Archive - Initial Treatments After Diagnosis of Prostate Cancer

Questions & Answers

ATRIAL FIBRILLATION AND PROSTATE CANCER TREATMENT: I am 67 years old with stage T1c, Gleason grade 4+3=7 prostate cancer and was preparing for robotic prostatectomy when my EKG showed atrial fibrillation. I am scheduled to undergo cardioversion next week. I am now considering being treated with radiation—possibly proton therapy— instead of surgery because I fear cardiac complications from surgery. Can you offer any guidance?

In my opinion, atrial fibrillation is not necessarily a contraindication to surgery, as I have operated on many such patients in consultation with their cardiologists. Also, I am unconvinced that proton beam radiation therapy offers any significant advantage over standard 3-dimensional conformal radiation or intensity modulated radiation therapy (IMRT).

5-ALPHA-REDUCTASE INHIBITORS: I was recently diagnosed with prostate cancer via a 12-core biopsy with 1 core containing Gleason 3+3 prostate cancer, involving less than 5% of the biopsy material. My PSA is 6.7. My urologist has recommended active surveillance. I have been taking Flomax to increase urine flow, and my urologist recommended adding Proscar to reduce the size of my prostate. What can be the effect of Proscar on current cancer?

In my opinion, your question cannot be answered with certainty. 5-alpha-reductase inhibitors (Proscar, Avodart, Jalyn, etc.) are widely used to treat men with benign prostate enlargement, and we know that some treated men may harbor undetected prostate cancer. However, several large studies have shown that men who have taken these drugs for several years have a significantly higher likelihood of being diagnosed with a very aggressive Gleason 8, 9 or 10 prostate cancer (see previous QUEST articles). Therefore, in my practice, I do not encourage the use of these drugs, and I inform my patients of this possible risk.

LARGE PROSTATE MORE DIFFICULT TO REMOVE: Can the size of the prostate complicate a radical prostatectomy? Can it affect outcomes such as potency and continence?

Yes, it is more difficult to remove a large prostate gland. It is particularly difficult to perform nerve-sparing surgery. It can be done, but it takes more skill and experience to do it successfully.

NERVE GRAFTS: I have heard about a nerve graft from the leg and ankle replacing, during the prostatectomy, the erection-producing nerves alongside the prostate. Is this procedure effective?

It is difficult to say with certainty whether this type of nerve graft works.

OPTIONS AFTER CRYOABLATION: Are all options such as radiation, surgery, hormone available after a patient has had cyrosurgery of the prostate?

Radiation and hormonal therapy are certainly available, but the side effects of radiation may be greater because the tissues already have some damage to the blood supply from cryoablation.

PERINEURAL INVASION: What is the significance if “perineural invasion is present and identified” in a post op pathology report?

There are small nerve fibers that pass through the inside of the prostate gland. These nerves secrete a growth factor that attracts prostate cancer cells. Accordingly, in the great majority of prostate cancers, the cancer cells are seen to be lined up surrounding nerve fibers. This is called “perineural invasion.” Perineural invasion is so common as to almost be a diagnostic feature of prostate cancer. Its clinical significance is that when it is found in a needle biopsy specimen, there is a greater chance that the tumor will be found to have spread outside the prostate gland. If the tumor has spread outside the prostate, there is a higher chance for tumor recurrence. However, if the tumor has not spread outside the prostate gland, there is little or no prognostic significance to perineural invasion.

WHERE TO GO FOR RADIOTHERAPY: I am going to have external beam radiation therapy for a large prostate with a Gleason 6 rating.I have a choice of sites. I would like to learn about the best equipment and skilled concerned doctors at each place. I do not want to ask the institutions. They are not likely to say there equipment is the latest or that any of their staff or less able. Do you know of any resource for obtaining this information?

You should seek a site that has state-of-the-art equipment. Minimum requirements (in my opinion) would be a high-energy linear accelerator that can deliver at least 15 million electron volt photons and give 3-dimensional conformal radiotherapy. I do not believe that intensity modulated radiation therapy (IMRT) or proton beam radiation therapy offer a significant advantage for treating prostate cancer. With regard to the skill and caring attitude of doctors and staff, this is more difficult to evaluate. The best way would be to review their credentials and ask to talk to other patients who have been treated there. Also, ask physicians who work in their region their opinion.

