Services List

We offer a variety of modalities in treating prostate cancer below. Should you need a better understanding of the diagnosis and staging of prostate cancer (such as the PSA level), please visit this section first. Please call us and make an appointment. We will be happy to counsel you on all of the options.

Featured Services

Precise and impartial approach

We strongly believe in informed consent, and that every patient is unique in his own right to decipher the options for treatment, and choose the optimal method in treating their prostate cancer, with the least side effects. We believe that an educated patient is an empowered patient, and that the choice a patient makes should be well-considered, and well-informed of the alternatives, and most importantly the side effects.

We present below the services, and treatments that we can offer for prostate cancer. There are other therapies that exists (such as high frequency ultrasound or HIFU) which are not FDA- approved at the present, and are considered experimental. We do not offer these therapies, unless they are part of a clinical trial we are are participating in. Please do inquire about other services at your initial consultation with us.

SURGERY

Radical prostatectomy is considered the premier treatment for men who have a greater than 10 year projected life expectancy. There are two approaches to remove the prostate to complete a Radical Retropubic Prostatectomy. This operation is very different compared to the “prostate rotorouter” done for men with BPH. This will remove the entire prostate, all or part of the seminal vesicles, transecting the vas deferens (causing infertility), and removal of the internal urinary sphincter (causing temporary incontinence). The remaining urethra will be reconnected (anastamosis) to the bladder neck over a catheter (a tube going from the outside to the bladder through the penis draining urine) for 10-14 days so that it can heal. The operation can be done through an open incision from the belly button to the pubis and will remove the lymph nodes in the pelvis on each side of the prostate. This is the open operation. The procedure can also be done laparoscopically using the DaVinci Robot. This is done through 6 “laparoscopic ports” or multiple small incisions with placement of only a camera and small instruments, and not the surgeon’s hands in the pelvic cavity.

The Traditional (open) Radical Retropubic Prostatectomy

Radical prostatectomy is an operation that removes the entire prostate gland, both seminal vesicles (small glands behind the bladder that produce most of the contents of semen) and a portion of both vas deferens (tubes that transport sperm from the testicles to the urethra). In certain instances, it may be necessary to remove lymph nodes from one or both sides of the pelvis. Lymph nodes are small glands associated with virtually every organ in your body. Their role is to filter infectious cells or cancer from the organ with which they are associated. If there is a high likelihood that the cancer has already spread to these glands, then removing lymph nodes at the very beginning of the operation, and finding out that they contain cancer, may stop a surgeon from removing the prostate. In other words, removing the prostate at that point may not likely result in a cure. There are instances in which we would continue the operation with positive (cancer containing) lymph nodes. The reason we perform this operation is to cure the patient of prostate cancer. In other words, when we perform this operation, we make the assumption that the cancer is still in the prostate and has not traveled out beyond the walls of the prostate or to distant areas in the body. Despite all modern technology, there is no way to guarantee that the cancer has not spread before the operation.

Radical prostatectomy has been the first treatment and has been performed for over 100 years. It was pioneered by Hugh Hamptom Young in 1905 through a perineal approach (space behind the scrotum). Dr. Millin pioneered the retropubic approach in 1947. In the early years of this therapy, there was a very high chance of urinary incontinence and erectile function loss. Dr. Patrick Walsh developed the anatomic radical prostatectomy in the 1970-80s and has since changed the surgical technique in allowing visualization and preservation of the cavernosal nerves and external urinary sphincter that preserves continence and erectile function in over 90%.

The open retropubic approach has been in practice for many years until the recent advent of the Da Vinci Robot. The laparoscopic approach essentially offers similar results achieved with open surgery, with the caveat that the surgeon is experienced.

Convalescence

The duration of the operation is different for every patient mostly reflecting difference in each patient’s anatomy. The general range is less than 3-5 hours (but longer is possible). Surgical time is about the same when the procedure is done using the Da Vinci robot (laparoscopically). As mentioned, you will have a urethral catheter draining your urine, and this catheter may give you a constant sensation that you need to urinate. This sensation typically disappears in a few days. There may also be small tube(s) in your abdominal wall that are called drains. These will be removed in the few days in the hospital depending on your surgeon’s preference and your progress. A typical hospital stay for an open radical prostatectomy is 2-3 nights. We have had rare instances of patients staying only one night as well as occasions when patients have stayed longer. When the catheter is removed in 10-14 days, a patient will likely need incontinence assistance until the external sphincter is trained by Kegel exercises. The return of continence takes an average of a few months, but in some instances can be as early as a few weeks or take up to a year with slow recovery over time. Erectile function returns slowly and can take up to 18 months. Most patients are back to work within 3 weeks with the caveat that there is no heavy lifting for 6 weeks.

