A patient with prostate cancer consults a urologist to start having a treatment. The urologist discusses the treatment of the patient in an uro-oncology council composed of a urologist, a radiologist, a medical oncologist, and a nuclear medicine specialist. The decision taken by the uro-oncology council is recommended to the patient.
For detailed information about prostate cancer, you can read our related article. >> Prostate Cancer
Treatment Period
When making decisions on the treatment of a patient with prostate cancer, some parameters are taken into account.
- How is the general health condition of the patient?
- How aggressive is prostate cancer?
- Is prostate cancer is confined to the prostate? Or has it metastasized?
- Are there metastases to distant regions?
A- If the cancer is confined to the prostate
Prostate cancers at this stage are called “localized prostate cancer". One of the following treatment options is selected based on cancer’s aggressiveness, location in the prostate, age of the patient, and compliance with the treatment.
Active surveillance: It can be recommended to young and sexually active patients. The prostate cancer of the patient should be of the type called Gleason score 3+3=6, and his cancer density should be below.
HIFU: It is a treatment procedure based on focusing intensified ultrasound waves on cancerous areas in the prostate. It is called the ‘focal treatment of prostate cancer’. The underlying logic is to treat only the cancerous areas inside the prostate, instead of treating the entire prostate. On the other hand, prostate cancer is multifocal cancer and we can identify 50-70% of the cancerous areas in the prostate, by using the actual imaging techniques.
Surgery: The surgical procedure involving removal of the cancerous prostate is called "radical prostatectomy". It can be performed with open, laparoscopic, and robotic surgery. Robotic surgery is superior to other procedures, in terms of bleeding and postoperative urinary incontinence.
For detailed information about radical prostatectomy, check out our related text. >> Robotic Surgery for Prostate Cancer
Radiotherapy: It is the procedure of burning the prostate from outside the body using radioactive rays. Radiotherapy can be performed with lower side-effect rates using conformal radiotherapy and IMRT techniques. Results of 10-year cancer treatment and results of surgical intervention are similar. If the patient lives longer, the success of surgical treatment in cancer control shows itself.
Side effects occur later in patients who have received radiotherapy, compared to those who have had surgery. When prostate cancer patients who underwent surgery were compared with prostate cancer patients who received radiotherapy, after 4 years; no difference was observed in terms of urinary incontinence and erectile dysfunction. Side effects increase with each passing day in people receiving radiotherapy.
B- If cancer has expanded beyond the prostate, but has not metastasized to distant regions
Prostate cancers at this stage are called “locally advanced prostate cancer". Two types of approaches are used for patients at this stage. Surgical treatment and then radiotherapy is preferred for younger patients, while high-dose radiotherapy after hormone treatment is performed for elderly patients (or patients with a life expectancy of <10 years).
Hormone treatment + Radiotherapy: The patient is given hormone therapy for a period of 2-3 months. This treatment makes prostate cancer tissues shrink and more sensitive to radiotherapy. Afterward, 78 Gy of Radiotherapy is given to the patient. During hormone treatment, the patient has no sexual drive and impotence develops. Hormone therapy continues for at least 2 years.
Surgery + Radiotherapy: First, prostate cancer surgery is performed on the patient. Since prostate cancer has expanded beyond the prostate, neuroprotective surgery is not performed on these patients. The lymph nodes around the prostate gland should be removed in such a way that the removed part is as wide as possible. Impotence develops in patients after surgery. If a postoperative increase is found in PSA levels or cancer tissue remains, additional radiotherapy is performed after surgery.
C- If cancer has metastasized to distant regions
Prostate cancer at this stage is called “metastatic prostate cancer”. In the case of metastatic prostate cancer, the aim is to stop the production of male hormone (testosterone). This process is called a colostomy. To prevent the secretion of testosterone, injections can be given to patients, the effect of which lasts 3-6 months, or the testicles can be removed.
