After you are diagnosed with prostate cancer, your urologist may recommend treatment. The traditional (and currently guideline-recommended) treatment approaches include surgery (radical prostatectomy), radiotherapy, or active surveillance.
The recommendation for each of these approaches is based on a balance of your overall health and symptoms, including urinary and sexual function. You also need to consider your priorities in terms of quality of life, and your cancer aggressiveness/risk.
With each of these approaches, the whole prostate is treated. This means that both the areas known to have cancer and the remainder of the prostate gland receive the same treatment. Treating the whole prostate gland has been the traditional approach for many years because it is known that prostate cancer is often found in multiple areas of the prostate at the same time (so-called “multi-focal” disease). However, many patients ask if it is possible to only treat the areas of prostate cancer and not the entire prostate gland.
It is increasingly recognized that some patients may have a single area of disease (“unifocal cancer”). Or they may have a single area that needs treatment with other areas being low risk and suitable for observation.
In many cancers (breast, thyroid, lung, kidney, and others), surgeons and oncologists focus treatment on the tumor while avoiding treatment effects on the surrounding tissues. For example, in breast cancer, many years ago, there was a move from surgically treating the whole breast (radical mastectomy) to a localized treatment (lumpectomy). In prostate cancer, focal therapy received a big boost when magnetic resonance imaging (MRI) became more commonly used. This is because MRI allowed urologists to take biopsies of specific areas of the prostate and then when appropriate, target focal therapies to these areas.
Focal therapy in prostate cancer seeks to balance cancer control and side effects. However, it is important to note that these treatments should, for the most part, still be considered experimental as we do not have the same, long-term outcome information for these treatments as for surgery and radiotherapy.
Who may be suitable for focal therapy?
While early studies in focal therapy used this treatment approach in low-risk prostate cancer, most clinicians would agree that active surveillance is a more appropriate treatment approach for most of these men. Because of this, focal therapy is often best suited for patients with intermediate-risk prostate cancer who have a single tumor that can be seen on MRI and no other cancer in their prostate.
How is focal therapy delivered?
Focal therapy is more of a concept (the idea of treatment of a specific area of the prostate/tumor) than a specific treatment technology or modality, of which there are many. In fact, there are many ways to perform focal therapy. Many different ways of destroying prostate tissue may be used for focal therapy. These include:
- High-intensity focused ultrasound (HIFU; which uses ultrasound waves to heat prostate tissue and tumor to destroy it)
- Cryoablation (which cools the prostate tumor to freeze and kill it)
- Photodynamic therapy (which uses laser energy to activate drugs in the prostate that then kills the cells nearby)
- Irreversible electroporation (in which electrical pulses are used to break up cell membranes and kill the cells)
- Laser ablation (which uses a laser to heat tumor tissue)
- Radiofrequency ablation (which uses radio waves to heat the tumor tissue)
Radiotherapy approaches that are traditionally used to treat the whole prostate including brachytherapy and external beam radiotherapy can also be used for focal therapy. Surgical approaches to focal therapy are not frequently considered.
In most studies, focal therapy has decreased rates of standard complications of prostate cancer treatment such as urine leakage (incontinence) and impotence (erectile dysfunction), compared to traditional treatments. However, there are other complications that may result from these treatments, including damage to the rectum (although infrequently).
The choice of a specific focal therapy technique depends on a number of factors, including your doctor’s comfort with each technology. If you are interested in focal therapy, you should discuss with your urologist if it is appropriate in your situation and, if so, what approach they would suggest.
While the idea of focal therapy is very exciting to many patients with prostate cancer (and to their physicians as well!) it is important to remember some important caveats.
First, focal therapy is not always the right treatment for a patient. In some cases, it may be too much treatment. In these cases, a patient is better off with active surveillance for low-risk disease. For others, it may be too little. In these cases, traditional therapies such as surgery or radiotherapy may be more appropriate for higher-risk disease.
