OVERVIEW

Prostate cancer is the most common cancer diagnosed among American men, accounting for nearly 200,000 new cancer cases in the United States each year.  Prostate cancer tends to occur most commonly in men over the age of 50, and greater than 65% of all cases are diagnosed in men 65 years and older.  The incidence of prostate cancer increases with age; the lifetime risk for the average American man is about one-in-six, but only 8% of men develop prostate cancer between the ages of 50 and 70 years.  Well-established risk factors include older age, family history, and race (African Americans are at greater risk).  Other potential risk factors thought to be associated prostate cancer include a Western diet high in saturated fat and obesity.

The overwhelming majority of prostate cancers are adenocarcinomas, which arises from the glandular (acinar) component of the prostate.  Other rare and atypical types of prostate cancer include:

• Ductal carcinoma
• Mucinous carcinoma
• Signet-ring cell carcinoma
• Small cell carcinoma
• Clear cell adenocarcinoma
• Giant cell carcinoma

These rare and atypical variants often act aggressively and may respond differently to therapy than the more common prostate adenocarcinoma.  As they are rare, however, most men are unaffected by these atypical variants. 

The face of prostate cancer has changed significantly over the past 2 decades.  Largely due to the widespread use of prostate specific antigen (PSA), most prostate cancers are now diagnosed at an earlier stage and younger age compared to 20 years ago.  Although prostate cancer deaths have decreased in recent years, PSA screening continues to be controversial.  While not endorsed universally, the American Cancer Society and American Urologic Association recommend prostate cancer screening beginning at age 50 for most men and at 40 years of age for African American men and those with a family history.


Local prostate cancer
Approximately 90% of prostate cancers are diagnosed at a localized stage (cancer confined to prostate without evidence of spread).  Localized cancers are most commonly detected through an elevation in PSA without causing symptoms.  Less commonly, prostate cancer may be detected by an abnormal digital rectal exam (DRE) or due to urinary symptoms, such as hematuria (blood in the urine) or problems with urination (difficulty or discomfort with urination).  Not all local prostate cancers are the same.  Some are indolent and will not cause problems while others are clinically significant and require treatment.  Even among clinically significant cancers, there are differences that further separate cancers by risk (for example, low, intermediate and high risk prostate cancer).  Factors that determine the risk and clinical significance of prostate cancer include PSA, Gleason grade and disease stage.  There are several effective treatment options for men with clinically significant local prostate cancer, including surgery, external radiation therapy and interstitial brachytherapy.  Treatment recommendations are usually made based on a number of factors, including disease characteristics, risk category, candidacy for a particular treatment, and patient preference.  In some cases (low- and intermediate-risk prostate cancer, for example), a single treatment may be adequate for disease control.  For others, particularly in high-risk prostate cancer, a combination of treatments may be required.  For low-risk prostate cancer and among older men, active-surveillance (observation) is another management option.  Although effective in cancer control, most prostate cancer treatments carry some risk of impacting urinary, sexual and bowel health.  Newer treatment methods, however, continue to be developed to minimize the risks of these side effects (for example, nerve-sparing radical prostatectomy).  Following treatment, approximately 15% to 25% of patients with early-stage (localized) prostate cancer experience a biochemical (PSA) recurrence, indicating possible need for additional therapy.  However, the overall 5-year survival for patients with localized kidney cancer is close to 100%.

Advanced prostate cancer  
Approximately 10% of prostate cancers are diagnosed at an advanced stage characterized by involvement of surrounding structures, spread to lymph nodes or metastasis to more distant sites.  Advanced prostate cancer more commonly causes some symptoms, such as hematuria, urinary obstruction or bone pain.  Treatment options for patients with metastatic prostate cancer are more limited, although in some settings, surgery or radiation therapy may still be indicated.  More commonly, androgen deprivation therapy (ADT), also known as hormone therapy, is used to control metastatic disease and slow the growth of more advanced prostate cancers.  Chemotherapy may also be used to manage patients with metastatic prostate cancer, although it is not a mainstay of management.  Common sites of metastatic spread include the bone, liver and lungs.  The overall 5-year survival for regionally advanced and metastatic prostate cancer is approximately 32%.