PROTON BEAM RADIOTHERAPY I’m 46, recently diagonosed with prostate cancer, PSA 4.3, Gleason 3+3, T1c.  I’m scheduled for surgery. I have recently become aware of an alternative to surgery, proton radiation therapy. Although the treatment has only been performed for 11 years, their results would suggest comparable recurrence rates at both the 5 and 10 year marks compared to surgery, for prostate cancer patients they have treated.  And, of course, virtually no side effects of the treatment as they are able to focus and confine radiation in such a way that surrounding tissue and organs are unaffected. What can you tell me about proton radiation treatment and why should I not consider it as a viable alternative to surgery?

Proton beam therapy is available only at Loma Linda University in Los Angeles and the Massachusetts General Hospital in Boston. It is essentially a (more expensive) type of 3-dimensional conformal radiotherapy. I am told that it is aggressively marketed in southern California. I do not believe that it offers any material advantage in the treatment of prostate cancer over standard 3-dimensional conformal therapy with photons or over intensity-modulated 3-dimensional radiotherapy (another more expensive form of radiotherapy). In my opinion, proton beam radiotherapy is not free of complications. Moreover, I do not believe that the results of radiotherapy are as good as with surgery in young patients with organ-confined prostate cancer. My views on radiotherapy as the primary treatment for prostate cancer are presented in more detail on my website, under the National Media link, article #4 and in the video on the treatment of early prostate cancer on the home page of this website.

PROSCAR BEFORE RADICAL PROSTATECTOMY: I will be having surgery in three months. Proscar was prescribed because of the length of time between my biopsy and the scheduling of my surgery. What is the theory behind using Proscar? My research indicates Proscar is used for BPH and reducing prostate size.

One of the problems about using hormonal therapy before surgery is that it can cause dramatic changes in and around the prostate gland (scarring around the prostate gland) in some cases. This sometimes makes it more difficult to perform nerve-sparing surgery. Proscar is a very mild form of hormonal therapy. When it was being developed, it was tested in patients with advanced prostate cancer. It was too mild when used alone to be an effective cancer treatment. However, in most cases the PSA levels declined for several months. This may be all that is necessary in patients who have a short delay before prostate surgery. However, there are other options that could be used, such as Lupron or Casodex (for example), but these stronger forms of hormonal therapy may cause more difficulty in performing nerve-sparing surgery.

DOES NERVE-SPARING SURGERY COMPROMISE CANCER CONTROL? Is there a difference between “nerve-sparing” surgery and more aggressive surgery in terms of cancer recurrence rate? Is it determined from real-time inspection of surgical margins during the operation whether the nerve-sparing techniques are can be used or should be abandoned in order to effect a greater possibility of non-recurrence?

Theoretically, because nerve-sparing surgery preserves the soft tissues around the prostate, there is a higher risk for cancer recurrence. It is not feasible at the time of surgery to check all of the margins in real time to determine with complete certainty whether the nerves can be preserved. The judgement about whether or not to spare the nerves involves consideration of the preoperative biopsy results, the findings on rectal examination and scans, and the PSA level. It also is strongly influenced by how easily and cleanly the prostate can be freed from the neurovascular bundles at the time of the operation.

PERINEURAL SPREAD OF PROSTATE CANCER CELLS AND NERVE-SPARING SURGERY: I have read that cancer cells like to spread along neural pathways. With a limited number of prostate biopsy samples showing no perineural invasion, is it still possible that this invasion could exist in other areas, and therefore would it be dangerous to do nerve-sparing surgery assuming the carcinoma could have spread into the surrounding nerves? Are there any stats on this sort of thing?

It is possible, but less likely, that the cancer has spread outside the prostate if perineural invasion is not seen on biopsy. If all other parameters look favorable, it is reasonable to perform nerve-sparing surgery in the absence of perineural invasion.

PROTON-BEAM RADIOTHERAPY: How effective is proton treatment for prostate cancer?

