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CANCER OF THE PROSTATE, SURGICAL ALTERNATIVES
This informational article is for men who have had a positive prostate biopsy and are contemplating treatment for prostate cancer. Most men these days have prostate cancer diagnosed because of an unusual PSA. On occasion, a rectal examination tips off the examiner that there may be a problem. Since prostate cancer may occur in only a portion of the prostate gland, multiple cores are taken to sample the prostate. The normal prostate gland is about the size of a chestnut and weighs about 15 grams in the young adult male. The prostate gland is composed of microscopic tubular-like structures that produce fluid, which help the sperm to live in the female genital tract. These small tubular structures are also called glands, which makes the terminology a little confusing. The architecture of these microscopic glands is different with respect to prostate cancer, and it may take on various forms depending on the aggressiveness of the cancer; the more aggressive the cancer, the shorter the life expectancy of the patient. The Gleason scoring system takes into consideration these various different forms, from the least aggressive, 1; to most aggressive, 5. Frequently, there are two different patterns of cancer. For instance, there may be a pattern 3 and a pattern 4. The life expectancy is midway between that of a patient with pure grade 3 and that of a patient with a pure grade 4 prostate cancer. A person whose prostate cancer carries a pattern 3 plus a pattern 4, would be classified as a prostate cancer, Gleason score of 3+ 4 = 7. If there were only one pattern, the Gleason score would be 3 + 3 = 6. As you can see, any prostate cancer can be grouped into a general class from 2 to 10 depending on the pattern seen on the biopsy, 2 being the least aggressive and 10 being the most aggressive. In addition to the Gleason score, the number of positive cores and the percent of each individual core that is positive has an impact upon the life expectancy as well.

An Illustration of the Gleason Grading System

1 Simple round glands, closely packed in rounded masses with well-defined edges. 2 Simple round glands, loosely packed in vague, rounded masses with loosely packed edges. 3A Medium-sized single glands of irregular shape and irregular spacing with ill-defined infiltrating edges. 3B Very similar to 3A, but small to very small glands which must not form significant chains or cords. 3C Papillary and cribriform epithelium in smooth, rounded cylinders and masses; no necrosis. 4A Small, medium, or large glands fused into cords, chains or ragged, infiltrating masses. 4B Very similar to 4A, but with many large clear cells, sometimes resembling "hypernephroma." 5A No glandular differentiation, solid sheets, cords, single cells, or solid nests of tumor with central necrosis. 5B Anaplastic adenocarcinoma in ragged sheets.

PSA stands for prostate specific antigen. It is a molecule made only in the prostate gland ejaculated with orgasm and helps the sperm live in the female genital tract. Some of it, however, leaks into the bloodstream. Under certain conditions, for instance, trauma to the prostate gland, cystoscopies, infection in the genital tract and cancer the PSA may rise.

Prior to any decision about treatment for the prostate cancer, we take into consideration several variables. Since prostate cancer usually grows slowly, patients should have a 10-year life expectancy prior to undergoing treatment. The reason this is important is if there are coexisting problems, for instance out-of-control diabetes, out-of-control hypertension or severe cardiac problems, prostate cancer treatment may not need to be considered especially in patients with a low aggressiveness prostate cancer. You must remember that cardiovascular disease is still the number one killer of men in the United States. If a man has a greater than 10-year life expectancy, we should look at the different options available for treatment of patients with prostate cancer. Since I am a urological surgeon, my expertise is in treating patients surgically for prostate cancer. Although there are various other modalities, for instance x-ray therapy, also called radiotherapy, also called external beam or brachytherapy, the intent of this article is to discuss the various different surgical options for prostate cancer treatment.