Signs & Symptoms
For most men, prostate cancer does not cause symptoms but is detected because of an elevation in prostate specific antigen (PSA).  However, symptoms of the lower urinary tract, such as hematuria (blood in the urine), frequency (need to urinate frequently) and dysuria (discomfort or pain with urination) may be signs of prostate problems, including prostate cancer.  Other uncommon symptoms of prostate cancer can include urinary retention, weight loss, abdominal pain, bone pain, or fracture.

Lower Urinary Tract Symptoms (Prostatism)
Frequency
Urgency
Hematuria (visible or microscopic)
Dysuria
Urinary retention

Pain Symptoms  
Back pain
Pelvic pain
Bone pain

Constitutional symptoms
Weight loss

Diagnosis

• Physical examination
• PSA blood test
• Prostate biopsy
• Abdominal and pelvic CT scan
• Bone scan (if indicated)

After taking a detailed medical history and performing a physical examination, including a digital rectal examination, a PSA blood test will be performed.  If the PSA level is elevated, a prostate biopsy will be recommended.  The biopsy is an outpatient procedure (you go home the same day) that is performed with local anesthesia.  Several samples of tissue are obtained from the prostate.  These samples are what tell us if you have prostate cancer.  If the biopsy is positive, other tests may be performed based on your PSA level, cancer grade and findings on exam.  Most commonly, a CT scan of the abdomen and pelvis will be obtained for clinical staging.  In high-risk cases, a bone scan may be recommended to determine if there has been spread to the bones.


Staging for prostate cancer
Clinical staging is performed with Physical Examination and Abdominal and Pelvic CT scan.  In cases of advanced or high-risk disease, additional testing such as Bone Scan may be necessary.

The prognosis of prostate cancer is directly linked to the stage of disease.  Staging is a process that demonstrates how far the cancer has spread.  Both treatment options and prognosis (or outlook) for prostate cancer depend significantly on the stage of disease. 

Treatment
Most prostate cancers are localized and can be treated with surgery, external radiation therapy or interstitial brachytherapy.  In low-risk disease, observation or active surveillance may also be an option.  Focal therapy using ablative technology is less common and is currently under investigation.  Treatments for localized prostate cancer include:

• Radical retropubic prostatectomy
• Robotic-assisted laparoscopic prostatectomy
• Radical perineal prostatectomy
• 3D-conformal radiation therapy
• Intensity-modulated radiation therapy
• Interstitial brachytherapy
• Focal therapy
• Active Surveillance (observation)

Radical retropubic prostatectomy (RRP) – consists of removal of the prostate gland and surrounding lymph nodes through an 8 cm open incision above the pubic bone.  Radical retropubic prostatectomy is the most common open surgical approach to treating prostate cancer, and can be used to treat a range of prostate cancer, including low, intermediate and high-risk localized prostate cancer, as well as radiation refractory prostate cancer (termed salvage prostatectomy).  Most patients spend 1-2 nights in the hospital and are sent home with a urinary (Foley) catheter, which stays in for a week following surgery to encourage healing of the urethra.  Depending on the stage and risk of the disease, radical retropubic prostatectomy can be performed with nerve-sparing.  Nerve-sparing prostatectomy provides the best chance of return of erections following surgery in men with good erectile function prior to treatment, and is typically used in low and intermediate-risk disease.  In setting of high-risk disease, however, nerve-sparing may not be indicated as it may limit cancer control (removal of all cancer tissue).  Like other types of surgical therapy, outcomes following radical retropubic prostatectomy (cancer control, urinary continence, erectile function and complications) tend to be better, on average, when performed by high-volume and fellowship-trained surgeons.

