Caduceus


Articles




























Marcus H. Loo, M.D.


Articles by Dr. Loo

The Prostate Diseases of the Prostate Prostate Cancer
Watchful Waiting Understanding the Risk Factors The Controversial PSA Test
Temporary Incontinence Radiation Therapy Restoring Potency
Surgery: Radical Prostatectomy | Brachytherapy

THE PROSTATE

Overview Mechanics Geography Hormones

Overview

Most men don't really know how long the prostate lasts, or what exactly it does, for that matter. Indeed they are often unaware of its existence until problems begin. Some mistakenly call it their prostrate, which may be a more appropriate word to describe how they feel when they have chronic problems with their prostate. Most do know, however, that the prostate has to do with sex and if it is removed it could ruin their sex life as they know it. This is a compelling fear, and probably the reason why so many men never seek treatment for prostate problems, even those brought on by the ordinary and natural condition of aging.

The prostate is a gland of the male reproductive tract and its primary role is to produce seminal fluid. It sits like a doughnut at the base of the bladder with the urethra passing through the hole of the doughnut. The urethra carries urine or ejaculate out through the penis. The rectum lies directly behind the prostate, and it is this back part of the prostate that can be reached by the doctor during a digital rectal examination (DRE).

When a man is born, his prostate gland is about the size of a pea, and weighs one gram, which is a fraction of an ounce. There are two spurts of growth in the prostate. One, at puberty, when the prostate gland grows until it matures around age 20 and is the size of a golf ball. It weighs 15 to 20 grams (still less than an ounce). Another growth spurt occurs when a man is in his 40s or 50s. This enlargement is known as benign prostatic hyperplasia (BPH), which is explained in the next chapter. By the time a man is 70 or 80, his prostate can weigh 30 to 60 grams (one to two pounds), or more. Some men have prostates bigger than an apple.

The prostate is made of smooth muscle, and spongy glandular and fibrous tissue. The glands are lined with cells that secrete fluid which is deposited in the urethra during ejaculation through a system of branching ducts. The smooth muscle and fibrous tissue are interwoven between the glandular tissue, much the way the glands and milk ducts are interwoven in the female breast. In middle age, or when the prostate begins to enlarge, the smooth muscle and connective tissue is known as the stroma. The most striking feature of the enlargement of the prostate is this stromal outgrowth.

  • Seminal vesicles, which look like two clusters of tiny grapes, lie on either side of the prostate. These glands produce the sticky secretion that gives semen its consistency, and about 60 percent of its volume. The substance contains sugars, minerals, and enzymes to help sperm survive in the female reproductive tract.

  • The vas deferens, two thick, muscular tubes, about 18 inches long, connect each testicle to the prostate and function as ducts to get the sperm from the testicles to the ejaculatory duct of the prostate. These are the tubes which are divided during a vasectomy, so that sperm can no longer pass into the semen. Thus, a vasectomy is a highly effective form of male contraception.

  • Neurovascular bundles. A network of nerves and blood vessels surround the prostate like a hairnet, and these are sometimes injured or severed in the surgical removal of the prostate causing impotence. There are two neurovascular "bundles" on either side of the prostate. These are sheaths containing the critical nerves that help mediate erection. Science still cannot explain exactly what causes an erection, but we know that the nerves tell the arteries to dilate and take more blood into the erectile bodies of the penis and keep it there. When blood fills the penis and is trapped there, the penis becomes engorged, and thus, erect. The vital nerves involved in this hydraulic system, run along either side of the prostate.

    One end of both these sheaths is connected to the network of signals to and from the brain. These sheaths lie up against the prostate and can also be the site of cancer cells escaping from the prostate. Because of their proximity to the gland itself, it is a very tricky surgical maneuver to keep these sheaths out of harms way during surgery. The nervesparing surgical technique of radical prostatectomy seeks to do this. Radiation treatment can cause the nerves and blood vessels to become calloused or scarified and no longer able to carry blood into the penis and hold it there. Thus; radiation therapy may also cause impotence.

back to index

The Mechanics of the Prostate

This small but complex gland has many tasks to carry out in its primary function to support and promote male insemination and fertility. It is a factory for production of nutrient?rich seminal fluid to help carry sperm from the testicles out of the body during ejaculation, and help them survive in the female reproductive tract. jobs. It is a gatekeeper, or valve, that allows sperm and urine to flow in the right direction through the urethra. A ring of muscles near the neck of the bladder, the internal sphincter clamp down during ejaculation to prevent semen from backing up into the bladder. If this mechanism is damaged, retrograde ejaculation or back up of semen into the bladder may result. The prostate is also a pump during orgasm, contracting the muscles to force semen into the urethra.

Sperm and Seminal Fluid
Sperm from the testicles is transported by the vas deferens to the ejaculatory duct, which runs through the prostate. Sperm is then mixed zenith fluid from the prostate and seminal vesicles to form the ejaculate. Half of the ejaculate comes from the seminal vesicles and 15 to 30 percent from the prostate gland. Sperm from the testicles make up about 5 percent of the ejaculate volume.

Using heterosexual intercourse as an example, when semen is ejaculated into the female vagina, it exists as a semi solid gel which forms a plug on the cervix of female reproductive tract. The plug serves as an effecient delivery system for sperm trapped in the seminal coagulant. The gel spontaneously liquifies after 10 to 15 minutes due to the presence of an enzyme known as prostate specific antigen (PSA), a protein which is also produced by the prostate gland. This protein molecule enters the bloodstream in greater amounts when something is wrong. Any process that disrupts the normal ductal structure of the prostate like prostate cancer, BPH, or prostatitis (inflammation) will cause more PSA to leak into the blood. So when serum PSA is elevated it suggests a process in the prostate is disrupting the normal glandular architecture.

The seminal fluid also contains minerals such as zinc and sugar such as fructose and glucose, as well as other enzymes and nutrients that sperm need to suvive in the female reproductive tract. It is believed that prostate fluid also serves in some anti bacterial capacity and that elderly men with chronic bacterial inflammation of the prostate (prostatitis), have reduced anti bacterial activity as well as reduced zinc levels. Nevertheless, studies with dietary zinc supplements have failed to confirm the use of dietary zinc as protection against recurrence.

When the prostate is removed, no seminal fluid is produced. In other words, there is no emission during sexual climax. However, this does not change the ability for sexual arousal and orgasm. Erection, orgasm, and ejaculation are three separate events, but usually are coordinated to occur together. Ejaculation and orgasm still occur with impotence or erectile dysfunction.

Despite its complex role, the prostate is not a vital organ like the heart or lungs. Men can live without it, although given a choice, most would rather not.

back to index

The Geography of the Prostate

For diagnostic purposes, the prostate is divided into three major zones. Knowing the geography of the prostate can help in understanding how symptoms develop when something is wrong with the prostate.

  • The peripheral zone, or the outside of the prostate, accounts for about 70 percent of the glandular tissue of the prostate and this is the site of approximately 70 percent of prostate cancer. This is the area directly behind the rectum, part of which the doctor can touch during a DRE.

  • The transition zone is the small inner core that surrounds the urethra. This area accounts for about 5 percent of the prostate's volume early on, but with age, this area gets larger. This noncancerous enlargement of the prostate begins after age 40 in all men. This enlarged tissue may cause a pinching off of the urethra or obstruction leading men to develop voiding symptoms with advancing age. While this area of the prostate is where urinary problems begin, it accounts for only about 10 percent of prostate cancer.

  • The central zone, comprises about 25 percent of the prostate's volume and is sandwiched between the peripheral and transitional zones. This is the least likely area for cancer to occur.

    There is also muscle and fibrous tissue in the front section (apex) of the prostate where no glandular tissue is present. This is the fibromuscular zone. The term "lobe" is also used to describe the right and left lobes of the gland, and whether a tumor is in one or both lobes.

back to index

The Role of Hormones

Testosterone is an essential player in prostate cancer. This hormone or androgen, as male hormones are labeled, is produced mostly by the testicles. It can produce prostate cancer in rats who are given large doses. However, while all men produce testosterone, not all men get prostate cancer. (Studies have found that men who have testicles damaged or removed prior to puberty, never get prostate cancer.)

The reason the prostate grows so rapidly during puberty, is that it is fed by the androgens which make it possible for the prostate to produce seminal fluid. Androgens also stimulate the development of body hair, deepen the voice, and increase muscle bulk in the upper body. The primary androgen is testosterone, but some androgens are produced by the adrenal glands which lie above each kidney. Briefly, here is how the process works:

  1. The hypothalamus, a small gland at the base of the brain, produces leutinizing hormone-release hormone (LHRH).

  2. LHRH acts on the nearby pituitary gland to produce leutinizing hormone (LH) and follicle-stimulating hormone (FSH) to stimulate secretion of androgens.

  3. FSH acts on certain cells of the testes to produce sperm.

  4. LH acts on other cells of the testes to produce testosterone, the primary androgen.

  5. An enzyme called 5-alpha reductase converts testosterone to its active metabolic and more potent form, dihydrostestosterone (DHT).

  6. DHT diffuses into prostate cells to influence growth such as the development of benign prostatic hyperplasia (BPH).

  7. Adrenocorticotropic hormone (ACTH) is produced by the pituitary gland to act on adrenal glands to produce other androgens that can also influence prostate growth. Thus, while these androgens nourish the prostate, they can also nourish prostate cancer cells. Testosterone, for example, is responsible for cell division in the prostate. This is similar to what estrogen does in breast cancer in women. It is responsible for the growth of breasts, as well as the growth of breast cancer. The enlargement of the prostate in middle age may be caused by the complex relationship of aging and hormones, although this does not always lead to prostate cancer.

back to top

DISEASES OF THE PROSTATE

Overview Benign prostatic hyperplasia
The dynamic and static prostate Symptoms of BPH
PSA and BPH How BPH is diagnosed
Treatment for BPH Prostatitis
Prostatic intraepithelial neoplasia (PIN)

Overview

The prostate of every man begins to enlarge in middle age and this is the primary cause of symptoms such as the need to urinate more often. The first wave of 76 million baby boomers in the United States turned 50 in 1996. The total male population over 50 will nearly double by the year 2020 and primary care physicians and urologists will see more men with symptoms developing from enlarged prostates. At this age, a prostate weighs from 30 to 100 grams (one to three and a half pounds) and is 10 times larger than it was at age 20 when it weighed only a few ounces. There are approximately 15 million men in the country with symptoms of BPH and the vast majority are not seeking treatment.

More than half the men over 60 have some degree of this problem, known as benign prostatic hyperplasia (BPH), and by the time they are 80, most men have the disease. BPH is one of two non-cancerous conditions of the prostate whose symptoms are sometimes confused with prostate cancer. The other is prostatitis, an inflammatory condition.

It is ironic that although the prostate is primarily concerned with sexual reproduction, when something goes wrong, it more frequently causes problems with urination. Because the prostate surrounds the urethra, an 8-inch long tube extending from the neck of the bladder through the prostate and penis, any change in the prostate's size can affect the dynamics of urinary flow. This close proximity to the urethra and bladder, make it a crucial link in the efficient flow of urine. For example, as the prostate enlarges, the space around the urethra -- the hole of the doughnut -- gets pinched off or blocked. The enlarged prostate gland squeezes on the urethra, the way a fist would squeeze on a straw. In extreme cases it can close off the passage altogether and impede the flow of urine.

back to index

Benign Prostatic Hyperplasia (BPH)

Benign prostatic hyperplasia, or BPH, is a very common disease of aging which develops gradually during the second growth cycle of the prostate, when a man is in his 40s and 50s. The inner core of prostate tissue -- the transition zone which surrounds the urethra -- expands from the proliferation of cells. This cell growth is called hyperplasia. The enlargement of the prostate tissue and the reduction of the doughnut hole, cause problems with urination, or ejaculation because of the pressure on the urethra. These same symptoms can be signs of cancer but with cancer, the symptoms usually develop more insidiously. The benign condition of BPH does not increase the risk of cancer. However, both conditions can exist simultaneously, so screening and treatment for BPH is always important. For this reason, it is important to understand as much as possible about the natural processes of the prostate.

Because BPH develops on the inside, or the core of the prostate, it cannot generally be detected with a digital rectal exam (DRE). Only about half the men with microscopic BPH develop prostate enlargement that can be felt with a DRE. The 50 percent of men who do develop enlargement to this degree usually need surgery to remove the excess tissue from the inner core and relieve the pressure on the urethra. According to some studies, approximately 25 percent of all men will require treatment for their symptoms of BPH if they live to be 80. A 60-year-old man has a 60 percent chance of developing microscopic BPH and a 25 percent cumulative chance of requiring surgery. With the advent of new pharmacological ways to treat BPH, this cumulative risk has significantly decreased. There is more about this later.

The natural history of BPH is highly variable and currently we don't have good data about how patients over time do with or without treatment. And we don't know if diet, smoking, or race, are contributing factors. Size or volume of the BPH tissue is different in so far as Asians have smaller prostates in general, but they develop symptoms with similar frequency, so size is not the important feature by itself.

It does appear in some men that the symptoms may not progress. Between 60 and 70 percent of patients studied with BPH, either stabilized or had spontaneous improvement over time. This lack of data explains the lack of uniformity about surgical treatment around the country. There are few absolute indications for intervention and treatment and many men with symptoms do not require surgical treatment to remove the excessive tissue growth.

While the cause of BPH is not completely understood, it is clearly related to aging, and the presence of functioning testicles. A number of clinical and experimental observations attest to this as a factor in development of BPH. It has been known since the 1800s that removal of the testes results in shrinkage of prostate tissue and clinical improvement of symptoms of BPH. It is also known that if testicles are removed from boys prior to puberty, the boys never develop BPH or prostate cancer later in life.

In the early 1970s, Dr. Julianne Imperato McGinley of Cornell Medical College, noticed an interesting genetic syndrome in a population of male infants in the Dominican Republic known as congenital 5-alpha reductase deficiency. This is the enzyme that converts testosterone to the more potent androgen, dihydrotestosterone (DHT). Boys with this recessive genetic disorder lack the enzyme, and so the prostate does not grow normally. At birth, these children have a small phallus, and in adulthood the prostate remains small. Some tissues of the body respond to testosterone itself whereas others, such as the prostate, require DHT for growth and differentiation. These males are otherwise normal, and have no sexual problems. From this observation it is clear that DHT, and not testosterone, is necessary for BPH development. Without DHT, the BPH cannot develop. Medications that block the conversion of testosterone to DHT are often used to treat BPH as well.

Treatment with medications for BPH can also affect the PSA. For example, if a man's PSA level was 3.0 before beginning treatment with Proscar, and after six months of treatment, the level decreased to 1.6, he should double that figure to 3.2 to learn exactly what his PSA level is.

back to index

THE DYNAMIC AND STATIC PROSTATE
The urethral obstruction caused by BPH comes from both a dynamic and a static mechanical component. The dynamic obstruction is due to the tone of the smooth muscle (stroma) and its ability to relax and contract, whereas the static or mechanical element is simply the presence of the large bulky prostate pressing on the urethra and causing outlet obstruction.

The dynamic and static components vary widely in men. It may be that for some men with a small prostate examined by DRE, their symptoms may be due more to the dynamic component. That is, the muscles of the bladder neck and prostate cannot contract or relax. On the other hand, in men with large prostates, the static component may be more predominant in causing symptoms of BPH because:

The symptoms of BPH are highly variable and most men are relatively symptom free. Symptoms are caused by obstruction of urethra and alterations in bladder function. The size of the prostate is not always a predictor of the type or severity of symptoms. Some men with very large prostates have minimal symptoms whereas others with relative small glands, are very symptomatic. Reasons for this paradox are incompletely understood but are believed due to relative contributions of dynamic and static conditions.

During voiding, urine flows from the bladder through the urethra. In a BPH prostate, the urethra is narrowed by mechanical obstruction of the enlarged prostate or by the dynamic obstruction of increased smooth muscle tone. The bladder tries to compensate for this increased resistance by generating a stronger and more forceful bladder contraction to force it out. Over time, the muscle is unable to compensate for the resistance and it fatigues. This gives rise to the inability to completely empty the bladder and the possibility of leakage and incontinence. Imagine a stretched rubber band. If it is stretched to a considerably longer length and kept stretched, and then released, it eventually looses its elasticity and fails to come back to its original shape. It becomes floppy and incapable of generating the same tension as it used to. Similarly, the bladder can lose its capacity to empty itself of urine if it is chronically obstructed and overstretched.

This happens to a bladder trying to overcome chronic mechanical outlet obstruction due to BPH. The retention of urine in bladder can lead to infection as well as bladder stones, and in more cases, can result in kidney failure, with long standing obstruction.

back to index

SYMPTOMS OF BPH
The symptoms of BPH are broadly classified as obstructive or irritative. Irritative symptoms include increased need and urgency to urinate, especially the need to get up during the night (nocturia), and also a burning sensation (dysuria) on urinating. In extreme cases, it can cause incontinence.

Obstructive symptoms are a result of the bladder muscle's inability to overcome the outlet obstruction. These include a poor and slow stream, feeling of incomplete empty, dribbling at the end of urination, interruption of flow, and hesitancy or inability to initiate urinary flow easily. Men with BPH may also develop blood in the urine due to the bursting of dilated blood vessels which are at the bladder neck or surface of BPH tissue during voiding. Some have obstructive and irritative voiding symptoms whereas other "silently" develop chronic renal dysfunction and urinary tract infections. Some have no real symptoms or complaints until these complications develop.

Ultimate control of the development of BPH, however, occurs in the brain's control center, in the interaction of the hypothalamus and pituitary glands. The hypothalamus releases a hormone known as leutinizing hormone releasing hormone (LHRH) which stimulates the pituitary gland to release leutinizing hormone (LH). LH travels in the blood and reaches the testicles where testosterone is produced. Testosterone is converted in the prostate epithelial cells to DHT by the enzyme, alpha reductase. DHT in turn combines with receptors in the nucleus of the prostate epithelial cell to produce cell growth and proliferation.

The paradox is that hormones diminish slightly as a man ages, yet the hormones are responsible for the increased cell proliferation that causes BPH. Normal growth and function of the prostate is dependent on androgens maintaining a balance between cell growth and cell death.

back to index

PSA and BPH
The presence of BPH does not mean prostate cancer is present or will develop. However, BPH can cause the PSA level to rise. This rise can be from the BPH alone, or it could be an early indication of cancer, so this needs to be seriously considered. The frequent existence of clinically hidden, or latent prostate cancer in men with BPH is well known. It is standard procedure when doing surgical treatment for BPH to examine any tissue removed under a microscope by a pathologist. From 10 to 20 percent of men who undergo prostatectomy for BPH through a transurethral resection of the prostate (TURP) procedure will be found to have microscopic prostate cancer of a small volume and low grade. For this reason, it is very important today when more and more men are electing non-surgical treatment for BPH to routinely have physical exams and blood tests so that occult cancer can be diagnosed before it causes symptoms.

Whether irritative or obstructive, symptoms of BPH are subjective, highly variable, unpredictable, and can vary in the same person. The perplexing issue is the complex relationship between prostate size and type and severity of symptoms. There is no correlation between severity and size of prostate.

Because so many men do not seek medical help for the problem, they suffer in silence and here is how most of them cope with their symptoms.

  • Stay close to a bathroom at all times.
  • Reserve seats on the aisle wherever they go.
  • Wear dark clothing to conceal leakage.
  • Take frequent naps to make up for loss of sleep at night.
  • Curtail social activities.

