Treatment Options

Determining which treatment option is best for you is dependent on your prostate cancer profile. Your prostate profile is based on the following factors:

  • Age and expected actuarial survival
  • Medical condition and risk factors
  • PSA level
  • Presence of significant illnesses, such as myocardial infarction, strokes, diabetes, etc.
  • Gleason Score
  • Presence of metastasis
  • Status of DRE (rectal exam)

Depending on your prostate profile, the following treatment options will be offered to you:

1. Surgery

If your prostate cancer profile is overwhelmingly positive and you have 7-10 years of expected healthy lifestyle, surgery will be recommended. The most common types of prostate surgery include: Radical Robotic Prostatectomy: With the advent of the da Vinci™ robot, Tulane University Health Science Center was among the first in the United States to acquire this advanced therapeutic option for management of prostate cancer. This technical innovation provides the surgeon with 3-D high definition viewing capabilities which enhances the surgical procedure so as to maintain quality of life issues which are of major concern to patients for management of their prostate cancer. Besides drastically decreasing pain and blood loss, the robotic prostatectomy greatly enhances the technical aspects of the procedure because the surgeon has the option of up to 10x magnification which greatly facilitates the nerve-sparing option which is now preferred in most patients who have early diagnosis of prostate cancer. The surgeons on the Tulane Urology robotic team not only provide this state-of-the-art option here in New Orleans but also have traveled extensively teaching this new art of surgery in several states around the country. In addition, Tulane Urology is the only approved fellowship training site in the entire Gulf South. Brief Description of the Procedure After pre-operative discussion and adequate consent, the patient is given general anesthesia. Laparoscopic trocars or ports are inserted into the abdomen to introduce a 3-D camera and the robotic working instruments. Additional trocars help the bedside surgeon to insert instruments, suture material, and drains. The magnification, as mentioned above, greatly improves the vision of the surgeon and thus the surgical procedure is more precise as compared to most open radical retropubic prostatectomy. The robotic procedure usually takes slightly longer than the open surgical procedure. However, the increased time usually is due to such factors as the robot set-up time, instrument turnover, or change time. Most patients stay in the hospital overnight and are sent home after having a regular breakfast. Most patient's pain are managed postoperatively using anti-inflammatory agents such as ibuprofen (Advil™, Nuprin™).

Experience Matters

As with all new technology, robotic surgery involves a significant learning curve. The importance of experience in robotic surgery is critical. The nerve-sparing approach is crucial to maintain quality of life as well as to ensure surgical margins are negative. Potential patients should ask about their urologist's experience using the da Vinci™ robot for radical prostatectomy. Advantages to robotic surgery include:
  • better visualization in 3-D
  • less invasive
  • less painful
  • quicker recovery
  • quicker return to normal activity
  Radical Open Retropubic Prostatectomy In this procedure, the prostate, seminal vesicles and surrounding lymph nodes are removed through an incision made in the abdomen. This incision is made from the belly button downwards. Depending on your biopsy results and your overall prostate cancer profile, your urologist will discuss the possibility of performing a nerve-sparing radical prostatectomy. Such a procedure removes the prostate and lymph nodes but spares nearby nerves. If these nerves are spared, it lowers the risk of impotence (not being able to have an erection of the penis) after surgery.   Radical Perineal Prostatectomy Tulane is among the most experienced clinics in the country in performance of radical perineal prostatectomy. This approach is through an incision made in the perineum (between the scrotum and the anus). Those urologists who are specially trained in this low-morbidity approach offer this procedure. Recovery is usually quicker and return to normal activity is easier using this approach. However, the lymph nodes will need to be evaluated using a minimally invasive laparoscopic approach. Laparoscopic Prostatectomy Prior to the introduction of the da Vinci™ robot, Tulane Urology performed laparoscopic prostatectomy for the management of prostate cancer. This option is still used at several medical centers around the world. Ask your urologist about best surgical treatment option for you. Very often if both your PSA and Gleason score are low, there is no need for a pelvic lymph node dissection. The advantage of surgery includes removal of the prostate gland, which can effectively be monitored by serial PSA exams in the future. Radical prostatectomy has been shown to offer the best surgical long-term effectiveness to control your prostate cancer. The disadvantages Laparoscopic Prostatectomy surgery include:
  • bleeding, transfusion requirement in a small percentage of patients
  • urinary tract infection (A catheter drains your bladder for approximately two weeks)
  • urinary incontinence
  • impotency. it is now well known that the degree of impotency following radical prostatectomy depends on various factors. Under similar circumstances, the younger the patient, the higher the likelihood of preserving potency. Conversely, the older you are, the less likely it is that you will be able to maintain your potency in a satisfactory manner.
Following prostate removal, you will have lack of ejaculation, since the prostate contributes significantly to your ejaculation, thus you will be sterile after the procedure. However, approximately 30-50% of patients will have erections satisfactory to perform sexual intercourse. Patients may also require the assistance of oral medications, such as Viagra™; injectables, such as Caverject™; a vacuum erection device (VED); or implantation of a penile prosthesis that can be inflated prior to sexual intercourse. Potency preservation is possible with a nerve-sparing prostatectomy. However, not all patients are candidates for potency-sparing prostatectomy. It depends on your prostate cancer profile.  