Robotic-assisted laparoscopic prostatectomy is one of the most common types of surgical treatments for prostate cancer, and its use in the management of localized prostate cancer has increased rapidly in recent years.  The robotic approach takes advantage of the benefits of laparoscopy as well as small surgical working elements that replicate the movement of the human hand.  In general, RALP is associated with less blood loss, a lower chance of requiring a blood transfusion, decreased pain post-operatively, and shorter convalescence.  As with RRP, lymph nodes are removed with the prostate for pathologic staging.  Patients tend to spend 1-2 nights in the hospital and are sent home with a urinary (Foley) catheter that stays in place for 7 to 10 days.  As with open surgery, this procedure should be performed by a surgeon familiar with the robot and who is trained in performing radical prostatectomy.  In general, high-volume (those surgeons who perform many procedures) and fellowship surgeons tend to have better outcomes than low-volume and non-fellowship-trained surgeons.

Radical perineal prostatectomy consists of removal of the prostate through an incision in the perineum (the area between the scrotum and anus), and was the first surgical approach used to treat prostate cancer.  Today, perineal prostatectomy is relatively uncommon, but it is still used in certain cases, such as in obese patients in which access to the prostate from pelvis would be difficult.  In intermediate and high-risk cases in which lymph node dissections are indicated, a separate lymph node dissection may be indicated to complete staging. Because it is an uncommon surgery, the surgeon should be familiar in this surgical approach.

3D conformal and Intensity-Modulated Radiation Therapy – Radiation therapy is an effective treatment for prostate cancer and can be used to manage low and high-risk cases.  Currently, two types of external radiation therapy are used.  3D-conformal RT targets the prostate with the aid of imaging guiding to more accurately deliver radiation dose to the prostate with less radiation therapy exposure to surrounding tissues.  Intensity-modulated RT uses more advanced technology to reduce dose to the areas of the bladder, rectum and bowel and boost dose to the prostate.  For both modalities, a total radiation dose of 76 Gy should be administered and some studies have shown that higher doses are more effective.  Radiation therapy is typically given in daily fractions over the course of 10 weeks.  In intermediate- and high-risk prostate cancer, RT should be administered with ADT to maximize the treatment effect.

Interstitial prostate brachytherpay involves placement of small radioactive pellets, or “seeds” into the prostate.  In general, this treatment can be used for small to normal sized prostates and for Gleason grade 6 or less tumors.  In settings of higher risk disease (PSA>10 ng/mL or Gleason grade ³ 7) where there is concern for extraprostatic extension, external radiation therapy should be used in conjunction with interstitial bracytherapy to ensure adequate cancer control.  In some cases, hormone therapy may be used before brachytherapy to help reduce the size of the prostate.

Active surveillance (observation) is used in some cases of low-risk disease, as well as among older patients for whom active treatment with surgery or radiation therapy may not be possible or necessary.  Active surveillance is most often used because some prostate cancers may never become life threatening.  PSA and DRE are typically checked periodically, and current active surveillance protocols recommend repeat biopsies to ensure that disease does not progress.

Focal therapy – ablative therapies such as cryoablation, radiofrequency ablation and high-frequency ultrasonic ablation are currently being studied as a way to limit treatment to the focal location of the cancer instead of treating the entire prostate with the hopes that focal therapy will be associated with fewer side effects than other non-focal treatments.  Selection of appropriate, low-risk patients is essential because less therapy may not be adequate to control higher-volume or high-risk prostate cancer.  Other concerns regarding focal therapy include targeting the tumor within the prostate accurately, identifying other areas of cancer within the prostate and offering more effective management compared to active surveillance.

Salvage therapy – In cases of prostate cancer recurrence following primary treatment, a secondary local therapy can lead to salvage and cure.  Depending on which type of treatment was first used, salvage surgery, radiation therapy or cyro-abalation may be used to control recurrent disease.  

OUR SURGEONS

At the University of Florida, Department of Urology, conventional (open) and robotic-assisted laparoscopic radical prostatectomy is performed by several experienced fellowship-trained surgeons.  Our surgical team includes Drs. Chester Algood, Phillip Dahm, Scott M. Gilbert, Sijo Parekattil, Charles J. Rosser and Li-Ming Su.