Always keep in mind that many of these symptoms are not unique to BPH and can also be caused by urinary tract infection, cancer, and neurological dysfunction. Such conditions must be carefully considered when there are BPH-like symptoms. Indications for treatment of BPH are not absolute and given the vast array of medical and non-surgical alternatives it is important to have a very thorough workup with a urologist before deciding on treatment for BPH.

back to index

HOW BPH IS DIAGNOSED
A proper evaluation of a man with BPH requires very detailed history and physical examination because the obstructive symptoms of BPH may also be due to other medical conditions such as stricture or scar tissue in the urethra, neurological conditions such as stroke, Parkinson's disease, or muscular sclerosis, which affect bladder function by misinterpretingthe brain's signals. Men who have had pelvic or abdominal surgery may often have injury to nerves that control bladder function. Urinary tract infections as well as stone disease and tumors of the bladder can bring on irritative symptoms, and may be confused with BPH.

A digital rectal exam (DRE) should be performed to assess the prostate as well as a urinalysis and urine culture to exclude possibility of a urinary tract infection. Blood studies, such as the serum PSA level and assessment of kidney function should be done.

If blood is found in the urine, either microscopically or is clearly visible, further evaluation is warranted. This should include an imaging study of the upper urinary tract with an intravenous pyelogram (IVP), an X-ray study of the urinary tract. A dye is given intervenously which is taken up by the kidneys and later excreted. When X-ray images are taken, the dye outlines the kidneys, ureters, and bladder. If abnormalities exist in the urinary tract such as a stone or blockage to the kidneys, it can be clearly seen. An ultrasound of the kidney can also be used to determine the problem.

Evaluation of the lower urinary tract -- the urethra and bladder -- is done with a fiberoptic scope known as a cystoscope. Possible causes for blood in the urine (hematuria) other than BPH include the presence of stones in the kidney or bladder, prostate cancer, tumors of kidney or ureter, or congenital abnormalities of the urinary tract.

Part of the workup for BPH may often include a urinary flow rate determination. In this very simple test a patient with a full bladder is asked to urinate into a funnel connected to a measuring device that records the urine (low rate in ccs per second). Then, with ultrasound it can be determined if any urine is still in the bladder. Men with severe BPH will often have a slow flow and a moderate or high level of residual urine in the bladder.

back to index

TREATMENT FOR BPH
Before the development of new drug therapies, surgery was the primary treatment for BPH. With mild symptoms, watchful waiting is also an option for this benign condition. It was recognized years ago that approximately 50 to 60 percent of patients with BPH reach a certain level of symptoms, and then stabilize or improve. The risk of developing such acute symptoms as the inability to urinate, is only one to two percent of the men who develop BPH.

Medications
The management of BPH is in transition with decreased reliance on surgery and increased interest in medical and pharmacological management. Many drugs could be used to affect growth of BPH tissue. As these drugs may act on the pituitary (for example, to block LHRH), or to block androgen receptor, or to block the conversion of testosterone to DHT in the prostate. The critical role of dihyrdrotestostcrone (DHT) on BPH growth is the rationale for use of Proscar (finasteride), a 5-alpha reductase inhibitor. When taken orally, it prevents the conversion of testosterone to DHT.

Therapy with Proscar is directed at the hormonal cause for BPH development and the goal is to reduce the size or volume of the gland to improve urinary flow and symptoms, and disrupt the progression of BPH by effecting the static or mechanical component of outlet obstruction. In clinical trials, men treated with Proscar for up to 12 months saw an approximately 25 percent reduction in prostate volume compared to men who did not take the medication.

Because it blocks some of the hormonal action that effects the prostate, this drug is also being studied for use as a possible prevention of prostate cancer in a large prostate cancer chemoprevention trial sponsored by the National Cancer Institute.

There appear to be two locations of 5-alpha reductase activity. One in the prostate and the other in the middle layer of skin where the hair follicles are located. The Food and Drug Administration is about to approve the use of Proscar to stimulate hair growth in balding men.

Side Effects
Most men have found few side effects with Proscar therapy, and it does not generally interfere with their libido. However, in about 3 percent of patients on Proscar for more than six months, impotence, decreased libido, and a decrease in the volume of ejaculate may occur.

After six months of therapy with Proscar, the prostate not only shrinks, but the medication reduces the PSA level by half. It is vital to understand this because if a man is using the PSA test for annual screening for prostate cancer, the reading will be misleading.

Other Pharmacological Treatment
Pharmalogic treatment with Proscar, affects the static component of obstruction, and other medications such as alpha receptor blockers, Hytrin (terazocin) and Cardura (doxazcin) treat the dynamic component of obstruction.

In men without BPH, the ratio of stromal to glandular tissue is 2 to 1. In men with BPH, the ratio is 5 to 1. So, BPH is primarily a stromal disease and studies have found that the stromal tissue of the prostate gland and bladder neck area are richly endowed with alpha I adrenogenic receptors with mediate the ability of the smooth muscle surrounding the prostate to contract and relax. These receptors are sparse in the body of the bladder so it has been observed that drugs that would block the receptor would relax the smooth muscle and reduce the resistance in the bladder neck and improve the flow of urine. The contractility of the bladder would not be effected because of the lack of alpha receptor innervation. This led to the development of a number of alpha one adrenogenic receptor blockers that could be used to medically manage patients with BPH. The idea behind this is by blocking the alpha one receptor, the smooth muscle tone, outlet obstruction would relax and decrease resistance, making it easier to urinate.

Like all alpha 1 receptor blockers, these drugs can lower blood pressure and therefore are useful in treating hypertension as well. They are taken once a day and unlike Proscar, have no significant affect on PSA. Side effects noted with these medications include dizziness, light headedness, fatigue and sometimes impotence.

Surgical Treatment
With the inevitable development of BPH with advancing age, some men have severe enough bladder obstruction to warrant surgical treatment to open up the doughnut hole by cutting away some of the prostate tissue. Among the indications for this surgery are the inability to urinate, acute urinary retention, renal failure, chronic obstruction, blood in the urine (hematuria), the presence of bladder stones, and recurrent urinary tract infections.

In 1992 over 400,000 TURPs were performed in the United States and was the second most costly surgical procedure performed on men after cataract surgery. It accounted for about 40 percent of major surgical procedures performed by urologists at a cost to the healthcare system of four billion dollars a year. With cost containment the focus of health care, there is a great deal of incentive to develop non-surgical alternatives for treating BPH. This has been achieved somewhat by the increased use of pharmocologic alternatives.

Transurethral resection of the prostate (TURP) removes some of the prostate tissue. Mostwiden the passageway and allow free flow of urine through the urethra. For obvious reasons, TURP is commonly known as the "Roto-Rooter" procedure. The entire gland is not removed during a TURP. Only the transition zone where BPH tissue develops. The peripheral zone is retained. However, if the prostate is very large, open abdominal surgery may be required to remove the excess tissue. These surgical procedures are all considered a form of prostatectomy, but they differ from a radical prostatectomy which is surgical removal of the entire prostate, a common treatment for localized prostate cancer.

TURP involves inserting a fiberoptic telescope through the urethra of the penis. Through this tube, the urologist can see and operate. Connected to this tube is the resectoscope, an electric loop, which removes prostate tissue and cauterizes-seals the blood vessels. Essentially, the instrument is used to make the hole of the doughnut larger and relieve pressure on the urethra. This procedure is used to relieve urinary symptoms such as weak stream or sense of incomplete bladder emptying. Treatment would require being in the hospital from one to three days, It may take from two to four weeks to recover from a TURF procedure and regain the ability to urinate normally.

While it is not used in the treatment of prostate cancer, TURP may sometimes be used to relieve the symptoms caused by the cancer, such as pressure on the urethra. It may also be used as a biopsy method to check the tissue at the inner core or peripheral zone of the prostate. Tissue removed during the TURP procedure is routinely sent to a pathologist to check for the presence of prostate cancer. About 80 percent of cancers found this way are cured.

Although not always successful, TURP was the most common surgical treatment for BPH before the development of medical therapies. It was recognized that 21 percent of patients treated with TURP were unsatisfied or did not improve, and 20 percent needed to be reoperated after 8 years because of regrowth of of BPH tissue. Clearly, there was a need to identify beneficial alternatives to TURP treatment in men with symptomatic BPH.

Prostate cancers found on pathological examination of TURP removed tissue are known as transition zone cancers because the BPH tissue comes from that zone. Of cancers found this way, 80 percent of transition zone cancers are cured after the TURP procedure removes the tissue because the procedure removes all the cancerous tissue. But there is a need to follow up because the peripheral zone is still vulnerable, and this zone is not removed by the turp. Therefore, you still need an annual DRE and PSA to monitor for prostate cancer.

The chance that symptoms will improve after TURP is from 75 to 95 percent compared to 60 to 85 percent with the alpha I receptor blockers, 50 to 70 percent with Proscar, and 30 to 50 percent with watchful waiting.

Side Effects of TURP
From 5 to 10 percent of men could be left impotent after a TURP, five percent may experience urinary tract infections, and a few will be incontinent if the sphincter is damaged.

Treatment with Microwaves
Alternatives to TURP have evolved over the last 10 years. They include transurethra incision of prostate, where an incision is made in the prostate but no tissue is removed. This procedure was popularized in Europe and is quite effective for patients with relatively small prostates. Laser therapy of the prostate or visual laser ablation of the prostate can also be done and carries less potential for complications and side effects than TURP. More recently, the FDA approved use of microwave therapy for prostate using Prostatron. This procedure is done in the urologists office and results so far have been encouraging.

The Prostatron is a device that heats the enlarged prostate with microwaves. A catheter is threaded through the urethra into the prostate. A computer sends microwaves through the catheter, heating the prostate to 111 degrees. This kills BPH tissue which sloughs off and relieves pressure on the blocked urethra, accomplishing the same result as the TURP does surgically. Cooling water circulates inside the catheter so the patient will not feel the heat or get burned. Treatment with the Prostatron? takes an hour, requires no anesthetic, and costs half as much as surgery. It has been used in 25 countries since 1991, and was approved by the Food and Drug Administration for use in the United States in 1996.

back to index

PROSTATITIS
Prostatitis is an inflammatory condition of the prostate which may or may not be caused by an infection. Infections of the prostate gland rarely occur before puberty but they are common in adult men. Because many aspects of prostatitis are poorly understood patients and doctors are often frustrated in dealing with it. Men will often have irritating or obstructive symptoms and their PSA will often be markedly elevated.

There are many different types of prostatitis depending on whether or not they are due to infectious agent. Acute bacterial prostatitis causes fever or chills as well as severe irritative and obstructive voiding symptoms, a general feeling of malaise, muscle aches and pains. When examined with a DRE, the prostate will feel very warm and pliable. Urine analysis will show bacteria as well as red and white blood cells.

In chronic bacterial prostatitis, clinical features are more vaiable. However the syndrome is unique because of the persistence of bacteria in the prostate which have not been fully treated and do not clear. It may feature relapsing recurrent urinary tract infection caused by the same bacteria as exists in prostate despite prior treatment with oral antibiotic. Non bacterial prostatitis is more common, but the cause of infection is unknown.

Symptoms of Prostatitis
Prostatitis symptoms include painful urination, possibly a burning sensation, and the need to urinate frequently. There may be fever, blood in the urine, a discharge from the penis, and lower back pain, but these last two symptoms are less common. Prostatitis also causes the PSA levels to elevate -- sometimes into the thousands.

Treatment
Treatments may include antibiotics and medications to relax compression of the urethra. Medications also need to be tailored to the type of bacteria which is cultured from the urine and typically antibiotic is prescribed for up to four or more weeks.

Because most antibiotics taken orally achieve poor levels of concentration within the prostate the bacteria in chronic prostatitis often persist during treatment with antibiotic. Also, symptoms may persist while repeated urine cultures fail to show any bacteria, once the antibiotic is stopped, the bacteria reinfects the prostate and symptoms return.

back to index

PROSTATIC INTRAEPITHELIAL NEOPLASIA (PIN)
The search for clues to indicate the best approach for treating prostate cancer has focused on the microscopic changes referred to as high grade prostatic interepethelial neoplasic, or PIN. This microscopic finding is considered the most likely precursor of invasive cancer and is characterized by cellular proliferation within the prostate ducts and glands -- atypia or displasia. PIN coexists with prostate cancer in more than 85 percent of cases. Therefore, the clinical importance of recognzing PIN is based on its strong association with invasive cancer. The identification of PIN in a prostate biopsy always warrants further search for invasive cancer.

PIN may develop decades before a cancer is detected. It is most often discovered when the PSA is higher than normal and indicates the need for biopsy and further screening. PIN is detected under the microscope in tissue removed with the needle biopsy. If it is low grade, it is not cause for alarm, but a high grade PIN calls for active surveillance, with periodic PSA tests and biopsies to watch for any change. Studies are in progress to determine if drugs can reverse the condition, but these are not yet completed. Like the other conditions of the prostate, PIN is most often related to aging. Whether PIN remains stable, regresses, or progresses, is not yet clearly understood, but there is strong implication that it can progress.

PIN has a very distinctive appearance and can only be diagnosed on biopsy. Because PIN has such a high predictive value as a marker of cancer, if it is identified it must be closely watched and followed up. PIN is divided into three grades with grade one low, and grades two and three being high. Patients with high grade PIN should have biopsies periodically to look for cancer, so that it can be detected early enough for curative treatment.

In some studies, up to 36 percent of patients who were identified with a high grade of PIN in an initial biopsy, were found to have prostate cancer on later biopsies. Autopsy studies of men with PIN and cancer increases with age. Interestingly, there is a marked decrease in the prevelance and extent of high grade PIN in men after hormonal therapy when compared with untreated patients. These findings suggest that prostate cells are hormone dependent. The decrease in PIN when androgens are blocked is believed to be caused by the acceleration of programmed cell death (apoptosis) and suggests that drugs such as Proscar may someday be used to prevent the development of prostate cancer.

back to top

HOW PROSTATE CANCER DEVELOPS

Overview Symptoms Metastatic cancer

OVERVIEW
There are two forms of prostate cancer: latent and clinical. Latent cancer shows no symptoms and is not yet detectable with a physical exam. But a rising PSA level indicates the potential for the presence of cancer. (See the next chapter for a full explanation of the PSA as a screening tool for prostate cancer.) Clinical cancer is disease that can be detected through a physical exam and has given rise to symptoms or complaints. It already exists in the form of a known carcinoma, a solid or self-contained tumor which can be seen or felt.

Cancer is really many different diseases. There are several major types of cancer and hundreds of subtypes. Lung cancer is very different from lymphoma, or skin cancer. However, all cancers have in common the abnormal growth and division of cells. DNA is in the nucleus of each cell and this is where the genes are.

The activity of human cells is controlled, or programmed, by DNA, much the way software controls what a computer will do. If the DNA programming runs amok for some reason, the genes lose control. It is as if the computer operator were hitting the command key over and over again without hitting the program key to give it direction. Cancer cells are normal cells which have developed the ability to multiply at an abnormal rate and are out of control. They do not attach to normal cells, but they do form abnormal groups and patterns. Cancer cells proliferate on their own and become autonomous. This is how they become "differentiated," meaning they are forming abnormal groups and patterns of their own.

A cancer forming in a gland is called an adenocarcinoma, which accounts for 90 percent of prostate cancer. Most prostate cells are glandular cells which produce secretions As mentioned earlier, the prostate is made up of a system of ducts in the fibrous tissue. A smaller portion of the prostate's cells make up the muscle and pumping activity. If the carcinoma is detected early enough, before it has spread out of the prostate capsule, it can potentially be cured.

Cancer is either in situ or invasive. In situ means "in place," contained within the gland. The cancer has not broken through the prostate wall into the surrounding soft tissue and fat. Invasive, or infiltrating, cancer can or already has broken through the ductal wall of the gland, perhaps pentrated through the prostate capsule and into the seminal vesicles, blood vessels, bladder, and spread or metastasized to the lymph system, or bones.

If the cancer is invasive, lymph nodes around the prostate will also be examined if surgery is done to find out if the cancer has begun to spread elsewhere. Lymphatic fluid flows through the body just like the blood stream does, and the bean?shaped lymph nodes are like filters, catching what comes through the pipes. As part of the immune system, they filter out and get rid of foreign or abnormal cells. It is here that cancer cells are likely to travel first when they migrate from the prostate.

Prostate cancer is generally slow growing and its "doubling time," the time it takes to double in size from one cell to two, or one million to two million, could be years long, rather than weeks or months, as in some other cancers. About half of all prostate cancer takes more than four years to double in size, while breast cancer does this every three months, although recent studies have indicated there may also be some slow?growing breast cancers. Prostate cancer grows so slowly, that in autopsy studies 80 percent of men who died of other causes after age 90, had latent prostate cancer unrecognized during their lifetime.

The proportion of histologic prostate cancer that will progress to clinical disease varies and there are interracial differences as well. African Americans have a higher number, Asians less, but this may have more to do with how the diseases progresses, not who gets it. In its early stages, prostate cancer may remain clinically obscure for years as one might expect if the doubling time of the cancer is four years or more. Most prostate cancer typically develops as a lesion in the peripheral zone so it is unlikely to cause urethral obstruction until it is advanced. The transition zone, which does cause obstruction when enlarged, however, is the site of only about 10 to 15 percent of prostate cancer.

back to index

SYMPTOMS OF LOCALIZED PROSTATE CANCER
Early prostate cancer gives no warning at all. It is the nature of the disease that symptoms do not appear until the cancer is advanced. This is made clear by the fact that histologic cancer exceeds the presence of clinical cancer by as much as 8 times. Prostate cancer cells grow for a long time before they become a tumor big enough to be detected by a DRE. But once they reach a certain critical mass, or volume, prostate tumors progress more quickly. This is when symptoms usually begin to appear, and by this time cancer cells may already have spread outside the prostate.

Commonly, local tumor growth in the prostate, whether it is benign or malignant, makes itself known by causing problems with urination, such as the need to urinate more often, having a sense of urgency, or a weak stream. If the cancer has metastasized, the symptoms will appear primarily in the bones. Prostate cancer can also be detected during a DRE by the change in the consistency, configuration, and symmetry of the prostate gland. Approximately 10 percent of men with voiding symptoms and no other clinical signs or symptoms of cancer have an occult (hidden) malignancy.

Obstructive and irritative symptoms are most common symptoms of local cancer growth. When the cancer is the cause rather than the incidental finding of the local symptoms, the cancer usually has appreciable mass and volume already, and is frequently not confined to the prostate.

Blood in the urine, or hematuria, is rarely associated with prostate cancer, but if it does occur, especially in an elderly man, this would suggest the need for further tests to look for cancer. Hematuria is an uncommon nonspecific sign in less than 15 percent of men with prostate cancer. Reasons for having blood in the urine involve local invasion of prostate cancer in the urethra or the base of the bladder. Renal failure may be a late manifestation of local spread, once the cancer has invaded the base of the bladder (the trigone) and obstructed the ureters.

Because the symptoms are so nonspecific, and because they resemble symptoms of benign prostate conditions, the only way to find out is through thorough screening with tests that will eliminate all other possibilities.

back to index

METASTATIC CANCER
The spread of cancer from the prostate to other areas of the body is called metastasis. This can happen three ways: through the lymphatic system (lymph nodes and fluids), the vascular system (blood vessels), or through what is called "extracapsular extension." For example, the tumor could break through the prostate wall and invade the fat surrounding the gland, or move into the neurovascular bundles. Because cells take the path of least resistance to get out, the neurovascular bundles are often the target. The potential for metastasis depends on volume of the tumor and aggressiveness of the cancer cells. Larger volume tumors are more likely to metastasize, and so are tumors with poorly differentiated, or aggressive cells. When a cell, or cells, break away from a tumor, they find other hosts and new colonies form. The apex of the prostate, where it is joined to the urethra, is the most common place for cancer to break through. Other sites of local metastasis are usually the lymph nodes and seminal vesicles. When traveling farther, it is more common for prostate cancer cells to go directly to the skeletal system. The cancer can travel to other organs including the liver or the lung. Metastasis of prostate cancer to the brain is not as common.

Cancer is always identified by the site of the primary. If we know of prostate cancer, and find cancer in the bone, it is not bone cancer. It is important to understand these differences because it will determine treatment.