It is effective, but not more so than standard external beam radiotherapy using 3-dimensional conformal treatment, which can be obtained in nearly every city. Proton beam therapy is only available in Boston and California.

TRANSITION-ZONE CANCER It is my understanding that 72% of prostate cancer starts in the Peripheral Zone, 20% starts in Transition Zone and 8% in the Central Zone. Has there been any research which would indicate whether it is more difficult or any easier to treat prostate cancer which started in the Transition Zone or the Apex Zone as opposed to the Peripheral Zone?

In general, it is believed that prostate cancer that arises in the peripheral zone is more aggressive than that which arises in the transition or central zones. The apex includes the transition and pheripheral zones.

IMRT RADIOTHERAPY FOR PROSTATE CANCER Only a few hospitals are now offering IMRT radiation with a Varion Clinac Linear Accelerator Mini-Multi Leaf Collimator [MMLC] and new Impac record and verify software. In your opinion does this have an advantage over previous IMRT treatments?

In my opinion, IMRT is not necessary to treat prostate cancer. I believe that the same treatment objectives can be accomplished with 3-dimensional conformal radiotherapy. See other Q&As that address this subject on this website.

NERVE GRAFT: My surgeon recommends nerve sparing for one side but believes that the risks are too great to spare the other side, based on evidence of perineural invasion on the biopsy specimen. This is my one and only chance at a surgical procedure (experimental) to possibly enhance my ability to regain potency after prostate removal. In my case is a one sided nerve graft a reasonable procedure?

There are several Q&As on my website about nerve grafting and about the meaning of perineural invasion. I would recommend that you read them if you have not already done so. If I were in your position, I would not elect to have the nerve graft because I am not convinced that this procedure works. However, the rationale given by your urologist and surgeon are sound, i.e., with perineural invasion on the biopsy, there is a higher risk (though not a certainty) of extracapsular extension, so the safest approach might be to resect the nerve on that side. However, with your relatively low Gleason grade and PSA, the tumor may be contained within the prostate and it might be possible to spare both nerves.

NERVE SPARING SURGERY There is evidence of perineural invasion based on the biopsy specimen on one side of the prostate,thus increasing the likelihood that cancer has spread to that nerve .Can a surgeon determine during surgery if there is extracapsular extension to that nerve and base a decision to save or resect the nerve on that determination?

The surgeon can get a good estimate, but it is not perfect. Microscopic extracapsular extension cannot be detected.

RADIATION FOR POSITIVE MARGIN: I had a radical prostatectomy 2 months ago. My pathology showed a Gleason 7 and the cancer had spread into the right margin area. My first PSA registered a 0.1. Does this mean cancer cells were left behind and I should get radiation? If so–when should I start the radiation?

It does not necessarily mean that cancer cells have been left behind, but some might have been. Actually, most patients who have positive margins and an undetectable postoperative PSA continue to have undetectable PSA levels even without radiation therapy. But there is approximately a 30% chance that the PSA will rise without radiotherapy. It becomes a matter of weighing the potential side effects of radiation versus the potential benefits of giving the radiotherapy early when there are the fewest possible cancer cells to treat. This is a dilemma discussed in detail on this website. I usually recommend postponing the radiotherapy until 3 to 4 months after the surgery until everything has healed and continence has returned. It is also probably true that not much would be lost if you carefully monitored the PSA and then, if it started to rise, received radiation therapy at once.

DELAYING SURGERY FOR ONE YEAR: I am 45. I was diagnosed as T1C. My PSA was 6.9, Gleason Score of 6 (3+3)involving 10% of 1 of 2 cores. I want to wait 1 year for surgery. What is the risk of the cancer spreading if I wait this long?

It does appear that you have a favorable situation, but a PSA of 6.9 is pretty high for a 45 year old man and a Gleason score of 3+3 is in the category of moderately aggressive cancer. I do not think it is possible to accurately assess the risk of cancer spreading if you delay surgery for one year, but I would think it is significant. Therefore, I usually advise patients to have treatment as soon as they can conveniently get it scheduled with the doctor of their choice.

