Comprehensive Urology

Prostate Cancer Treatments

Comprehensive Urology offers a variety of treatment methods for prostate cancer. Like other forms of the cancer, prostate cancer treatment is determined by a few factors, including the grade and stage of the disease, a patient’s age, and more. Once your cancer has been diagnosed and studied, our specialists will determine a specific treatment plan that’s unique to you and your lifestyle.

High-Intensity Focused Ultrasound (HIFU) involves the use of high-frequency ultrasound waves to heat and destroy cancer cells in the prostate. During this procedure, a HIFU probe is placed in the rectum via computer imaging. Next, the HIFU probe is heated to nearly 100°C (212°F) within 3 seconds. The probe is designed to treat only a specific area; as such, all other areas of the body remain intact.

Now, whole gland and focal HIFU therapies are available. Whole gland therapy is intended for men diagnosed with prostate cancer who want to treat their entire prostate gland. Comparatively, focal therapy allows men to simultaneously cure their prostate cancer and preserve their urinary and sexual function. Following focal therapy, most men can preserve their urinary control and erections. Plus, many men with focal therapy are able to preserve their ejaculation.

Comprehensive Urology offers many whole-gland and focal HIFU prostate cancer therapies, and these include:

Whole Gland Therapies for Prostate Cancer

  • da Vinci® Robotic Prostatectomy: Involves the use of a sophisticated robotic platform to perform complex surgery. The da Vinci® system scales, filters, and translates a surgeon’s hand movements to minimize the risk of human error during minimally invasive procedures.
  • HIFU: Leverages high-frequency ultrasound waves to simultaneously destroy prostate cancer cells and keep surrounding tissue intact.
  • IMRT (Radiation Therapy): Uses radiation treatments to pinpoint cancer cells in the prostate.
  • MRI Brachytherapy: Involves the insertion of radioactive seed implants into the prostate gland to localize radiation treatment to the prostate and limit its impact on the bladder, rectum, and other nearby structures.

Focal Therapies for Prostate Cancer

  • MRI fusion HIFU: Combines MRI images with live ultrasound images to help a doctor identify prostate cancer during a HIFU procedure.
  • Active Surveillance: Involves monitoring prostate cancer patients; active surveillance may include performing a clinical assessment, conducting rectal examinations and Prostate-Specific Antigen (PSA) testing, imaging the prostate, and completing regular prostate biopsies.

Patients with prostate cancer can benefit from the following treatments. Each treatment option is beneficial to certain individuals, as there is no “one size fits all” approach to prostate cancer treatments. However, the prostate cancer specialists at Comprehensive Urology can help you choose a treatment plan that is specifically tailored to you and your condition.

Whole Gland Therapy Prostate Cancer Treatments

Men diagnosed with prostate cancer who pursue a treatment option typically undergo treatment of their entire prostate gland. The cancer removal is typically performed surgically (open, laparoscopic or robotic prostatectomy), with external beam radiation, with internal radiation, or with cryotherapy (freezing of the prostate). While these modalities can be effective with varying success rates, all have the potential of causing erectile dysfunction and urinary dysfunction ranging from urinary frequency, urinary urgency, obstructive voiding symptoms to urinary incontinence.

HIFU (high intensity focused ultrasound) is an outpatient treatment modality that can similarly treat the entire prostate gland with curative intent. As with other, above-mentioned, modalities, HIFU can be a very effective treatment modality for treating this cancer. However, because of its precision, HIFU can have favorable outcomes in regards to erectile function and urinary symptoms as compared to surgery, radiation therapy or cryotherapy.

Many patients who choose to have HIFU do so with the aim of treating their prostate cancer while trying to minimize their post-treatment side-effects. The other advantage of HIFU is that it performed as an outpatient (not requiring hospitalization). HIFU treatment for prostate cancer typically takes about 3 hours to complete.

Robotic Prostate Cancer Surgery

Robotic prostate cancer surgery is changing the face of prostate cancer treatment. Also known as a robotic prostatectomy, this surgery allows the urology team at Comprehensive Urology to operate on patients with greater precision and flexibility than previously available with traditional “open” surgical methods.