Symptoms of Metastatic Prostate Cancer
Because prostate cancer rarely causes symptoms in the early stage, men often do not become aware of the disease until they have symptoms of distant spread as the first manifestation of prostate cancer. Persistent and often severe bone pain in the back or hip is a common symptom of metastatic cancer. The most common site of metastasis, about 70 percent, is in the spine, but it also travels to the ribs, pelvis, femur, and shoulder.

The pelvic lymph nodes are another common site of metastatic cancer, often swelling and obstructing the flow of blood and lymph fluid. Such swelling, called lymphedema, occurs in the legs, feet, and scrotum. The presence of such symptoms needs to be studied with bone scan and CAT scan to determine the extent of metastasis.

Urinary symptoms are very much like those of BPH. There may be more urgency to urinate, more frequent urination, a burning sensation, or blood in the urine. There could also be blood in the semen, and a decrease in the amount of semen ejaculated. By themselves, these are not symptoms of cancer, but they indicate that the urethra or ejaculatory ducts are blocked by something. When cancer is advanced, it may cause impotence, or a less rigid erection.

Hormone Refractory Prostate Cancer
This is a term used to describe prostate cancer that no longer repsonds to treatment with hormones. All prostate cancer eventually becomes resistent to hormonal manipulation for reasons still not clearly understood. The length of time it takes to reach this point is different in all men, and new ways of applying hormone treatment have helped to delay this process. Although prostate cancer does not respond to traditional chemotherapy, it is sometimes used tp treat hormone refractory cancer.

back to top

WATCHFUL WAITING

Overview Controversy of early treatment Degrees of difference in early cancer

OVERVIEW

In general, a man 70 or older with a slow growing cancer, who has the temperament to live with cancer in his body, may be an excellent candidate for watchful waiting. There are exceptions to all rules and each man is unique. A 72 year old may be much stronger and healthier than a 58 year old, so this must be considered. But in general, the difference between the ages of 50 and 80 (assuming a cancer doubling time of four years) is that there are seven doubling times for the cancer cells. Watchful waiting would be much more of a risk for the younger man.

A 76 year old retired diplomatic liaison who chose this option more than four years ago, is still doing fine with no symptoms or changes in his lifestyle. When he discovered prostate cancer, and he had a T2A tumor, a Gleason score of 5, a PSA of 8, and no symptoms at all. Bone and CT scans showed no metastasis. His cancer was confined to the prostate, but there was no way of knowing if it would stay there, or how aggressive it might become. He had hypertension and was on some medications, but he decided he did not want hormonal treatment or radiation. He would not have been a candidate for surgery because of his age.

This man's attitude was philosophical. He liked his life the way it was. He was enjoyhing himself, and did not want to risk changing that with possible side effects of radiation or hormonal therapy. Now 80, his PSA is 14, but he has no symptoms and is still content. Bone and CT scans once again showed no sign of metastasis.

This is the primary gamble of this choice. What if your cancer's aggressiveness has been miscalculated and the disease will spread faster than assumed. Clinical estimates of the extent and aggressiveness of cancer cells are not 100 percent accurate. Your particular cancer could be resistant to hormone therapy aimed at slowing the cancer's growth. Another risk factor is the possibility that you may become ill from other conditions, such as heart disease or stroke, which will mean that should you choose to have surgery if your cancer grows, you may no longer be a good candidate for this treatment. The highest death rates from prostate cancer are in Scandinavia where the wait and watch approach is preferred.

Watchful waiting is not the same as doing nothing. You could decide to wait a year and during that time, use hormone therapy to slow the progress of the disease. You can also change your diet as a way of possibly slowing the progress of the cancer, avoiding a high intake of animal fat, and adding more fresh fruits, vegetables, and grains. So this is not a "do nothing" choice. It means you will religiously monitor your disease through regular PSAs and DREs.

back to index

CONTROVERSY OF EARLY TREATMENT
Before any man can choose to do nothing, or watchfully wait, he needs to understand the controversy surrounding treatment of early localized prostate cancer. He needs some idea of the chances for cure, and/or recurrence of the cancer with more aggressive treatment such as surgery and radiation to compare with the more conservative choice of doing nothing. Are his chances better or worse?

Despite hundreds of articles and treatment regimens, the appropriate treatment for early stage prostate cancer remains controversial. Surgical and radiation studies are hampered by an inadequate staging system. We don't have enough clinical trials and long term studies. The disease itself adds to the dilemma with its long natural history and slow doubling time.

Surgical studies have often reported results based on pathological staging done after surgery. Radiation studies have not had the advantage of removing patients with positive nodes or extracapsular disease from the studies. Patients have different PSA levels. These factors make direct comparison of surgery with either external beam or bracytherapy difficult.

Gleeson grade and stage have been historically reported as the most important pretreatment factors for predicting the outcome for early stage cancer. However, directly comparing surgical and radiation outcomes on the basis of stage alone is frought with problems because patients with higher PSA and grade are more frequently treated with radiation therapy, either external or internal. Several recent surgical and radiation studies have indicated that PSA levels before treatment may be more significant thatn either grade or stage as an objective prognostic factor. Grade also appears to be an important factor.

How do you measure a successful treatment outcome? Normalization of the PSA? The fact that he is still alive? But couldn't the patient have been incompletely treated and still be alive? In recent years, it has been more difficult to analyze outcomes of prostate cancer treatment. In the past, local control was established by performing periodic DRE to look for evidence of recurrance of prostate cancer. However, it can take a decade or more for cancer to become detectable this way, so we look to more sensitive parameters through biopsy after treatment, or by following the PSA levels. The rise in PSA following treatment is considered "biochemical evidence" of either local failure or progression of the disease.

back to index

DEGREES OF DIFFERENCE IN EARLY CANCER
Cancer that has been staged at TI with the TNM system is early and localized within the prostate. But it is important to distinguish between the degrees of this stage, A, B, and C. Men with TIA have low volume, and also low grade tumors, with little likelihood of the disease progressing any time soon. The cancer is equal to or less than five percent of the volume of the prostate and the Gleason score is between 2 and 7.

In contrast, TIB, means there is a slightly higher volume and grade and progression rates could be as high or higher than a stage with a larger volume. This stage is comparable to T2A. The cancer is more than 5 percent of the volume of the prostate, and the Gleason score may be between 8 and 10. Men with either of these stages have a higher risk that the disease will progress and metastasize.

Men with cancers staged at TlA and TIB might probably be safe with watchful waiting, but cancer staged at TIC is borderline. The number of men diagnosed with TIC disease has increased markedly since the introduction of PSA screening.

Although there are obvious benefits of detecting more organ confined prostate cancer, there is still major controversy about the large numbers of men with clinically insignificant cancer staged at TIC. It is believed this stage poses no threat, and may safely be followed with watchful waiting.

To determine criteria for TIC, Johns Hopkins University examined the pathological results of men who had radical prostatectomies, and who had been staged TIC before treatment. After study of the prostate specimens, the staging remained about the same. Most were between Stage TIA and T2. The tumors were confined to the prostate, their Gleason scores were less than 7, and the tumors were small.

Such minimal tumors were found in 16 percent of Stage TIC patients. The cancer was confined to the prostate in half of the men. Almost 20 percent had cancer which had progressed to the wall of the prostate. Therefore, Stage TIC represents a different kind of tumors. So while 20 percent may have cancer that will not progress, some men had evidence of a significant cancer, but potentially curable with surgery. Obviously, we need a reliable means of distinguishing between low volume, indolent tumors, and those that will progress. This is a rationale for using PSA density and velocity, as well as Gleason score, and cancer volume.

Studies reporting results of watchful waiting or conservative management are flawed by design, but it is clear that most men with moderately differentiated cancer will not die from the cancer ten years later. This suggests overall survival in men with a life expectancy of 10 years or less, and who have many other health conditions, are unlikely to improve with aggressive treatment of early prostate cancer.

However, the risk of progression to metastastic cancer in 10 years is approximately 40 percent in men who are watchfully waiting with moderately differentiated tumors. Although these men avoid the side effects of radiation and radical prostatetcomy, many are likely to suffer from side effects from secondary symtpoms such as urinary problems if the disease progresses. In additional to hormonal therapy which can be palliative for bone pain, some may also need surgery to relieve bladder obstruction.

Men who are diagnosed with early localized cancer face difficult choices. Conflicting studies, reports that are often incomplete or biased in the media, add to the confusion. It is important to be fully informed about the pros and cons of sugrery and radiation before considering this treatment.

back to top

UNDERSTANDING THE RISK FACTORS

OVERVIEW
AgingFamily HistoryRace
ENVIRONMENT & DIET
High Animal FatVegetables & FruitsTomatoes
UNPROVEN RISK FACTORS
Sunbelt TheoryBenign Prostate ConditionsVasectomy

OVERVIEW

We do not yet know the cause of prostate cancer, but we do know the strongest risk factor is age, despite the recent discovery of a prostate cancer gene implicating family history as a risk factor for so called hereditary prostate cancer. Cancer of any kind can be defined as an acquired genetic disease produced by exposure to environmental carcinogens that have caused damage to normal cells that accrues over many, many years. During our lifetime, we are all exposed to potential carcinogens in the environment: cigarettes, radiation, gasoline, animal fats, pesticides. Prostate cancer is a multi-stage process and the passage of time is needed for these chance events to accumulate and produce the mutations in our genes that cause the cancer.

In the United States, where one in four deaths is from cancer, men have a 20 percent lifetime risk of developing prostate cancer by the time they are 80. Lifetime risk is the probability that anyone over the course of a lifetime will develop cancer or die from it. However, the relative risk must also be taken into consideration. This is a measure of the relationship between risk factors and a particular cancer. Relative risk increases with exposure to particular environmental element, or there is an inherited predisposition. Smokers, for example, have ten times the relative risk of developing lung cancer compared to nonsmokers. A woman with a first degree relative with breast cancer, has far greater risk of developing that cancer.

Aging
The longer you live, the greater the risk of prostate cancer. More than 80 percent of prostate cancers are found in men over 65, and more than 90 percent of deaths are in this age group. Many autopsy studies have revealed that men who died of other causes, had prostate cancer so microscopic it had never been discovered. About 20 percent of men in their fifties are believed to have microscopic--latent--cancer cells which may or may not clinically manifest or become symptomatic in their lifetime. But we are beginning to realize that younger men--three out of ten men in their 30s and 40s--have potentially precancerous cells in their prostates known as prostatic intraepithelial neoplasia (PIN). PIN is not yet a cancer but high grade PIN is potentially a precursor to cancer.

By the age of 40, the number of men getting prostate cancer each year begins to accelerate, doubling every decade until about age 80. For the majority--about 70 percent--of patients diagnosed with prostate cancer, the only risk factor they have is their advancing age.

Family History
If your father had prostate cancer, your risk is about double that of a man whose father did not have the disease. The risk increases with the number of family members. For example, if your father and grandfather, or your father and your brother have it, you are five times more likely to get it. If three men in your family have it, such as your father, grandfather, and a brother or uncle, the risk increases to eleven times.

Until the discovery of the prostate cancer gene in 1996, there was no conclusive link between family history and incidence of prostate cancer. That is, we were not sure if the family connection was genetic, or environmental; the idea being that people in the same families may experience the same environmental or dietary risk factors.

When this gene--HPC1 for hereditary prostate cancer--is inherited in mutated form, it predisposes a man to prostate cancer. The risk`of developing prostate cancer by age 80 is about 50 percent in all men, but if you have the mutated gene, the risk increases to 88 percent. While the significance of this discovery is important, it accounts for only a small number--perhaps three percent--of prostate cancers. Men who get prostate cancer early in life are thought to carry this gene, just as women with the BRCA I breast cancer gene, get breast cancer earlier than most women. The discovery of the prostate cancer gene may also shed some light on genetic factors responsible for the high incidence of this cancer in African American men.

When prostate cancer does occur in several members of a family, it is likely to be a more aggressive form of the cancer, and thus, it appears at an earlier age. Men with a history of this cancer on their father's--or their mother's--side of the family, should begin screening for prostate cancer no later than age 40.

There has been some speculation that if your mother has breast cancer, you are at increased for prostate cancer. However, more research needs to be done before we can be certain of this connection.

back to index

Race
African American men have the highest rates of prostate cancer in the world, and native Chinese and Japanese men, the lowest. However, the incidence of prostate cancer is low in Chinese men until they move to this country when more of them develop prostate cancer. Epidemiological studies have shown the incidence of prostate cancer in Shanghai, China to be one per 100,000 population. In comparison, the incidence of prostate cancer among Chinese American men in San Francisco, California was 25 per 100,000 population, suggesting lifestyle has some effect. Is it the dietary switch from fish and rice to bacon cheeseburgers? Whether or not geography and diet are important risk factors for prostate cancer, remains to be proven. But we do take it into consideration because of the differences in the incidence of prostate cancer. But whether it is genetic or environmental--or both--we are not sure.

When we look at a racial and ethnic cross section of men at the age of 50, latent prostate cancer in all men is equal; there are no inter-racial variations. About 20 percent of these men will have prostate cancer among all races. The potential inter-racial differences come with the rate of progression of the disease and this may be influenced by genetics and diet.

African-American men generally discover prostate cancer later, and this could be why the death rate is double that of white men, but it does not mean the cancer is more aggressive. It could mean as a group, they have less access to good healthcare, or they do not participate in early detection programs.

We need to do more research to compare the PSA levels in comparable communities. For example, is the PSA rate effected by the size or density of the prostate? Or by the amount of testosterone produced? So far, much of the research into prostate cancer has compared apples to oranges rather than apples to apples. PSA rates need to be compared among men with the same racial background, age, and prostate size. This is being done in the Chinese community in New York City. In exchange for free screenings, these men become part of a large study on prostate cancer. Each year the men are invited back to repeat the test, so that the PSA results can be monitored over a period of years.

One of the areas of investigation is the difference in the PSA levels in Chinese and non-Chinese men. A 4.0 PSA is normal for western man, but should it be the same for Chinese man with a smaller prostate? This could be an added clue to the PSA measurement. Perhaps the PSA level must be measured against the size or density of the prostate. The density of the PSA may be higher in a smaller prostate. Chapter 6 includes comparisons of PSA levels in Arican Americans, Asians, and white men.

back to index

ENVIRONMENT AND DIET

Many variables affect the growth of cancer cells, from genetic susceptibility, to diet to exposure to carcinogens. Perhaps something in our environment--in the industrialized western world--causes prostate cells to become cancerous. Interestingly, the dog is the only animal that gets prostate cancer. Is this because the dog lives in our environment?

Studies have highlighted certain occupational risks, too. For example, higher death rates from prostate cancer are reported in farmers, mechanics, welders, plumbers, newspaper workers, and men who work with metals or rubber manufacturing. No occupation has been linked conclusively, but some research would indicate that men exposed to cadmium--welders and electroplate workers--may be at increased risk. Cadmium is a trace mineral found in cigarette smoke and alkaline batteries. It is related indirectly because it diffuses the body's zinc, which is necessary for cellular growth. Of all body organs, the prostate has the highest need for zinc.

In these studies, too, we cannot be sure if these men are at greater risk because of their jobs, or because they are the types of men who might be eating higher fat diets, or perhaps they smoke more than other men. Much more still needs to be studied.

A change of diet is not as dramatically therapeutic against prostate cancer as quitting smoking would be in preventing lung cancer, but you are more likely to have many other health problems if your diet is loaded with animal fats and no fiber from grains and vegetables and fruits.

back to index

High Animal Fat
We know that too much animal fat clogs the arteries and this increases the risk of heart attack, but does a high fat diet also cause prostate cancer? Many medical scientists believe it does, but all the evidence is not yet in. Animal fat or protein, such as that found in meat and butter, is said to be more harmful than vegetable fats like olive oil and certain fish oils. There tends to be less prostate cancer in regions where fish is a big part of the diet. Also, supplements of marine fish oils were shown in some studies to lower the risk, because some fish oil is believed to contain other fats that protect against cancer.

Animal fat, especially red meat, has been heavily implicated in prostate cancer. Although we do not know if a high fat diet causes prostate cancer, we do know that there is some evidence in animal studies to suggest that it may affect the course of the disease. Conversely, these studies also suggest that a low fat diet can often be considered a way to slow the progress of prostate cancer.

A Harvard study showed a 79 percent increase in risk for men who eat a high-fat diet. One theory is that dietary fat increases the serum sex hormone levels. A study showed that when fat consumption was lowered, these hormone levels in the urine were lower, too. Studies also show that diet is most strongly related to risk, so change can be beneficial.

Earlier studies at Harvard have proven to medical investigators that men who eat a lot of fat, at least 5 or more servings a week of red meat, for example, are at the highest risk for prostate cancer. Their risk is almost double that of men who do not eat this much. Researchers theorize that this may be because fat is necessary for the production of testosterone, which in turn feeds the cancer cells. Fat contains an ingredient called alphalinolenic acid. This is found in red meat, whole milk, butter, and processed soybean oil.

Studies at Memorial Sloan Kettering Cancer Center found that prostate tumors grew only half as fast in mice with diets of about 21 percent fat as in mice with diets of about 40 percent fat, which is what most American men consume. Tumors did not disappear, but the slower growth rate was impressive. Most prostate cancers develop around the age of 60, so if you change your diet to slow down the growth, you may live many more years without clinical progression of the cancer. Interestingly, tumor growth was two and a half times greater in mice fed the high fat diet.

A new dietary study of men who have prostate cancer was begun by Dr. William Fair, chief of urology at Memorial Sloan Kettering Cancer Center and Dr. Warren Heston in collaboration with the American Health Foundation. Half the men are consuming a normal diet with 30 percent of their calories coming from fat. The other half are consuming only 15 percent of their calories from fat.

This research is being done to find out why there are such vast differences in the incidence of prostate cancer in America and elsewhere. Autopsies have shown that the incidence of undiagnosed latent prostate cancer is about the same in American men as in Chinese men, but the incidence of full blown clinical cancer is 120 times greater in America than it is in China, where men eat a low-fat, high-fiber diet, compared to western meateating diets.

While there is meat in the Chinese diet, there is less of it, because the bulk of a meal is made up of grains and vegetables. In this country, meat often provides more than half the calories for a meal. The American quarter pounder with bacon and cheese, is a good example. When compared with the Chinese, Americans eat 6 times more meat and eggs, 55 times more milk, slightly more fats and oils, and 3 times more fruit than the Chinese. The Chinese, on the other hand, eat 3 times more fish and grain, and 30 times more vegetables. Overall, the American diet contains 43 percent fat, while the Chinese diet contains less than 20 percent.

Much research has been done and continues to be done about the effect of what we eat on our risk of cancer. Although no nutrients have been proven to prevent cancer, many scientists believe low fat can slow the growth of already slow-growing prostate cancer. While we cannot say a man who eats lots of animal fat and no fiber, will get prostate cancer, neither can we say for sure that every person who smokes will get lung cancer. However, with such obviously poor dietary habits, the odds are stacked against you. Most lung cancer is found among smokers. Most prostate cancer is found in societies with high animal fat and animal protein diets. Studies tell us that western populations, where red meat is highly consumed, have more cancer--prostate, breast, and colon--than communities where it is not, such as in Asia. Additionally, the highest number of overweight people live in the industrialized nations.

Whether or not such poor habits cause prostate cancer is almost beside the point, if your prostate has been removed. But proper diet could make a difference simply because we do know that balanced diet will keep you feeling better and protect you against many ordinary ailments. But if research is correct, and too much animal fat, has an effect on prostate cancer, then by changing your diet you can quite possibly slow down the development of prostate cancer.

Very few American men who have had treatment for prostate cancer, ask if they should change their diet to make themselves healthier, yet most Chinese patients do ask.

back to index

Vegetables and Fruit
Vegetables and fruit are not only good sources of fiber and vitamins, they may contain other elements that play a role in cancer prevention. Chemists analyzing vegetables have discovered many properties. Some of these vegetable compounds seem to retard the cell breakdowns that result in cancer.