NEOADJUVANT HORMONAL THERAPY Is neoadjuvant hormone therapy a good idea when delaying surgery two months after diagnosis, especially when the prostate is enlarged? My doctor has prescribed 150 mg. of Casodex a day, but only after I asked about such therapy. However, I have since read that it takes 3 months or more of hormone therapy to have any effect on positive margins, that it does not seem to affect long term survivability, and that the therapy might even make nerve-sparing surgery more difficult due to potential scarring. I also see that Casodex prescribed is quite costly. In general, is a two month wait before surgery (1% prostate tissue involvement, Gleason 5, PSA 7 [down to 4 after antibiotics], Age 57) taking an unnecessary risk? Should I schedule it earlier if I forego neoadjuvant therapy?

There is no good evidence that neoadjuvant hormonal therapy improves the outcomes of surgery (it has been shown to be beneficial in high-risk patients treated with external beam radiotherapy). It can make it more difficult to perform nerve-sparing surgery. I do not think patients with relatively low risk tumors (Gleason grade less than 7, PSA less than 10, low volume involvement of the biopsy cores) need to take neoadjuvant therapy if surgery is delayed for a few months. Obviously, it is best to have the surgery performed as soon as feasible, but early detection through PSA testing probably give 5 to 13 years lead time. This means that without PSA testing, the cancer might not have been detected until 5 to 13 years later. So, a few months delay would seldom affect the ultimate outcome of treatment. Specifically, in your case, I do not think neoadjuvant hormonal therapy is necessary.

ROBOTIC LAPAROSCOPIC PROSTATECTOMY: I have been diagnosed with prostate cancer; PSA 4.5; Gleason 6; Stage T2b; I am 59 years old, physically fit and very active; no other medical problems. My Urologist has recommedned the da Vinci Prostatectomy (from Intuitive Surgical Inc) which is a robotic / computer controlled laparscopic radical prostatectomy. Do you have any experience with robotic laparscopic surgery?

I have no personal experience in performing robotic laparoscopic radical prostatectomy. My comments on this procedure would be that I place it in the same category as other forms of laparoscopic radical prostatectomy in terms of the results that can be consistently obtained, i.e., it is uncertain at this time whether they are equivalent to those that can be obtained by a surgeon who specializes in open nerve-sparing radical prostatectomy. Please see articles from Quest on this topic which are posted on this website.

LOCALLY ADVANCED, HIGH-GRADE PROSTATE CANCER During surgery for prostate cancer, the doctors discovered the cancer had spread to the left side of the pelvis in my 50 year-old husband, and they did not remove the prostate. The doctors are not in agreement on how to treat him. One doctor wants to put him on chemo while another wants to wait. The doctor who performed the surgery did not give me much hope. What hope can you give me and what can I do to help him?

It is important to realize that hormonal therapy can be effective for many years in patients with advanced prostate cancer. Chemotherapy is also effective in many patients, but has more severe side effects. Also, a variety of new experimental treatments are in various stages of development.I believe that the best course at this time would be to go with the hormonal therapy in order to “buy time.” In the futures, it may be necessary to have chemotherapy,as well. The hope is that soon, newer, more targeted forms of therapy will become available. Of course, nobody can predict what treatment or when, but that’s the hope you and he need to hold on to. Stay on top of his treatment, take good care of his (and your) health, and plan to hang in there until something better is available.

IS SURGERY MY ONLY SAFE OPTION: I have been diagnosed with prostate cancer; PSA level 6.4; gleason 3+3 in 3 of 10 biopsy samples (both lobes) ranging from 15 – 25% by volume. The cell structure still showed close resemblance to normal cells in the biopsy. My consultant has recommended radical prostatectomy. I am very concerned about the post operative effects of impotency and as a fit and active man of 55 yrs is this really my only safe option? If this really is my only course of action would waiting 6 months for surgery be a problem?

Because of your age and the features of your tumor, I believe that radical prostatectomy is your best option, but that is not to say that it is your only safe option. I would not advise waiting 6 months to be treated. The complications you fear can best be avoided by chosing a surgeon with considerable experience in radical prostatectomy.

