In the early 1990s, roughly 30 percent of prostate cancer patients in the United States were treated by surgery, 30 percent by radiation, and 20 percent by watchful waiting. (Most of the rest were treated with a combination of therapies). In Europe, by contrast, watchful waiting constitutes the standard treatment for asymptomatic prostate cancer.
The popularity of surgery in this country has grown tremendously in recent years. A study of Medicare patients' records found that the number of men nationwide receiving radical prostatectomy by 1990 was six times greater than the number recorded for 1984, and the increase was seen in all age groups, from the youngest (that is, age 65) to men in their eighties.
The growth of the popularity of surgery has corresponded with the advent of minimally invasive surgical options that reduce side effects and promote faster recovery times. Two surgical options touched on in this section are radical prostatectomy and cryosurgery.
An operation called radical prostatectomy completely removes the prostate and nearby tissues. A radical prostatectomy is further described in terms of the incisions used by the surgeon to reach the gland. In a retropubic prostatectomy, the prostate is reached through an incision in the lower abdomen; in a perineal prostatectomy, the approach is through the perineum, the space between the scrotum and the anus.
In radical prostatectomy, the surgeon excises the entire prostate gland, along with both seminal vesicles, both ampullae (the enlarged lower sections of the vas deferens), and other surrounding tissues. The section of urethra that runs through the prostate is cut away (and with it some of the sphincter muscle that controls the flow of urine). Pelvic lymph node dissection is done routinely as part of a retropubic prostatectomy; with a perineal prostatectomy, lymph node dissection requires a separate incision.
Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. Guided by TRUS, the doctor places needles in preselected locations in the prostate gland. The needle tracks are dilated for the thin metal cryo probes to be inserted through the skin of the perineum into the prostate. Liquid nitrogen in the cryo probes forms an ice ball that freezes the prostate cancer cells; as the cells thaw, they rupture. The procedure takes about 2 hours, requires anesthesia (either general or spinal), and requires 1 or 2 days in the hospital.
During cryosurgery, a warming catheter inserted through the penis protects the urethra, and incontinence is seldom a problem. However, the overlying nerve bundles usually freeze, so most men become impotent.
The appearance of prostate tissue in ultrasound images changes when it is frozen. To be sure enough prostate tissue is destroyed without too much damage to nearby tissues, the surgeon carefully watches these images during the procedure. A suprapubic catheter is placed through a skin incision on the abdomen into the bladder so that if the prostate swells after the procedure (which usually occurs), it won't block the passage of urine. The catheter is removed 1 to 2 weeks later.
After the procedure, there will be some bruising and soreness of the area where the probe was inserted. You will likely stay in the hospital for 1 or 2 days. Cryosurgery is less invasive than radical prostatectomy, so there is less blood loss, a shorter hospital stay, shorter recovery period, and less pain than radical surgery. But compared with surgery or radiation therapy, doctors know much less about the long-term effectiveness of cryosurgery.
Current techniques using ultrasound guidance and precise temperature monitoring have only been available for a few years. Outcomes of long-term (10- to 15-year) follow-up must still be collected and analyzed. For this reason, most doctors do not include cryotherapy among the options they routinely consider for initial treatment of prostate cancer.