Second, even for patients in whom focal therapy is reasonable, we do not have long-term information on outcomes both in terms of cancer control and complications. Patients who are interested in focal therapy for prostate cancer should speak with their urologist to learn more about this treatment approach to find out if it is suitable for them.
For some men with prostate cancer, their doctor may recommend surgery to remove the prostate. This is called a radical prostatectomy. It depends on the stage and risk of your cancer, as well as your overall health and preferences.
What Happens During Radical Prostatectomy?
During a radical prostatectomy, the surgeon removes the prostate gland and the seminal vesicles. The seminal vesicles are small glands behind the prostate that help make semen.
Your surgeon may also remove nearby lymph nodes. This is more likely if you have a higher risk that the cancer has spread to the lymph nodes. Your risk is based on factors such as your PSA level, Gleason score, Grade Group, and how far the cancer has spread. Before surgery, ask your urologist if lymph node removal is recommended for you and why.
A radical prostatectomy usually takes about 3 to 4 hours.
Robotic-Assisted vs Open Surgery
Radical prostatectomy can be done using different methods. Today, robotic-assisted surgery is commonly used, but open surgery is still a good option for some men. Robotic surgery uses small incisions, and open surgery is done with a single large incision. You can learn more about each below. Your surgeon can explain which they advise for you and why.
What is Robotic-Assisted Radical Prostatectomy?
During robotic-assisted surgery, the surgeon makes 4 to 5 small incisions in the abdomen. The incisions are about 8 to 12 millimeters each. Small tools that are part of a specialized robotic system are put through these incisions. The surgeon controls the tools at all times. The robotic system does not perform the surgery on its own.
Compared with open surgery, robotic-assisted surgery results in:
- Less blood loss
- A faster recovery for some people
What is Open Radical Prostatectomy?
With open surgery, the surgeon makes one larger incision in the lower abdomen. The incision extends from the pubic bone toward the belly button. Open surgery was the standard approach for many years. It’s still a good option for some men.
What to Expect After Surgery
After the surgery, you will have a Foley catheter. This is a thin tube put into the penis to drain urine from your bladder. The catheter usually stays in place for about 5-7 days, but may stay up to 10 to 14 days based on your surgeon’s preference.Some men also have a small drain in the abdomen for a few days. The drain helps remove fluid from the surgical site while you heal.
Your care team will encourage you to get out of bed and walk soon after surgery. If you are able, you may start walking on the evening of your surgery. Moving around after surgery is important. It helps lower your risk of blood clots in your legs and pneumonia.
Most men stay in the hospital overnight and go home the next day. Depending on the method of surgery and how you’re recovering, you may go home the same day or need to stay more than one night.
Follow-Up After Surgery
You will usually see a member of your urologist’s team for Foley catheter removal (5-7 days after surgery) and then see your urologist about 10 to 14 days after surgery. At this visit, your doctor will:
- Check your incisions.
- See how you are doing after surgery.
- Talk with you about your pathology report.
The pathology report gives detailed information about the prostate cancer that was removed during surgery. It can show how much cancer was present, how fast-growing (aggressive) it was, and if the cancer had spread beyond the prostate or into nearby lymph nodes. This information helps your doctor determine if you need more treatment or monitoring.
What Are the Risks of Radical Prostatectomy?
As with any surgery, radical prostatectomy has risks. Short-term problems can include:
- Bleeding
- Infection
- Injury to nearby organs or structures, such as the rectum
Serious complications are not common. They happen in fewer than 5% of surgeries.
There are also two important long-term risks:
- Urinary incontinence. This means leaking urine or having trouble controlling your bladder.
- Erectile dysfunction. This is trouble getting or keeping an erection.
Your risk of these problems depends on:
- Your bladder function before surgery
- Your sexual function before surgery
- The location and extent of your prostate cancer
- How much tissue was removed
- If the nerves involved in erections can be spared during surgery
- Your overall health
These side effects are common concerns after prostate surgery, but not every man will have them, and recovery can take time. Talk with your urologist before surgery about your own risk and what you can expect during recovery.