	Chester B. Algood, MD, FACS Clinical Assistant Professor Medical Director, Urology Clinic
	Phillip Dahm, MD, MHSc Associate Professor Director of Clinical Research
	Scott Gilbert, MD Assistant Professor of Urologic Oncology Medical Director, Urology Quality & Safety Program
	Sijo J. Parekattil, MD Co-Director of Robotic Surgery Director of Male Infertility and Microsurgery Assistant Professor of Urology Adjunct Professor of Bio-Engineering
	Charles J. Rosser, MD, FACS Assistant Professor of Urology
	Li-Ming Su, MD David A. Cofrin Professor of Urology Associate Chairman of Clinical Affairs Chief, Division of Robotic & Minimally Invasive Urologic Surgery

APPOINTMENTS

To schedule an appointment with one of our surgeons, please contact the UF Shands Medical Plaza GU Oncology Clinic at 352-265-8282. For  more information, directions to the Medical Plaza and local accommodations please visit: http://www.urology.ufl.edu/urocare_patientinfo.php

PROSTATE CANCER PRE-SURGERY

What to expect during you preoperative consultation

Prior to your initial consultation with your surgeon it is important that we obtain all radiological diagnostic and staging results pertaining to your diagnosis of prostate cancer.  Our office may request these records from your referring physician/hospital, including physician notes, biopsy reports, radiology reports and films, as well as pathology slides if available.  Your surgeon will then review your chart to determine the best course of action individualized to your particular circumstance.  In some cases, additional tests may be required to complete the staging evaluation, provide additional information regarding your disease and/or direct the best course of treatment.  During your consultation, all treatment options for prostate cancer will be discussed with you.  A physical examination will also be performed and if you choose, a surgery date will be determined with one of our Surgery Scheduling Coordinators.

What to expect prior to the surgery

Once your surgery date is secured by one of our Surgery Scheduling Coordinators, the items listed below will be ordered as necessary based upon your age, medical history and risk for surgery.  These will be performed through a preoperative anesthesia consultation at the Presurgical Center at UF & Shands that will be arranged for you at your initial visit.  During this consultation you will have the opportunity to speak to the anesthesia staff regarding the types of anesthesia available and the risks/benefits.

• Physical exam
• EKG (electrocardiogram)
• Chest X-ray
• CBC (complete blood count)
• PT / PTT (blood coagulation profile)
• Comprehensive Metabolic Panel (blood chemistry profile)
• Urinalysis

Preparation for surgery

Medications to Avoid Prior to Surgery
The following is a list of medications to avoid at least 7-10 days prior to surgery.  Many of these medications can alter platelet function or your body’s ability to clot and therefore may contribute to unwanted bleeding during surgery.  Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery.  Do not stop any medication without contacting the prescribing doctor to get their approval.

Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix

A formal list of these medications and others will be provided to you by our Surgery Scheduling Coordinators.

Bowel Preparation and Clear Liquid Diet
Patients should adhere to a clear liquid diet 48 hours prior to surgery.  An example of a clear liquid diet is listed below.  In addition, bowel preparation with Fleets Phosphosoda or Magnesium Citrate the evening before surgery is often prescribed.  These can be purchased at your local pharmacy.  Do not eat or drink anything after midnight the night before the surgery.


Clear Liquid Diet
Remember not to eat or drink anything after midnight the evening before your surgery.
Clear liquids are liquids that you are able to see through.  Please follow the diet below.

• Water
• Clear Broths such as chicken or beef (no cream soups, meat, noodles etc.)
  
• Juices (no orange juice or tomato juice)
• Apple juice or apple cider
• Grape juice
• Cranberry juice
• Tang
• Hawaiian punch
• Lemonade
• Kool Aid
• Gator Aid
• Tea or coffee (you may add sweetener, but not cream or milk)
• Jello, popsicles, Italian ice (without fruit)

THE SURGERY

The Operation

Prostatectomy can be performed through an open retropubic, perineal or robotic-assisted laparoscopic approaches.  In most cases, general anesthesia will be used, although in some, a regional anesthetic with an epidural catheter will be recommended. While operative time varies from one individual to another and according to the type surgery used (laparoscopic or open), the average operating time is approximately 3 hours.
Radical Retropubic Prostatectomy:
Robotic-Assisted Laparoscopic Prostatectomy:
Perineal Prostatectomy:

Video Clips

The following is a series of video clips that demonstrate key steps of radical prostatectomy.