In recent years, the term ‘oligometastatic prostate cancer’ has been coined. A new approach has become popular, which recommends surgical removal of the prostate and radiotherapy of the metastasized areas in the bone, in cases where the bone has no more than 3 points metastasized by cancer in the prostate,
It is recommended to initiate chemotherapy and hormone therapy together in prostate cancer patients with very expansive metastases if their general health condition is suitable.
- Surgery + Radiotherapy (Oligometastatic disease)
- Surgery (removal of the testicles)
- Hormone treatment (Medical castration treatment)
- Hormone treatment+ Chemotherapy
New Treatments in Metastatic Prostate Cancer
1- New Hormone Treatments
Thanks to the R&D studies of the pharmaceutical industry, many new treatment procedures that have been shown to prolong life expectancy in prostate cancer have appeared in recent years. These treatments were performed when patients have initially received all treatments and there are no other treatment options started to be among the preliminary treatment procedures for metastatic prostate cancer, after the proof of its effects on prolonging life expectancy.
Abiraterone: In recent years, in the western world, it has been routinely started with hormone treatment to treat metastatic prostate cancer. Patients who start using abiraterone should also use steroid hormones.
Enzalutamide: It is a drug recommended to be used when resistance to first-line hormone therapy develops, which prevents the male hormones from affecting the tissues.
2- Nuclear Medicine Treatments
This kind of treatment is radioactive atom treatment. When PSMA PET is performed on patients, 70-80% of areas with prostate cancer are viewed. In these treatments, atoms bind to the PSMA molecule that destroys the points it reaches. When prostate cancer tissues bind to the PSMA, radioactive atoms bind to the prostate cancer tissues, and consequently, tumor tissues are treated.
Lutetium Treatment: It is a treatment performed with lutetium atoms. Currently, this treatment procedure is performed in many nuclear medicine centers. As a result of this treatment, kidney functions are affected by 1/30 every year.
Actinium Treatment: It is a much more effective treatment than lutetium treatment. However, it is performed in a limited number of medical centers, and its cost is not covered by insurance institutions. It is performed in 3 sessions, and each session costs about 7,500 dollars. As a last resort treatment, it has prolonged the life of many patients.
Prostate Cancer Surgery
Prostate cancer surgery is the most common surgical procedure in the treatment of prostate cancer.
The physician removes the prostate and the glands around it called vesicula seminalis, and connects the sperm channels coming from the testicles. In some cases, the physician may deem it appropriate to perform the surgery with a neuroprotective technique. In this type of surgery, the nerves that provide erection (the condition in which the male genitalia becomes suitable for sexual intercourse) can be preserved.
The main type of surgical procedure for prostate cancer is radical prostatectomy. In this procedure, the surgeon removes the entire prostate gland and some tissues surrounding it, including the seminal vesicles. So, how are these types of prostate surgeries performed?
Prostate tissue is an organ located in the deepest part of the body, surrounded by muscles ensuring urinary continence attached to the prostate, as well as and blood vessels and nerves ensuring erection. In addition, the prostate is covered with a vascular bundle.
Therefore, there prostate cancer surgery carries the following risks.
- The risk of bleeding
- The risk of urinary incontinence after surgery
- The risk of loss of erection after surgery
- The risk of stenosis at points where the urinary canals are reconnected
In the treatment of prostate cancer, two different surgical approaches can be used to remove the prostate.
- From the abdomen (Retropubic radical prostatectomy)
- From the perineal region, i.e., from the region between the testicles and the anus (Perineal radical prostatectomy)
In terms of results, neither technique is superior to the other. However, an effective lymph node dissection cannot be made in operations that involve the use of only the perineal route. Therefore, it is more appropriate to access the intended site through the abdomen in the treatment of aggressive prostate cancers that require extensive lymph node dissection.
The perineal approach is not appropriate for prostates larger than 100 grams.
There are three different surgical techniques used to remove the prostate.
