Pathology of Prostate Cancer

Treatment choices for
Non-Metastatic Prostate Cancer

The treatment available for Non Metastatic prostate Cancer includes Radical prostatectomy, Radical Radiotherapy and Active Surveillance.


Active Surveillance

Includes close observation with periodic physical examination, PSA, biopsies at regular intervals. Advantages – Avoids treatment preserves Quality of Life. Disadvantages – Under diagnosis of grade / stage / progress during the surveillance

Treatment with Curative Intent

Radical Prostatectomy Radical Radiotherapy
Methods Open/ Laparoscopic/ Robotics External Beam / IMRT / IGRT/ Cyber knife/ Brachytherapy
What does it entails Operative intervention Remove the whole prostate with vas and seminal vesicles +/- lymph nodes. Patient will have catheter after the op for 7 – 14 days before it is removed. Hospital stay is about 1-2 days. Recovery period – few weeks in Robotics & few months in open surgery Treatment with radiation Can be from 1 -6 weeks (depending on the modality). Initially scans are performed and then radiation is initiated Usually does not need anaesthesia hospitalisation (except Brachy) Recovery period 4- 6 weeks after radiation is completed.
Complications Bleeding / infection / injury to surrounding tissues. Rectal injury can happen on rare occasion and will need further treatments / operations. Bleeding / infection / Urinary and feacal urgency can happen and may stay forever. Patients with pre existing urinary difficult may have precipitation of retention. Late secondary pelvic cancers are known to happen rarely.
Urinary symptoms Symptoms like difficult in passing urine/ slow stream.etc will resolve. Symptoms might improve , usually does not resolve completely and if necessary may need an operation to core the prostate (TURP).
Incontinence (urine leakage) Stress Leak will happen in most patients immediately after surgery & will require 3-4 pads a day. Improves in 2- 6 weeks with active pelvicfloor exercises With time almost all patients will become dry. Stress leak usually does not happen with RT. Almost all patients experience urinary urgency. Some will have urge leak as well, especially as a late symptom.
Erection problems All patients will experience it after operation. Nerve sparing operation + Viagra will improve erections in some patients. RT will affect erections in many patients. Brachytherapy appears favourable for preserving erections.
Cancer cure / control Depends on final histopathology (grade/ stage) and PSA at 3 months. Surgical patients have better survival than radiation patients in large retrospective studies (1, 2) Depends on grade / stage.
Long term Local symtoms As prostate is removed, worsening of urinary symptoms, late obstruction of Ureters, recurrent blood in the urine usually does not happen. As prostate is still inside, worsening of urinary symptoms, late obstruction of Ureters, recurrent blood in the urine may happen.
Further (adjuvant / Salvage) treatment After operation , if necessary further radiation can be done with no increased risk of complications. After radiation , salvage operation can be done on very rare circumstances with reasonably high levels of complications.

References

1. Abdollah . F Eur Urol 2011
2. Sooriyakumaran P, BMJ 2014
3. www.baus.org.uk
4. www.chennaiurologyclinic.in