During robotic prostatectomy, a computer-guided system focuses on a targeted area of the prostate gland to remove tumors with high accuracy. The arms of the robot are more flexible than human arms and can focus on a smaller and more targeted surface area, providing surgeons with greater manual dexterity while performing surgery. Robotic surgery is a tool that works as an extension of the surgeon’s hand; they remain in control of the surgery and of the patient at all times.

da Vinci® Surgical System

The da Vinci® Surgical System is a revolutionary platform that allows Comprehensive Urology to offer patients minimally invasive prostate cancer surgery. The da Vinci® system is distinguished from earlier surgical tools and procedures with many unique features:

  • Innovative EndoWrist instrumentation for greater manual dexterity and control
  • High-resolution brilliant color 3D stereo viewer offers higher magnification to enhance natural depth of field
  • Four robotic arms with jointed-wrist design for greater dexterity and flexibility
  • Motion scaling and tremor reduction of surgeon’s hand movements
  • Multi-level fail-safe design to help minimize potential for human error

Robotic surgery allows the experts at Comprehensive Urology to offer patients a less invasive and more precise operation. Minimally invasive surgery generally has many advantages over traditional open surgery, including:

  • Smaller incisions
  • Less blood loss
  • More precise preservation of the erectile nerves
  • More accurate urethral anastomosis
  • Lower risk of complications and infections
  • Potentially shorter hospital stays and healing time

HIFU

HIFU is a state-of-the-art prostate cancer treatment method pioneered by the urologists at Comprehensive Urology. During a HIFU procedure, high-frequency ultrasound waves are used to heat and destroy cancer cells within the prostate. The highly focused nature of this treatment helps to ensure that ONLY cancerous tissue is targeted; tissue outside of the focal point is untouched, leading to safer and better treatment outcomes.

HIFU has numerous benefits over traditional prostate cancer surgery, but treatment ultimately comes down to whichever option our specialists feel is right for you and your unique condition.

Intensity-Modulated Radiation Therapy (IMRT)/MRI TrueBeam Therapy

Traditionally, radiation treatments have been delivered to the entire prostate gland. The state-of-the-art facilities and equipment at Comprehensive Urology make it possible to offer each patient-targeted and localized radiation treatments to the prostate gland in many cases.

TrueBeam intensity-modulated radiation therapy (IMRT) is a modern, highly sophisticated method for delivering targeted radiation treatments to the prostate gland with greater accuracy and precision. Because the positioning of the prostate gland tends to shift regularly due to its location near the bladder and rectum, older methods for administering radiation made it difficult to pinpoint the precise location of the gland. This increased the likelihood of applying radiation to healthy tissue by mistake. The enhanced imaging capabilities of the MRI TrueBeam system make it possible to target and administer radiation to the cancer cells in the prostate with greater accuracy and precision.

IMRT typically takes eight and a half weeks to deliver. Radiation is delivered in small fractions on a daily basis, Monday through Friday for 42 sessions. Each day that a patient shows up for his treatment, the prostate is in a slightly different position. This is because the prostate sits on top of the rectum and just below the bladder. Therefore, depending on the amount of fecal material in the rectum or the amount of urine in the bladder, the prostate can actually shift up or down slightly on a daily basis.

Standard IMRT radiation therapy cannot visualize the prostate with high accuracy. For this reason, to ensure that the prostate is being adequately radiated, some of the healthy tissue around the prostate also receives radiation. This is done to compensate for the lack of prostate visualization. The downside is that normal, healthy tissue gets destroyed with standard IMRT therapy.

External Radiation Therapy

Radiation therapy can take different forms – either externally beamed from a machine or by radioactive seeds implanted in the prostate (see brachytherapy below). Radiation therapy can be used as an alternative to surgery for localized prostate cancer or to treat cancer that has spread beyond the prostate. In certain clinical situations, radiation treatment can be useful in treating prostate cancer after surgery. Radiation therapy can also help shrink tumors in men with advanced forms of the disease, and may also be used to relieve pain caused by prostate cancer.

Recently, radiation therapy has been widely used in conjunction with hormonal therapy when treating aggressive forms of localized prostate cancer.

The course of external beam radiation therapy is usually 6-8 weeks. Newer therapies are continuously being developed (i.e. conformal beam radiotherapy, intensity modulated radiotherapy) to improve localization of radiation treatment to the prostate without damaging adjacent structures like the bladder or rectum. Widespread long-term data is awaited to determine durable cure rates compared to other therapies (such as radical prostatectomy).

MRI Brachytherapy

During brachytherapy treatment, radioactive seed implants are placed into the prostate gland to help localize radiation treatment to the prostate and minimize the effects to the surrounding structures (bladder and rectum). The technique is performed by implantation through the skin, utilizing ultrasound and x-ray for localization into the gland. Results show good control of cancer at 5-8 years following treatment in persons with very low-grade cancers. Overall, the treatment appears to be as effective as external radiation. Long-term results are awaited in order to determine durable cure rates compared to radical prostatectomy.

MRI brachytherapy utilizes the advancements in imaging and diagnostic capabilities that have occurred in recent years to help deliver precise, targeted radiation to the portion of the prostate gland where the cancer cells are located. This focused treatment helps preserve as much healthy tissue as possible and avoids over-treatment.

