How do I decide which treatment is best for me?

Currently, the burden of medical decision making falls on you, the patient, and it is our job as physicians to provide you with the information that will allow you to make the decision. When forced to make a difficult decision, we often rely on loved ones, close friends, and knowledgeable individuals to help us, but these people do not have to live with the effects of that decision. As you weigh the pros and cons of each of the various treatment options, it is very important that you think of how they will affect you. Now is the time to be very honest with yourself about what side effects you can and cannot tolerate. It is your physician's responsibility to accurately inform you of the likelihood of side effects of each of the treatment options and the remedies that are available to treat those side effects. When faced with a diagnosis of prostate cancer, the first impulse may be to get rid of the cancer at any cost. Unfortunately, once the prostate cancer has been treated and that worry quiets down, the side effects of the treatment can become more bothersome—so you should think seriously about them beforehand.

When counseling a patient, the first question that I typically ask is "Can you live with your prostate inside of you over the long term?" If the answer is no, that you would be constantly worrying about whether cancer remained in the prostate if it were left in place, then a radical prostatectomy is probably best for you. Other issues to bear in mind are the impact of incontinence and erectile dysfunction on your lifestyle. Virtually all forms of therapy can cause erectile dysfunction. If this is particularly worrisome to you, then it may be appropriate to meet with an urologist who treats erectile dysfunction to discuss the treatment options before you begin treatment for your prostate cancer. Similarly, it may be helpful to discuss the various treatments for incontinence or inability to urinate (retention^[1]) with your urologist or radiation oncologist before undergoing treatment. Your physician may make some treatment recommendations based on your age, medical conditions, and clinical stage of your prostate cancer. If you have questions as to why certain recommendations are being made, now is the time to ask them. Remember, no question is stupid. Your physician wants you to feel comfortable with your decision and will help you find the information that you need. There are also organizations that can provide you with information regarding treatment and side effects (see Appendix B).

In an effort to help determine which therapies have the best chance of curing you of your prostate cancer, researchers have stratified prostate cancer into low-risk, intermediate-risk, and high-risk for disease progression. The treatment recommendations vary with the risk.

Low-risk:

T1c or T2a prostate -cancer PSA < 10 ng/mL Gleason score < 6

Intermediate-risk:

Clinical stage T2b

Gleason score 7

PSA 10 ng/mL-20 ng/mL

High-risk:

Clinical stage T2c or higher PSA > 20 ng/ml Gleason score 8-10

Low-risk patients usually do well with a single therapy, such as radical prostatectomy, external beam radiation therapy, or interstitial seed therapy. High-risk patients are more likely to experience a treatment failure, and combination therapy, such as external beam therapy and hormonal therapy, is often recommended.

What is a radical prostatectomy? Are there different types?

Cliff's comment:

It has been 10 years since my radical prostatectomy, and I feel great. I am doing all of the things that I had done before the surgery and more. So far, my PSA has remained undetectable, and it is very reassuring to hear this at my urology clinic visits.

Radical prostatectomy is the surgical procedure whereby the entire prostate is removed, as well as the seminal vesicles, the section of the urethra that passes through the prostate, the ends of the vas deferens, and a portion of the bladder neck. After the prostate and surrounding structures are removed, the bladder is then reattached to the remaining urethra. A catheter^[2], which is a hollow tube, is placed through the penis into the bladder before the stitches that attach the bladder to the urethra are tied down. The catheter allows urine to drain while the bladder and urethra heal together. In open radical prostatectomy a small drain is often placed through the skin of the abdomen into the pelvis. This drain allows for drainage of lymph and urine that may occur during the first few days after the surgery. This drain is removed when the fluid output decreases. At the time of radical prostatectomy, depending on the approach used, the pelvic lymph nodes, which are a common location of prostate cancer metastases, may also be removed (see

Radical prostatectomy is the surgical procedure whereby the entire prostate is removed, as well as the seminal vesicles, the section of the urethra that passes through the prostate, the ends of the vas deferens, and a portion of the bladder neck.

