature of this targeting procedure, there is little risk of impotence or incontinence. HIFU is only advisable if the tumor is small and confined to the prostate.