Cryotherapy

Cryotherapy is performed by freezing the prostate with liquid nitrogen. In the operating room, small probes are placed by ultrasound guidance into the prostate and then are used to freeze the gland, while the urethra is monitored to minimize the risk of damage to it as well as the rectum. Cryotherapy was first developed in the 1960’s and refined in the early 1990’s, but had significant side effects to the urinary tract and rectum. Improved technology and the use of ultrasound has allowed for improved localization of treatment to the prostate gland. The overall cure rate with this technique is yet to be determined due to the short-term data that is available.

Cryotherapy has gained more widespread acceptance not in the primary treatment of prostate cancer, but in the recurrence of prostate cancer after radiation treatment has failed. It appears that this may be the more promising role for cryotherapy in the treatment of prostate cancer.

Hormonal Therapy

Many men choose hormonal therapy for advanced prostate cancer to help cut off the supply of testosterone, the hormone that makes prostate cancer cells grow faster. As it is not a curative mode of treatment, hormonal therapy is generally not used for early stages of cancer. Hormonal control can be achieved through the use of medications or through surgical means. These medications help stop the production of these hormones or block them from feeding the cancer cells. Surgical options include removal of the testicles, which are the main source of testosterone production in men.

Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments (such as surgery or radiation therapy). Hormonal therapy is also helpful in alleviating the painful and distressing symptoms often found in advanced stages of prostate cancer. This treatment is also being used in conjunction with external radiation therapy for more aggressive but localized prostate cancer. Furthermore, it is also used as a treatment for prostate cancer recurrence after previous treatment.

Focal Therapy Partial Gland Prostate Cancer Treatment

Due to effective screening, most men with prostate cancer are being detected when the cancer is still localized to the prostate and has not spread elsewhere. Many such men are diagnosed when the cancer is relatively small in volume and localized to only one segment of the prostate (the prostate has not overtaken the entire gland). Prostate cancer focal therapy treats a portion of the prostate gland.

MRI Fusion Biopsy

In the past, if a man was diagnosed with significant prostate cancer, he would have his entire prostate removed surgically or have it radiated. However, for most men, over-treating the entire prostate is not necessary anymore. Because of advances in magnetic resonance imaging (MRI) and MRI fusion technologies, we are now able to accurately identify the extent and location of prostate cancers for most men. Now that we can reliably locate the tumor, we no longer have to over-treat the entire prostate gland. Instead, we can use HIFU to destroy only the cancerous area and preserve the normal prostate tissue.

Why is this important? By preserving the normal prostatic tissue and surrounding structures, men undergoing focal HIFU therapy have better preservation of their erections, better preservation of their sexual function and better preservation of their urinary control, than men undergoing treatment of the entire prostate.

Years ago, women who were diagnosed with breast cancer underwent surgical removal of their entire breast. With improved localization of tumors, most women no longer have their entire breast removed. Instead, they undergo a “lumpectomy,” where only the lump of breast cancer is removed and the normal breast tissue is preserved.

Active Surveillance

Active surveillance (also known as “watchful waiting”) is an option for older men with a relatively shorter life expectancy, especially if the cancer is small and slow-growing. For these individuals, chances are good that without any form of treatment, cancer will not affect them in their lifetime. However, for men who are healthy and have a longer life expectancy (greater than 10 years), some type of active treatment to potentially cure the disease is generally recommended.

Active surveillance involves monitoring cancer by:

  • Assessing the clinical symptoms of the patient,
  • Monitoring his prostate with rectal examinations and PSA testings
  • Imaging the prostate
  • Repeating the prostate biopsies at regular intervals

On follow-up biopsies, patients typically move forward with treatment with curative intent (for example surgery or radiation therapy) when their prostate cancer has progressed or when they no longer want to be on active surveillance. Traditionally in both of these situations, patients will undergo treatment of the entire prostate gland with either full removal of their prostate surgically or with radiation applied to their entire prostate gland. As noted, either of these therapies has the potential of sexual and/or urinary side-effects.

To date, patients diagnosed with this localized cancer have had the option of being placed on active surveillance or to undergo whole gland treatment.

In effect, men with small volumes of prostate cancer can delay their therapy until their prostate becomes more voluminous or more aggressive, requiring intervention. While this approach can be effective for some men, there is always the risk that the initial volume or aggressiveness of the prostate cancer may have been underestimated and that by delaying treatment, a patient’s outcomes may have been compromised. Patients who are appropriately placed on active surveillance, are monitored over time with repeat clinical exams (PSA testing and digital rectal exams), and repeat prostate needle biopsies.

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