Potential Risks and Complications

As with any major surgery, complications, although rare, may occur.  Potential risks and complications with this operation include but are not limited to the following:

• Bleeding: Blood loss following open radical prostatectomy ranges between 500-1000 mL.  For robotic prostatectomy, blood loss is usually less than 200 mL.  Blood transfusions are uncommon, but more likely following open surgery.  Your surgeon will review your individual risk of bleeding with you during your consultation and in planning for surgery.  If you are unable to receive a blood transfusion for medical or personal reasons, please convey this information to your surgeon as soon as possible. 

• Infection: Although patients are given broad spectrum intravenous antibiotics immediately prior to surgery, infections of the urinary tract and skin incisions may still occur but are rare.  If you develop any signs or symptoms of infection after the surgery (fever, drainage from or redness around your incisions, urinary frequency/discomfort, pain) please contact us at once.

• Tissue / Organ Injury: Although uncommon, adjacent organs and tissues may be injured as a result of your surgery.  This includes injury to the rectum, bowel, vascular structures, nerves.  On rare occasions, further surgery may be required to address unexpected injuries to adjacent organs.

• Functional Outcomes: Most men regain urinary control (continence) following surgery, although recovery may take some time (up to 6 to 12 months in some men).  The risk of urinary incontinence requiring persistent use of pads or further medical management is between 2-5%.  Between 3-5% of men develop bladder neck contracture, a stricture or scar tissue at the site where the bladder was reconnected to the urethra.  This can be managed with a straight-forward endoscopic (camera) procedure, although it can delay recover of your urinary continence.  Sexual function (erections) return in between 60-75% of men depending on their age, quality of erections before surgery and use of nerve-sparing.  However, erections may take up to or more than a year to return and may be weaker than those obtained prior to surgery.

POST-SURGERY

During your hospitalization

Immediately after the surgery you will be taken to the recovery room and then transferred to your hospital room after a period of observation.

• Postoperative Pain: Pain at their incision sites is common, but is generally well controlled by use of intravenous pain medication, patient-controlled anesthesia pump, or oral pain medication provided by your nurse.

• Nausea: Nausea is common following any surgery especially when general anesthesia is used.  This is usually transient and controlled by medication which can be administered on an as needed basis by your nurse.

• Urinary Catheter: During your surgery, a urinary catheter (also called Foley catheter) will be placed to monitor your urine output.  After surgery, the catheter is generally left for a week following surgery.
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• Drain: During your surgery, a temporary surgical drain may be placed to drain any excess fluid from around the surgical site.  Drains are typically removed before you go home, although in some cases they may be left longer.

• Diet: Your diet will be advanced following surgery from sips of water to liquids to solid food.  You may not have an appetite following surgery because of the effects of the procedure and anesthesia.  If you are nauseated, you should go slowly to avoid exacerbating your abdominal discomfort.  While you are not eating, you will receive intravenous hydration through an intravenous catheter.

• Fatigue: Fatigue is quite common following surgery and should subside in a few weeks following surgery.

• Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you by the nursing staff during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.

• Ambulation: Usually the day after surgery you will begin to ambulate with the supervision of your nurse or family member.  Walking helps prevent pneumonia and blood clots from forming in your legs.  You can also expect to have SCD's (sequential compression devices) wrapped around your lower legs and calf area to prevent blood clots called deep vein thrombosis from forming in your legs.  In the days that follow surgery, patients are advised to walk at least 4-6 separate times a day in the hallways.  This serves to further reduce the change of deep vein thrombosis and speed the return of bowel function.

