Mar 30
First, let’s review the territory. For a surgeon, this is precarious terrain indeed: The prostate is located deep in the pelvis, surrounded by structures that are fragile and vulnerable to injury—the rectum, the bladder, the sphincter responsible for urinary control, some large blood vessels, and the bundles of nerves that are responsible for erection. The [...] [...more]
Posted: under Men's Health-Erectile Dysfunction.
Tags: Men’s Health
First, let’s review the territory. For a surgeon, this is precarious terrain indeed: The prostate is located deep in the pelvis, surrounded by structures that are fragile and vulnerable to injury—the rectum, the bladder, the sphincter responsible for urinary control, some large blood vessels, and the bundles of nerves that are responsible for erection.
The operation begins with an incision through skin and muscle in the abdomen that extends from the pubic area to the navel. Almost immediately, before the prostate is ever reached, the surgeon removes a triangle of tissue on each side of the bladder; these triangles contain important lymph nodes. This is called a staging pelvic lymphadenectomy—dissection of the pelvic lymph nodes, to make sure they’re free of cancer. These lymph nodes are removed, then rushed to a pathologist for what’s called frozen-section analysis to check for cancer; the tissue is frozen, then sliced into very thin sections to be examined under the microscope.
(Note: Some doctors only have frozen-section analysis done if a man’s Gleason score is 8 or higher. One reason for this is that with lower-grade, well-to moderately well-differentiated tumors—Gleason 7 or less—the long-term prognosis of patients is different than for men with high-grade, poorly differentiated tumors. Most men with Gleason scores of 8 or higher will have metastases to bone within the first four years after surgery; therefore, removing the prostate ultimately does not benefit these men. But with Gleason scores of 7 or lower—even when there is a tiny bit of cancer in a lymph node—60 percent of men have no sign of metastases on bone scans ten years later. This doesn’t mean the cancer won’t eventually come back in these men, but that it can take years longer to return when the tumor is of a lower, better-differentiated grade. So, because these men can live for many years, they often benefit from having their prostate removed. And removing it now will help them avoid problems with urinary tract obstruction and bleeding later, when the cancer does return.) If the cancer has spread massively to the lymph nodes, the surgeon will stop the operation at this point, because surgery won’t help the situation. But if the
The radical retropubic prostatectomy (continued) lymph nodes are cancer-free—or nearly so (see above), and the cancer cells are not poorly differentiated—the operation continues.
Next, the major vein system that overlies the prostate and urethra (this is called the dorsal vein complex) is cut. Blood loss must be kept to a minimum so that the operation can be performed in a “bloodless field.” This is a crucial step; control of these veins makes a huge difference in the surgeon’s ability to see what’s happening, and it’s particularly significant for what happens next—cutting through the urethra. If the urethra is cut too close to the prostate, some cancer might be left behind; but if it’s cut too far away from the prostate, the urethral sphincter might be damaged—and such an injury can make a man incontinent.
Next, depending on the degree of cancer, the surgeon must make a decision that will affect the patient’s potency—to leave intact the neurovascular bundles, the wafer-thin packets of nerves that sit on either side of the prostate, or to remove one or both along with the prostate. These are the nerve bundles responsible for erection.
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Mar 30
Say a man is in otherwise good health, and he can reasonably expect to live at least ten more years. His cancer is localized to the prostate, and therefore it’s curable now. If he does nothing about it, he may miss his golden opportunity for cure. There’s no way of predicting if or when cancer [...] [...more]
Posted: under Men's Health-Erectile Dysfunction.
Tags: Men’s Health
Say a man is in otherwise good health, and he can reasonably expect to live at least ten more years. His cancer is localized to the prostate, and therefore it’s curable now. If he does nothing about it, he may miss his golden opportunity for cure. There’s no way of predicting if or when cancer will make that fatal leap beyond the prostate. Even in its earliest stages, prostate cancer doesn’t always spread considerately, in logical, creeping, easy-to-predict steps. And unfortunately, men with the earliest stages of prostate cancer can have metastases before they ever even develop a palpable tumor that can be felt by a doctor’s gloved finger during a rectal exam.
But say a man is in his eighties. Even if his cancer is organ-confined and curable, it’s not likely that he will live long enough for
Watchful waiting doesn’t mean your doctor has written you off—it just means you get treatment for specific symptoms if and when you need it.
So who should opt for watchful waiting? At the top of this list should he men who are too old or too ill either to undergo the rigors of treatment or to live another ten years (long enough for such treatment to be worthwhile). Also in this group should be men with cancers that are considered too advanced to cure — men with stages T3 T4 N+, C and D. And finally, for men with cancers that are truly incidental (some men with, stage T1a and lie disease), watchful waiting is probably a reasonable gamble.