Almost everyone who has a diagnosis of prostate cancer has had a rectal examination, a PSA and the results of the biopsies. Using these and some information developed by Allen Partin, M.D. from John Hopkins University, we are able to classify patients into certain categories to predict the extent of the prostate cancer that will be found at surgery. For a full discussion of the Partin tables please see the web site at Johns Hopkins http://urology.jhu.edu/Partin_tables/. Following surgery, there are certain categories that can be defined when the prostate gland is submitted for its analysis. The prostate cancer can either be confined to the prostate gland (organ-confined disease). It may penetrate through the capsule but the cancer may still be removed (established capsular penetration). It might invade the seminal vesicles (seminal vesicle involvement) or it might have already spread to the local lymph nodes (lymph node involvement). Knowing the inputs, which are physical examination, Gleason score and PSA values; we can accurately predict the final stage of the cancer. Prior to the PSA era, almost everyone had a lymph node dissection to determine whether the prostate cancer had spread outside the prostate gland or not. If the prostate cancer has spread, it is generally agreed that prostate surgery will not be beneficial. Therefore, if the lymph nodes are involved, there is no reason to remove the prostate. Now that we are fairly able to predict this "lymph node involvement" with some certainty and if the chances are low, perhaps the lymph nodes do not need to be sampled at all. If the lymph nodes do not need to be sampled, then perhaps a different approach to the prostate gland can be attempted. Whereas most urologists would remove the prostate gland through a retropubic approach, an approach very similar to a cesarean section for delivering babies in women, I prefer the perineal approach, which, using the same analogy, is an approach very similar to a vaginal delivery. The perineum is that area of the body between the anus and scrotum in males (in females it is the area between the anus and vagina). The advantages to a retropubic approach would be the removal of the lymph glands at the time of surgery. With our ability to "stage" the prostate cancer and determine ahead of time the chances that the lymph nodes will be positive, we can tailor the route of removal so there is less impact on the patient. If there is a very low chance that the lymph nodes are going to be positive, then perhaps removing the prostate gland through the perineum would be preferable. The perineal approach does have its drawbacks in that lymph nodes are not available for sampling.

Advantages of radical perineal prostatectomy compared to radical retropubic prostatectomy:

• A small hidden incision for better cosmesis
• Avoidance of major muscle groups
• Less pain
• Faster return to work and strenuous activities
• Fewer adverse cardiovascular effects due to reduced fluid shifts
• Less blood loss
• Excellent posterior exposure to limit positive margins posteriorly, laterally, and apically
• Precise watertight anastomosis done under direct vision
• Easier for patients who are obese
• Avoidance of scar tissue from previous abdominal surgery
• Better visualization of the prostatic apex than with RRP, facilitating avoidance of positive apical margins, ease in sparing the neurovascular bundles, and better visualization of the membranous urethra.

There is an excellent web site http://www.emedicine.com/med/topic3053.htm#target1 that has much information including pictures of an actual operation, that the interested reader is encouraged to visit.

There are risks associated with any surgery including bleeding, infection, pain and damage to adjacent organs. Specific to the radical perineal prostatectomy, the risks are:

• Bleeding, perhaps requiring blood transfusions;
• Thromboembolic phenomenon, (blood clots forming in the leg or pelvic veins, then breaking off and floating downstream to the heart or lungs);
• Injury to the rectum (since the prostate sits right next to the rectum this can be lacerated);
• Sciatic neuropraxia (stretching of the sciatic nerve with subsequent pain in the back of the leg);
• Bladder spasms;
• Persistent wound drainage;
• Urinary fistula (urine draining out of the incision);
• Anal incompetence (loss of control of the bowel);
• Scrotal hyperesthesia (increase of sensation or pain of the scrotum);
• Anastomotic strictures (narrowing or scar formation at the level of the connection of the urethra to the bladder);
• Detectable PSA (after surgery the PSA should be zero);
• Impotence (this can be treated with medications or an implant);
• Incontinence ( loss of urinary control);
• Enterocutaneous fistula (a connection between the bowel and the skin);
• Perineal hernia (a weakness of the supporting structures of the perineum).
• Death.

Most of the risks are uncommon, manageable, and not life threatening.

Prostate cancer if left untreated in a man with a ten-year life expectancy can be devastating. The risks of untreated prostate cancer include:

• Bleeding;
• Thromboembolic phenomenon;
• Urinary incontinence, or leakage;
• Urinary obstruction including blockage of the kidneys leading to kidney failure and the need for dialysis;
• Impotence;
• Spread of the cancer to adjacent organs;
• Bladder spasms;
• Spread of the cancer to distant organs, and bones including the spinal collumn;
• Bone fractures, spinal fractures and paralysis;
• Anemia;
• Death.

If you would like to come in to discuss the surgical options for prostate cancer, please schedule an appointment for a private consultation. Spouses are welcome to attend.

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