Minimally Invasive Procedures for Kidney Cancer & Prostate Cancer

Prostate Cancer
Prostate Cancer
Prostate Cancer

Prostate Cancer

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

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Prostiva® RF Therapy

Prostiva® RF Therapy (Prostiva) is a safe, effective, in-office treatment that that provides long-term relief from BPH symptoms and urinary obstruction. Prostiva is appropriate for men experiencing moderate to severe BPH symptoms especially patients who do not want to take daily medications for the rest of their lives, dislike the side effects and ongoing costs of medication or do not want the risks, side effects or high costs of surgery.

Here are some examples of prostate shapes that Prostiva® RF Therapy can treat:

  • 20-50 grams
  • Long Lobes
  • Short Lobes
  • Asymmetric Glands
  • Median Lobes

How Does Prostiva Work?

Prostiva® RF Therapy treats BPH utilizing low level radio frequency energy to destroy enlarged prostate tissue. The movement of the electrons causes the tissue to heat.  This produces predictable and repeatable lesions, which are located directly around the electrodes. The Prostiva® RF Therapy procedure helps to reduce the constriction of the urethra and relieve BPH voiding symptoms.

Benefits

Prostiva RF Therapy provides significant benefits to patients.

  • Relief from the uncomfortable, systematic effects of BPH drugs
  • Treatment completed in-office generally 1-1.5 hrs (including preparation and recovery time)
  • Minimally-invasive treatment which does not require general anesthesia
  • 15 computer-monitored safety checks
  • Effective results – clinically significant improvements in IPSS, peak uroflow, and quality of life at five years1
  • Durable results – re-intervention not necessary in over 86% of patients at five years1
  • Low rate of side effects1

Risks

As with all medical procedures, there are some risks involved with this procedure. 2

  • Obstruction (blockage)
  • Bleeding
  • Pain/discomfort
  • Urgency to urinate
  • Increased urinary frequency
  • Urinary tract infection

Clinical Results

Prostiva® RF Therapy has currently has currently treated over 100,000 patients worldwide and there have been at least 75 published articles on RF Therapy for BPH.

Increased Necrosis, Greater Durability3,4

More tissue necrosis equates to a better long-term outcome for patients.  Tissue necrosis is a function of time and temperature.  50°C is required to produce tissue necrosis in 60 minutes, higher temperatures produce a larger volume of necrosis in less time.  Treatment times at temperatures below injury threshold product no irreversible damage.  Prostiva® RF Therapy reaches intraprostatic temperatures of 110°C allowing it to create a lesion in the tissue in just two minutes and 20 seconds.

Source: http://www.urologix.com/

References

1Hill, B., et al Transurethreal Needle Ablation vs TURP for the Treatment of Symptomatic BPH: 5 Year Results of a Prospective, Randomized, Multicenter Clinical Trial, Journal of Urology Vol 171, 2336-2340, June 2004 2Data derived from the Prostiva RF Therapy System User Guide 8930 CRMRef_R06 3Larson, T, et al., Detailed Interstitial Temperature Mapping During TUMT Treatment for BPH, Journal of Urology, January 2998 4Bhowmick, P., et al, In vitro assessment of the efficacy of thermal therapy in human benign prostatic hyperplasia, Int. J Hyperthermia, Vol 20, No 4, June 2004, pp 421-39.

 

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

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Although radiation therapy and surgery are effective treatments for prostate cancer, they also can have serious long-term side effects such as incontinence and erectile dysfunction. Active Surveillance (AS) is a management strategy for prostate cancer that, for eligible patients, offers the possibility of delaying and minimizing the impact of treatment. By using AS, doctors can avoid subjecting patients to potentially unnecessary treatment and reduce the related morbidity associated with some treatments. Recent investigations suggest that AS, for select patients, can help them maintain urinary and sexual function without compromising disease-specific outcomes or the success of a delayed curative intervention.

Management objectives of AS:

· Appropriate selection of patients meeting the definition of low-risk prostate cancer to safely avoid radical treatment and its associated potential for morbidity.

· Regularly monitor the cancer via:

o Physical Examination

o PSA

o Biopsies

o Imaging

· If evidence of disease progression is seen, initiate treatment with curative intent.

After beginning AS, the 2-year probability of remaining on AS is 91%: the 5-year probability is 75%. Of patients undergoing delayed treatment, 95% were without disease progression.

It is important to note that no treatment is a perfect fit for all men. The decision to begin AS must be decided by the doctor and the patient together based on the details of the patient’s biopsy. Occasionally, certain x-rays will help see the extent of a tumor.

It is also important to note that AS is investigational at this point. No data has been provided regarding the safety of AS for men with more than a 15-year life expectancy who have low-risk disease. Thus, men with more than a 15-year life expectancy, and especially more than 20 years, should be informed that active surveillance is investigational.