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Mar 30
For tumors that are confined to the prostate—stages T1 and T2 (A1, A2, B1 and B2)—there are two main choices: Surgery, the radical prostatectomy; and radiation therapy. Radiation also is used when the cancer has spread just outside the gland, to kill cancer cells and to shrink the prostate. High-energy X-ray beams are aimed at [...] [...more]
Posted: under Men's Health-Erectile Dysfunction.
Tags: Men’s Health
For tumors that are confined to the prostate—stages T1 and T2 (A1, A2, B1 and B2)—there are two main choices: Surgery, the radical prostatectomy; and radiation therapy. Radiation also is used when the cancer has spread just outside the gland, to kill cancer cells and to shrink the prostate. High-energy X-ray beams are aimed at the prostate and sometimes at nearby lymph nodes.
Table 4.1 Treatment Pros and Cons
Radical Prostatectomy
Radiation Therapy
Ideal candidate
Age
Younger than 70
Any age
Stage
T1b, T1c, T2 (and some men
TI, T2, T3, T4
with Tia disease)
Chief advantages
If cancer is confined to the
Less invasive
prostate, this is the best way
to cure
Chief disadvantages
Side effects:
May not cure localized cancer;
impotence 25-75%
Side effects:
incontinence 2-5%
rectal injury 1-2%
death 0.2%
impotence 40%
death 0.2%
.
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Mar 30
Recently, research published in the New England Journal of Medicine summarized a number of studies involving watchful waiting. In these studies, the article’s authors reported, the men treated with watchful waiting were carefully selected from a large group of patients because they were felt to have slow-growing cancers that were unlikely to spread. These patients [...] [...more]
Posted: under Men's Health-Erectile Dysfunction.
Tags: Men’s Health
Recently, research published in the New England Journal of Medicine summarized a number of studies involving watchful waiting. In these studies, the article’s authors reported, the men treated with watchful waiting were carefully selected from a large group of patients because they were felt to have slow-growing cancers that were unlikely to spread. These patients were not representative of the usual patient who walks into a doctor’s office—in other words, they were almost all “best-case scenarios.” Even so, ten years later, 40 percent of the men in these elite groups who had Gleason scores from 5 to 7 had developed metastases to bone, and by fifteen years, 70 percent had developed these metastases. (The survival time for patients with metastases to bone is about two to three years.) These observations drive home two points: One is that prostate cancer marches on; it continues to progress in most patients— even in those with the mildest-looking disease. And the other is that if a man with localized prostate cancer does not get effective treatment, and if he lives long enough, he will very likely die of prostate cancer.
Results of still another study show something different: In men with clinically localized prostate cancer, radical prostatectomy reduced the development of metastases and death from prostate cancer by 50 percent when compared with men who were followed with watchful waiting.
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Mar 30
A standard staging pelvic lymphadenectomy (dissection of the pelvic lymph nodes) generally is performed just before a radical prostatectomy. (This varies among doctors and hospitals; some doctors base this decision on the Gleason score.) If the lymph nodes are entirely free of cancer or—in some cases, almost entirely free—the surgeon proceeds with the operation to [...] [...more]
Posted: under Men's Health-Erectile Dysfunction.
Tags: Men’s Health
A standard staging pelvic lymphadenectomy (dissection of the pelvic lymph nodes) generally is performed just before a radical prostatectomy. (This varies among doctors and hospitals; some doctors base this decision on the Gleason score.) If the lymph nodes are entirely free of cancer or—in some cases, almost entirely free—the surgeon proceeds with the operation to remove the prostate.
We need to clarify here: When prostate cancer has spread to the lymph nodes, it cannot be cured. However, if the cancer fits certain conditions—if cancer in the lymph nodes is microscopic and the Gleason score is lower than 8—there is still a chance that surgery will help control the disease locally. This is important for younger men who can expect to live a long time. In this case, for men younger than 70, many surgeons will still perform a radical prostatectomy, because there is a good chance that these men may live for many years before the cancer reappears elsewhere. Also, surgery in these men reduces the risk of other cancer-related problems, such as urinary obstruction or bleeding, developing later.
If disease that was thought to be localized turns out to be widespread, however, the operation generally does not continue; it wouldn’t do any good. (Imagine what a blow this is to the patient; worse, even though he didn’t have the full operation, he still had an incision and his lymph nodes removed; he’ll have to be in the hospital for nearly a week, just to recover from this. This is why staging candidates carefully before surgery is so important—because it could help a man avoid such an ordeal.)
The laparoscopic pelvic lymphadenectomy has a reduced hospital stay (see above). But if the lymph nodes are negative, giving the green light to a radical retropubic or perineal prostatectomy, many men then go ahead and have that surgery.
The goal behind the “Minilap” is to provide the best of both worlds. It begins with an incision slightly larger than in the laparoscopic procedure. If there’s cancer in the lymph nodes, the incision is closed. But if the lymph nodes are cancer-free, this incision is lengthened and the radical retropubic prostatectomy is performed under the same anesthetic.
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