But reports are contradictory. Betacarotene, the precursor of Vitamin A, is a good example. For years it was believed that betacarotene inhibited cancer cell proliferation, but in 1996, the conclusion of along-term study revealed that it had no effect on cancer cells, and in fact, may have increased the incidence of cancer in some cases.

The scientific community has only just begun to study our diets and there are many things they don't know. There could be elements' in vegetables that give us cancer, too, although the positive benefits far outweigh any potential hazards. Naturally-occurring food substances can be metabolized into mutagens. For example, bracken fern, which cattle eat (and thus, we eat), contains at least two carcinogens. Another potent carcinogen is a natural substance of mushrooms. Eating five pounds of mushrooms a day you might be pushing the risk level, but the digestive system is so complex and variable, that we cannot know for sure if these processes will take place. To put it in the most simple terms, a cancer cell or mutagen can take up residence in the body, hang around and do nothing, and eventually leave of its own accord. Or, it can dig in and start trouble with nearby cells.

Pesticides and fertilizers are also under scrutiny by medical researchers. The metabolic fate of toxic chemicals synthesized by plants as a defense against bugs, animals and bacteria, is extremely complex, and varies greatly in every individual.

Variety and moderation offers the best protection from the naturally occurring mutagens and carcinogens we cannot avoid. Whether they are pesticides used to grow our fruits and vegetables, hormones fed to market animals, or pollutants ingested by fish. If we tried to avoid everything that might potentially cause a cell mutation, we would starve to death.

back to index

Tomatoes
A nine-year study, of 47,000 men and 46 fruits and vegetables, showed that 10 servings a week of tomato-based foods sharply reduce risk of prostate cancer. According to Harvard University study by Dr. Edward Giovannucci reported in The Journal of the National Cancer Instilute, more was better, and in any form--juice, sauce, raw, or on pizza, showed a 20 percent reduction in cancer. Spaghetti sauce was the most common "tomato" food eaten by the men. Tomatoes are rich in anti-oxidant called lycopene. This makes them one of the few vegetables that are more beneficial cooked than raw. Apparently heat makes the cells burst and release more lycopene.

Soy - Several studies have concentrated on soy products, including one at the comprehensive cancer center at the University of Alabama, to find out if the consumption of soy foods reduces the risk of prostate cancer. Genisten is an' element found in soybeans and some cruciferous vegetables, which blocks angiogenesis-the growth of new blood vessels. If this could be used in treatment, it might prevent cancer cells from developing new capillaries that supply blood to tumors.

Antioxidants - certain foods contain anti-oxidants. These act like our body's own nutrition police, protecting us from free radicals. While we are breathing and burning up energy our cells continuously generate hazardous waste which can set the stage for cancer. This waste is made of molecules known as free radicals. Poor nutrition leaves our anti-oxidant levels low. Vitamins A, C, and E, are all antioxidants. Good food sources are melons and citrus fruits, yellow and green vegetables, tomatoes, green leafy vegetables, potatoes, wheat germ, oatmeal, peanuts, and brown rice.

Garlic and broccoli are especially rich in anti-oxidants. In fact, the National Cancer Institute puts garlic high on its list of natural anti-oxidants. Eaten raw, garlic also stimulates immunological functions, lowers blood cholesterol, thins blood, and helps prevent embolisms.

Cruciferous vegetables such as broccoli, cabbage, cauliflower, and Brussels sprouts, contain indoles, which are thought to inhibit cancer in animals, but there is still no definitive proof that they will protect humans.

Vitamin C, and E, may have preventive components, according to some studies. However, large numbers of people must be studied for long periods of time before we can come to any conclusions about the benefit of vitamins in preventing cancer. A well balanced diet will provide most of the vitamins we need.

back to index

UNPROVEN RISK FACTORS

The Sunbelt Theory
Because prostate cancer rates are highest in the northeastern part of the United States, and lowest in the sunbelt, a connection has been made between exposure to vitamin D--the sunshine vitamin--and prostate cancer. Sunlight stimulates the body to make vitamin D. It is thought this vitamin inhibits the growth of tumors, that it somehow prevents microscopic prostate tumors from progressing. Only small amounts of sun exposure are needed to produce vitamin D. This vitamin can also be ingested with fish or fortified milk. While this has not been proven yet, the idea is plausible and studies continue.

Benign prostate conditions
Because BPH has symptoms similar to prostate cancer, and both diseases depend on hormonal stimulation from testosterone. Both develop as a man ages, and can co-exist with cancer, but no direct link has been found.

Vasectomy
For awhile there was a suspicion that men who had vasectomies were getting more prostate cancer. However, this is unfounded. The increased incidence of prostate cancer can most likely be explained by the fact that these men were under care of a urologist, and were screened for disease earlier than most men. Thus, they are more likely to discover it.

back to top

THE CONTROVERSIAL PSA TEST

Overview How PSA is measured Age & race
Density & velocity Screening dilemmas

OVERVIEW
This simple blood test has revolutionized screening for prostate cancer and signaled an increase in the number of men who discover prostate cancer that is potentially curable because of this early detection. The PSA blood test is a tumor marker that measures levels of a protein called prostate specific antigen in the blood. The test was approved by the FDA in 1994 for the early detection of prostate cancer provided it is used in combination with the DRE.

PSA is a protein molecule, or protease, produced by the epithelial cells of the prostate. The purpose of PSA is to liquefy the gelatinous seminal fluid once it is inside the female reproductive tract. PSA is normally present in the blood of all men in low amounts. When PSA is elevated it means a "process" is disrupting the normal ductal architecture of the prostate causing more PSA to leak into the blood. This can be caused by benign prostate disease such as BPH, infections such as prostatitis, as well as prostate cancer, so the PSA test alone cannot determine the presence of cancer.

For example, the PSA rises with BPH, but usually not as fast as it does with prostate cancer. However, the PSA reading could be confused if the prostate is enlarged with BPH, and cancer was also present. The two most definitely can co-exist. To add to the confusion, a man who is taking Proscar to treat BPH, would have a reduced PSA level. It could decrease to half the normal baseline value. PSA levels also increase after ejaculation, so having a blood test for PSA within 24 hours of ejaculation could present a false reading. The same thing can happen after riding a bicycle for any length of time.

In BPH patients treated with Proscar, for example, the PSA level will decrease to half its baseline value. This would be an artificial decrease induced by the medication, however, and you would need to double your PSA in order to get an accurate reading.

PSA levels can go into the thousands in cases of acute prostatitis or if a recent needle biopsy has been performed on the prostate. A higher reading means something may be wrong and investigation with ultrasound or biopsy should be considered. However, it does not automatically mean prostate cancer is present. Many men who showed PSA levels of 10 and higher, turned out not to have cancer.

back to index

HOW PSA IS MEASURED
Because PSA is produced by the prostate gland, and not the prostate cancer, it is a prostate-specific substance, not a cancer-specific substance. Therein lies the controversy. It is possible to have prostate cancer and still have a normal PSA. Some men--about 40 percent--with prostate cancer have PSA levels under 4. Moreover, 25 percent of men with BPH have PSA levels higher than 4. Taken together, this limits the usefulness of the PSA alone in the early detection of potentially curable prostate cancer. It is difficult to tell the difference between cancer and BPH when the PSA level is between 4 and 10.

Now, here is another aspect to add to the dilemma. PSA exists in more than one molecular form in the blood. From 60 to 95 percent of PSA in the blood is bound to another substance--alpha I antic hymotrypsin--while the rest is circulating free and unbound. Studies suggest that prostate cancer detection is more accurate if we analyze the ratio of unbound PSA with complex PSA. Detection ability may improve as much as 20 percent.

The PSA is measured by nanograms per milliliter (ng/mL) of blood serum. The normal range is 0.1 to 4.0 ng/mL. The assay used for measuring PSA does not go to zero, so the lowest possible measure is 0.1. (For purposes of simplicity, the ng/mL will be omitted in the text, and only the numbers will be used.) While the laboratory baseline reading for a normal PSA is less than 4.0, this level has a different meaning for a 40-yearold man and an 80-year old. For men over 70, for instance, a 6.5 would be considered normal if age is taken into account.

back to index

ADJUSTING FOR AGE AND RACE
The PSA's usefullness as a tumor marker depends on proper variables of age and race. PSA is produced by the epithelial cells that line ducts of the prostate gland. It is well known that the prostate gland increases in size with age. In general, this suggests that older men have more tissue to produce PSA, and therefore, a greater likelihood that PSA will leak into the blood because the normal barriers that keep PSA in the ductal system are less tight because BPH and sometimes inflammation, have disrupted the internal architecture of the prostate gland. Because of this, older men would naturally have higher PSA levels than younger men.

It is no longer appropriate to use one reference range for men of all ages. Investigators show that the use of age-specific ranges make the PSA more sensitive in younger and more specific in older men. These ranges also improved detection of curable cancer in younger men, and the decision not to do invasive biopsies in older men.

So, to get a true picture of what a PSA level means, a man's age needs to be con sidered. So does his race. Asians have smaller prostates compared to caucasians of the same age. African Americans, are at higher risk for prostate cancer, and this needs to be considered. Several studies of the distribution of PSA levels have been done, and agespecific guidelines have been established for white, African American, and Japanese men.

Age Japanese African-Americans Caucasians
40 to 49 0 to 2.0 0 to 2.0 0 to 2.5
50 to 59 0 to 3.0 0 to 4.0 0 to 4.5
60 to 69 0 to 4.0 0 to 4.5 0 to 4.5
70 to 79 0 to 5.0 0 to 5.5 0 to 6.5

By using narrower reference ranges, the sensitivity of PSA as a tumor marker is increased. This should help to make the early detection of more cancers in younger men in their 40s or 5Os. By using wider reference ranges in men 60 and over, the specificity of the test is increased. This means that many men in their 60s or 70s are spared further invasive testing with ultrasound needle biopsy, for example. However, it could also mean that some of the older men would not have their cancer detected.

With these age specific reference ranges, we can develop a more accurate diagnostic picture for early curable prostate cancer.

If the PSA is less than or equal to the range, and the DRE is not remarkable, the patient should be followed with annual checkups to monitor for change. If the PSA level is greater than the age-specific range and a DRE is unremarkable, then an ultrasound biopsy should be done.

back to index

ADJUSTING FOR DENSITY AND VELOCITY
There are three factors that influence PSA levels in men with prostate cancer: the volume of cancer, the volume of BPH, and the grade of cancer. The variable that correlates most closely with PSA is the cancer volume.

There is a variable amount of BPH tissue in men with and without prostate cancer that contributes to the overall PSA. Thus, PSA values appear to overlap greatly in men with prostate cancers of similar stage and between men with glands that harbor cancer cells and BPH. Another complication is that on a volume to volume basis, poorly differentiated cancers produce less PSA than do well differentiated cancers.

So PSA is not a perfect marker. It has confounding variables. Two methods of coping with these variables are to look at the PSA density (PSA-D) and velocity (PSA-V). Density is the ratio of PSA compared to the size, or volume of the prostate. Velocity is the rate of increase of PSA. Density can be measured with ultrasound biopsy, and velocity can be measured with periodic blood tests.

In general, cancer spikes PSA levels more than BPH does. Since PSA is related to the volume of cancer, it seems reasonable that men with cancer should havve more rapid rise in PSA. We have evidence that these significant differences in rate of change in PSA in men with cancer and those with BPH. The most effective way to distinguish between the two was to use the average velocity to find rate of change per year by measuring PSA three times in 6 months or a year. If the rate of change is greater than .75, it may be an indication that cancer is present. Velocity may be best used to follow men with normal PSA levels, and those who had biopsy but not evidence of cancer. If PSA is over 10, velocity is not a useful indicator.

back to index

SCREENING DILEMMAS
While some studies suggest that the PSA test could find 80 percent of aggressive prostate cancers five to 10 years before they are clinically evident, there is also a 35 percent margin for error in this test. Forty percent of men who have known prostate cancer, have a PSA within normal limits. If a PSA level is high, all other reasons for this must be ruled out before your physician can determine if the cause is cancer. In order to rule out cancer, doctors usually recommend an ultrasound test and a needle biopsy to take samples from prostate tissue.

By screening with PSA, about 20 percent of the cancers found are clinically indolent and this is the root of the controversy about whether it is helpful or harmful for a man to know he has this cancer. Prostate cancer is the only cancer with such a high disparity between the occult--latent--and the clinical. There is an argument that screening is not helpful unless it helps people live longer.

When men first come to their doctors with prostate cancer, about one third have potentially curable cancers, while the other two thirds have cancer which has already broken through the wall of the prostate, and metastasized. Among those with potentially curable cancer who choose surgery, about half will have their cancer upstaged after surgery when more information is available from the pathologist who has examined the prostate and surrounding tissue. About a third of this group may develop local or metastacized cancer ten years after radical prostatectomy.

So what is the value of aggressive therapy? Now that the PSA has allowed us to detect latent cancer in large populations, there are many controversies about treatment. There is an argument that identifying a large population of men offers nothing if curative therapy is not available.

Before it is rational to answer this question, and to do universal early screening, we need more studies. We need answers to questions on whether treatment alters the natural history of the prostate cancer. The appendix in the back of this book lists information about some of the clinical studies in progress.

Over detection is the greatest problem of screening. This gives us the big discrepancy between latent and clinical cancer and leaves little doubt we are identifying men who have no likelihood of ever getting clinical prostate cancer. Without a reliable way to predict the aggressiveness of the cancer cells, we would be treating men with no benefit at all. To further support critics of early detection, the disease has a long naturalhistory and a low death rate. The economic burden for screening, patient education, treatment of complications, primary and secondary therapy, follow up care, also needs to be considered.

Screening is associated with benefit as well as problems. In order to reduce the death rate by 3 percent, we need to identify the cancer in 6 percent of all men. The use of the PSA annually may identify enough men to achieve this, but the identified cancer must be one of the aggressive ones that will cause death. Most studies suggest that screening programs identify those cancers exhibiting the greatest malignancy potential.

Whether universal screening results in less death remains to be seen. But it must be remembered that nearly 60 percent of men whose cancer is detected only by a DRE have already advanced disease, while only about a third of those whose cancer was detected after an increase in their PSA, have advanced disease. This by itself appears to be a good reason for screening. Obviously, the clinical trials will help answer.

Whatever is finally decided about the usefullness of the PSA for screening early prostate cancer, one prostate cancer has been diagnosed, the PSA becomes a very important yardstick for monitoring the effects of treatment on the progress of the disease. It is imperative to keep tabs on the PSA level.

back to top

COPING WITH TEMPORARY INCONTINENCE

OVERVIEW
TYPES: Stress, Urge, Overflow, Global
Functioning with a catheter
STRENGTHENING THE EXTERNAL SPHINCTER
Kegals, Biofeedback, Diet
PROTECTIVE PRODUCTS | SEVERE INCONTINENCE

OVERVIEW
Incontinence following prostate cancer surgery or radiation treatment is rarely permanent. Most men have no problem after a few months, but about 40 percent have some degree of stress incontinence--leakage or dripping after exertion, or increase in intrabdominal pressure when coughing or sneezing. With today's more advanced surgical techniques, permanent incontinence is extremely rare, and occurs in about three percent of men.

The psychological problem is usually much worse than the physical problem. During the weeks or months of recovery you may need incontinence pants or pads to protect you from stress leaks and you may feel you are not in control of your own body, that you are like a baby wetting your pants. Perhaps you cannot play golf, or dance, or laugh out loud, for fear of leaking or worse. And how do you enter a locker room, or public men's room without feeling mortified.

The encouraging news is that this incontinence is rarely permanent, and there is a great deal that you can do to speed the process of complete recovery through special exercises, diet modification, and medications. There is no way to predict how long this will last. Every man is different. It can take longer the older you are. Some men regain control in days, while others need months. Nighttime continence always comes back first because when you are lying down, there is no pressure on the bladder or the sphincter and the pelvic floor. In time you may notice that you are sleeping longer through the night and your diaper is dry in the morning.

Before surgery you had two sphincter muscles that control the flow of urine. The internal sphincter, the one at the bladder neck, is the involuntary smooth muscle that is always at work without your conscious control. Because of the prostate's location at the base of the bladder and because the urethra passes through the prostate, the internal sphincter muscle is disrupted when the prostate is removed. The bladder neck itself, with its ring of muscles to control the flow of urine, may be completely removed in most cases. This sphincter is gone for good after prostatectomy. It is replaced by the anastomosis which rejoins your urethra to your bladder.

Without your internal sphincter muscle, your body must rely only on your external sphincter. This is a skeletal muscle located in the pelvic floor muscle, which is like a sling that supports your bladder and other organs. The external sphincter is the one that you are aware of, the one you tighten up when you control the urge to urinate, and the one you release when you want urine to flow. This muscle may be weakened by surgery, but there are ways to retrain and strengthen it. When any part of this system fails, some type of incontinence occurs.

back to index

TYPES OF INCONTINENCE

  • Stress incontinence causes leakage of urine when you sneeze or cough. The increase in intraabdominal pressure increases pressure on the bladder causing the bladder neck to open. The external sphincter cannot remain closed, and urine spills out. This can happen when you get up from a chair, or lift a heavy object from the floor. Many people with stress incontinence avoid doing any exercise because they are afraid to cause leaks.

  • Urge incontinence is due to the involuntary contraction of the bladder muscle which causes pressure in the bladder to increase and this stimulates a reflex arc to the brain telling the patient that you need to urgently go to void otherwise you will leak because pressure is overcoming the sphincter's ability to maintain continence.

  • Overflow incontinence occurs when the urethra is obstructed and bladder never completely empties but when full, leakage occurs. The urethra is so narrow that the bladder never completely empties.

  • Global incontinence means there is no ability to control the flow or urine and the bladder constantly empties. This condition is extremely rare.

back to index

Functioning With a Catheter
A Foley catheter will extend from your penis for a few weeks so that the urine will drain without putting any stress on your rebuilt urinary tract. A balloon attached to the other end of the catheter is inside your bladder to hold it in place. It will take about three weeks for the anastomosis -- the newly created connection of your urethra to your bladder neck -- to heal.

The hospital staff will teach you how to manage the catheter, so that the urine can drain without backing up. In fact, most hospitals cannot discharge you until they are confident you can operate the overnight bag and the leg bag.

The catheter drains into an overnight bag. When you get up or go out, you can connect the catheter to a leg bag which will not show beneath your clothing. (Bring baggy trousers for trip home to hide the bag. Put gauze pads in your underwear in case the catheter leaks.) This is strapped to your leg and is unobtrusive. However, this bag does not hold as much urine, so you cannot allow it to get full. The bag will not overflow and leak out, but urine backs up in the bladder with not place to go, it can cause problems, such as infection.

Don't worry if your catheter and leg bag get wet when you shower. This won't hurt anything. Be sure to keep the tip of your penis clean, where the catheter comes out. Your penis may be swollen for a while after surgery, and your scrotum, too. When you are walking around, wear jockey shorts for support, and when you are resting, try to elevate your scrotum and penis by placing a rolled up towel or pillow beneath them. It may be uncomfortable sleeping with a catheter but you will adjust by finding the best position.

Urine will constantly drain during the first few weeks. It is not a stop and start action during this time. When you empty the receptacles, be aware of anything unusual and alert your physician if any of these problems occur.

  • If no urine has entered the bag for over two hours.
  • If bladder spasms causing squirts of urine are so strong and frequent or painful. (There is medication to relax the bladder.)
  • If your catheter is plugged up by clots or debris.
Three weeks after surgery, your physician will remove the catheter. Urination could be painful the first few times once the urethral catheter is removed.

back to index

STRENGTHENING THE EXTERNAL SPHINCTER
Kegel exercises are simple exercises that are extremely effective in strengthening your pelvic muscles and thus, the external sphincter muscle and the control of urine flow. The pelvic floor muscles act as a sling or a support for the bladder, keeping it elevated in place. When the muscles are weak, the organs drop down, and become more difficult to control. Kegel exercises, which can be done anywhere anytime, are the best way to restore your external sphincter muscle. Squeeze and release the muscles used to control urination and excretion. These squeezing maneuvers are the single most effective thing you can do to cure incontinence. And nobody knows you are doing them.