• Constipation/Gas Cramps: You may experience sluggish bowels for several days following surgery as a result of the anesthesia.  Suppositories and stool softeners are usually given to help with this problem.  Taking a teaspoon of mineral oil daily at home will also help to prevent constipation.  Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.

• Hospital Stay: The length of hospital stay following prostatectomy is typically 1-2 days.  In general, laparoscopic surgery results in a shorter hospitalization compared to open surgery.

What to expect after discharge from the hospital

• Pain Control: For the majority of patients, one to two weeks of oral narcotic pain medication may be necessary after which Extra Strength Tylenol is usually sufficient to manage their pain.  Again, narcotics should be minimized to avoid constipation and over sedation.

• Showering: Patients can shower immediately upon discharge from the hospital allowing their incisions to get wet.  Once out of the shower, pad your incision sites dry and avoid any heavy creams or lotions.  Tub baths or hot tubs in the first 2 weeks are discouraged as this will allow for prolonged soaking of your incisions and increase the risk of infection.  If you received skin staples to close your wound, they will be removed 1-3 weeks after surgery.  Adhesive tapes called Steri-stripes may be applied to the incision and can be removed in another 1-2 weeks.

• Activity: Walking 4-6 times a day for the first two weeks after surgery on a level surface is strongly encouraged as prolong sitting or lying can increase your risk of pneumonia and deep vein thrombosis. It is permissible to climb stairs. No heavy lifting or exertion for up to 4 weeks following surgery.  Patients may begin driving once they are off of narcotic pain medication and have full range of motion at their waist (around 4 weeks after surgery). Most patients can return to full activity including work on an average 6-8 weeks after surgery.

• Diet:  Generally, there are no dietary restrictions once you return home from your hospitalization. You should, however, drink plenty of fluids.

• Follow-up Appointment: Patients should make a follow-up appointment with their surgeon by contacting the Shands Medical Plaza Urology Clinic at 352-265-8240. Your surgeon will let you know the timing and schedule of clinic visits following surgery.

• Pathology Results: The pathology results from your surgery are usually available in 1-2 weeks following surgery. This will provide information regarding the type of cancer, extent of growth, final pathologic stage. Your results will be discussed with you in the office during a follow-up clinic appointment. At this time, the significance and prognosis of your diagnosis will be discussed.

• Blood Tests and X-rays: Patients are advised to adhere to a strict follow-up regimen which will include blood tests to monitor your electrolytes and kidney function and radiographic tests including Chest X-ray and Abdominal CT scan.  Periodic testing allows for early detection of any problems following your surgery.

WHEN TO CALL YOUR DOCTOR

Serious adverse events are rare following prostatectomy, but it is important for patients to recognize these events and know when to contact their surgeon. You should contact your surgeon or primary care doctor immediately if any of the following occur:

• Worsening pain over the ensuing days following your surgery despite the use of oral pain medication/.
• Fevers >101^o F may indicate a serious infection. 
  
• Persistent nausea and vomiting
  
• Chest pain or difficulty breathing

Frequently Asked Questions (FAQs)

What can I do to limit the side effects of surgery?
The important factors related to recovery of urinary and sexual function after surgery are related to your function prior to surgery and recovery following surgery.  To improve your urinary control, you can practice Kegel exercises both before and after surgery.  Erections may take longer to return and you may require some assistance from medications, such as sildenafil (Viagra).  Pelvic rehabilitation with a dedicated physical therapist may also be helpful if problems continue.

What are my chances of cure following surgery?
Prognosis following prostate cancer surgery varies depending on the final pathology and disease stage, but in general is very good.  For early-stage, localized disease, survival at 5-years approaches 100%, although approximately 25% of men may experience a PSA recurrence following treatment.  Your surgeon will discuss your specific prognosis with you when reviewing your pathology.

Will I need further treatment following surgery?
Depending on your risk of recurrence and/or final pathology, you may benefit from additional therapy in the form of adjuvant radiation therapy or androgen deprivation (hormone) therapy.  The need for additional therapy will be discussed with you during your consultation and follow-up visits.