A wide variety of conditions may affect a person’s urologic system, which consists of the kidneys, ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymis, vas deferens, seminal vesicles, prostate and penis). These conditions include, but are not limited to cancers like prostate, bladder and kidney cancer, and benign conditions like ureteropelvic junction (UPJ) obstruction and vesicoureteral reflux.

When medication and other non-surgical treatments are either unavailable or cannot relieve symptoms, surgery is the accepted treatment for a broad range of conditions that affect the organs of the urinary tract and the male reproductive organs.

Depending on your condition and its stage, treatment options for urologic conditions may include:

Open Surgery

When medication and other non-surgical treatments are either unavailable or cannot relieve symptoms, surgery is the accepted treatment for a broad range of conditions that affect the organs of the urinary tract and the male reproductive organs.

Traditional open urologic surgery – in which large incisions are made to access the pelvic organs – has been the standard approach when surgery is warranted. Yet common drawbacks of this procedure include significant post-surgical pain, a lengthy recovery and — depending on the procedure performed — unpredictable and potentially long-term impact on continence and sexual function.

Open urologic surgery procedures include:

  • Radical prostatectomy
  • Partial nephrectomy
  • Radical nephrectomy
  • Cystectomy
  • Pyelopasty

Fortunately, less invasive surgical options are available to many patients facing urologic surgery. The most common of these is laparoscopy , or minimally invasive surgery, which uses small incisions. While laparoscopy can be very effective for many routine procedures, limitations of this technology often prevent its use in more complex urologic surgeries, including those performed to treat cancer.

A new category of surgery, introduced with the development of the da Vinci ® Surgical System, is being used by an increasing number of surgeons worldwide for prostatectomy and other urologic procedures. This minimally invasive approach, utilizing the latest in surgical and robotics technologies, is ideal for complex urologic surgery. This includes prostatectomy, in which the target site is not only tightly confined but also surrounded by delicate nerves affecting urinary control and sexual function. Using da Vinci , your surgeon has a better tool to spare surrounding nerves, which may enhance both your recovery experience and clinical outcomes.

1.AUA 2007 Guidelines page 4 (Of the 234,460 men in the United States diagnosed with prostate cancer annually, 91% have localized disease.)

2.AUA 2007 Guidelines page 14

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Minimally Invasive Surgery

Traditional open urologic surgery – in which large incisions are made to access the pelvic organs – has been the standard approach when surgery is warranted. Yet common drawbacks of this procedure include significant post-surgical pain, a lengthy recovery and an unpredictable, potentially long-term impact on continence and sexual function.

In the late 1990s, another evolutionary stage in the development of surgical technique was achieved with the application of robotics to surgical technology. At the forefront of this new era, Intuitive Surgical introduced the da Vinci® Surgical System. The da Vinci features wristed instruments with seven degrees of freedom, three-dimensional, intuitive visualization and ergonomic comfort. These innovations created the preconditions for minimally invasive solutions to complex procedures in a wide range of surgical specialties.

A new category of surgery, introduced with the development of the da Vinci® System, is being used by an increasing number of surgeons worldwide for prostatectomy and other urologic procedures. This minimally invasive approach, utilizing the latest in surgical and robotics technologies, is ideal for delicate urologic surgery. This includes prostatectomy, in which the target site is not only tightly confined but also surrounded by nerves affecting urinary control and sexual function. Using da Vinci , your surgeon has a better tool to spare surrounding nerves, which may enhance both your recovery experience and clinical outcomes

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Radiation therapy

Patients may have the option of using radiation to treat their prostate cancer. The two forms of radiation are external beam radiation and radioactive seed implants (also known as brachytherapy). When prostate cancer is localized, radiation therapy serves as an alternative to surgery.

External beam radiation therapy is also commonly used to treat men with regional disease, whose cancers have spread too widely in the pelvis to be removed surgically, but show no evidence of spreading to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain.

Radiation, despite continuing improvements in targeting doses, may damage healthy tissues. There is also a documented risk of long-term impotence, urinary incontinence and elevated rates of secondary cancers (such as bladder or rectal cancer) following radiation treatment for prostate cancer. Patients should discuss the potential for effective cancer control, as well as side effects of radiation treatments with their doctor.

External Beam Radiation Therapy

External beam radiation therapy generally involves treatments of 5 days a week for 6 or 7 weeks. In many cases, if the tumor is large, hormone therapy may be started at the time of radiation therapy and continued for several years. The primary target is the prostate gland itself. In addition, the seminal vesicles may be irradiated (since they are a relatively common site of cancer spread). Radiating the lymph nodes in the pelvis, once common practice, has not proven to produce any long-term benefits for most patients, but it may be necessary in certain circumstances.

Radioactive Seed Implants

Radiation can also be delivered to the prostate in the form of dozens of tiny radioactive seeds implanted directly into the prostate gland. This approach, known as interstitial implantation or brachytherapy, has the advantage of delivering a high dose of radiation to tissues in the immediate area.

As practiced today, internal radiation therapy relies on ultrasound or CT to guide the placement of thin-walled needles through the skin of the perineum. Seeds made of radioactive palladium or iodine are delivered through the needles into the prostate according to a customized pattern—using computer programs—to conform to the shape and size of each man’s prostate.