How to Do Kegels
While urinating, try to stop the (low of urine to get some idea how weak or strong your external sphincter muscle is. Then try to do Kegels every hour. Do them while sitting at your desk, reading or watching TV.

While standing, squeeze and hold for ten seconds. Breathe and count out loud. Relax for ten seconds. Stop and start and gradually increase the number of squeezes. Repeat this up to 15 times until you are too tired, or unable to hold the squeeze for ten seconds.

If you do Kegel exercises every day for at least two or three months, you will notice the change. They should be done 30 to 80 times a day for pelvic muscle rehabilitation. The more often you do these exercises, the sooner you will see results. They are especially effective if you do them when you are engaged in an activity that causes urine leakage, such as when you feel a cough or sneeze coming on, when you are about to get up from a chair, or lift something, do them.

You might even keep a record of how often you lose urine, what activities cause leakage, so you can be ready for it, or practice a Kegel to try to prevent it. Such a record will also keep track of your progress, as well. Make a chart for each day, for example, every two hour time frame. For each time period, record any incontinence episode -- small or large -- and the reason for it. For example, you sneezed, or got up from a chair. Record the amount of liquid you drank, and when or if you urinated. Keep track of the number of times you got up during the night to urinate. At the end of each day's record the total number of episodes.

Once the muscles of your pelvic floor are stronger, they are better able to control urine leakage.

Biofeedback
Biofeedback uses electrical and mechanical instruments to help patients retrain the pelvic floor muscle, when it is weak or damaged. A tiny electric current is sent to the pelvic floor and bladder, and prompts them to contract and get stronger. This may be effective if you have trouble doing the Kegel exercises. A therapist operates the equipment and teaches you how to monitor your progress.

While you are connected to the instrument and sensors, a video monitor displays information on a video monitor about electrical impulses from your body. These sensors read electrical signals you create when you contract or relax your muscles. You see what is happening on the computer screen, and this is how you learn to control the muscles. By watching how you learn to control your reaction, you are encouraging yourself. The positive feedback from the therapist reinforces the exercises.

Diet Modification
All that you eat and drink creates urine. Naturally, the more you drink, the more you need to urinate. However, the logical step to reduce amounts of urine generated, it not to stop drinking fluids. This can be dangerous. If you don't drink enough fluids, you can become dehydrated. That condition will irritate your bladder and make the incontinence worse. It's important to maintain a balance and to know which foods and beverages create more urine and which ones do not.

Carbonated drinks, citrus fruits and juices, spicy foods, and artificial sweeteners can irritate your bladder and cause more need to urinate. Alcohol is a diuretic and also works like a sedative and can impair the muscles needed to prevent incontinence.

Some medications and drugs can have the same affect. High blood pressure pills, sleeping pills, tranquilizers, antidepressants, sedatives, diuretics, antihistamines, decongestants, or cold remedies. Some pain killers, too. If you are taking a medication that cannot be discontinued, then there may be other ways to create a balance, such as cutting out coffee, tea, and alcohol, or one of your other medications.

back to index

USING PROTECTIVE PRODUCTS
When the catheter is removed, about three weeks after your surgery, and until the urinary incontinence recedes, you may need to use protection from leakage. Absorbent pads and external condoms are widely available. These products and devices should be considered temporary remedies for particular situations. They should never be used in place of exercise and treatment, but can make you feel more secure while you are going through the process. The cost of these items are covered by medical insurance, although you may have to file claims to get reimbursed.

  • Absorbent pads. A variety of products can absorb urine whether it is a few drops, or the entire contents of your bladder. There are pads that can be inserted into underpants, such as Depends Guards for Men. A bulkier and larger pad, with a waistband, is more like an undergarment. Then there are adult briefs, which are the bulkiest but offer total protection. They are fastened with self-adhesive tape. Bed pads are available in several sizes and degrees of absorbency.
  • External condoms. These are made of latex and are strapped on to collect urine, much like a catheter bag. When they till up, they become heavy and can drop off if you do not tend to them right away.

back to index

TREATING SEVERE INCONTINENCE
In rare cases where incontinence is more severe, or if it is caused by other conditions combined with prostate cancer treatment, there are other options.

Collagen Implants
Contigen is a synthetic polymer, very much like the natural collagen, a protein found in animal and human bodies. This can be used as a way to "bulk" the urethral tissue so that your muscles don't have to close such a wide gap to stop the flow of urine.

While these do not work for everyone, and many physicians believe they are not a good solution to the problem, some physicians believe they can be effective for some men. The implanting is done in a hospital on an outpatient basis with local anesthesia.

A cystoscope is used for this procedure. This is a fiberoptic tube with a telescope inserted into the penis, that allows the physician to see inside the urethra. Then, a needle is inserted through the cystoscope so collagen can be injected through the needle into the wall of the urethra near the external sphincter. The collagen builds up the wall of the urethra, closing the gap. This is called bulking the urethral tissue. The bulk creates a seal to stop leakage, but the tissue separates naturally when you need to urinate. A month later your doctor will examine you to see if you need more implants.

Complications are rare, but there is the possibility the implants could make the incontinence worse, or close up the urethra too much so urine cannot get out. Implants can sometimes cause pain and discomfort, an infection in the bladder or urethra, or an allergic reaction.

Artificial Sphincter
In rare cases of persistant or global incontinence, an artificial sphincter can be implanted after a prostatectomy. This assistive device cannot be implanted, however, after radiation treatment.

This is a silicone device with a cuff and a pump. The inflatable cuff wraps around the urethra to stop the flow of urine. The pump is implanted with a valve inside the scrotum. When you need to urinate, you squeeze your scrotum and let the fluid out of the inflated cuff. This allows urine to flow through the urethra. The cuff can then be inflated to restore urinary continence after voiding is completed.

Implanting an artificial sphincter is very complicated and specialized surgery. Only urologists with special training and experience feel qualified to do this procedure. Ten separate studies showed cure rate from 75 to 95 percent.

Complications can be with the mechanism itself, such as mechanical failure, or an infection could set in. The artificial sphincter is considered by most urologists to be reasonable solution to global incontinence.

back to top

EXTERNAL BEAM RADIATION THERAPY

Overview How it works
Side effects Therapies
Follow-up care Radiation

OVERVIEW
Radiation therapy, like surgery, is local treatment -- it treats only the area it touches. Where surgery cuts out and removes the prostate and the tumor, radiation kills the prostate cancer cells by altering the DNA so they cannot multiply, and by scarifying the blood vessels so blood cannot flow and feed the cancer. This prevents progression of the disease.

Radiation therapy, which has been in use in one form or another, for over a hundred years, uses approximately 500 to 1,000 times more energy than what is used with regular diagnostic X-rays. This high dosage from high energy equipment penetrates the tissue as it passes through the body and is absorbed. It radiates all the cells in its path, good and bad, so they cannot grow and multiply. Radiation damages the cells' DNA. Cancer cells are more sensitive than normal cells to radiation because they are dividing rapidly, so treatment prevents the cancer cells from multiplying.

Radiation is also known as irradiation or radiotherapy, and it can be delivered externally or internally. External beam radiation is most commonly used, but the implantation of radioactive seeds -- brachytherapy -- into the prostate is becoming more popular as treatment techniques improve.

The side effects of radiation therapy have a lasting impact on your life style so it is important that you understand what they are and how you can correct them, or live with them. Despite sophisticated high precision techniques, it is impossible to prevent some damage to the blood vessels around the prostate. Damage can also occur to the neurovascular bundles. When these vessels become scarified, blood cannot flow into the penis, and nerve damage can also result and can cause erectile dysfunction in 30 to 40 percent of patients.

Although radiation therapy is used for all stages of prostate cancer, it has the best chance of curing low volume prostate cancers, those diagnosed as T1 or T2 tumors. More advanced cancer is sometimes treated with radiation, but then it is meant to eliminate pain or treat symptoms in the prostate such as obstructions in the urethra. It is common to use radiation to treat patients who have pain from bone metastases, as palliative therapy.

Some radiation oncologists believe radiation therapy is effective in any cancer that has not yet metastasized, no matter how big the tumor. For example, a patient with a T3 tumor would not be a good candidate for surgery but he may be a reasonable a candidate for radiation. When prostate cancer spreads, it often causes obstruction in the bladder area, resulting in difficult urination or damage to kidney function. But radiation can get to those areas and relieve the obstructive symptoms, and this is one of the reasons for its importance in treating more advanced prostate cancer.

Although there is still a wide disparity of opinions among radiation oncologists and urologists, most would agree that any man who has a life expectancy under 10 years, and has other medical problems (comorbid diseases) that would preclude surgery -- heart or lung problems -- would be a better candidate for radiation because surgery might be too risky.

Some look at it this way: Surgery may be a good choice if your PSA is under 10, when there is an 80 to 90 percent cure potential. If it is over 10, either surgery or radiation could be effective. When the PSA is over 20, then radiation is usually a better choice than surgery. For example, radiation therapy would not necessarily get all cancer cells, but it would get many, and also avoid the risks of surgery.

We need more long-term studies before we can know for sure how effective radiation treatment will be against prostate cancer. As of 1997, five-year studies showed that radiation therapy compared favorably with surgery for treating early stage cancer. About half the men with T 1 or T2 tumors and low Gleason scores appear to be cured with external beam radiation therapy. The results are not clear with bulkier tumors which have a lower chance of cure. Radiation in combination with hormone therapy can add additional survival time by downstaging the tumor.

Despite the lack of long-term studies that show us that radiation is as good as or better than surgery for curing prostate cancer, there has been an increased interest in radiation therapy because of greater media attention in the 1990s. Many high profile men have had this treatment and have written about it in books and magazines.

There is also the matter of the technology itself, which has improved dramatically in recent years with increasing numbers of hospitals installing the kind of sophisticated machinery and computer equipment needed to deliver more precise treatment.

back to index

HOW IT WORKS
External beam radiation has been used in the treatment of prostate cancer since the 1950s. Cobalt, a radioactive isotope was used in the earliest treatments, but currently many centers utilize the high energy radiation produced by a linear accelerator which generates and directs the beams -- X-rays, gamma rays or electrons -- to the target area. Radiation treatment is delivered and designed to each individual case.

Radiation is measured much the way watts of electricity are measured. The unit of measurement for radiation is the Gray (Gy). The old measurement unit was a rad and some physicians and technologists still use this measurement term. One Gy equals 100 rads. A typical daily dose of radiation to treat prostate cancer is 1.8 to 2.0 Gy - or 180 to 200 rads.

Naturally, the higher the dose of radiation, the better the chance of killing the cancer, but there are limits to the amount of radiation that can be safely delivered to the human body. Although your body can tolerate large amounts of radiation, it cannot tolerate it all at once. It was believed until the middle of the 1980s that the maximum safe dose for prostate cancer was 70 Gy (7,000 rads) administered in smaller doses over a period of weeks. To prevent harm to other organs, such as the bladder and rectum, the 7,000 rads of radiation are given in small daily doses, five days a week, for a period of 7 to 9 weeks for prostate cancer. With more sophisticated technology, like high quality CAT and MRI scans, and computer assisted planning modules, higher doses can now be delivered safely.

3 Dimensional (3D) Conformal Technique
Until the end of the 1980s, conventional two dimensional radiation (still in use in many places) provided a dose of only 7,000 rads in what is called the four-field technique with beams aimed at the front, back, left, and right side of the patient. In so doing, a wide area of pelvis was irradiated, including the rectum and bladder in an attempt to get all of the cancer.

Computers helped radiation therapists move from simple two-dimensional X-rays to three dimensional - 3D - conformal treatment. This has made a profound improvement in the accuracy of the treatment and it is no longer necessary to irradiate such a wide area around the prostate. Conformal means the radiation field "conforms" to the shape of the prostate and the radiation beam can be aimed in an oblique angle to hit the target more precisely without doing as much damage to the other adjacent organs. This technique requires more sophisticated computer software, but this equipment is becoming more widely available in medical centers.

By the middle of the 1990s, experts seemed to agree that as much as 80 Gy (8,000 tads) could be delivered safely. The new technology allows penetration of the target area with very little radiation touching the bladder and rectum. Beams can be focused on the prostate and seminal vesicles with only an inch or so of margin. Thus, by limiting the area around the prostate that could be damaged, increased radiation doses can be applied directly to the cancer. Still, not all physicians are willing to use higher doses until more long-term studies have been completed. This, too, has added to the controversy in prostate cancer treatment.

Simulation: Planning Treatment
Radiation treatment requires about a week of preparation. First, one or two consultations with the radiation oncologist are needed before you begin. Then there are several days of preparation with your treatment team to be sure the radiation is delivered as precisely as possible. Your radiation oncologist will review your medical history, your pathology reports, medical records, bone scan, CT or MRI scans, and talk with you about your particular treatment. There may be some additional testing such as blood tests or Xrays. Your actual treatment usually begins within a week or two from your initial consultation.

The need for accuracy in delivering radiation to the cancer cells is of critical importance in order to avoid damage to the bladder and rectum. Thus, the need for precise planning, a sort of dress rehearsal known as simulation. The treatment center's physicist and dosemetrist can study your prostate and the surrounding area while you are in the CAT scanner. The computer then calculates the location of all the other organs on the CAT scan. They carefully map out a plan for sending the radiation beams into your tumor with as little damage to the bladder, and rectum as possible.

The simulation for this technique is the same as for the conventional treatment. Your pelvic area is measured and marked first with marking pens, and then finally, with tiny tattoos to guide the technicians in aiming the radiation beam at your prostate. Your prostate and surrounding organs are uniquely your own, and are not exactly the same size and shape as any other man's, so your treatment must be tailored to fit you just like a good suit. The bladder and rectum are not static organs. They live and breathe with you so their exact location may change by a fraction of an inch in different positions. Careful planning and a custom?made plastic body cast or cradle. hold you exactly in place during treatment. Lead blocks may also be custom designed to protect nearby healthy tissue from the radiation.

All this sophisticated preparation will determine not only at what angle the beam should enter your body, but what shape the beam should be. Several beams will be entering your body to intersect at the target area. The ability to plan treatment from the perspective of the beam is known as the BEM (beam's eye view). The beam entry is controlled, and the tumor is viewed from all angles. This technique reduces complications, especially rectal bleeding and bladder burning.

back to index

The Treatment Process
Radiation treatment for prostate cancer is given daily from Monday through Friday for 7 to 9 weeks. Daily treatments are administered by the radiation therapists. From start to finish, you should be in the treatment center no more than an hour from the time you sign in, change into a dressing gown and leave your clothing in a locker, and wait to be called into the treatment area.

For the treatment itself, you lie on the table on your back or on your stomach. The technicians get you into place on the table. They return to the control room and watch you through the window, as well as through a closed circuit television while they administer the treatment. The radiation machine revolves around you and the radiation is sent into your prostate area for only a few seconds, although you may be in position for five minutes or more. You won't feel a thing.

It is always best to lead as normal a life as possible during the weeks of treatment. However, radiation can make you tired, it can irritate your skin, and may cause some gastrointestinal problems, so don't expect to function at full capacity. Rest when you need to. If you can schedule treatment for mornings or late in the afternoon, you can continue your work with little interruption to your day. If you miss a treatment because of a holiday or bad weather, another day can be added to the treatment schedule, but if treatments are missed often, it can interfere with effective treatment. As many as five days delay should not interfere with cure, but more than that can.

Many patients who live far away move to the radiation treatment center, relocate to that city, either for the entire two months; or during the week, so they can avoid the long commute. If you do this, be sure to ask about available or discounted housing that may be available through the hospital. Ask the patient services representative.

back to index

SHORT-TERM SIDE EFFECTS
Side effects from radiation treatment don't normally show up until you have been in treatment for about two weeks. Then, the cumulative dose of radiation may begin to give you minor problems such as inflammation of the prostate, skin irritation, more frequent urination and possibly burning urination, diarrhea, and fatigue. Once treatment ends, these side effects gradually diminish in a few weeks.

  • Skin irritation. After a week or two, your pelvic area may swell and your skin may become slightly pink or a deep red and itchy in the treated area. The intensity varies with each individual and skin type. Avoid irritation by wearing clothes that will not rub against your skin. Boxer shorts and loose fitting trousers will be more comfortable. To take care of your skin during radiation treatment, use clear warm water instead of soap and creams in the treatment areas. Pat yourself dry, don't rub. If you are itchy, ask your therapist about special creams that will not interfere with treatment. Prescription creams or a light sprinkling of cornstarch may help. Avoid heavy lotions. They may leave a coating on your skin that can interfere with your treatment and cause further irritation.

  • Urinary changes. After the first two weeks, you may urinate more often, especially during the night, and you may also feel a mild burning sensation if your prostate is inflamed from the radiation. However, these symptoms usually level off after about three weeks of radiation and do not get any worse. Long-term urinary complications are rare, but your bladder function may not be exactly as it was before treatment. You may always feel a sense of urgency, or feel the need to urinate more often. Perhaps one in every one hundred patients will have some form of incontinence.

  • Bowel problems. Diarrhea was a common side effect with the older radiation technology because more of the pelvis was irradiated during the treatment exposing the bowel to potential injury. This is less common now. The back of the rectum is about an inch behind the prostate and this part of the rectum will receive as much radiation as the prostate. This can cause irritation during bowel movements, as well as diarrhea, and an increase in the number of bowel movements. These symptoms will subside two to three weeks after treatments end.

    About 5 percent of treated men may experience rectal bleeding after radiation if the area of rectum was particularly sensitive to the radiation. This usually occurs only during bowel movements because of the pressure of stool passing through the rectum, and increased irritation of hemorrhoidal tissue. This type of bleeding usually goes away by itself within 1 to 5 years. If the bleeding is severe, you may need a temporary colostomy. This will divert the colon and the fecal stream to a bag outside your body until the rectum heals. Sometimes, the rectum will heal and the colostomy can be reversed. Chance of such complication is less than one percent. Permanent rectal damage is extremely rare.

    One case that was ironic involved a 72 year-old retired stock broker who was such an avid golfer, that he deliberately chose radiation over surgery because he so feared surgery would leave him incontinent. He could not imagine life without golf, and he believed that being incontinent would mean he could no longer play. However, during his external beam radiation treatment he developed proctatitis and urinary frequency. Although medications relieved the symptoms, he did not play golf during the seven weeks of treatment. Six months later, his symptoms are improving and his PSA is down, but he will still not play golf for fear of having to race off the course to get to a bathroom in time.

LONG-TERM SIDE EFFECTS
While the urinary and bowel symptoms will generally subside quickly, there are longer term side effects, such as impotence that can progress anywhere from six months to two years after the end of radiation treatment. Impotence caused by radiation is permanent, and the chance of this happening increases over the years. This is caused by a combination of the effects of radiation as well as the natural effects of aging. After one year, about 10 percent of irradiated men are impotent. Overall, there is a 30 to 40 percent chance of impotence after radiation.

Radiation scarifies the blood vessels that carry blood to the penis for an erection and may damage the neurovascular bundles so this is what causes impotence. But impotence does not decrease your sexual desire (libido), or your ability to achieve orgasm. Impotence does not mean that you will no longer have a sex life. It simply means that you will have to adapt to new ways of achieving an erection. It is very important to discuss this openly with your physician as well as your spouse or intimate partner, so you can learn how to deal with it. There are medications and mechanical devices, as well as surgical prostheses to help men with erectile dysfunction.

Other long-term effects.
A small amount of "scatter radiation," something like nuclear fallout, may reach your testicles, and there can be some damage to sperm. Although most men who undergo prostate treatment are past their parenting years, if you are planning to father a child, it would be wise to bank some sperm before treatment.

