The term, "local therapies" refers to treatments administered directly to the prostate gland, i.e. surgery, implanted seeds, radiation and cryotherapy. The term local therapy is to be contrasted with another term, "systemic therapy" that alludes to medical treatments that circulate in the blood throughout the body. Examples of systemic treatments are hormonal therapy, chemotherapy and immune therapy.
Treatment with small "seeds" that emit radiation is called brachytherapy. If the seeds are properly placed throughout the gland, the whole prostate receives a high dose of radiation while the surrounding organs are spared. Brachytherapy is a 60-minute outpatient procedure under spinal anesthesia. About two-thirds of patients encounter short-term urethritis which is an inflammation of the urinary passage from the bladder out the penis. Urethritis lasting for several years and impotence are the most common long-term risks of brachytherapy. Patients who have enlarged prostate glands or preexisting urinary symptoms from BPH are more prone to develop urethritis. Brachytherapy comes in two forms, permanent seeds and temporary seeds. In skilled hands both methods are effective. Permanent seeds are more popular for Low-Risk and Intermediate-Risk prostate cancer. High-dose temporary seeds are more popular for High-Risk and Locally-Advanced prostate cancer. For a more detailed discussion of the local therapies, brachytherapy, IMRT and surgery, you can request the booklet How to Pick the Best Treatment for Prostate Cancer from our office.
Intensity Modulated Radiation Therapy (IMRT)
Historically the word "radiation" evokes strong negative reactions. Before the advent of modern computerized targeting in the early 2000s, prostate radiation therapy was both ineffective and damaging. Now, however, doctors can reduce the width of the radiation beam to precisely match the external dimensions of the prostate gland. Therefore, radiation exposure to the surrounding structures like the bladder and the rectum is dramatically reduced. Moreover, the intensity of radiation beam can now be "modulated." The beam can be "shaped" to match a spherical target like the prostate. This limits "overspray" of radiation into the sensitive surrounding organs like the rectum and bladder. Short term side effects of IMRT tend to be mild. The long term risks of IMRT are impotence and a small risk of proctitis (radiation burn of the rectum). For a more detailed discussion of the local therapies, brachytherapy, IMRT and surgery, you can request the booklet How to Pick the Best Treatment for Prostate Cancer from our office.
Cryotherapy is accomplished by circulating liquid argon through small hollow needles inserted into the prostate to create an expanding ice-ball at the tip of the needle. The size of the ice ball is controlled by adjusting the flow rate of the argon. Originally, cryotherapy was used for freezing the whole prostate. However, the popularity of whole-prostate cryotherapy is limited because impotence occurs 90% of the time. Whereas when surgery or radiation is expertly administered, 50% of men maintain erectile function. Therefore, whole-gland cryotherapy is reserved for men that have nothing to lose in this regard - the ones with preexisting impotence. Whole-gland cryotherapy is done in the hospital and requires a urinary catheter for a few days after the procedure. The risk of incontinence is about 5%. Very rarely, cryotherapy can cause an opening between the bladder and rectum, a fistula, which in some cases can be very difficult to correct. For a more detailed discussion of the local therapies, brachytherapy, IMRT and surgery, you can request the booklet How to Pick the Best Treatment for Prostate Cancer from our office.
Surgical removal of the prostate provides useful information about the size and grade of the cancer enabling physicians to estimate the risk of future relapse more accurately. Such information may be useful in selecting treatment if larger amounts of high-grade cancer are discovered. Recent studies of implementing immediate Testosterone Inactivating Pharmaceuticals (TIP) right after surgery in men found to have advanced disease at the time of surgery suggest that cure rates can be augmented. Also the possibility of administering adjuvant Taxotere can be discussed. The removal of the prostate also creates a "clean slate" by removing all non-cancerous PSA producing tissue. This simplifies the monitoring process as PSA elevations greater than 0.07 allow doctors to be confident about the presence or absence of relapsing cancer.
The disadvantage of a radical prostatectomy is that it entails a major surgical procedure with its attendant discomfort and risks. A urinary catheter remains in place for about a week or two after the operation. Urinary incontinence usually takes several months to be restored and in about 10% of men it never recovers. Impotence is universal for the first months after surgery. Patients who eventually recover function do so slowly over a 2 to 24 month period. Even after recovery occurs only 5% of men describe their erections as being identical to the erections they had before surgery. Patients with slow recovery are at risk for penile atrophy. To reduce this risk "penis exercises" either by prophylactic injection therapy with prostaglandins or by the use of a vacuum assist device should be started right after the operation.
It cannot be over emphasized that urologists vary greatly in surgical ability. One of the best measures of surgical skill is determining how often the surgeon leaves cancer behind while trying to remove the gland. The best surgeons get the cancer out 90% of the time. Studies have documented that many urologists, even those operating out of large universities, can leave cancer behind up to 50% of the time. Leaving cancer behind is called a positive margin.
High hopes for robotic surgery have not panned out. Men recover from robotic surgery more quickly because the operation is performed through a smaller incision. Unfortunately the risk of impotence and incontinence is not improved compared to standard surgery.