LOCALLY ADVANCED PROSTATE CANCER INVOLVING THE BLADDER I recently had surgery. My PSA was 19 and Gleason scale was 7. The cancer was in the central area of the gland rising up to the bladder and did not show a clear margin at the bladder. My doctor suggested radiotherapy. Will this damage my bladder and am I at risk in getting cancer in my bladder?

There is a 5-10% risk of having some permanent injury to the bladder following adjuvant radiotherapy. This usually means intermittent bleeding from the bladder or an irritable bladder syndrome. On the other hand, radiotherapy reduces the risk of having a recurrence of the prostate cancer in your bladder.

TREATMENT OF GLEASON GRADE 8 PROSTATE CANCER THAT IS CLINICALLY LOCALIZED: My father was recently diagnosed with prostate cancer. His PSA levels have always been low with the most recent being 3.4. A biopsy was taken following a digital exam that indicated abnormalities. His Gleason score was 8-9.It does not appear that the cancer has spread outside of his prostate. We have been told that surgery is not recommended because his cancer is aggressive and surgery may not remove all of the cancer. He is currently on hormone therapy with plans to start external beam radiation followed by seed implants. What is your opinion on this recommendation?

This would be the typical recommendation for patients with prostate cancer that is believed to have spread outside the prostate gland. However, several studies have demonstrated that the results of radical prostatectomy are favorable with Gleason grade 8 prostate cancer if the cancer is still contained within the prostate gland. Thus, if the doctors truly believe that the cancer is organ confined, radical prostatectomy also would be an option.

PROSCAR TO RETARD CANCER PROGRESSION: Considering the recent results of the study showing a more aggressive form of prostate cancer in men who have taken Proscar, would you now consider it advisable to use Proscar to retard cancer growth while, for example, waiting for a pending prostatectomy?

The results of the Prostate Cancer Prevention Trial suggest, in my opinion, that long-term administration of Proscar can mask the presence of prostate cancer and allow its more aggressive elements to emerge in men who initially have PSA levels <3 and normal findings on digital rectal examination. I no longer recommend that men take Proscar on a long-term bais. The effect of short-term administration of Proscar in men with established prostate cancer who are waiting for surgery is uncertain. Certainly, it is possible that in this setting, Proscar could retard only the less aggressive cancer cells while the more aggressive ones continued to grow and spread unchecked.

SMALL AMOUNT OF CANCER ON BIOPSY I am a 59 year old white male with PSA 4.8,Free PSA 21% and complexed PSA of 3.8. A recent prostate biopsy revealed that one area presented small focus of adenocarcinoma with a Gleason grade of 3+3=6.In a note by the pathologist,in cases similar to this with 0.5mm of Gleason score less than or equal to 6 cancer on one biopsy core,approximately 50% of the corresponding radical prostatectomy specimans contain very small(less than 0.1cc)cancer. I had a radical nephrectomy in 1989. No follow up needed. My urologist said that because I only have one kidney, surgery could be risky, and is leaning more to the option of radiation. My MRI and Bone scan are both normal. What are your thoughts?

In my opinion, the prior kidney surgery by itself should not prevent you from having a radical prostatectomy, all other matters being satisfoctory for surgery. Sometimes, considerably more tumor is found in the radical prostatectomy specimen. In my opinion, it would be safest to treat the prostate cancer with an effective treatment like radical prostatectomy.

BRACHYTHERAPY AFTER TURP I recently had a TURP and 2 of 90 chips had cancer with a grade of 3 + 3. My PSA is 2.9. I am scheduled for a RP very soon. Should I also pursue High Dose Rate Braketherapy?

In my opinion, no. Brachytherapy is not usually recommended after the prostate has been resected transurethrally because it might not hold the seeds properly. Also, I believe that radical prostatectomy is more effective treatment. Your situation seems very favorable for a cure.

COMBINED HORMONAL RADIATION THERAPY FOR LOCALLY ADVANCED PROSTATE CANCER: My dad was recently diagnosed with prostate cancer that has already gone outside the prostate. PSA 7.8. He started hormone treatment immediately and they want him to start radiation soon. Should he start immediately? Does he stand a chance at quality and quantity of life after having these treatments?