There is no evidence that radiation will increase the risk of any other cancer, such as lymphoma.

back to index

COMBINATION THERAPIES
There are different strategies for treatment with implants alone or in combination with external beam radiation. The combination is usually used for more locally advanced tumors, while implants alone for early stage and small tumors. The combined treatment can raise the level of radiation that can be delivered to the site of the cancer. Sometimes seeds are implanted before or after a course of external radiation therapy to act as a booster. If you have an aggressive cancer, this may work, but it is not generally used for men whose cancer has metastasized.

Neoadjuvant Hormone Therapy
In some cases, two or three months of hormonal therapy may precede treatment with radiation. The goal here is to shrink, or downstage the tumor and reduce the field of radiation. With a smaller target, less surrounding tissue will be damaged from radiation. There are studies underway to determine if this strategy delays recurrence of the disease. In theory it is very appealing, but we won't know the answer for several years.

A 75 year old man with moderate Gleason score and cancer in both lobes of the prostate, Stage T2C, had three months of Lupron, and his PSA dropped down to 0.5 before radiation treatment. After treatment, one year later, he is doing well and his PSA is 2.3. Radiation and "Salvage" Surgery Prostate surgery for persistent prostate cancer after radiation therapy is sometimes called "salvage" surgery, but most physicians consider this ineffective except in rare cases. About half the men who have this surgery after the failure of radiation therapy, become incontinent, and nearly all of them become impotent. However, because as many as 20 percent of men may appear to be cured after such treatment, some are willing to take the risk if they are in good general health. Salvage surgery is difficult because once the prostate has been irradiated there is considerable scar tissue. The normal anatomic planes of dissection are often lost and surgery can potentially injure the rectum, bladder, and surrounding blood vessels. Using this is highly individual decision.

For example, a 50 year old investment banker had a PSA of 7.4 and the DRE revealed evidence of a large tumor on both lobes of the prostate. He was diagnosed with inoperable cancer because of stage, tumor size, and Gleason score, and advised to have neoadjuvant hormonal therapy to shrink the tumor and follow this with a course of radiation therapy. But thinking ahead, this man wanted to know his options if cancer recurred after radiation. Would his doctor try salvage surgery to remove the prostate? This does not normally accomplish much, especially since the radiated prostate is all scar tissue and falls apart when it is dissected. However, because this was an otherwise healthy man, and young, he and his physician considered salvage surgery an acceptable option if he needed it.

back to index

FOLLOW-UP CARE
When radiation therapy is completed, expect to have a routine checkup with your radiation oncologist within two months, and then alternate checkups between your radiation oncologist and urologist every three months for two years, then every six months for five years. This may include periodic transrectal sonogram.

If cancer was destroyed by radiation therapy, your PSA should gradually fall to low levels within the year following therapy. If it drops to less than 1.0, it is likely the cancer is gone. If the level is above 2 after a year, it is likely there is still some cancer there. If the PSA rises after treatment, then a bone scan can determine if there is any metastatic disease present.

THE RADIATION TREATMENT TEAM
Teaching hospitals and comprehensive cancer centers often provide the best radiation therapy because they treat so many more patients, attract more experienced physicians, and use up-to-date equipment. You'll want to know that there is a CT scanner available and a physicist on staff to handle problems that may arise with the equipment. Radiation oncology centers, and hospital departments of nuclear medicine, must be approved by Federal and State Nuclear Regulatory Agencies. Most important, you want to know how many cases of prostate cancer they treat.

You can find a radiation oncologist and radiation treatment center by calling the American Cancer Society, the National Cancer Institute, or the American College of Radiology. Libraries, cancer hotlines, and support groups are also good sources of information. For more information on radiation treatment for prostate cancer, call the National Cancer Institute for their free booklet, Radiation Therapy acrd You.

Radiation Oncologist
A radiation oncologist (sometimes called a radiation therapist or radiotherapist) is a physician who is specially trained in treating cancer with radiation therapy. This is not the same as a radiologist who specializes in the diagnosis of disease using X-rays. The radiation oncologist will probably be recommended by your urologist, but do not accept a radiation oncologist with whom you do not feel, comfortable. In large treatment centers there will be more than one you can talk with. Expect your radiation oncologist to consult with you and your urologist, review your medical reports, and examine you thoroughly before administering your radiotherapy. Ask questions about the physician's background and experience in treating prostate cancer. You want to know about his or her board certification, and number of years treating the illness. Will the radiation oncologist personally supervise your treatment or will technicians handle the daily routine? If this is the case, expect your radiation oncologist to talk with you and examine you at least once a week during your course of treatment. Be sure to ask about the side effects. Also ask about the chance of receiving this treatment again in the future, should the cancer metastasize. How often will you be able to talk with this doctor? Can you call with questions?

The Technicians
The other healthcare professionals directly involved in your treatment include the therapist, and behind the scenes, the physicist and dosimetrist. Therapists are state licensed technicians with two to four years of special training. They generally administer your daily treatment following the guidelines set up by your radiation oncologist. The therapist will position you for each treatment and direct the linear accelerator to deliver your precise dose of radiation.

Radiation physicists and dosimetrists are the planners of your treatment. The physicist, with the radiation oncologist, designs and develops the best possible therapy for cure according to your individual case. The physicist is also in charge of quality control for the equipment. The dosimetrist calculates the exact amount of radiation you will get.

THE COST OF RADIATION THERAPY
A complete program of radiation therapy for prostate cancer can cost tens of thousands of dollars in a large medical center. This includes treatment planning and 35 to 45 treatments. There will be professional charges from the people who give you the treatment, as well as hospital charges for delivery of the services. Most medical insurance covers this cost in the treatment of cancer Medicare covers 80 percent of the cost and Medicaid covers it all. If you are insured by a health maintenance organization, be sure you understand the rules governing radiation treatment.

Also, keep in mind, that if you are traveling from a distance to get treatment, or you are actually living in a different city during the weeks of treatment, those expenses may be covered by your insurance. (They are also deductible as a medical expense on your income tax.) Some treatment centers have access to reduced cost hotels in the area or other moderately priced temporary housing. Brachytherapy is less costly than external beam radiation and requires only a single procedure rather than weeks of treatment. This could be an advantage to men who live far from a radiation facility.

back to top

RESTORING POTENCY AFTER PROSTATE CANCER

OVERVIEW: Mechanics of an erection
TREATMENT OPTIONS | VED
TRANSURETHRAL THERAPY
Side-effects, PEP, Injecting yourself, Penile prosthesis
COST OF TREATMENT

RESTORING POTENCY AFTER PROSTATE CANCER
Most men are just happy to be alive after treatment for prostate cancer and they rarely worry about their sexual potency until after a year of recovery. Then they often do much soul searching before attempting to use mechanical or pharmaceutical means to achieve an erection. Studies have shown that in general, men who enjoyed a good sex life before cancer treatment, will find a way to continue that enjoyment.

Impotence or erectile dysfunction is the inability to achieve or maintain a rigid erection for intercourse. This is not the same as loss of libido or sex drive caused by hormonal therapy. It is important to understand that you still have desire, and you can still achieve orgasm. There are many options--and new ones being developed all the time, but it is vitally important for you and your partner to participate together in any discussions or therapy geared around erectile dysfunction.

Affection and intimacy are important during recovery and while you are learning a new way to make love. It may take some trial and error, to see whether injections, or a vacuum device suits you and your partner better, and how it affects the process of lovemaking. Some men say the vacuum device makes their penis feel cold, others say the injection makes it feel artificial. But for many men, either of these systems works.

The National Institutes of Health estimate that from 10 to 20 million men in this country between the ages of 40 and 70, suffer erectile dysfunction, but less than 10 percent do anything about it. Indeed, many men simply assume it is a condition of age, and do not realize it is a medical condition that can be treated. While it is more common as men age, it is not inevitable with age, and much more commonly caused by physical conditions, and sometimes emotional ones.

A 1987 to 1989 study by the Massachusetts Male Aging Study found that erectile dysfunction correlated with abdominal surgery or trauma, heart disease, hypertension. low values of HDL, diabetes and the use of certain drugs to treat it. In men with heart disease, hypertension, and diabetes, cigarette smoking added to the problem. Emotional reasons included depression, anger, and low degrees of dominence.

About one in 10 men becomes impotent as the result of health problems such as diabetes, high blood pressure, spinal cord injuries, and even certain medications. Some are impotent because of treatment for prostate cancer and colon cancer. Only about 20 percent of long-term impotence problems have a psychological cause.

Impotence, even when it can be overcome, can create psychological problems to compound the situation. Men worry about their sexuality but few are able to talk about this, but there is help for it. Even when men realize they need to get help -- medical help -- or lose their marriages, it is hard for them to talk. Women generally have the advantage of being better able to talk about any problems they may be having, and in knowing how to seek help. That is why it is so important to learn all that you can and communicate your feelings with your partner and with your doctor.

Following prostate surgery or radiation treatment, nerves and blood vessels critical to the erectile process may be damaged. The neurovascular bundles located on the sides of the prostate may have been severed during surgery in order to remove all the cancer. If both bundles are gone, the risk of impotence is higher. If only one is gone and you are young, you will probably remain potent. put chart here It is important to wait 9 months or a year to be sure you are impotent. This means you cannot achieve an erection with any girth and rigidity that lasts long enough to penetrate the vagina so you can have intercourse.

After radiation therapy impotence is gradual. The treatment accelerates atherosclerosis which produces a reaction in the walls of the arteries. The arteries become thickened and the lumen (passageway) becomes obstructed. Radiation can leave blood vessels callused and scarred and in this condition the vessels are unable to transport blood into the penis.

back to index

The Mechanics of an Erection
Explanations of just how a penis becomes erect have been revised over time, but it is generally believed the blood circulation changes when a man is aroused by physical or psychological means. More blood flows in and less flows out and this makes the penis hard. This increased blood flow causes spaces in the penis filled with spongy tissue called "corporal bodies" to expand. These spongy areas run along the length of your penis on the right and left side. When your brain lets your penis know that you are sexually aroused, the erection begins. Nerves relax the blood vessels in the spongy tissue so more blood can get in. As these spongy tissues fill with blood -- just like a sponge -- and press against veins which normally take blood out of the penis. The blood becomes trapped in the penis and an erection results. This pressure traps the blood and this is what makes the penis firm for intercourse.

However, it is a complex dynamic involving nerves, blood vessels, and voluntary and involuntary reactions. The veins, arteries and nerves must be intact and healthy to achieve and maintain an erection. After radical surgery or radiation, most of these nerves and blood vessels may become damaged and not function properly resulting in erectile dysfunction.

back to index

TREATMENT OPTIONS
There are many new and improved therapies are available to correct erectile dysfunction. It is possible to continue having sexual intercourse with the help of a vacuum erection device, implanted penile prostheses, or medications injected into the penis or inserted into the urethra. As this book is written, new drugs are being studied and it may soon be possible to take a pill to have an erection.

Urologists specializing in sexual dysfunction are available in most major medical centers. There are more than 40 such centers around the country that specialize in correcting it with the penile injection system.

There are sex therapists who can counsel about the emotional aspects of sexual dysfunction, but it is important to check their credentials first, and ask them many questions about how they have helped other men, and how many men have continued to enjoy their sex lives using such treatment plans.

Books and videos are available through doctors, drug companies, and the manufacturer's of vacuum devices. These can help you and your partner learn how to adapt new methods for restoring sex to your lives.

The American Cancer Society has two excellent booklets about sexuality after cancer treatment. Call your local branch to get a copy.

Sexuality and Cancer and For the Man Who Has Cancer and His Partner
VACUUM ERECTION DEVICE (VED)
This is a simple mechanical device with a cylinder, pump, and a rubber band. The cylinder fits over the penis and when air is pumped in, a vacuum is created. The vacuum draws blood into the penis, so an erection can be achieved. Then the penis is clamped off at the base with a rubber band to trap the blood in the penis.

The results differ somewhat from a normal erection. For example, the penis may feel slightly cold. It may be larger in circumference, and it will pivot at the base. The penis will not be stiff at the base, but may be very hard at the end. Veins may be distended and it may look blue. Sometimes men notice a numbness while the constriction is in place, but this does not usually decrease pleasure. Some men find it easier to reach orgasm when they use the device, but a few find it more difficult.

An advantage of the vacuum device is that it mimics the natural process and allows complete control of when you want the erection to begin and end. Some men and their partners believe it is better than nothing, while others say it seems mechanical and artificial. The major disadvantage, however, is that time is taken away from foreplay to use the pump, and some men and their partners feel that this ruins the mood.

TRANSURETHRAL THERAPY
In 1996, the FDA approved a new drug called Muse for use in 1977. It helps provide an erection by inserting a medicated pellet into the urethra. The pellet releases a medication called prostaglandin which diffuses into the erectile bodies of the penis to cause dilation of the blood vessels and, thus, an erection. The pellet contains, alprostadil, a synthetic form of a natural substance in semen which works to open blood vessels. While this drug was known for years, in the past it had to be injected directly into the penis. The discovery that the urethra can absorb medications and distribute them into the surrounding tissue may gradually replace the penile injections for many men.

Muse and Caverject - which is the penile injection therapy, open up or dilate the blood vessels to allow blood to flow. Some drugs achieve this by relaxing the muscle cells in the arterial walls. This relaxation causes increased blood (low into the penis. At the same time, blood flow out of the penis, through the veins, is reduced so that blood is trapped in the penis and the erection is maintained.

Muse is the first time that alprostadil can be used in the treatment of erectile dysfunction without having to inject it. It comes in a pre-filled plastic applicator with a suppository of the drug to be dropped into the urethra. It comes in four dosages from 125 to 1,000 micrograms. Lower doses are usually given in the beginning. It is not a good idea to use this system more than twice in a 24 hour period.

The Muse pellet is absorbed by the mucous lining of the urethra in about 10 minutes. This relaxes the smooth muscle and this allows blood to enter the penis and stay there to form an erection. Erection occurs about 5 to 10 minutes after application.

It is necessary to urinate first, and then insert the tip of the applicator into the penis, about an inch or so. The button on top of the applicator acts as a plunger to push the suppository into the urethra.

Side effects are known only from the clinical trials. The MUSE study was the largest study on erectile dysfunction to date, and included 1500 patient couples in 58 locations across the country, who had a history of erectile dysfunction of at least four years.

Most patients were successful with the MUSE, but many needed to experiment with different dosages before satisfaction. Some could not tolerate the MUSE because of penile pain.

The most serious side effects were priapism, which is a rigid erection lasting four to six hours or more. In general, a lower dose of the drug eliminated this condition. The most frequently reported effect was mild to moderate penile pain, reported by about a third of the men. Some of the female partners reported vaginal burning or itching, 5.8 percent.

Men with hypertension, or abnormal penile anatomy, with conditions that predispose to prioapism, and in whom sexual activity is not advised, should not use MUSE. It should not be used if your partner is pregnant unless you use a condom barrier.

From what has been observed in a short amount of time, Muse seems to work only in about 15 to 20 percent of men after a radical prostatectomy. It seems to work better for men who can almost get an erection, but who need a boost to augment the limited erection they can achieve.

The medicated pellet comes with an applicator to help push the pellet into the urethra almost two to three centimeters, or about an inch and a half. You can do this sitting or standing. Stretch your penis slowly upward to its full length, and gently squeeze on the glans (the head of the penis) to open the urethra While the penis is stretched, you can insert the applicator stem into the urethra. When you push a button on the applicator, the medication will drop into the urethra. You need to hold this position, and rock the applicator from side to side to make sure the pellet gets into the urethra.

Then, keeping your penis extended to its full length, firmly roll it between your hands for about 10 seconds. This is to ensure that the medication is absorbed along the walls of the urethra; so it can get to the blood vessels. If it causes a burning sensation, keep rolling your penis for another minute or so until it stops. If you have a curved or unnaturally shaped penis, this drug may not be safe. It's effectiveness is based on a straight penis and urethra, so the drug can pass all the way through the length of the penis. After the drug has been administered, it is important that you do not sit or lie down for at least ten minutes. Keep walking around because this will increase the blood flow to your penis and you will get a better erection.

You and your partner may want to experiment with positions that keep the blood flowing and your erection rigid. An erection should last from 30 minutes to an hour.

back to index

Side Effects of Transurethral Therapy
Because this was a brand new therapy, there are obviously no long-term studies of its effectiveness and the side effects. However, the most common side effects observed in clinical trials of the medicated pellet are:

  • Burning or warmth in the urethra

  • Redness of the penis from the increased blood flow

  • Some urethral bleeding or spotting if the drug was not administered properly

  • An ache in the penis, pelvic area, and legs Longer term side effects included fainting or dizziness, a rapid pulse, and a prolonged erection. Call your doctor if any of these occur, especially if an erection lasts more than four hours.

All vasodilators can cause side effects in some men. Some of these drugs can produce a painful, sustained, prolonged erection, known as priapism which requires immediate medical attention if it lasts more than three hours. This is usually caused by too large a dose of the medication. With proper education and testing in the doctor's office, the correct amount of drug will be prescribed, and priapism can be avoided.

Other side effects which are very rare, include dizziness or headache, or an increase in liver enzymes. Injecting medication can be painful. Muse is painful too.

Men with sickle cell disease are unable to use this method.

Pharmacological Erection Program (PEP)
The same type of medication used for the transurethral therapy is used by injection directly into the penis. If you cannot succeed with transurethral therapy, the injection system may work for you.

The penile injection system initially requires training and monitoring by a physician. To begin generally requires two office visits designed to teach you how to give yourself the injections and test your response to the drug. Finding the correct dosage is vitally important. Too little will not be effective and too much could case an erection to last too long and become painful. During initial testing, the urologist may use the Doppler ultrasound test to scan your penis in its flaccid state then again after an injection, to measure the arterial blood flow and note the difference in diameter of the dilated penile artery. Then you will get a prescription for kits with disposable sterile syringes and needles.

It is important for men to visit their physician every three months to review their technique and for examination of the penis to be sure he is not exhibiting any side effects. Injections should not exceed 12 a month and it is best if they are evenly spaced.

Injecting Yourself
The kit comes with everything you need for a treatment: a vial of medication called caverject, syringe, needle, and alcohol swabs. The vials come in strengths of 10 or 20 micrograms and are for one time use only. They should be kept in the refrigerator.

Wash your hands and set out the items from the package on a clean surface. Assemble the syringe, remove the cap and swab the stopper with alcohol. Remove the needle guard, and holding the needle pointed toward the ceiling, push the plunger into the syringe to force the air out. Then push the needle into the vial of medication and swirl the medication around. Pull the plunger back and the medication will fill the syringe. If you see air bubbles inside the syringe, just tap it gently and the bubbles will burst, and the air will leave the syringe.

Always alternate injections on the left and right side of your penis so that you don't irritate one side. The site should be alternated between the right and left side of the penis to minimize scarring. Retract the foreskin, and avoiding veins, hold the needle at a 90 degree angle from the shaft of your penis. The needle is short and you may feel a pinch, but there is little pain. You should have an erection in five to ?0 minutes, correlates with the extent of arterial blockage. It should last for 45 minutes to an hour. If it lasts too long your physician will lower the dosage of medication. This is one reason it is so important to practice this under your physician's guidance.

There is a high response rate (80 percent) to the penile injection system, but there is also a high dropout rate (30 to 50 percent) over the long term. Some men say it is unnatural, and they or their partners are afraid to touch their penis. Others claimed they felt they were not in control.

Before you consider using the penile injection system, consider your own manual dexterity, your past medical history, and genital anatomy. This system would not be appropriate for you if you have poor vision, or poor manual dexterity, and you are unwilling to follow instructions which can create potential for misuse.

