Prostate Cancer may not be life-threatening, sometimes it does not even need active treatment.
You have time to get all the information you need before deciding on treatment. You should be comfortable that the treatment is right for you before you go ahead.
Get other opinions if necessary.
Prostate Cancer is quite common these days. Since we have been doing community screening with PSA we have found more cases than previously. This means that some of the men we find today having Prostate Cancer would never have been diagnosed in years gone by. They may never have known that they had Prostate Cancer and would ultimately have passed on with some unrelated problems. Today we make these diagnoses. For at least some of the cases we find, it would be better if they were never treated, as the Cancer is not serious enough to warrant treatment.
On the other hand some cases definitely should be treated, some are definitely life-threatening.
An important advance in treatment of Prostate Cancer is that today Urologists are much better at working out which cases need to be treated and which can be observed. There are several important factors in this decision, these include the PSA level (and how quickly it is rising), biopsy results, MRI scans and the general health and life expectancy of the patient.
For those men who have had a Prostate Cancer diagnosed, but who are not recommended to have surgery (or other treatment aimed at cure), Urologists will usually set up a careful program known as Active Surveillance. This will involve regular PSA tests, often at least one more prostate biopsy and maybe other scans. If the initial recommendation (that surgery is not required) seems to have been wrong, ie that the disease is progressing, treatment is undertaken. The good news is that studies have shown that men who had delayed treatment are no worse off. They do as well as those men who were treated at day one.
So, while some cases of Prostate Cancer are serious and can spread and kill, many are not. It is important that these issues are carefully understood. There is usually no great rush in making treatment decisions. Take your time, get all the information you need and don’t agree to surgery unless you are comfortable that it is right for you.
- Open Surgery
Most men who are found to have prostate cancer are at an early stage of the disease and can be cured. There are a number of factors which tell us how much risk there is of the cancer spreading. Sometimes it is so low that we do not recommend treatment.
These men are followed on a protocol called Active Surveillance. If the cancer progresses while under observation we can change to active treatment, still with excellent prospects of cure. If this protocol is carefully adhered to, outcomes are very good and men do not have the complications and costs of active treatment.
The commonest type of Curative Treatment is Radical Prostatectomy, this involves removing the entire prostate, and often adjacent lymph nodes, in case the cancer has spread to them. The operation used to involve an incision in the lower abdomen and frequently left men with varying degrees of incontinence and impotence. These problems are much less today, whether the operation is done with or without the help of the surgical robot.
Radiotherapy also offers hope of cure of Prostate Cancer. It is given by shining X-rays from outside the body onto the Prostate (“External Beam”) or by surgically inserting radioactive seeds into the prostate (“Brachytherapy”). Proponents claim similar cure rates to surgery, but a different group of complications is a problem. Most patients develop impotence within six months of external beam treatment, some also develop distressing bowel upsets. Brachytherapy has fewer of these complications, but it requires an operation and the long term results for serious cases of Prostate Cancer are questionable.
For most patients requiring curative treatment for Prostate Cancer the choice comes down to Robotic or Open Radical Prostatectomy, and there is very little to choose between these other than cost.
The major difference between the Robot and conventional open surgery for Prostate Cancer is cost.
The commonest type of Curative Treatment is Radical Prostatectomy, this involves removing the entire prostate, and often adjacent lymph nodes, in case the cancer has spread to them. The traditional approach to operate on Prostate Cancer was via open surgery, where the Urologist makes an incision in the lower abdomen to get to the prostate. The prostate is often difficult to reach, as it is deep in the body. In recent years doctors have used laparoscopy to reach the prostate, this is “key hole surgery”, putting instruments and cameras into the body through quite small holes in the body wall.
The advent of the surgical robot fifteen years ago made laparoscopic surgery much easier. The surgeon still directs everything and does all the surgery, but he is seated at a console away from the patient and the robot translates his actions at the console to control tools within the patient. It also controls the video cameras inserted inside the body during the operation to give the surgeon an excellent view.
The differences between the outcomes of “Open” and “Robot” surgery have been controversial. Many surgeons expected the results of the new technology would be better, but, in spite of widespread usage of the technique around the world, there is no clear difference in outcomes. Cancer clearance rates are identical, which is the bottom line for most men. The major complications (things that can go wrong) of Radical Prostatectomy have always been urinary incontinence (wetting, often day and night) and impotence (loss of erections). In recent years these complications have become less common with improvement in surgical techniques, but there is still no real difference between Open and Robotic surgery. The Robot procedure usually involves less bleeding during the operation, somewhat less post-operative discomfort and a shorter time in hospital.
There is now widespread use of the Robotic Radical Prostatectomy technique. Most Australian Urologists use it. Nevertheless a recent highly credible study from Brisbane showed the early results of the two types of operation were indistinguishable.