Question 12). A radical prostatectomy may be performed via three different approaches. A common form is the open retropubic approach, in which an incision is made that extends from the umbilicus (belly button) to the symphysis pubis (pubic bone) (Figure 9). The radical prostatectomy may also be performed laparoscopically through several small incisions made in various locations in the abdomen (Figure 11), or through a perineal approach, with the incision being made in the area between the scrotum and the anus (Figure 10). More recently, the radical prostatectomy may be performed with the use of a robot, robotic-assisted radical prostatectomy, which has quickly become the most popular technique for radical prostatectomy.

Radical prostatectomy differs from a transurethral resection of the prostate (TURP) and an open suprapubic prostatectomy in that the entire prostate is removed in a radical prostatectomy. Therefore, unlike TURP and open suprapubic prostatectomy, the PSA should decrease to an undetectable level within a month or so after the procedure if no prostate cancer cells are present.

The decision as to what approach will be used for a radical prostatectomy depends on your urologist's preference and skills, your body characteristics, and whether a pelvic lymph node dissection is planned.

An advantage of the retropubic approach is that it allows for easy access to the pelvic lymph nodes so that a pelvic lymph node dissection can be performed easily at the same time. In addition, the blood vessels and nerves that control your potency are visualized easily. A disadvantage of this procedure is the abdominal incision, which may lead to a longer recovery time and increased discomfort and a higher blood loss compared to laparoscopic and robotic-assisted radical prostatectomy.

The perineal prostatectomy^[3] does not involve an abdominal incision, is reported to be less uncomfortable and the recovery period shorter. The perineal approach allows for good visualization of the outlet of the bladder and the urethra for sewing the two together; however, the nerves that control potency are not seen as easily as with the retropubic approach. Another disadvantage of this procedure is that it does not allow for removal of the pelvic lymph nodes through the perineal incision and would require an additional incision for the pelvic lymph node dissection. This procedure is best suited for overweight men, for whom the retropubic approach is more difficult.

Laparoscopic radical prostatectomy^[4] is a procedure that has the advantages of the retropubic approach but, because there are several small abdominal incisions as opposed to the longer midline incision, the discomfort is less and the recovery is quicker with this approach. The disadvantage of this procedure is that it is relatively new and requires a urologist with advanced skills in laparoscopy^[5]. It may take longer to perform than an open radical retropubic prostatectomy. The outcomes of laparoscopic prostatectomy, such as urinary incontinence, erectile function, and positive margin^[6] rates are similar to open surgery. Robotic-assisted radical prostatectomy has surpassed laparoscopic radical prostatectomy in terms of the number of procedures being performed.

Robotic-assisted prostatectomy^[7] is the newest form of minimally invasive surgery for prostate cancer. The procedure is performed using a three-armed robot. The robot is controlled by the surgeon, who sits at a specialized desk and controls movement of the robot's arms. Advantages of robotic-assisted prostatectomy are its ease of use compared to laparoscopy and the surgery

The perineal prostatectomy does not involve an abdominal incision, is reported to be less uncomfortable and the recovery period shorter.

tends to be quicker as compared to laparoscopy. In addition, the arms of the robot have movements similar to a human arm/hand/wrist, but the tremors that may be present with human movements are controlled. A disadvantage of the robot is the expense of the robot, so not all hospitals can afford to purchase one. The outcomes with the robot are similar to those of laparoscopic^[8] and open radical prostatectomy; however, long-term outcomes are limited for the robot and are limited for laparoscopy (Figure 12).

• [1] Difficulty in emptying the bladder of urine; may be complete, in which one is unable to void, or partial, in which urine is left in the bladder after voiding.
• [2] A hollow tube that allows for fluid drainage from or injection into an area.
• [3] Removal of the entire prostate, seminal vesicles, and part of the vas deferens through an incision made in the perineum.
• [4] Removal of the entire prostate, seminal vesicles, and part of the vas deferens via the laparoscope.
• [5] Surgery performed through small incisions with visualization provided by a small fiberoptic instrument and fine instruments that fit through the small incisions.
• [6] The presence of cancer cells at the cut edge of tissue removed during surgery. A positive margin indicates that there may be cancer cells remaining in the body.
• [7] A radical prostatectomy performed with the assistance of a robot.
• [8] Performed with a laparoscope.