Possible Complications of the Procedure

All surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes (although most are very rare) which may include, but are not limited to: blood loss, incontinence, impotence, infection, sepsis, wound dehiscence, bladder neck contracture or scar formation, deep vein thrombosis, bowel obstruction, lymphocele, rectal injury, bowel injury, ureteral injury, obturator nerve injury, cardiac or pulmonary complications, and in the case of the laparoscopic approach- CO2 embolism, pneumothorax, and open conversion.

Da Vinci Robotic Assisted Laparoscopic Prostatectomy

Our newest approach is the DaVinci Robotic Laparoscopic Prostatectomy (DvP). Dr. Schuessler and his colleagues in 1997 successfully completed the first pure non-robotic laparoscopic prostatectomy. However, the operative times and the length of hospital stay were very long. It was not widely accepted initially. In 2000, Urologists in France (Drs. Guillonneau and Vallancien) rekindled worldwide interest that was further adapted with the advent of the Da Vinci surgical robot in 2002. The robot reduced both operative times and learning curve by incorporating the sophisticated endowrist technology and 3-D optics with the 2-scope system. The Da Vinci Robotic prostatectomy strives to duplicate the open radical prostatectomy with the exception that the pelvic lymph node dissection is usually omitted. The decision to perform the lymph node dissection depends on the Gleason histotype of the tumor and the statistical likelihood that the lymph nodes will be positive. The procedure lasts 3 to 5 hours due to the need to set up the robotic instrument. This technique is the most progressive, and in most early research studies cancer control and complications rate are grossly similar to the open operation. For more information on the robot, please visit www.intusurg.com. Since the first generation robot, there has been 4 more generations incorporating 3D high definition visualization, more instrument choices, and a more compact system. The Da Vinci robot is used in many other surgical subspecialties and represents one of the most progressive surgical instruments in the twenty-first century.

 

Post surgical follow up

After the surgery, the PSA level will be indicative of recurrence. The level of PSA should be below 0.1 ng/mL and if it should rise- it indicates a biochemical recurrence. We now generally use the ultrasensitive PSA, also called post-prostatectomy PSA, which can detect PSA levels as low as 0.03 ng/mL. Unlike radiation therapy which leaves the prostate in place, surgery strives to remove all of the prostate cells that make PSA. Therefore, we monitor PSA levels closely throughout the first few years after surgery and further annually.

CONFORMAL RADIATION THERAPY

Just as surgery has been progressive with the Da Vinci robot, radiation therapy has also experienced an advance in technology. In the last 10 years, we have seen a generation of linear accelerators and conformal techniques that are capable of delivering high doses of radiation deep within the pelvis while simultaneously sparing the anterior rectal wall, the bladder neck and prostatic urethra and femoral heads.

Until the 1970s, radiation oncologists treated cancers without knowing the precise location of the anatomy. In essence, surrounding tissue injury was very high, and radiation was delivered to a fairly large field. In the past, prostate radiation was given by inferring its location on an X-ray or cystogram with a catheter in place, which was not very accurate. There was a progressive group of radiation oncologists who placed prostate cancer patients on a 360 degree rotating platform while a radiation beam was aimed at the level of their pant pockets, and this was considered very advanced at the time. This lead to a component of radiation therapy called “treatment planning”, and drives the tools radiation oncologists use today to optimize the delivery of the radiation dose while sparing surrounding structures. The days of a patient’s hair falling out from radiation therapy has gone by the wayside.

With the advent of CT scanners using rapid computational power (using Fourier transform) to get 3D images, radiation therapy changed significantly for prostate cancer. The results today far exceed even results generated even as recent as the late 1980s. The terms external beam radiation therapy (EBRT) was generic has progressed to Intensity Modulated Radiation Therapy (IMRT) and now the advent of Image Guided Radiation Therapy (IGRT).

