Surgery is a mainstay in the treatment of prostate cancer. Men diagnosed with localized disease (no evidence of distant cancer spread) are stratified into risk categories: low, intermediate or high. Although men from each of these groups are candidates for surgery, various factors may exclude them. For example, heart disease or other serious medical conditions may make general anesthetic risky, in which case a treatment such as radiation (no anesthetic) is more appropriate. Surgery isn’t an option for men with metastatic disease (cancer outside the prostate).
Various methods are currently available and the pursuit continues for new and improved approaches. Nonetheless, prostate cancer surgery remains a serious, life-altering experience. Being proactive, having a good support network and staying positive all help.
How do surgical choices compare?
Standard options in Canada include open radical retropublic prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALRP). While there’s controversy around which is the ideal approach, they all have similar goals: to achieve negative margins and preserve urinary continence and sexual function. To clarify, a positive margin suggests that there’s still cancer in the pelvis (where the prostate was) and further treatment in the form of radiation may be required. ORP has the longest track record and, in Canada, remains the most commonly used method. It entails dissection and removal of the prostate, along with the seminal vesicles and part of the vas deferens, through a midline incision several centimetres long. LRP and RALRP are similar in that they both involve introducing carbon dioxide (CO2) into the abdomen to create a working space, then inserting plastic cylinders (ports) that allow placement of a camera and instruments to perform the surgery, which is visualized on a monitor.
Comparisons of the techniques have been published, but there has never been a randomized trial (patients arbitrarily assigned to one surgery or the other) to determine which one is best.
- RALRP and LRP are associated with less blood loss and lower transfusions rates (1–5% for LRP and RALRP versus 5–25% for ORP). This is likely due to the enhanced view allowing identification and management of blood vessels as well as the CO2 pressure in the abdomen that keeps small veins from bleeding.
- The rate of bladder neck stricture (narrowing of tissue where the bladder and urethra are sewn back together) is consistently reduced with LRP and RALRP: 1–3% compared to 8–10% with ORP.
- Laparoscopic procedures are generally associated with less postoperative pain and quicker recovery. These differences are less pronounced in prostate surgery, but given the lower transfusion rates with LRP/RALRP, it makes sense that people feel better and more energetic. (Patient-related factors also play into recovery. A positive, motivated patient tends to “bounce back” more quickly. Also, expectations have been shown to be higher in men who choose RALRP, and this can lead to greater disappointment if urinary and sexual functions don’t return to preoperative states.)
- In terms of surgical margins, continence and sexual function, there are varying reports favouring one technique over the other. Many biases exist, and in the absence of a randomized trial it’s difficult to know which one is truly superior.
It’s generally accepted that surgeon experience (studied in volume-outcome analyses and evaluations of learning curves) plays a critical role in outcome for all of the techniques. When a new technique is developed, a well-described curve represents its uptake (use) as well as the relationship of increased experience to improved outcomes. With greater surgeon experience, most patients who are candidates for ORP are also eligible for LRP or RALRP.
RALRP and LRP are more costly and currently, robotic surgery is only available at several centres across Canada in BC, Alberta, Ontario and Québec. In contrast, RALRP has overtaken ORP in the US as the most common surgery for prostate cancer.
There’s a lot of debate regarding PSA screening, overdetection and overtreatment of prostate cancer. Many men with low-risk prostate cancer are more likely to die of other causes, and an intervention that diminishes quality of life will reduce the benefits of screening. Although active surveillance is an option, some men wish to be treated. But conventional treatments are associated with side effects, in particular a risk of urinary incontinence and sexual dysfunction. High-intensity focused ultrasound (HIFU) and cryotherapy are ablative (based on tissue destruction, not removal) strategies that can be performed under spinal anesthetic as outpatient procedures. They rely on energy (heat for HIFU and freezing for cryotherapy) delivered via probes to destroy cancerous tissue under ultrasound guidance. The hope is that targeted tissue ablation may lead to better preservation of urinary and sexual function, with excellent cancer control. Although there have been some excellent results, a review of existing literature suggests a great variability in outcomes, with some centres reporting very poor results. Thus, the role of HIFU or cryotherapy for first-line treatment of prostate cancer remains controversial.
A newer management concept is focal therapy, often referred to as the “male lumpectomy.” Although prostate cancer is multifocal, it’s believed that there’s usually one dominant nodule that is significant and the source of cancer spread if and when that occurs. Therefore, some investigators began to offer therapies that would remove this dominant focus. Several energy forms have been tested, including laser, cryotherapy, HIFU and brachytherapy, but the concept is the same: visually directed ablation of part of the prostate. This approach is highly dependent on imaging, usually involving magnetic resonance imaging (MRI). By removing only one area of the prostate, the likelihood of urinary or sexual dysfunction is very low.
We anxiously await mature data from studies of these exciting new technologies.
How to choose among a vast array of options?
In most cases, men will be diagnosed with low- or intermediate-risk prostate cancer and will have time to do research and speak to others about the different options. Reading up on them first will make your encounter with a healthcare professional more fruitful and allow you to ask questions relevant to your situation. Reputable websites from leading cancer centres and reading materials provided by clinics and support groups are great places to start. Newly diagnosed patients should do their due diligence and ask for expected outcomes based on the surgeon’s own track record and not those from the published literature or another institution. This is important when choosing a physician to perform your treatment.
Finally, it’s important to have realistic expectations; whatever the outcome, radical prostatectomy is life changing. Cancer control, urinary control and sexual function are discussed frequently, but mood, energy level and other aspects of life may also be affected. Thankfully, most patients have a good support network in place and for those who don’t, support groups exist in most communities. ov
Dr. Tony Finelli is a Urologic Oncologist at Princess Margaret Hospital, University Health Network (UHN), and Associate Professor of Surgery at the University of Toronto.
Leah Jamnicky, RN, is a Urology Clinical Coordinator with the UHN in Toronto, and co-author of The Canadian Guide to Prostate Cancer.