Side Effects of Penile Injections
In addition to side effects of the medication itself described above, there are two types of potential side effects of the penile injection program. One is simply that whenever a needle is stuck in the body a bruise can develop. Over time a small nodule or lump may develop by injecting again and again in the same site. Also extremely rare, is a slight, dull ache in the penis, but this usually subsides after about 15 minutes.

PENILE PROSTHESIS
Penile prostheses, made of silicone, adapt well to the body and have a very low risk of infection. Once you have one implanted, however, you will never be able to have an erection any other way. Mechanical failure is the most significant problem with prostheses, and some need to be replaced when they wear out. There are several types of prostheses.

  • The malleable type is the easiest to implant and can be done with regional anesthesia Two semirigid rods are implanted into the penis, which will always be erect. It is simply bent down to conceal it and raised when needed.

  • The two-cylinder prosthesis can leave the penis erect or flaccid. One cylinder is implanted in the penis, the other is implanted in the pelvic area. A hardening agent is transferred from one cylinder to the other when the prosthesis is activated. This is done by squeezing the head of the penis where the pump is located. Fluid is then released into the other cylinder to make the penis erect. To turn off the erection, the penis can simply be bent downward and the fluid will leave the penile cylinder and return to the storage cylinder.

  • The fully inflatable device is the most expensive and complex, but also most natural. This one requires surgery, in the hospital. Inflatable cylinders are implanted into the penis, a release valve or pump is implanted in the scrotum, and the reservoir of fluid is implanted in you lower abdomen. This reservoir can be implanted at the same time you have your prostatectomy if you plan ahead. Squeeze the scrotum where the pump is located, to get an erection. Then, to release it, squeeze the scrotum again, and the erection will relax.

Surgical Implantation
Surgical implantation requires about one to two days in the hospital. You may feel pain or discomfort for several days until you get used to it and the surgery heals. The first erection can be painful, but it gets easier as you get used to it. The main advantage of such prostheses, is that a you can have an erection for as long as you need it.

Once you have the device implanted, you will never be able to have an erection any other way, so you will have it for life.

Men often have the reservoir implanted at the time of their prostatectomy, so that they will not need additional surgery later. If they eventually find that they do not need the prosthesis, then the reservoir can simply remain in place without causing any harm. (is this true?)

back to index

COST OF TREATMENT
Some medical insurers still do not recognize that sexual dysfunction is a medical condition. This is the result of years of thinking "it was all in your head," and therefore was an emotional problem rather than a medical one. The fact is that a very small percentage of impotence problems have psychological causes. Most are the result of chronic health conditions or radical surgery.

A vacuum device costs from $400 to $500 depending if you get the battery assisted model or manual unit. It is covered by Medicare and most health insurance. Penile injections cost anywhere from $10 to $25 per injection depending on the medication used. It may cost about $200 for a two month supply of drugs and syringes plus doctor visits.

Penile implants, requiring surgery, are naturally, more costly.

back to top

SURGERY: RADICAL PROSTATECTOMY

OVERVIEW
TECHIQUE:Retropubic,Nerve-Sparing, Perineal Approach, Shrinking
RISKS:Incontinence, Impotence
LYMPHADECTOMY:Traditional, Laparoscopic
PATHOLOGY:Report, Positive Margins
RISKS | QUESTIONS

SURGERY:RADICAL PROSTATECTOMY
Radical prostatectomy is performed when prostate cancer has not spread beyond the prostate. Don't let the word radical scare you. It describes the removal of the entire prostate, as well as the lymph nodes that drain the prostate and the seminal vesicles. With some cancers, only part of the, diseased organ is removed. For instance, with colon cancer, only the diseased section of the colon needs to be removed, and there are mastectomies that do not remove the entire breast. A transurethral resection, known as the TURF is also a form of prostatectomy, but this is used only to remove tissue on the inner core of the prostate when BPH is present. Once there is known cancer, the entire gland must be removed.

In the past, prostatectomies left all men impotent and most men incontinent as well because the muscles, nerves, and blood vessels vital to these functions are so close to the prostate. The relationship of these structures to one another was not fully appreciated, so they were very commonly severed during surgery. Surgical techniques have improved considerably in recent years, but there is still a risk for both incontinence and impotence, after radical prostatectomy, although permanent urinary incontinence is now extremely rare. And impotence can be overcome with medical alternatives.

In 1988, surgeons at Johns Hopkins University developed the "anatomic technique" for radical prostate surgery so that the neurovascular sheaths, also called bundles, alongside the prostate were not severed during surgery. This "nerve-sparing" radical prostatectomy is now widely used but still controversial, because some surgeons believe that when they avoid these bundles, they risk leaving cancer behind and there is the potential of a higher risk of recurrence. Surgical treatment has increased dramatically in recent years because we are finding operative cancer in younger men because of early detection with PSA. More patients under 70 now have Stage TIC disease, compared to five years ago. In past with only the DRE as a diagnostic tool, by the time we found it, the cancer was usually inoperable. Surgery is usually recommended as a curative treatment for all early prostate cancer, when the tumor is confined to the prostate, PSA is less than 10, and the patient is under 70 years of age (or has a greater than 10 year life expectancy), and has no other medical conditions, such as heart or lung disease, that put him at risk for higher post operative complications. After prostatectomy, PSA should decrease to almost nothing.

back to index

TECHNIQUE OF RADICAL PROSTATECTOMY
Prostate surgery can be performed through an incision in the lower abdomen, or through the perineum, the area between the scrotum and the anus. This perineal approach was first practiced in 1858, and the abdominal approach developed in 1947. The abdominal approach allows more room to work so the urologist can remove the prostate and examine the pelvic area, including the lymph nodes. The key to success in prostate surgery is being able to see everything clearly.

When the prostate is surgically removed, a small amount of tissue around the prostate is also removed, in order to determine if any cancer has grown beyond the prostate. This border is called a margin and you will hear about it as a positive margin or a negative margin. If any part of the margin is positive it means cancer has reached that border and possibly has already gone farther. And if the margin is negative, it means there is a cancer-free border around the prostate. The chance cancer cells have traveled elsewhere is lessened. The margins exist at the level of the bladder neck and urethra, two places where the prostate is cut away from the body. To achieve negative margins, the urologist may have to remove some of the delicate muscles that help control urinary function, and some of the nerves that produce erections. Some doctors want wide margins around the prostate to be safe. The nerve-sparing surgery requires leaving a narrower margin around the prostate to avoid severing the nerves.

The sheath containing the neurovascular bundles lie along both sides of the prostate. This is also the area where more than half of prostate cancer escapes from the gland. The decision whether to take the neurovascular bundles to develop a wide excision is made at the time of surgery if the disease is palpable on the ipsilateral side, the same side where the tumor was noted on biopsy. With an abdominal incision, the surgeon has the opportunity to sample the lymph nodes so the pathologist can examine with a microscope wherever the cancer has spread. Lymph nodes are generally removed and checked for the presence of cancer before the prostate is removed. If the lymph nodes are positive then the prostate is not removed because there is no opportunity to locally control the disease with surgery.

back to index

The Retropubic Approach
Most prostate surgery in the United States is done with the retropubic technique--an incision in the lower abdomen between the navel and the pubic bone using a lower midline incision about 8 inches long.

Retro means behind, and by making an incision in the lower abdomen, the urologist can reach into the pelvic area from behind the pubic bone. From this entry, the urologist can gently move aside the intestines, neurovascular bundles, and other organs, suction out blood, and visually examine the entire area for anything suspicious. He or she can remove lymph nodes and leave wide margins as he cuts away the prostate.

After dividing the urethra, the surgeon separates the prostate from the rectum, and then divides the bladder neck. The prostate specimen with the seminal vesicles are then removed carefully and both connections from the kidney to the bladder, called ureters, are inspected to make sure they are not injured during the dissection. They are identified by a blue dye called methylene blue, given intravenously. The bladder neck and urethra are then joined with sutures. This connection is an anastomosis.

back to index

The Nerve-Sparing Technique
This technique also uses the same retropubic approach through an incision in the lower abdomen. The outcome of any surgery--but especially this one--depends upon the skill of the surgeon and his or her knowledge of anatomy. Prostate surgery is not easy surgery, and many urologic surgeons wish they could do their first operations over again.

The goal is to preserve the nerves responsible for erections. These are in two sheaths called neurovascular bundles leaning right up against either side of the prostate. Sometimes, even if only one of these bundles can be saved, impotence is avoided, especially in younger men. If the operation spares one bundle it is called unilateral. It is bilateral if both are spared.

Some urologists are unwilling to leave behind any tissue that may be harboring cancer cells, and they assume that if the cancer has progressed to one neurovascular bundle, it is probably in the other one as well. They will remove both sides. The area of the prostate where the bundles lie cannot be felt during a DRE, so when the urologist exposes the prostate during surgery, and the prostate feels hard with a tumor close to the nerves, the nerve-sparing procedure generally will not be done.

There is much controversy here, even about the accuracy of some of the studies. It is critical that you ask your urologist to be frank about how many of these nerve-sparing surgeries he or she has performed, what complications have been encountered, as well as how many retained their potency.

The attempt to prevent impotence with this technique also increases the chances of cutting into cancer cells. Half of all cancers that escape from the prostate go into the spaces that surround these nerves. Examination of hundreds of radical prostatectomy specimens in some clinical studies found that the nerve-sparing operation exposes men to a serious risk of leaving cancer cells behind. Reports on the incidence of positive surgical margins vary, but as more and more urologists employ this technique and gain the necessary skills, it becomes much less risky.

back to index

The Perineal Approach
The prostate gland can also be removed through an incision made in the perineum, the region between the scrotum and the anus. With this approach, a patient spends less time under anesthesia, and therefore the operating time is shorter, making it a better choice for a man who has heart or lung condition that put him at risk for complications after surgery. For an obese man with a small prostate gland, it may also be a better surgical approach.

However, the prostate is approached from a different angle, and only a relatively small prostate can be removed this way because the opening is so small. If your prostate is enlarged, it might not be easily done. The perineal technique does not allow for the removal of lymph nodes and this may need to be done, either ahead of time laparoscopically through the abdomen, or later through traditional surgery. If that is the case, it will lengthen the hospital time to more than a week. Another drawback is that the surgeon cannot see if any other cancer is apparent. This "gross" examination is an important part of surgery.

This is a better technique for bladder neck reconstruction; there is usually less blood loss and a shorter recovery time--usually three days in the hospital.

back to index

Shrinking the Tumor Before Surgery
Some physicians may recommend two or three months of hormonal treatment (neoadjuvant therapy) before surgery to shrink the tumor or the prostate itself. The production of testosterone can be reduced with an androgen blockade, and the prostate examined with ultrasound to document the reduced size. By reducing the volume of the tumor--or downstaging the cancer--some physicians believe they also reduce some of the risks of surgery such as less blood loss, and length of time on the operating table. They feel this also reduces the chance of positive surgical margins.

A random study of 100 patients given Lupron(R), a hormone to block testosterone production, before surgery and those who were not given Lupron first, showed a 50 percent reduction in positive margins after radical prostatectomy. This led researchers to determine that the androgen deprivation caused a downstaging of the tumor. For example, from stage T3 to stage T2. Downstaging implies that we can alter programmed cell death, or retract a tumor from outside the capsule to inside the capsule.

Dr. Ferdinand LaBrie looked at a group of men getting surg alone and another group getting lubpron and flutamind before surgery. His studies show the positive margin rate was significantly lower with the neoadjuvant treatment.

Other physicians believe shrinking the tumor makes the surgery more difficult because it distorts the anatomical planes and body tissue looks different, and the location of the neurovascular bundles can be distorted. They also argue that you cannot make a tumor go back into the prostate once it has already spread outside. If it has grown large, the cancer cells are already multiplying elsewhere. Thus, it is argued that neoadjuvant hormonal manipulation prior to surgery makes no biological sense.

In most patients, neoadjuvant hormonal treatment decreases the volume in both primary prostate cancers, as well as metastatic cancers. However, it is known that many prostate cancer cells are resistant to hormone manipulation, either initially, or after a certain amount of therapy, so there is no guarantee this will work. The surgery also needs to be timed so that it is performed at the optimum time during treatment. That is, before the cells become resistant to hormone manipulation and the tumor begins to grow again.

The best candidates for neoadjuvant therapy are men whose cancer can be completely removed surgically once the hormone therapy has accomplished the task of downstaging. If this is not the case, then the cancer will almost certainly begin to grow again. Neoadjuvant treatment was still investigational in 1997 because there are no long term studies to indicate longer survival time. We have no proof yet that even though the tumor was reduced, and the margins were negative after surgery, that a cancer cell or cells had not already traveled to the other organs to take residence and grow.

back to index

RISKS OF PROSTATECTOMY
Any major surgery carries risk of complication. Blood clots can form in the veins during or after surgery causing a deep vein thrombosis or pulmonary embolism. The incidence of this is low, less than three percent, but the risk increases with age and would, naturally, be higher if you have a history of cardiopulmonary problems. You are at higher risk for surgery if you smoke, drink, or have a chronic illness such as heart, lung, gastrointestinal problems, or diabetes. Also, if you are overweight, or emotionally stressed.

Your health will have impact on your follow up treatment, too. Ask your prostate cancer treatment team members to consult with your family doctor or other medical specialists who treat you. These conditions may increase your risk of surgical complications. To prevent the need for a blood transfusion from an unknown donor, you may donate your own blood before surgery. This is known as autologous blood donation.

Rectal injury sometimes occurs because the back of the rectum is only a fraction of an inch away from the prostate, but this happens in less than one percent of cases. When it does occur, a primary repair can be performed or a colostomy is temporarily constructed to divert the colon and fecal stream to a bag outside the body until the rectum heals.

The urethral channel becomes too narrow in 5 to 10 percent of cases. This urethral "stricture" impedes the flow of urine, and it can be relieved with a dilation procedure performed in your physician's office.

The most feared risks of prostate surgery are incontinence and impotence.

Studies from Prostate Disease Patient Outcomes Research Team of the US Agency for Health Care Policy and Research, found about 25 percent of men experienced some form of urinary incontinence after surgery, and 85 percent noticed changes in sexual function.

back to index

Incontinence
Everyone is incontinent for awhile after a radical prostatectomy. This can last for a few days or a few months, but with special exercises, behavior modification, and sometimes, with medications, normal continence is eventually restored in most men.

The internal sphincter muscle which automatically controls the flow of urine is damaged when the prostate is removed and the urethra is sewn directly to the bladder neck. The internal sphincter muscles are part of a ring of muscles around the bladder neck. Once the internal sphincter is gone, all the work of starting and stopping the flow of urine must be done by the external sphincter located on the pelvic floor. Until this muscle is strengthened again, about 15 percent of patients experience a degree of stress incontinence. This happens when you cough or sneeze, or change position from sitting to standing. Other types of incontinence are: urge incontinence, which means you feel the urge to urinate that is so extreme that you might leak if you do no urinate right away. Overflow incontinence is caused by a obstruction like BPH and you are "flowing over the top." Global incontinence means you have absolutely no control, that you are leaking urine all the time. This condition is extremely rare after prostatectomy and occurs in less than 3 percent of patients 12 months after radical prostatectomy.

Impotence
Impotence occurs because nerves and blood vessels necessary for erection are damaged or severed during surgery. Impotence means you cannot achieve or maintain a rigid erection. It does not mean you cannot achieve orgasm, or that you lose desire for sex. Based on various studies, your age and potency before the operation have a great deal to do with your outcome.

If you are over 70, it may be unrealistic to think you will be potent following prostatectomy. But most men can figure the averages this way, assuming nerves were spared on both sides of the prostate.

  • If you are in your seventies, you have a 30 percent chance of return of potency
  • If you are in your sixties, you have a 50 percent chance
  • If you are in your fifties, you have a 70 percent chance
  • If you are in your forties, you have more than an 80 percent chance. Refer to Chapter 19 for ways to restore potency.
back to index

LYMPHADENECTOMY: REMOVING LYMPH NODES
Lymph nodes are small glands that act as the filters in the body's drainage system and they are encased in fatty tissue in strategic locations throughout your body. Lymphatic fluid flows upward from the prostate. Each man's lymph nodes are different sizes, shapes, and patterns. Some nodes are like heavy bunches of grapes. Others are spread out and far apart like marbles dropped on the floor. Some nodes are like tiny seeds, others more like jelly beans. Sometimes lymph nodes are enlarged, either from infection or inflammation, or if they are filled with cancer cells.

It is possible for lymph nodes to be cancer-free even in the presence of a fairly large prostate carcinoma, but it is much less likely. It is also possible for lymph nodes to be enlarged and showing no cancer. If the cancer has spread to the lymph nodes, it means there is a greater chance it has escaped into other parts of the body.

Traditional Technique
When the prostate is removed, the urologist will also dissect the lymph nodes-usually 7 or 8 from either side of the prostate. Lymphadenectomy is critical not only for staging, it is also believed by some to be therapeutic. If any lymph nodes do contain cancer, then their removal has eliminated additional cancer from your body.

Once the fatty tissue containing the lymph nodes is surgically removed, the pathologist examines the tissue to free all of the lymph nodes for inspection. Normally, a pathologist is standing by to quickly analyze a "frozen section" of the nodes under the microscope. This takes a few minutes and is done in the lab or in the operating room. Each dissected lymph node is examined carefully by the pathologist for the final pathology report.

If the frozen section shows cancer, most urologists would not proceed with the prostatectomy, since now that the horse is already out of the barn, removing the prostate would not provide a cure. They will close up the incision and suggest treatment with hormones. However, even if the lymph nodes are negative--showing no cancer--a small number of men can still develop evidence of metastatic disease over time because the cancer had begun to escape the prostate gland prior to surgery but was too microscopic to be detected by preoperative staging.

back to index

Laparoscopic Technique
A laparoscopic lymphadenectomy can be performed in the hospital before the prostatectomy. This is an expensive procedure and most doctors use it only when they are already pretty sure the cancer has spread, and they want to confirm that diagnosis in order to spare the patient further surgery. This type of investigation of the lymph nodes is generally done in men with a T3 or T4 tumor, who are contemplating surgery or external beam radiation treatment.

Several small incisions are made in the abdomen and a scope with a video camera attached is inserted into the pelvic area. By watching a monitor, the urologist can guide the scope to the lymph nodes, and with special tools, remove the lymph nodes and send them to the pathologist for analysis. If there is no cancer in the lymph nodes after laparoscopic dissection, some urologists will go ahead with the radical prostatectomy immediately. But some will schedule the surgery for a another day.

Laparoscopic lymphadenectomy is not commonly used because it requires two procedures. It is much more efficient to do traditional surgery and remove the lymph nodes during that time.

back to index

PATHOLOGY OF THE PROSTATECTOMY SPECIMEN
Once the prostate gland is removed from your body, it is no longer called a prostate, but is now called a prostate specimen. For the surgical specimen after radical prostatectomy, pathologists examine separately the prostate, lymph nodes, seminal vesicles, and look for cancer cells. This serves as the basis for the final staging of the disease. If the stage changes from the earlier clinical biopsy, it more commonly goes up, rather than down.

The pathologist plays a critical role in your surgery. A careful and deliberate pathologist will analyze the prostate and lymph nodes with great care. When the prostate is removed, the pathologist puts ink around the gland. There are actually two cut ends, one at each point where the prostate is cut from the body. One at the apex, where the prostate joins the urethra, and one at the base, the bladder neck. The prostate is sliced into sections which are meticulously examined with the microscope and computer. Each slice is measured, and it is through this system that the amount of cancer in the prostate is determined. This measures the volume of cancer, compared to the total volume of the prostate. Measurement is also taken of whether or not the cancer cells are near the edges of the slices, or appear to have already penetrated those edges, or margins.

When the pathologist slices into the prostate specimen, he can check each slice to see if any cancer cells have reached the inked margin. The pathologist who makes more and smaller slices is more likely to discover positive margins than one who takes larger and fewer specimens to study under the microscope.

