A wide variety of treatments are used for prostate cancer, depending on the stage of the disease, the patient’s age and overall health, and patient preferences or concerns about potential risks and side effects such as erectile dysfunction, urinary incontinence, and other bladder or bowel problems. For early-stage disease when remaining life expectancy is at least 10 years, prostate cancer surgery is often the preferred option. For most men, this means a nerve sparing radical prostatectomy, in which the prostate is removed while, in most cases, potency is preserved.
Increasingly, this prostate cancer surgery procedure is now done robotically: This minimally invasive prostate cancer surgery shortens hospital stay and may shorten recovery time, while achieving comparable results to traditional open surgery. At UCLA, robotic instruments have been introduced for prostate cancer surgery to improve surgical precision.
Prostate cancer demands individualized treatment. UCLA has expertise in virtually every form of treatment of prostate cancer including radioactive seed implants, new techniques in external radiation therapy, nerve sparing prostate cancer surgery, and cryotherapy. Appropriate patients are offered an “active surveillance” program, allowing avoidance of treatment related side effects until such time as the cancer begin to behave in an aggressive fashion and must be treated.
UCLA has the latest in robotically-assisted minimally invasive technology, and a great deal of experience in this technique. For decades the institution has been known for its success in surgical management of prostate cancer. It is also the home of one of the largest programs that studies the outcomes of treatment and quality of life after prostate cancer treatment. This has enabled the physicians to tell patients, with great accuracy, the exact risk and probability of any complications of treatment.
Robotic Procedure | Minimally Invasive (laparoscopic) Prostatectomy
For many men with early-stage prostate cancer, the robotically assisted minimally invasive prostatectomy has emerged as an attractive option. UCLA physicians are achieving results that are equivalent to the traditional open surgical approach to nerve sparing radical prostatectomy in terms of eliminating cancer and preserving sexual potency and urinary continence for many early-stage prostate cancer patients. Surgeons are able to obtain pictures of the surgical site with 15-fold magnification, and insert miniaturized instruments to remove the prostate. The introduction of robotic instruments has helped to improve surgical precision. Surgeons are able to sit in a console with a three-dimensional view inside the patient and move three robotic arms with the full natural range of motion, while a fourth robotic arm controls the camera. The instruments can act like human wrists, giving surgeons greater flexibility as they use the robot to manipulate the tiny surgical tools inside the bodyThe minimally invasive approach offers the advantages of shorter hospital stay and recovery time and less blood loss.
Studies of outcomes with the robotically assisted minimally invasive prostatectomies at UCLA have been very encouraging. Arguably the most important indicator of the success of a nerve sparing radical prostatectomy is whether there are positive surgical margins - cancer found at the farthest edges of the specimen after it is removed. When this occurs - as it does as often as 40% of the time in the community - the risk of recurrence is twice as high as when it does not. Of more than 100 robotically assisted minimally invasive prostatectomies at UCLA, the positive margin rate is only 10% - equal to the rate of the open approach, and as low as any rates reported in the nation.
Early-stage prostate cancer can also be successfully treated with prostate radiation therapy – the use of high-energy rays delivered by external beam, or, more recently, by radioactive seeds implanted into the prostate under ultrasound guidance, which then emit high doses of radiation exclusively to the prostate over the course of several months (an approach known as brachytherapy). For patients with early-stage prostate cancer in whom radical prostatectomy or radiation is not a good option, cryoablation is a minimally invasive procedure that destroys the cancer cells by rapidly freezing and thawing the cancerous tissue. Still others, particularly older patients, choose an “active surveiilance” approach in which there is no immediate treatment but the tumor continues to be closely monitored.
For patients with later-stage prostate cancer, or those who are at high risk for recurrence, treatment often includes hormone therapy, which aims to lower the levels of androgens – male hormones such as testosterone – that help prostate cancer cells to grow. Hormone therapy can control but will not cure prostate cancer, and eventually patients’ cancer cells will develop a resistance to the treatment. For this reason, many patients with advanced disease choose to enroll in clinical trials of promising new experimental treatments.
Several non-surgical options are also available for early-stage prostate cancer patients:
Since the early 1990s, UCLA has offered brachytherapy, in which a urologist, working in collaboration with a radiation oncologist and physicist, implants small radioactive pellets, or seeds, into the prostate under ultrasound guidance. The pellets then emit high doses of radiation exclusively to the prostate over the course of several months, minimizing prostate radiation exposure to the surrounding healthy tissues. At UCLA, which has an extensive database of brachytherapy cases, patients return for follow-up visits one month after the procedure so that their doctors can ensure through a CT scan that the radiation is being appropriately distributed.
High-dose-rate (HDR) Brachytherapy can be used as the only treatment for prostate cancer or it can be used in combination with external beam radiation therapy (EBRT). When used as single treatment it is known as "HDR Monotherapy" and when given with external beam it is known as "combined HDR and EBRT".
UCLA is also bringing the latest advances in radiotherapy to patients who opt for prostate radiation treatment over surgery. With advances in computer and imaging technology, radiation treatment has evolved in recent years from conventional extra-beam radiation therapy to three-dimensional, image-guided therapy that better conforms to the tumor. More recently, radiation oncologists have begun intensity-modulated radiotherapy, a more advanced approach to high-precision, three-dimensional image-guided radiotherapy.
During the course of prostate radiation treatment, which typically lasts six to eight weeks, the tumor and prostate gland can move. Therefore, UCLA physicians have begun using the newest technique, image-guided radiotherapy (IGRT). Three seeds are implanted inside the prostate to provide a way of tracking the gland; this allows doctors, with the aid of the computer-guided technology, to adjust the radiation beam based on a more up-to-date view of the position of the target tumor and organs. IGRT is currently being offered to patients with low-risk early-stage prostate cancers.
When patients experience a cancer recurrence following radiation treatment, surgery tends not to be a good option. For these individuals, cryotherapy can be an effective alternative. Cryotherapy involves the application of extreme cold to destroy diseased tissue, including cancer cells. In addition to patients who have previously had radiation treatment, men who are not concerned about potency may find cryotherapy appealing: Aside from impotence, which occurs in all patients, the procedure's side-effect profile is favorable compared to other prostate cancer treatments.