Some of the risks of AS are that a tumor, which in an earlier stage could have been treated with nerve-sparing prostatectomy, may enlarge as a result of growth of the tumor over time to the point that the nerve may no longer be able to be spared.

When the change in treatment is due to the tumor spreading, it is known as “upstaging.” When a change in treatment is due to the tumor becoming more aggressive, it is known as “upgrading.” Both may mean that a patient requires the additional treatments of radiation or hormones or other chemotherapy.

 

Men who undergo radical prostatectomy (RP) for a tumor detected by screening show better long-term outcomes than their peers who undergo the surgery after opportunistic diagnosis, a recent study by Loeb et al shows.

42,376 men were randomized to annual screening for 6 years or treatment as usual that included opportunistic screening.

In total, 1,151 men in the screening group and 210 in the control group were diagnosed with prostate cancer, respectively. Of these men, 420 (36.5%) screen-detected cases and 54 (25.7%) controls underwent RP with long-term median follow-up data of 9.9 years.

After RP, men from the screening group showed better outcomes than their peers in the control group with a significantly higher 10-year progression-free survival (88% vs. 72%), metastasis-free survival (98% vs. 86%), and cancer-specific survival (98% vs. 88%).

Additionally, the screening group had a significantly lower risk for biochemical recurrence and metastasis compared with the control group (hazard ratio = 0.43 and 0.18, respectively).

The results of the study suggest that a reduction in tumor burden at diagnosis is a mechanism through which PSA screening improves treatment outcomes.

Reference:

Loeb, S., Zhu, X., Schroder, F. H. and Roobol, M. J. (2012), Long-term radical prostatectomy outcomes among participants from the European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam. BJU International. doi: 10.1111/j.1464-410X.2012.11367.x

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

CLICK HERE to schedule your appointment today!

It has been proposed that sparing the seminal vesicles could reduce manipulation of the neurovascular bundles and improve the quality of postoperative erections.The idea that sparing the seminal vesicles improves continence after radical prostatectomy stems from the possibility that dissection in this area may disrupt the innervation of the trigone, blader neck, and posterior urethra.

In a study by Zlotta and colleagues, univariate analysis revealed that in patients with PSA levels <10 ng/ml, there was a statistically significant difference between the percentage of positive biopsy cores and the biopsy Gleason score, but there was no significant difference in age or PSA level between patients with and without seminal vesicle invasion. The investigators concluded that some patients could be safely selected for a seminal vesicle-sparing procedure.

The oncologic risk is still not well defined for patients who undergo the seminal vesicle-sparing procedure.  It is not known if, in the seminal vesicles that are spared and have no evidence of invasion, the risk of recurrence is higher.

McIntosh J and Holzbeierlein J.Commentary on Do Seminal Vesicles Always Need to be Removed During Radical Prostatectomy? The American Journal of Urology Review 2005 Vol 3 No 4:201-203.

Screening and Watchful Waiting

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

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The future of prostate cancer screening holds the potential for increasing accuracy of distinguishing whose prostate cancers are reliably indolent and slow growing vs. whose tumors harbor more aggressive cells which are potentially life threatening.

Small volume low to moderate grade tumors can be further delineated with dynamic contrast enhanced imaging.  Tumors that are not visible on Dynamic Contrast Enhanced MRI are candidates for less risk of metastasis during active surveillance.

Surveillance of low risk prostate cancer offers better early quality of life with no period of temporary post operative incontinence or temporary or permanent impotence.  Studies have shown that the uncertainty of whose prostate cancer will metastasize and whose will not has demonstrated that only about 40% of men can psychologically tolerate watchful waiting.

Many men cite dissatisfaction with watchful waiting:

  • The inconvenience and discomfort of prostate rebiopsies

  • Uncertainty leading to anxiety

  • Peace of mind with choosing a therapy (Surgery, radiation, or cryotherapy).

Studies of tumors on watchful waiting are unable to delineate whose tumor, which was low risk and able to have nerve sparing robot assisted radical prostatectomy at the time of diagnosis, changes on watchful waiting to a tumor that enlarges or upgrades in aggressiveness to the point that nerve sparing is no longer an option.

A thorough understanding of the risks of active surveillance is needed for the patient to understand the risks associated with their choice in their care.

Living After Treatment

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

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Managing Side Effects of Treatment

  • Treatment for prostate cancer may affect your sexuality.  It can result in erectile dysfunction or a lowered sex drive.  These effects are often treatable.

  • Incontinence or other urinary problems can occur due to treatment for prostate cancer.  Effective treatments exist for most urinary problems.