2. Radiation Therapy

This treatment option employs high-energy x-rays to destroy cancer cells. Such high-energy x-rays are delivered by the following methods: External Beam Radiation Therapy Directs high-energy x-rays from a machine outside the body onto the area affected by the cancer. Usually this involves a base-line evaluation to be followed by approximately six weeks of treatment. Treatments are given Monday through Friday and last a few minutes for each session. Since the x-ray beams have to travel through the skin onto the prostate (see figure), because of male anatomy, the x-ray beam very often has to travel through the bladder and the rectum. Side-effects include: radiation cystitis (inflammation of the bladder) and radiation proctitis (inflammation of the rectum). Most patients get relief from this within a few weeks after the radiation is completed. Sometimes the radiation oncologist will suspend radiation if the side effects are significant and will resume it once these symptoms have subsided. Click here for location and contact information. Brachytherapy Also known as internal radiation therapy, this procedure involves small radioactive seeds placed directly into the prostate. Brachytherapy is performed under anesthesia and is a team effort between the urologist, the radiation oncologist, and the radiation physicist so as to provide safe application of this treatment. This procedure also involves mapping and evaluating the prostate in order to estimate the number of radioactive seeds needed for a given brachytherapy procedure. Advantages of brachytherapy include fewer complications from treating adjacent organs, such as the bladder and the rectum. Long-term studies are pending to see the overall effectiveness of brachytherapy. However, short-term data is promising. Your radiation oncologist can answer further questions on radiation therapy, including brachytherapy. Radioactive iodine and palladium are used to deliver the energy into the prostate. 3-D Conformal Radiation Therapy This is a newer type of radiation therapy which focuses high-energy x-ray beams very precisely, with less effect on normal surrounding organs.  

3. Hormone Therapy

Most prostate cancers are hormone-dependent and use the male hormone testosterone to grow. Hormonal therapy works by lowering the amount of testosterone available in the body to act on the prostate and thus it slows the cancer growth. Hormonal therapy is given by medication, which decreases or blocks testosterone in the body or by removing the testicles (orchiectomy). Hormone therapy is usually given either to shrink the prostate or in cases where the cancer has spread beyond the confines of the prostate gland.  

4. Cryosurgery

This procedure uses liquid nitrogen to freeze the prostate. The treatment is delivered through tiny incisions made in the perineum (Between the scrotum and the anus). Several small metallic tubes are inserted while you are under anesthesia, and liquid nitrogen is instilled into the prostate. This drops the temperature in the prostate to way below freezing. Usually the cycles are repeated, and this process is meant to kill the cancerous cells. The entire prostate is treated. Who are candidates for Cryosurgery? The ideal candidates are those who have failed radiation treatment (either external beam or brachytherapy). In certain cases, patients may choose this as a primary treatment, however one should carefully consider the side effects and complications of cryosurgery and whether your insurance policy will reimburse for this procedure. At many institutions and health care plans, this procedure is still considered investigational Once again, please consult your urologist and locate a center nearest you that performs cryosurgery to get all of the facts and details.  

5. Chemotherapy

This treatment modality employs strong drugs to destroy cancerous cells in the body. It can be given in the vein (intravenously) or by mouth. Often a combination of several drugs may be given to make this treatment more effective. Chemotherapy is usually used in men with advanced prostate cancer who are no longer responding to hormone therapy.