|Through a vertical incision in the lower abdomen or behind the scrotum, the entire prostate and seminal vesicles are removed. When the cancer is confined within the tissues removed at surgery, radical prostatectomy can cure localized prostate cancer. The PSA level in the blood should fall to undetectable levels (near zero) shortly after radical prostatectomy, since the entire prostate has been removed. PSA then becomes an excellent test to detect even small amounts of cancer left behind after surgery. Either of two approaches can be used for surgical removal of lymph nodes:
1) In surgical lymphadenectomy, pelvic lymph nodes are removed through an incision in the lower part of the abdomen. This is usually done at the time of surgery to remove the prostate.
2) Alternatively, a laparoscope (a miniature telescope connected to a TV monitor) can be used by a doctor to look at and remove the lymph nodes through four small incisions in the lower abdomen. Removing lymph nodes using a laparoscope usually requires a much shorter stay in the hospital than does open surgical lymphadenectomy. But you also may require a second surgical procedure if the nodes are negative. This is usually done only when there is a high risk that the tumor has spread to the lymph nodes.
There are risks and side effects associated with surgery. About 1 of every 200 to 400 men die from complications such as heart attacks or blood clots related to the operation. Patients are usually in the hospital for two to four days after a radical prostatectomy and wear a Foley catheter (a tube through the urethra and into the bladder to drain urine) for two weeks afterward. Most patients have at least some degree of incontinence (leakage of urine from the penis) for up to two or three months after surgery. The great majority of men eventually regain good urinary control after surgery.
Impotence is sometimes a side effect of radical prostatectomy. The nerves that help cause erections lie very close to the prostate. These nerves can sometimes be spared during surgery, depending upon the location of the cancer. If the nerves can be spared, recovery of erections is best in younger patients who had no difficulty achieving erections before surgery. For men who do have problems with erections after surgery, there are a number of ways to help restore erections and the ability to have sexual intercourse.
Radiation therapy is another effective treatment for localized prostate cancer. The radiation can be administered externally or internally with radioactive seed implants (brachytherapy) or with the two in combination. External beam radiation therapy is usually delivered on an outpatient basis for seven to nine weeks. This treatment utilizes a machine that generates high energy X-rays. There appears to be no major difference between the two treatments in the percentage of men still alive ten years after treatment. Whether there are differences in results after that time is uncertain.
Interstitial irradiation (Brachytherapy) involves the permanent placement of radioactive “seeds” inside the prostate. Different types of radiation seeds are used, and there is not agreement on which type is best. Interstitial irradiation for prostate cancer has been used for more than 20 years. Previously, the radiation sources were implanted into the prostate through a lower abdominal incision, but the results were not as good as those obtained with other treatment techniques. Today radiation seeds are inserted using needles through the skin.
There are side effects associated with radiation therapy. Some degree of discomfort with urination, frequent and urgent urination, and diarrhea are common during radiation therapy. Side effects are especially likely during the second half of the treatment course. In most patients, these symptoms usually go away within a few months. Men treated with radiation therapy for prostate cancer may eventually become impotent. As is the case with patients treated by radical prostatectomy, younger and more sexually active men are more likely to remain potent.
Hormonal therapy may be useful because prostate cancer cells depend, at least partially, upon male hormones for growth. Testosterone is the most important of these hormones.
Treatment that deprives the cancer cells of testosterone can slow the growth of prostate cancer. Hormonal therapy can consist of either surgical removal of the testes (orchiectomy) or monthly injections of a drug called luteinizing hormone releasing hormone (LHRH) analog, which blocks the production of testosterone by the testes. Sometimes an oral drug called an anti-androgen is used in combination with surgical castration or an LHRH analog. Anti-androgens block the effects of any remaining male hormone produced elsewhere in the body, particularly male hormones produced by the adrenal glands.
Hormonal therapy is not considered a curative form of treatment, but rather, a way to temporarily slow the growth of prostate cancer cells. Hormone therapy usually is not used unless there are signs that the cancer has spread beyond the prostate. Hormone therapy causes hot flashes in about half of men and usually produces impotence and loss of libido (sexual desire). Hormonal therapy also may be used in conjunction with radiation therapy.