Dieting Effectively

  • Eating smart can result in better overall health.  Fish high in omega-3 may help protect against prostate cancer.  Try to eat 5 to 9 servings of fruit and vegetables daily.  Tomatoes have also been linked to a reduction in prostate cancer.  You should work to eliminate dairy and meats from your diet, avoid tobacco products, avoid excessive alcohol consumption, choose organic produce, and drink 3 to 5 cups of decaffeinated green tea daily.

  • Consider reducing your fat intake.  Studies have suggested that to promote good prostate health fat intake should be reduced to 20% of your daily intake of calories.

  • Also consider increasing your intake of soy products each day (20-40 grams per day, or at least one soy product per day).

  • Selenium and Vitamin E supplements can also be taken to increase a protective, preventative dietary effect against prostate cancer.

  • Many dietary recommendations that prevent prostate cancer development listed above also prevent cardiovascular disease.

Staying Active

Exercise can better prostate health.  Try to exercise 30 minutes or longer at least three times weekly.  Find an exercise that works for you.  Good choices include walking, hiking, jogging, bicycling, and swimming.It’s also a good idea to practice stress reduction and relaxation techniques.

The Stay Well Company.  Prostate Health: What You Need to Know to Maintain Good Prostate Health.  2008 p 1-19.

Radiation Therapy

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

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  • Used to destroy cancer cells.  Cancer cells continue to die for months after the therapy ends.  Radiation therapy also damages some normal cells.  This damage causes side effects which can be controlled.

  • External-beam radiation is done using a machine that sends beams of radiation from outside your body to the cancer.

  • Risks and complications: mild to moderate diarrhea, frequent urination (possibly with a burning feeling), erectile dysfunction, some loss of pubic hair, fatigue, bloating or gas pains, bleeding or scarring of the bladder or rectum, urinary retention, and irritation or inflammation of the rectum with diarrhea, an urgent need to pass stool, or rectal discomfort.

Removing the Prostate (Radical Prostatectomy)

  • Surgery to remove the entire prostate which may be done if diagnostic tests show that the cancer is confined to the prostate.

  • Surgery may be performed through an incision in the abdomen or behind the scrotum.  Surgery can also be performed laparoscopically or robotically.

  • The urologist may remove and check the lymph nodes near the prostate to see if cancer has spread.  If the cancer has spread, the urologist may decide not to remove the prostate.

  • The prostate, the seminal vesicles, and a portion of the urethra will then be removed.

  • Nerve-sparing techniques may be used to help preserve erectile function.

  • Risks and complications of Prostatectomy include; erectile dysfunction, incontinence, infection, excessive bleeding, difficulty urinating, pneumonia, blood clots, and bowel perforation.

The Stay Well Company.  Prostate Health: What You Need to Know to Maintain Good Prostate Health.  2008 p 1-19.

Evaluating Cancer

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

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Cancer is graded by a pathologist using tissue removed from a biopsy.  The higher the grade, the faster the cancer is likely to be growing.  The pathologist gives a report to the urologist.

  • Grade 1 or 2: Cells are abnormal but still appear to be organized in rings. This may indicate a slow-growing cancer.

  • Grade 3 or 4:  Cells vary more in size and shape.  Fewer rings are visible.  These cancer cells may grow more rapidly.

  • Grade 5: Cells don’t form rings.  They vary even more in size and shape than lower-grade cells. This indicates a fast-growing cancer.

Stages of Cancer

  • Stage T1: A tumor that is completely inside the prostate (can’t be felt during a DRE).

  • Stage T2: A tumor that can be felt during DRE but is still completely inside the prostate.

  • Stage T3 or T4: Cancer that has spread to the outside of the prostate or to the seminal vesicles.

  • Stage N+, M+: Cancer has spread to the lymph nodes (N+), or to the bones or other organs (M+).

The Stay Well Company.  Prostate Health: What You Need to Know to Maintain Good Prostate Health.  2008 p 1-19.

Screening vs. Waiting

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

CLICK HERE to schedule your appointment today!

There is currently no universally accepted definition of clinically significant or insignificant prostate cancer.  This leads to a debate between screening and waiting.

Pros of Screening

  • Many experts believe screening saves lives.  Prostate cancer is the second leading cause of cancer death in men.  Screening is the best way to find prostate cancer in its early stages.

  • When found early, prostate cancer can nearly always be successfully treated.  When it is found at a more advanced stage, the outlook often is not as good.

  • The side effects of prostate cancer therapies are often temporary and can be treated.

Cons of Screening

  • Screening tests show how likely cancer is, but they are not perfect.  So some of the biopsies done based on these tests will be unnecessary.  Doing a biopsy has risks, such as bleeding and infection.