When cancer is confined to the prostate and has not reached the margins, fewer than one patient in ten has a recurrence. Recurrence is more likely if cancer has spread to the margins. In this case, with cure unlikely, palliative treatment with hormones or radiation would be considered.

Generally, if the cancer has penetrated the fat around the prostate, there is a 60 percent chance of recurrence in five years. If it has penetrated the seminal vesicles, the chance increases to 86 percent, and if it has gone into the lymph nodes the chance is 97 percent.

back to index

The Pathology Report
The pathologist's report will usually be available within five business days, so you may be out of the hospital before the results are known. This report will have a great bearing on your prognosis and whether future treatment is needed. This is the final clinical "staging." Pathologists have a certain agenda to follow when investigating prostate cancer, according to the Association of Directors of Anatomic and Surgical Pathology. Your pathology report should include:
  • A description of the tumor in terms of percentage of tumor in relation to the amount of prostate tissue that is not cancerous.
  • The presence of tumor at the surgical margins.
  • The site of an extracapsular tumor involvement.
  • The presence or absence of carcinoma in the neurovascular bundles.
  • The presence or absence of carcinoma in the seminal vesicles.
  • Metastasis in the lymph nodes, and whether or not it extended through the capsule of the lymph nodes.
This is one of your most important medical reports, and it is a good idea to become familiar with it while you are undergoing treatment. Be sure to ask for a copy so you can show it to your other physicians.

back to index

When Margins are Positive
About 40 to 50 percent of men who have a radical prostatectomy for TI or T2 disease, have positive margins. This means residual cancer cells may be lurking in the area. The most common sites are the apex, near the bladder neck somewhere else. It is highly likely that if the margins are positive, the cancer has penetrated the wall of the prostate. It may take many years for the cancer to recur or become detectable, so the PSA must be monitored faithfully.

The PSA of a 52-year-old man, who had positive margins after a radical prostatectomy, began to rise four years after surgery. A CT scan showed a tiny nodule in the area where the prostate had been, and biopsy confirmed that it was cancer. He opted for external beam radiation treatment, and he has been okay since then.

Treatment of men with positive margins is also controversial. Positive margins may indicate a need for adjuvant therapy after surgery, but this depends on the timing of the disease, the extent of the margins, and other pathological information. Also to be considered is the patient's age and medical condition, and the possibilities of complications from further treatment. Treatment options include radiation or hormonal treatment, as well as watchful surveillance.

Another question is whether to begin treatment right after surgery, or wait until symptoms appear. A detailed work-up would need to be done, not only to determine PSA levels, but possibly bone and CT scans, and ultrasound biopsy.

  • If the PSA is rising, but the other tests are all negative, then the suggested treatment would be hormonal therapy to begin early.
  • If the PSA is rising, and the biopsy is positive, but there is no metastasis, radiation or hormonal therapy could be offered.
  • If the PSA is rising and there is evidence of metastasis, then hormonal therapy would be the wisest choice.
back to index

THE RISK OF RECURRENCE
If cancer is cured, it never comes back. But we have no long term studies with meaningful data on prostate cancer recurrence rates after surgical treatment. Does surgery add years to your life? The Jury is still out. Because prostate cancer grows so slowly researchers need at least 15 years to determine if a treatment is effective. A 1992 study found that when cancer did not escape the confines of the prostate, only two percent of men had local recurrences within five years after radical retropubic prostatectomy and one percent had distant metastases. A Medicare survey of older men showed 28 percent to have recurrence after radical prostatectomy. Overall, the recurrence rate is 12 percent.

Recurrence means it reappears in the same region--where the prostate used to be. This is different from metastatic prostate cancer, which means it appears outside the prostate area, such as in the bone, liver, or lung. Some investigators suggest that if you are 65 or younger, you will live an average of 14 months longer than if you had chosen watchful waiting. The National Cancer Institute has initiated a long-term study--The Prostate Cancer Intervention Versus Observation Trial (PIVOT)--to find out if surgery is really more effective than doing nothing.

The treatment of recurring cancer is highly individual. Palliative treatment with radiation or hormonal therapy is an option.

back to index

QUESTIONS TO ASK A UROLOGIST ABOUT SURGERY
Q: Please describe the operation?
It is important that your urologist describe the way the surgery will be performed so that you understand the technique used, and whether the plan is to spare the nerves needed for potency.

Q: Will any nerves or blood vessels be damaged?
Even with the nerve-sparing technique, it is possible that some may be damaged. For example, if the cancer is close to one of the neurovascular bundles, those may be severed, leaving you with only one bundle intact. Obviously, you need to understand this possibility before surgery.

Q: If nerves are spared, is the risk of recurrence of prostate cancer greater?
Some studies have indicated that there is more recurrence of prostate cancer in men who have had the nerve-sparing surgery. In the meantime, urologists are gaining more experience and skill and this surgical technique has improved since its early days.

Q: What are the side effects of surgery?
Naturally, the two major side effects are the possibilities of degrees of incontinence and/or impotence. Each man is unique, and your doctor should tell you how much of those side effects to expect. However, there may be other side effects to consider, too, such as psychological issues, depression, and quality of life.

Q: Will you remove any lymph nodes?
It is generally standard procedure to remove some of the lymph nodes around the prostate if a prostatectomy is performed. This provides more information about whether or not the cancer has begun to spread outside the prostate.

Q: If you find cancer in the lymph nodes, will treatment change?
Yes, it is possible your prostate will not be removed if the lymph nodes are shown to contain cancer. In the operating, a frozen section of the nodes may be done. This means the pathologist does an on-the-spot examination of the nodes to find out if, in fact, cancer is present. A more thorough and detailed examination is done, later, when all the nodes have been removed.

Q: How much pain will I have after surgery?
Some men experience very little pain, and other have a great deal, so find out what kinds of treatment will be available for your pain and see the next chapter for more detail about pain control.

Q: What kinds of follow up care will you provide?
Most urologists will see you several times after surgery to check up on your recovery to the surgery itself. Depending on your particular case, you will always need periodic examinations and consultation with your urologist

Q: What are my options if the cancer recurs?
This is a subjective questions, but your doctor should explain the possibility of radiation or hormonal therapy if the cancer recurs.

back to top



BRACHYTHERAPY (INTERSTITIAL RADIATION)

OVERVIEW
TREATMENT COMPLICATIONS
PROCEDURE SIDE EFFECTS
QUESTIONS & ANSWERS

BRACHYTHERAPY (INTERSTITIAL RADIATION)
Brachytherapy is a form of radiation therapy in which radioactive isotopes are surgically implanted directly into the prostate. Brachy means short distance, and the radiation from the isotopes, or seeds as they are called, works in the immediate area over a continuous period - 24 - hours a day - compared to the daily bursts of radiation used in the external beam treatment. This type of radiation is sometimes called interstitial (in the narrow spaces) radiation therapy.

As local control rates after external beam appear to be dose dependent, it is theorized that higher doses of radiation can be given directly to the prostate if the isotopes are accurately placed through a needle into the prostate.

In the past, there was no technique to assure this accurate placement. In the 1970s, a study of men at Memorial Sloan Kettering Cancer Center using an open surgical technique did not allow the brachytherapist the ability to clearly visualize placement of needles and seeds during the procedure. Few seed implantations with open surgery had a homogeneous distribution of seeds within the prostate. In retrospect, it was not possible to determine whether the seeds were placed in the exact area where the cancer was located. With very early cancer, this technique seemed to provide reasonably good local control only in men who had an adequate dose. But what was adequate?

Most modern brachytherapists consider these mixed results of the open surgical technique are due to the inconsistency of the seed placement into the prostate. Because results of those early brachytherapy treatments was inferior to most external beam treatment it was abandoned until better seed placement techniques were developed. The same technology that made 3D conformal therapy possible, now makes this possible. In most cases, treatment can be given as a single outpatient treatment and men can return to normal life in a few days. Risk of urinary incontinence is extremely low, and the expectation of maintaining potency is high. Seed implantation is now used as a stand alone treatment or as a boost treatment following moderate doses of external Beam radiation therapy. Separating patients into low risk group suitable for seed implantation alone, and the high risk group for combination seed therapy and external beam therapy is difficult and again, we must wait for results of long term studies.

For some patients, brachytherapy is considered an attractive alternative to surgery and external beam radiation. Some clinical series suggest that the progression free survival rate for five years may be superior to external beam therapy and equal to radical surgery for patients with PSA less than 10.

The radioactive seeds are smaller than sesame seeds and they emit radiation over a long period of time. In the past radioactive gold was used, but now, palladium and iodine are used. Seeds of palladium 103 provide over 12,000 rads, and seeds of iodine 125 provide over 10,000 cads or 100 Gys. Palladium treats for 20 days, while iodine treats for more than 60 days. When the radiation is used up, the seeds become dormant and remain in the prostate. Disadvantages are that we have no long term studies that can lead us to believe conclusively that seed implant therapy is any better than watchful waiting, surgery, or external beam radiation. We do know it may delay the recurrence of prostate cancer even though it may not cure it. There are also no long-term studies to tell us whether leaving seeds in the prostate causes any damage to other organs. About 10 to 30 percent of men are left impotent from brachytherapy, compared to 30 to 40 percent with external beam radiation.

Who is a Candidate for Brachytherapy?
The ideal candidate for permanent seed implantation is a man with an intact prostate with a volume of less than two ounces. Such a patient would be less likely to suffer serious rectal or urinary complications or side effects.

Internal radiation is generally recommended for a small localized tumor, and a PSA of less than 10. If cancer cells were found in more than one lobe of the prostate during needle biopsy, or anywhere near the seminal vesicles, then brachytherapy would not be as effective.

Brachytherapy alone appears to be suitable to patients who have a high chance that their cancer is still confined to the prostate. Those with a substantial chance of extracapsular disease (cancer that appears to have broken out of the prostate) may be more suitable to combination therapy of both external beam radiation as well as brachytherapy. Some patients even consider having hormonal therapy before having brachytherapy in an attempt to make the tumor smaller, or downstage it. This can be done three months or more before brachytherapy. Long term studies of this treatment are in progress, but we will not have results for several years.

In general, men with Tl or T2A cancer, a PSA of less than 10, and a Gleeson score between 2 and 6, are reasonable candidates for brachytherapy alone. Those with T2B or T2C disease, a PSA greater than 10, or Gleeson score from 7 to 10, should consider combined therapy. Men with cancer staged at T3, or with positive lymph nodes, would not be good candidates for permanent seed implantation.

back to index

Treatment
Treatment Planning
Today we can use transrectal ultrasonography (TRUS), and computer docimetry, to place seeds accurately and we hope to significantly improve the quality of the results. With TRUS allowing the therapist to visualize the needle placement, and the computer reconstructing the prostate in three dimension, before implantation, we can create an ideal model for treatment planning. We can determine the amount of radiation needed for a particular individual, and use sophisticated systems of seed placement customized to prostate size and shape. The needles are inserted through the perineum, the area between the scrotum and rectum, guided by the ultrasound. The physician can plan placement of needles which will transport the seeds as well as the type of activity and number of seeds to be planted. The amount of radiation needed to optimize the dose to the prostate and minimize the dose to the bladder and rectum is calculated with computer docimetry.

Treatment Team
A dedicated team of urologist and radiation oncologist and physicist can perform the technique successfully. The procedure is done in the operating room, while the patient is under anesthesia.

Permanent transperineal seed implantation is typically done as a single operative treatment using spinal anesthesia. There is no surgical incision, however, for needles are inserted through a template system directly into the perineum and directed to the predetermined targets under TRUS guidance. A typical implant requires from 80 to 120 seeds. Following the operation, patients are usually given antibiotics, anti inflammatory, and antispasmodic medications to prevent bladder pain and infection. Once the seeds are placed, they can be assessed with x-rays or a CT scan. This type of assessment is usually done after the PSA evaluation has been done and at three month intervals. In some cancer treatment centers, TRUS guided biopsies of the prostate are performed several years or more after seed implant to see whether residual prostate cancer exists.

back to index

Complications
Brachytherapy done on an outpatient basis has negligible complications. Most patients have some early symptoms of urinary frequency or urgency, and outlet obstruction for four to eight months after surgery. If urine is retained, temporary catheterization may be required. This symptom usually occurs in men who had urinary obstruction problems before treatment.

Complications of greater concern include proctatitis, which occurs in from 2 to 12 percent of patients. This irritation of the rectum and anus from radiation, causes diarrhea and blood in the stool, as well as pain in the rectum.

Although there are as yet no long-term studies on the effectiveness of this therapy, researchers at Memorial Sloan-Kettering Cancer Center in New York found that this treatment may be as effective as surgery for early stage cancer. The study showed 60 percent of men treated with seeds had no evidence of cancer five years after treatment. A Seattle study found 97 percent of men free of cancer four years after brachytherapy. While the early data looks promising, we cannot be sure until long-term studies are completed. Modern ultrasound guided transperineal permanent seed porostate brachytherapy is still relatively new and therefore, most available clinical series report short follow up periods. More importantly, 10 to 15 years data is not yet available. The use of absolute PSA, biopsy results, or PSA progression to report treatment success is still controversial. However, rising PSA has been demonstrated to predict failure two to five years prior to clinical relapse. Therefore, the use of these parameters as end points may provide early clues for early therapeutic effectiveness.

One man chose the treatment because of an unexpected circumstance. He was 67 and had a TIC tumor with a Gleason score of 6. A bone scan showed no metastasis but the CT scan showed a kidney tumor. If this was cancer, it posed more of a threat than his prostate cancer did at that moment. Surgery for the kidney tumor was done first, and the tumor was cancerous. AI though the surgery was successful, the men went into a prolonged post operative depression, and six months later, when it was time to do another surgery, to remove the prostate, he said he could not face it again. Part of his depression may have had to do with his forced retirement, and living alone at home while his wife was still working and supporting both of them. And on top of this to have a kidney and prostate cancer, was too much for him. He did, however, agree to go and talk with a leading brachytherapist. The therapy worked, and he had few side effects, and no symptom. This has made a difference in his emotional outlook, as well. Not all men come away from brachytherapy without complications, however, and it is important to have it done where the doctors performing it are experts. There is a steep learning curve needed for a urologist to become adept at this procedure. The first thing to ask the physician is how many brachytherapies he or she has performed.

back to index

The Procedure: Planting the Seeds
The radioactive seeds are implanted in the prostate by a urologist and a radiation oncologist in the hospital while you are under spinal or general anesthesia. The urologist and radiation oncologist work together on this procedure, with the guidance of the physicist. The same sophisticated computer and scanning techniques that make 3D conformal radiation so precise, are also used to place the seeds with great accuracy.

The implanting is generally an outpatient procedure with regional anesthesia to numb the patient from the waist down. Various templates are positioned against the perineum to guide the needles along the right path. Most of these procedures are done with needles inserted through the perinea( area, between the scrotum and the anus. Guided by ultrasound, the physician can accurately place the seeds through a thin tube (catheter). When this is withdrawn, the seeds are left in place. The number of seeds implanted depends on the size of your prostate and the extent of the cancer, but on average, there may be 50 to 100 seeds implanted in your entire prostate. (Although 200 is not uncommon.) The seeds are implanted one at a time while the surgeon monitors the ultrasound screen. Sometimes seeds are implanted in the seminal vesicles as well.

back to index

Short-Term Side Effects Of Implants
All those needle implants will leave the prostate and perinea( area sore, and you will feel this discomfort for about a week. A catheter placed in the bladder will control urination for a day or two. In general, the more potent the seeds, the more severe the side effects. Fewer side effects seem to occur in treatment centers where large numbers of these procedures are performed because the brachytherapists are more experienced.

  • Urinary complications. Most complications involve the urinary tract, causing increased frequency of urination, or discomfort or urgency. One in 4 men experience urinary problems such as urgency, frequency, burning, and blood in the urine. This side effect appears to be a permanent condition in about 7 percent of men, according to one study. Incontinence occurred in 5 percent of patients, and half of these were due to stress incontinence. Men who have not had a TURP, and who have modest prostate volumes, urinary incontinence and cystitis rates are less than 3 percent. In those who have had a TURP, the chance of incontinence increases to 6 to 20 percent.
  • Rectal problems. Pain, burning, frequency, urgency, and diarrhea, is a problem in about 5 percent of cases. This occurs in greater numbers in men with large tumors.
  • Sexual concerns. Semen may appear red or brownish for awhile because of blood. This is perfectly normal after this procedure. It will take several weeks or months to clear. The risk of impotence is 10 to 30 percent.
For several months the seeds will be radioactive. This is not a danger to you or to your spouse or partner. But in the first few months it would be wise to use a condom during intercourse in case a seed should accidentally come loose and be ejaculated. The Nuclear Regulatory Commission has determined that constant close proximity by another person will not harm them. So your spouse or partner need not worry about being too close to you. However, they will receive some radiation, so if you are having intercourse with a woman who is or wants to be pregnant, avoid this for the first several months after treatment.

back to index

QUESTIONS TO ASK ABOUT RADIATION THERAPY
Q: What is the goal of this treatment?
Radiation therapy can be used to try to cure the cancer, or it can be used as a way to slow it down. It is important for you to understand the goal.

Q: How will the radiation be given and who will give it?
External beam and brachytherapy are both complex and sophisticated procedures involving the skills of several people. With the external beam treatment, your radiation oncologist is in charge of your treatment with the aid of technicians and the physicist. Brachytherapy, which combines radiation and surgery involves your radiation oncologist working with your urologist and the physicist. If you have questions about brachytherapy, you would ask your urologist, and questions about external beam treatment would go to your radiation oncologist.

Q: How many prostate cancer patients are treated at this facility?
It is always better to be treated where the staff has in depth experience and treats many patients similar to you. Because accuracy is so vital to successful treatment or either external beam, or internal radiation, it is wise to a facility that treats at least several cases a week like yours. For example, you might not want to have external beam treatment where the majority of cases of breast cancer or brain cancer. If you are to receive brachytherapy, which involves particular skills of the urologist as well as the radiation oncologist and physiciast. Ask each doctor how many of these treatments they have done in the past. Keep in mind, that brucytherapy has not been in practice very long, so you are more likely to find skilled practitioners in teaching hospitals. Studies have shown that success rates for brachytherapy are higher where many such procedures are performed. There is a steep learning curve to overcome regarding accurate placement of the seeds which directly effects treatment outcome and long term results.

Q: What side effects can I expect and what can I do about them?
Everyone responds differently to treatment, but your doctor should explain all the possible side effects such as urinary or rectal problems, as well as the chances of impotence.

Q: Can I choose the time of day when I get my treatment?
External beam radiation can usually be scheduled at the most convenient time of day for you. Most people continue to go to work throughout the seven weeks of treatment, and it may be possible for you to have treatment early in the morning or late in the afternoon, or even at lunch time.

Q: How up to date is your radiation equipment?
The most recent, and most sophisticated equipment has the capability of performing the 3D conformal radiation. A physicist and highly skilled technicians program and operate this equipment. More and more facilities have this technology, but some still operate with the older, less advanced equipment. You should expect a thorough explanation before you decide to have treatment.

Q: Who will treat me for any side effects?
If you are having external beam radiation treatment, the radiation oncologist is responsible for your care during and after treatment. If you are having brachytherapy, the urologist and radiation oncologist are involved together in the treatment. It is a good idea to know who to call with a problem.

Q: Will I have to wait long each day for treatment?
In an efficiently operated radiation therapy facility, you should be in and out in less than an hour. This includes time to arrive, change your clothes, receive treatment, and get dressed again.

back to top



Refer a Friend

Marcus H. Loo, M.D.
525 E 68th Street Rm F9W (9th Fl)
New York, NY 10065
Tel: 212.925.8388
Fax: 212.941.7426
Email: Mhloo_3001@hotmail.com

» Map

Chinatown Office
254 Canal St., Ste. 3001
New York, NY 10013
Tel: 212.925.8388
Fax: 212.941.7426
» Map