- Radical prostatectomy with open surgery: It is a surgery that involves removing the prostate and surrounding tissues by making an incision of about 15-20 cm on the body. This surgical procedure can cause serious bleeding and complications that can threaten the life of the patient.
- Laparoscopic radical prostatectomy: 5 ports (in the form of the tube) with a diameter of 5 to 10 mm are placed in the abdomen. After the abdomen is inflated, the prostate and lymph nodes are removed using a camera and straight instruments. The need for using straight, non-curving instruments during the surgery makes it very difficult to perform the procedure optimally.
- Robotic radical prostatectomy: After 5 ports (in the form of the tube) are placed in the abdomen, and the abdomen is then inflated. The robotic system is connected to the ports placed in the abdomen. The surgeon performs the surgery using the robotic system.
Pelvic lymphadenectomy: It is not routinely performed during radical prostatectomy. The probability of metastasis to lymph nodes in aggressive prostate cancers is calculated using Briganti nomograms. In patients at high-risk, lymph nodes in the pelvic region are removed and analyzes to determine the metastatic condition of the cancer.
Comparison of open surgery, laparoscopic surgery and robotic surgery in prostate cancer
|
|
Open Surgery |
Laparoscopic Surgery |
Robotic Surgery |
|
Cancer clearance rate |
80-85% |
85% |
85-90% |
|
Urinary incontinence (permanent) |
15% |
15% |
7% |
|
Urinary incontinence in the first week after catheter |
90% |
80% |
65% |
|
Urinary incontinence in the first month after catheter |
50% |
40% |
20% |
|
Maintaining the erection |
40-50% |
35-40% |
65-75% |
|
Bleeding during surgery |
800 - 1000 cc |
200 cc |
50 - 100 cc |
|
Postoperative pain. |
High |
Low-Medium |
Low |
|
Hospital stay |
4 days |
2-3 days |
1-2 days |
|
Catheter removal time |
14 days |
10 days |
6 days |
|
Return to work time |
1 month |
20 days |
15 days |
|
Anastomotic stenosis |
3-4% |
1-2% |
0% |
Open Prostate Surgery in Cancer Treatment
Open prostate surgery is a traditional “open” surgery procedure. The surgeon accesses the prostate gland through a standard surgical incision. For most patients, the length of an incision is 15 to 20 cm.
The duration of radical prostatectomy with open surgery is 2 to 3 hours on average. However, this period may be shorter or longer depending on the experience of the surgeon. In an open prostatectomy, the length of the hospitalization period is 4-5 days. About 85 percent of patients regain their urinary continence and less than half maintain their sexual potency.
With the proven advantages of robotic surgery, the place of open surgery in the treatment of prostate cancer has gradually decreased. 99% of prostate cancer surgeries in the USA and other developed countries are performed with robotic systems.
How is Its Postoperative Healing Process?
Recovery after surgery differs in each case, depending on the type of surgical technique used.
In the first few postoperative days, the patient may need painkillers due to pain. It takes time for the urethra to heal after surgery. A urinary catheter is attached for enabling urine to pass from the bladder to the urethra. The urinary catheter remains attached to the patient for a period of 5 to 21 days.
Since the best repair between the urethra and bladder is made with robotic surgery after the removal of the prostate, the catheter is removed after 6 days on average from patients treated with robotic surgery. The catheter is removed 14 days after an open surgery on average.
In the first three postoperative months, urinary incontinence may occur, but bladder control is regained later.
Some patients may encounter permanent impotence, which may require some medications for treatment. Since the prostate is removed, semen production is not possible and therefore the patient cannot have children.
Patients may ask before surgery which surgical procedure would be suitable for them and what would be the side effects of those procedures.
If there is a large tumor quite close to the nerves, the neuroprotective technique cannot be used. Otherwise, cancerous prostate tissues are left behind. Each surgical procedure has its own benefits and risks.