  • Prostate cancers are often slow-growing.  Many never become life-threatening and never need treatment.  If you find out you have cancer, you may feel you need to treat it, even if tests show that it’s not a dangerous cancer.  Prostate cancer treatments have side effects that can affect quality of life, such as incontinence and erectile dysfunction.

Treatment Options

  • There are many ways to treat prostate cancer including surgery, radiation, medications, and in some cases watchful waiting.

  • Treatment depends on factors such as age, overall health, how fast the cancer is growing, and whether it has spread.

The Stay Well Company.  Prostate Health: What You Need to Know to Maintain Good Prostate Health.  2008 p 1-19.

The Importance of PSA

Important: This article is not intended to replace a physician examination, review of your pathology report and consultation.

CLICK HERE to schedule your appointment today!

  • Prostate Specific Antigen is a protein made by prostate tissue. PSA level (amount of PSA in the blood) is tested to evaluate a man’s risk of prostate cancer. A high or rising PSA level may mean an increased cancer risk. PSA testing can also evaluate the success of cancer treatments.

  • Factors that affect PSA levels include; age, BPH, and prostate cancer (ongoing factors), prostatitis and sexual activity (temporary effect).

  • Screening is associated with a 20% reduction in prostate cancer deaths. Studies have shown that long-term survival is considerably diminished in men diagnosed with prostate cancer that has already spread beyond the prostate to regional lymph nodes or to more distant sites.

  • The development of PSA has resulted in 48% of prostate cancers diagnosed with US today being found in their clinical stage T1a to T1c, and 85% are found to be clinically localized. This is a tremendous improvement when compared to statistics prior to 1987 (the pre-PSA era): 35% of patients with positive lymph nodes at surgery (when they were thought to have clinically localized disease), and 67% were found to have pathologically advanced disease.

  • The serum PSA level is generally proportional to the risk of prostate cancer, the extent of the cancer, and the long-term outcomes after treatment of the cancer.

  • The average man older than age 50 years with a nonsuspicious DRE has about a 10% likelihood of having biopsy-detectable prostate cancer if his serum PSA level is 0.0 to 2.0 ng/mL; 15-25% if the PSA level is 2.0 to 4.0 ng/mL; 17% to 32% if the PSA level is 4.0 to 10.0 ng/mL; and 43-65% if the PSA level is above 10.0 ng/mL. Thus, there is no PSA level which a man can be reassured that prostate cancer does not exist.

  • When compared with men with a PSAV of 2.0 ng/mL/year or less in the year before diagnosis, men with a PSAV above 2.0 ng/mL/year may have an approximate 10-fold greater risk of death from prostate cancer in the decade after radical prostatectomy.

  • The decision to use PSA for the early detection of prostate cancer should be individualized.

  • Screening in men with less than a 10-year life expectancy, either due to age or comorbidity, is discouraged.

  • Early detection and risk assessment of prostate cancer should be offered to asymptomatic men 40 years of age or older who wish to be screened with an estimated life expectancy of more than 10 years.

  • Among men in their 40s and 50s, a baseline PSA level above the median value for age is a stronger predictor of future risk of prostate cancer than family history or race.

  • Death from prostate cancer occurs, on average, 15 to 20 years after diagnosis of an early cancer, men dying at age 55 to 64 likely could have been cured by diagnosis and effective treatment prior to age 50.

  • When compared to men more than age 50, younger men are more likely to have curable prostate cancer.

  • Measurement of the PSA level is a more specific test for cancer in younger men compared to older men because prostatic enlargement is less likely to confound the interpretation of the estimated PSA value.

  • Infrequent testing of men in their 40s and after age 50 might reduce prostate cancer mortality and the cost of screening when compared to annual testing beginning at age 50.  Possibly screen every other year if the PSA level is less than 0.7 mg/ml.

  • Establishing baseline PSA values against which to compare future PSA measurements after age 50 could help identify those men with life threatening prostate cancer at a time when cure is still possible.

 

PSA Use Once Prostate Cancer Is Diagnosed

  • Pretreatment serum PSA predicts the response of prostate cancer to local therapy.

  • Patients with serum PSA levels less than 10.0 ng/mL are most likely to respond to local therapy.

  • Serum PSA should decrease and remain at undetectable levels after radical prostatectomy.

  • A detectable PSA above 0.2 ng/ml following radical prostatectomy is associated with eventual clinical disease recurrence in some, but not all patients.

  • Serum PSA should fall to a low level following radiation therapy, high intensity focused ultrasound and cryotherapy and should not rise on successive occasions.  A PSA 2.0 above the lowest level after radiation therapy should be cause for a repeat biopsy and possibly salvage cryotherapy.

Green, K, et al.  The Use of PSA for Early Detection of Prostate Cancer.  The Journal of Urology.  Vol 182, Issue 5, November 2009, pg 2232-2241.
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