He does stand a good chance for an excellent response to treatment and years of remaining good quality life. The radiotherapy and hormonal therapy have side effects that are discussed elsewhere on this website, but hopefully these will not be a major problem in his case.

I have been diagnosed with prostate cancer. I have been researching treatments and speaking with specialists and feel like I am getting more confused. I have had Crohn’s Disease for 36 years – have had 2 resections and have had anal fistulas as well as a fistula from the bladder to the intestine( fixed by surgery). The urologist is uncertain about a radical because of possible scarring and the oncologist radiologist is concerned with the radiation speading and hitting the intestines (anus). Have you had any experience with patients in my situation and what would you suggest? PSA is 6.9 and Gleason is 4+3.

In my opinion, there is no simple answer; however, in similar cases I have recommended surgery as the preferred curative option. Although it is sometimes difficult, it has been feasible in every case I have encountered so far. A non-curative option would be hormonal therapy.

What are your views on Laetrile therapy or taking vitamin b17 in the form of apricot kernels (in moderation)?

I do not recommend it to my patients and would not opt for it myself if I had prostate cancer.

I would like to know where I might get more information on the limitations/restrictions of surgery in the unfortunate event of failed radiotherapy.

The complications of surgery after failed radiation therapy are up to 10-fold more likely, and they are more serious and more difficult to treat when they occur. I wrote an editorial in the Journal of Urology several years ago about this. However, there are some centers that have pursued salvage surgery. Sometimes it requires removal of the bladder as well. I would suggest that you search for “salvage radical prostatectomy” on PubMed.

Age 64-PSA 5.35 Gleason 6. 2 core biopsies showed 5% cancer. Planning on surgery. Is a bone scan or CT Pelvic necessary before surgery? I want the nerve sparing procedure-would you recommend open or lap?

I routinely order a bone scan and abdominal/pelvic CT scan to obtain a good base-line evaluation of the patient; however, these tests are not mandatory if the PSA is low and the Gleason grade is not high. Most surgeons would forgo them. In my opinion, successful nerve-sparing is more likely to achieved with an open procedure, but it depends upon the preference of the surgeon. Please see other Q&As concerning laparoscopic radical prostatectomy.

I have been diagnosed with T1 Gleason 6. I will be seeing the surgeon. What are the chances of cell shedding during a lap as opposed to the open technique?

I do not know of there being a different risk of cell shedding between surgical approaches. However, I do believe the risk of inadvertently leaving some tissue behind, especially in the region of the bladder neck, might be higher with the laparoscopic approach.

PROTON THERAPY: How does it compare to other therapy for the treatment of prostate cancer?

Proton beam radiotherapy is effective but only a few facilities in the United States have the equipment.I think the same results could be achieved with 3-dimensional conformal therapy and a high-energy linear accelerator, which is available in almost every city of any size.

In performing a nerve-sparing radical prostatectomy, what role does a 2nd doctor play in the surgery? Is the 2nd doctor just a standby or is he supposed to be assisting in the surgery in some way? Does a patient need to investigate a 2nd doctor’s credentials?

The role of the second doctor varies, but usually he or she assists the first doctor, who actually performs the surgery. If you have any questions about the role of the second doctor, you should directly ask the first doctor.

My husband has a Gleason score of 9 and is being treated with Casodex. Why has he not been offered surgery or radiation therapy? I believe the cancer has spread into his lymph glands and possibly into the pelvic bone but that was inconclusive. Should he be seeing an oncologist?

If it is believed that the cancer has spread beyond the pelvic area, primary hormonal therapy is the preferred treatment. It might be helpful to see an oncologist to verify the wisdom of the treatment choice.

TREATMENT OF EARLY PROSTATE CANCER My PSA increase from 1.2 to 3.9 in two years. I am 57. A twelve sample biopsy revealed a small amount of cancer in one sample, lower right quadrant. A T1C with Gleason of 3+3, according to local pathologists. Urologist has sent for second pathology reading. If it comes back confirmed, what would you recommend?

In my opinion, you should have treatment. If you are otherwise healthy, I believe that a radical prostatectomy would offer the best chance for cure.