Making Your Decision
Before deciding whether to have a radical prostatectomy, talk with your urologist about the possible benefits, risks, and alternatives. Ask about your personal risk of side effects, and what recovery is likely to be like. Understanding what to expect can help you make a treatment decision that is right for you.
Among patients newly diagnosed with localized prostate cancer, a large number will have low-risk cancer. The doctor determines this using PSA blood test levels, tumor extent (the size and volume of the tumor as measured by digital rectal examination and/or magnetic resonance imaging [MRI]), and microscopic tumor appearance on biopsy (tumor grade; as described using the Gleason score). While treatments such as surgery or radiotherapy are recommended for many men with prostate cancer, a non-interventional treatment approach called active surveillance may be more appropriate for most men with low-risk prostate cancer.
To be a candidate for active surveillance, men must first have a prostate biopsy to diagnose prostate cancer (low grade, low volume). Men with an elevated PSA who do not have a prostate biopsy (or have had a negative prostate biopsy – no cancer) are on “PSA surveillance,” rather than active surveillance (for prostate cancer).
Active surveillance is based on the fact that only a small number of men diagnosed with low-risk prostate cancer will have their disease cause symptomatic problems by growing to cause urinary issues or by spreading outside the prostate (metastasizing). Prostate cancer treatments, including surgery and radiotherapy, are associated with risks and complications. These include urine leakage (incontinence), impotence (erectile dysfunction), difficulties urinating, and bowel problems. As a result, avoiding (or delaying) treatment may provide a benefit to a patient’s quality of life as long as it doesn’t lead to worse cancer outcomes.
Beginning in 1995, Dr. Laurence Klotz from the University of Toronto and others devised a method to systematically monitor patients. Their intention was to wait to start treating a patient with a plan to cure their prostate cancer. They would begin this treatment if there were any changes indicating that the cancer was more aggressive over time. This became known as active surveillance. It included repeated PSA blood testing, physical examination with digital rectal examination, and repeated prostate biopsy.
Prostate biopsies were repeated for a number of reasons. First, because prostate biopsy is performed as a sample of the prostate, the first repeat (“confirmatory”) biopsy is important to make sure that more aggressive cancer wasn’t missed on the first biopsy. After the repeat biopsy, ongoing biopsies are performed every few years. They are also performed at any point when changes in the physical exam or PSA test results warrant.
Twenty years after first starting this program, Dr. Klotz published results showing that active surveillance was very safe: while 149 of 993 patients had died, 134 of these were from reasons other than prostate cancer and only 15 patients died of prostate cancer. Even more impressively, only 267 (27%) of patients switched from active surveillance to needing treatment. Thus, the majority of men who were followed using this approach needed no treatment, and their cancer did not get worse after 15 years.
Many other groups, including Johns Hopkins Medical Institute, the Royal Marsden Hospital in London, the University of California San Francisco, the Princess Margaret Cancer Centre in Toronto, Memorial Sloan Kettering Cancer Center in New York, the Prostate Cancer Research International Active Surveillance (PRIAS), and the University of Miami have studied this approach, using slightly different rules to determine which patients would be eligible for active surveillance. Each has shown that this is a safe and effective treatment approach.
As a result of these studies, the American Society for Clinical Oncology (ASCO) recommends active surveillance as the “best available care option” for patients with very-low risk prostate cancer and the “preferable care option” for most patients with low-risk prostate cancer. Recent studies have shown that active surveillance is being used more and more in the United States. However, it is used much more commonly in other countries such as Canada, Sweden, the United Kingdom, and others.
MRI now has become much more commonly used for prostate cancer patients, including those considering active surveillance. This has given increased precision to the active surveillance approach. Today, patients treated on active surveillance are likely to have periodic physical examinations, PSA blood tests, MRIs, and prostate biopsies.