Be careful of the terms and the equipment used to deliver radiation therapy. IMRT is now applied in a generic fashion to a modality of delivering conformal radiation therapy that uses treatment planning and a computer to modulate the intensity of the beam. IMRT uses a series of “ports”, about 5-7 of them, to deliver the radiation. These ports are essentially lead shielded windows to the pelvis at some centers. Secondly, patient motion can easily affect the results as the prostate target is moved in and out of the radiation window, and the bladder and rectum can veer in and out as well, receiving unwanted radiation. Radiation is delivered daily in “fractions” every weekday (Monday to Friday) for about 2 months totaling about 81 Gray.

Image Guided Radiation Therapy

At the our centers, we use Varian's Rapid-Arc linear accelerators that takes IMRT to the cutting edge.  There is a CT-scanner attached to the linear accelerator that incorporates real time image information in guiding the radiation beam.   Varian uses leaf interdigitation with a Varian multileaf collimator (shielding) and Varian's dynamic "sliding window" approach to beam shaping.  The linear accelerator also uses the Varian patented "gridded gun" to vary the dose rate as a function of the gantry angle.  As a result, a single arc can deliver essentially similar dose distributions compared with IMRT plans that incorporate as many as 36 fields.  In lamen terms, the machine rotates around the pelvis, and a computer dynamically adjusts the collimator (individual lead shields) to dynamically shape the radiation beam, while varying the dose based on the angle of the beam hitting the patient.   In terms of patient motion, we place radiopaque gold markers in the prostate, standard to any IMRT, to improve the prostate motion from day to day fractions.  However, intrafaction motion (or movement during when the beam is on) is difficult to manage- we would have to totally immobilize the patient.  Another technique to get the therapy session completed as fast as possible while the patient is instructed to lie very still (and this is more difficult the longer the therapy).  Thus, Varian’s Rapid-Arc linear accelerator completes the therapy within 2-4 minutes- Less time, less motion, less waiting for patients, resulting in better outcomes and quality of life. To further learn about the technology, visit Varian Systems and View the video about Varian Rapid Arc.

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Adjuvant Hormonal Therapy

There have been multiple studies supporting the use of hormonal therapy (also mentioned and detailed below) with radiation therapy to improve outcomes. Hormonal therapy uses medications that temporarily cause the pituitary gland to cease the production of gonadotropins (or testicular stimulating hormones) that result in lowering testosterone to castrate levels. The prostate cancer cells are dependent on testosterone, and hormonal therapy sensitizes the cells to radiation; thus, promoting more cancer celluar DNA damage. Generally, we recommend 6 - 8 months of hormonal therapy for intermediate risk prostate cancer (PSA between 10-20, Gleason score 7, Stage T2b). For high risk (PSA >20, Gleason score 8-10), studies have shown that longer term hormonal therapy (2-3 years) have more benefit than shorter (6 - 8 month) terms. However, hormonal therapy has side effects when testosterone is at castrate leves- causing hot flashes, low libido, erectile dysfunction, low energy or fatigue.

Treatment Response

Unlike surgery in which the prostate gland is removed, radiation slowly damages the DNA of the cancer cell, and may not immediately kill it. What happens over time is that when the cancer cell tries to divide, it then dies. Essentially, the PSA slowly reaches a nadir (some value around < 1.0 ng/mL) over a long time. Sometimes, it takes up to 36 months, and the longer it takes, the better. This is counter-intuitive, but there are studies showing that when the PSA takes more than 12 months to reach its nadir, the patient’s survival rate is higher. In a study, 75% of men who reached a nadir in less than 12 months had distant metastases (spread of the cancer) in less than 5 years compared with 25% of those who took more than 12 months. In other words, the cell does not die with radiation but is programmed to do so, and if the cancer is aggressive, the cell divides very fast- leading to a lot of cells that die and a very short time to reach a low nadir. If the cancer is low in grade, it takes a long time to divide, and therefore takes a long time to die and reach its nadir. If this is confusing, please come in for a consultation.

Brachytherapy

Brachytherapy is the use of brachy or “close” therapy to radiate the cancer cells. This is achieved by implanting radioactive seeds that slowly radiate the cancer over 6 to nine months. We employ Iodine 125 isotopes with a half-life of 60 days or Palladium 103 isotopes with a half-life of 17 days. Palladium is usually used with combined conformal radiation therapy (albeit at a lesser dose of 45 Gray) and brachytherapy for higher-grade cancers. Placing the brachytherapy seeds is done with surgery in the operating room under anesthesia, guided by a transrectal ultrasound device and fluoroscopy. A cystoscopy is also done at the end of the case. Men who have very large prostate glands and/or very severe obstructive urinary symptoms are not advised to undergo this procedure.