HORMONE THERAPY TO SHRINK AN ENLARGED PROSTATE BEFORE BRACHYTHERAPY: I have a normally enlarged prostate for a man of 65. My radiologist wants to shrink it with hormones prior to seed implantation. I’ve read that there is one school of thought that says you can implant seeds in virtually any size prostate. Is it argued that a larger prostate allows for easier and better distribution of the seeds. So why bother with hormones?

I am not an advocate of brachytherapy and, therefore, cannot speak from personal experience. But most physicians who are experienced in brachytherapy feel that it is difficult to achieve an adequate distribution of radiation with a large prostate gland, and, if the prostate does not shrink, will recommend a different form of treatment.

I have been hearing a lot of good things about DaVinci Robotics for removing the prostate. I know that you do not practice the procedure, but what would you say about its benefits for preserving potency and continence? And which patients should consider it as a treatment alternative?

In my opinion, the robotic prostatectomy (often called the DaVinci prostatectomy) is not as effective as the traditional open prostatectomy for simultaneously accomplishing complete removal of cancer and preserving potency.
One of the reasons is that the robot lacks the “human touch” and it is not possible to appreciate how the prostate gland feels and how readily it separates from the nerves and other surrounding tissues.

The robot does not handle the prostate gland as gently as the human hand, and not infrequently the robot punctures the capsule of the prostate, leading to positive surgical margins.

Another limitation is that with the robotic prostatectomy, the prostate is removed by burning it out with electrocautery or a so-called harmonic scalpel that cuts by heat, and if the heat is too near the nerves, it irreversibly damages them. Also, if the burning is too close to the prostate gland, it risks cutting into the prostate, resulting in positive surgical margins and possibly leaving cancer behind.

Advocates of robotic surgery say that there is less bleeding and greater magnification with robotic surgery. However, excellent magnification and visualization can be provided with open surgery, and with an experienced surgeon, few patients require blood transfusions from another person.

With robotic surgery, it is more difficult to suture and apply hemostatic clips and it is more difficult to perform a lymph node dissection.

Enthusiasts of the robotic procedure claim it is “less invasive” and has a quicker recovery time. But actually it is more invasive because the surgeon has to go through the peritoneal cavity to get to the prostate (a more invasive approach associated for greater risk for injury to the bowel, major blood vessels, and the ureters and a greater risk for later intestinal obstruction from adhesions). Usually 6 one-inch incisions are made for robotic surgery, while for open surgery, one 4 to 5 inch incision is made that does not enter into the peritoneal cavity. With the smaller incision now frequently used for open surgery, there is no material difference in the recovery time and return to normal activity…
The complications with robotic prostatectomy are more serious than with open prostatectomy and they lead to more postoperative emergency room visits, more re-hospitalizations, and more re-operations.

I believe that with the robotic or laparoscopic prostatectomy, the patient and the surgeon have to make more of a stark choice between removing all of the cancer or preserving the nerves to maintain potency. I believe that there is a greater likelihood of accomplishing both objects with the increased access provided by the open approach.

Most importantly, however, the robotic prostatectomy has no track record in terms of long-term cancer control. If small amounts of cancer are left behind, it may not become apparent for years.

Patients sometimes tell me that they know someone who underwent a robotic prostatectomy a few months ago and seems to be doing fine. However, the final outcome of the operation may not become apparent for up to 10 years. Thus, long-term cancer cure rates are needed before one can truly evaluate the effectiveness of the operation.
In sum, I do not believe the robotic prostatectomy is as safe a cancer operation as open radical prostatectomy, and I do not believe that nerve-sparing can be as readily or safely accomplished.

For patients, the most important outcomes of radical prostatectomy are: Is he cured of his cancer? Is he continent? Can he have erections sufficient for intercourse?

These questions have been well documented for open rostatectomy. The jury is still out with laparoscopic/robotic prostatectomy. The most important factor is the surgeon and not the technique.

My husband has been diagnosed with a form of prostate duct cancer, which has spread into the neck of the bladder. We have been told this cancer is rare and there is little information on it. What can you tell us about it?