Cryotherapy

Cryotherapy uses a series of needles that carry liquid argon and helium gas to cool and warm cells resulting in cellular shock and hypoxia. The first generation of cryotherapy machines were not very precise and caused urethral fistulas, contractures, incontinence, sloughing of the urethra, etc. There has been 3 generations of cryotherapy machines that have been developed. Cryotherapy is also done in the operating room under anesthesia and guided by a transrectal ultrasound device. We generally employ cryotherapy for men who have failed radiation.

Hormonal Therapy

Hormonal therapy as mentioned above can be given with radiation therapy to help sensitize the cells to radiation, or before brachytherapy to shrink the prostate gland, and in this section, can be given alone as primary therapy. This therapy started with Dr. Huggins in the 1940s and is still being used today. This was achieved with surgical castration in the past. We now have in our armamentarium a series of medications that can modulate the pituitary gland in halting the release of gonadotropins (FSH and LH) or hormones that shut off the testis. These medications can be given as an injection a month at a time, a few months at a time, or a year at a time via an implant in the arm. There are also oral forms of medications that can achieve similar results by blocking the testosterone receptor on the cell. Men who present with widespread disease (metastatic disease), who have significant co-morbid medical problems, who have less than a 10 year life expectancy, or who are not interested in curing the cancer, opt to receive primary (by itself) hormonal therapy. This treatment does not cure the cancer, but slows it down. Hormonal therapy can be given continuously or intermittently, at on and off cycles dependent on when the PSA rises above an arbitrary number. However, over time, it selects out the cells that are resistant to castration (or low testosterone levels) and eventually the population of cells become androgen-refractory or castrate-resistant prostate cancer. When the cells reach that state, these medications are ineffective. The side effects of hormonal therapy include hot flashes, loss of erections, low energy, gynecomastia, low blood count, changes in body habitus, and osteoporosis.

Chemotherapy/Immunotherapy

When prostate cancer becomes androgen-refractory or castrate-resistant, it will grow regardless of the testosterone level. In the past decade, research has shown that certain microtubule inhibitors have activity against the cancer. Clinical trials are ongoing, and some have prolonged the median survival to 16-18 months while decreasing PSA up to 45% and decreasing pain from bone metastases. In the upcoming future, a prostate cancer vaccine has shown some short term benefit and may become available. It requires that the laboratory harvest CD54+ dendritic cells from patients and then manipulated in the lab to be given back to the patient.

Active Surveillance/Watchful Waiting

We group this section under what is called expectant management of prostate cancer. Active Surveillance dictates that there is frequent monitoring of the PSA level, yearly biopsies that surveys the cancer and then transition to a therapy with curative intent (i.e. surgery or radiation) when the cancer progresses. In essence, Active Surveillance can be valid for a young individual who wants to delay radical treatment to avoid the side effects. Watchful Waiting, on the other hand, has no intent on radical therapy, does not require monitoring, and treats the cancer if it becomes metastatic and causes symptoms. Watchful waiting is optimal for an elderly individual with less than 10 years of life expectancy. The true art in selecting Active Surveillance is identifying those patients with cancers that are clinically indolent or low-risk in progression to metastases. We do not have an accurate test to dictate how a cancer will behave. Therefore, selecting Active Surveillance inherently carries the risk of metastases (spread of the cancer outside the prostate) during the surveillance period. The problems with surveillance is that the PSA test does not accurately predict disease progression, and there is no established protocol on how to survey (i.e. when to get the PSA, at what cut-off is considered progression).

 

 

Services overview

Da Vinci Prostatectomy

Our physicians are fellowship trained and has the case volume experience that exceeds the learning curve in
using the Da Vinci Robot for surgical therapy.

IMRT/IGRT

We use the latest in the delivery of precise radiation therapy. The Rapid
Arc linear accelerator from Varian delivering a therapy session in under 4 minutes.

Brachytherapy

Our physicians are trained at the pioneering center for prostate brachytherapy.

Cryotherapy

Our physicians are trained at delivering cryotherapy for radiation therapy patients who have failed.

 

Hormonal Therapy

We have access to many regiments that can bring testosterone to castrate levels and maintain them.

Chemotherapy

The latest microtubule inhibitors such as Docetaxel offers patient with hormone or castrate resistant cancers new hope.

 

Active Surveillance

For those who pursue watchful waiting or active surveillance, we can follow closely should the need arise to engage therapeutic strategies.