Prostatic ductal cancers are uncommon but not rare. Often they produce very little PSA or none at all.
Ductal carcinomas generally are more aggressive than the more common prostate cancers that arise from the small glands in the prostate called prostatic acini (thus the typical prostate cancer is sometimes referred to more formally as an “acinar adenocarcinoma.”

The most effective treatment for ductal cancers is radical prostatectomy if the cancer is contained within the prostate gland.

The response to radiation therapy or hormonal therapy is not as good for ductal cancers as for acinar cancers.
The most effective chemotherapy drug used for acinar cancers is docetaxel (Taxotere) but little information is available on its effectiveness with ductal cancers.

I have heard that some surgeons do not remove lymph nodes with a laparoscopic prostatectomy. Could that be possible? Is there any other way to tell if cancer has spread without lymph node removal?

Yes, it is possible. It is more inconvenient for the surgeon to remove the lymph nodes with a laparoscopic prostatectomy, but it can be done.

My husband was diagnosed with prostate cancer and an enlarged prostate in August of 2007. He was given a harmone shot in September to reduce the size of his prostate. His PSA is 5.0 We were told that his prostate is too large for surgery. Does the size of the prostate impact surgery in a negative way and can there be such a thing as a prostate too large for surgery?

Radical prostatectomy is more difficult to perform in patients with a very enlarged prostate gland; however, this situation rarely precludes performing surgery. The normal prostate gland has a volume of 30 ml, and the largest prostate gland I have removed was 379 ml. Thus, an extremely large prostate gland can be removed safely by an experienced surgeon.

DELAYING SURGERY: I have Gleason 3 + 4 prostate cancer that appears to be clinically localized. Is it safe to delay surgery for 3 months?

My practice is to wait for 6 weeks after the biopsy to allow any inflammation to resolve. Then the surgery should be performed as soon as it can be conveniently scheduled. Many patients who delay their surgery are found to have positive margins or extension of cancer outside the prostate and then need to have postoperative radiation. They often wonder whether if they had not delayed, the result would have been different.

COMPARING RADIATION THERAPY AND SURGERY AS FIRST-LINE TREATMENTS: I am scheduled to have a radical prostatectomy. My urologist has informed me that approximately 15- 20% of patients will require radiation after the operation. If this is so, then why opt for surgery when I know there is a strong possibility that I may need radiation therapy as well?

If the cancer is confined to your prostate, surgical removal is more effective in curing it. If it is not, there is still a chance that it can be cured with a lower dose of postoperative radiation therapy. Radiation therapy alone has 3 downsides: (1) sometimes even the higher dose of radiation required to treat the whole prostate gland does not cure the cancer; (2) sometimes a new cancer can arise in the remaining prostate tissue, and (3) there is an increased risk of (radiation- induced) bladder cancer and colo-rectal cancer in patients who have been treated with radiotherapy for prostate cancer. You can safely have radiotherapy after surgery, but surgery after radiotherapy is associated with a 10-fold higher complication rate, including urinary incontinence, erectile dysfunction, and even the possibility of needing a temporary colostomy.

PROSTATECTOMY OPTIONS: I am 43 years old with Gleason 3+4 and Gleason 3+3 low-volume (5%) prostate cancer diagnosed during a workup for urinary difficulties. My PSA was 2.5. I am about to see a surgeon for an open nerve-sparing prostatectomy. Is robotic-assisted surgery a better procedure, and what are my chances to be cured?

In my opinion, a nerve-sparing prostatectomy is the preferred treatment for you because of your relatively young age, the presence of Gleason pattern 4 cancer in the biopsy specimens, and your relatively high PSA (the median PSA for men in their 40s is 0.7). I perform open nerve- sparing prostatectomy because I believe (1) it offers the advantages of the surgeon having the ability to touch the tissues and appreciate how readily or not the prostate separates from the surrounding tissues, (2) the ability to avoid burning the prostate using heat or electrocautery as is commonly used in robotic surgery, and (3) better access to the surgical field. The amount of pain and recovery is essentially the same for both approaches, and, in my hands, the need for transfusions is the same as with robotic prostatectomy. I believe my outcomes are as good as any. Nevertheless, the most important factor is the experience and skill of the surgeon. Please visit my website,, for more information and search “robotic prostatectomy.

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