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Cryosurgery

Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. Guided by ultrasound, the doctor places needles in pre-selected 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 two hours, requires anesthesia (either general or spinal), and requires one or two 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. But compared with surgery or radiation therapy, doctors know far 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 cryosurgery among the options they routinely consider for initial treatment of prostate cancer.

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Watchful Waiting

Watchful waiting, or active surveillance, is based on the premise that some cases of localized prostate cancers may advance so slowly that they are unlikely to cause men ― especially older men with a short life expectancy ― any problems during their lifetimes. Some men who opt for watchful waiting have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately.

Watchful waiting has the obvious advantage of sparing a man with clinically localized cancer, who typically has no symptoms, the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control a disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don’t want the worry of living with an untreated cancer.

Patients should educate themselves on the risks vs. benefits of not initiating definitive treatments for prostate cancer, and discuss the option of watchful waiting with their doctor.

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Hormonal Therapy

Hormone therapy (androgen deprivation therapy) may be used in conjunction with other treatments or alone as a primary treatment. Hormone therapy may act to halt or slow the growth of prostate cancer, and it is often used in men with advanced disease. A variety of hormonal drugs can produce a medical castration by cutting off supplies of male hormones. Female hormones (estrogens) block the release and activity of testosterone. Antiandrogens block the activity of any androgens circulating in the blood. Still another type of hormone, taken as periodic injections, prevents the brain from signaling the testicles to produce androgens.

Hormone therapy has the potential to cause a number of side effects including impotence. Men should discuss the potential benefits and side effects of hormone therapy with their doctors.

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Treatment comparison

Surgery vs. Radiotherapy

The following table compares outcomes following prostate cancer treatment — specifically, surgery (radical prostatectomy), which is considered the gold standard treatment for localized prostate cancer — and radiation (brachytherapy and external beam radiation). Data is provided on survival, cancer recurrence, incidence of rectal and bladder cancer, bowel function, urinary issues and long-term erectile function.

In this table, radical prostatectomy includes all approaches to prostate surgery (open surgery through large incisions; conventional minimally invasive, or laparoscopic radical prostatectomy – also called LRP – as well as da Vinci Prostatectomy, or dVP). As you can see, surgery offers measurable advantages over radiation in terms of outcomes and surviability.

*Open surgery; comparable long-term data not yet available on da Vinci Prostatectomy.
**External Beam Radiation Therapy (EBRT) unless otherwise noted in the citation

da Vinci vs. Open Surgery & Laparoscopy

The following table looks at patient outcomes following surgery for prostate cancer (radical prostatectomy), and compares “best in class” data from three types of surgery. As you can see, da Vinci Prostatectomy (dVP) shows measurable advantages as compared to both conventional open surgery (open), performed through large incisions, as well as conventional minimally invasive laparoscopic (lap) surgery.

Key Comparative Studies

1. Long-term survival probability in men with clinically localized prostate cancer treated either conservatively or with definitive treatment (radiotherapy or radical prostatectomy)

Ashutosh Tewaria, Jay D. Ramana, Peter Changa, Sandhya Raoa, George Divineb and Mani Menon
Urology, Volume 68, Issue 6, December 2006, Pages 1268-1274

Outcome

Radical prostatectomy*

Radiotherapy**

survival duration compared to conservative disease management1

8,6 years

4,6 years

15 years prostate cancer survival rate2

92%

87%

survival rate for high grade cancer patients3

45% increase in overall survival rate vs. radiotherapy

risck of cancer specific death for high grade cancer patients4

 49% less risk vs. radiotherapy

cancer recurence5

easy to detect

difficult to detect

risk of rectal cancer (within 10 year follow-up)6

5,1 ‰

10‰

risk of bladder cancer7

0,8%

1,3% developed bladder cancer

bowel functon impairment8

significantly greater vs. surgery

disease specific long term quality of life9

stable

unstable

painful urination (at 18 month follow-up)10

1%

30%

long term erectile dysfunction11

lower risk

higher risk

Objectives:
To report the long-term survival probability in more than 3000 men with localized prostate cancer treated either conservatively or by definitive treatment (radiotherapy or radical prostatectomy).

Methods:
We studied 3159 men with biopsy-confirmed, clinically localized prostate cancer diagnosed from 1980 to 1997. We restricted our analysis to men 75 years of age or younger. The extent of comorbid disease was measured using the Charlson score. The Cox proportional hazards regression model was used to compare long-term survival in patients who were treated conservatively versus survival in patients treated with either radiotherapy or radical prostatectomy.

Results:
After adjusting for age, race, tumor grade, comorbid disease, income status, and year of diagnosis, the overall survival rate at 15 years was 35% for conservative management, 50% for radiotherapy, and 65% for radical prostatectomy. The corresponding prostate cancer-specific survival rates were 79%, 87%, and 92%. Patients undergoing radiotherapy or radical prostatectomy had lower overall mortality than patients undergoing conservative management (adjusted relative risk 0.67 for radiotherapy and 0.41 for prostatectomy; P <0.001). The increase in the survival duration was 4.6 years with radiotherapy and 8.6 years with radical prostatectomy.

Conclusions:
The results of this study have shown that compared with conservative management, both radiotherapy and radical prostatectomy increase survival for men with localized prostate cancer.

References for Chart 1:

  1. 1.Tewari A, Raman JD, Chang P, Rao S, Divine G, Menon M. Long-term survival probability in men with clinically localized prostate cancer treated either conservatively or with definitive treatment (radiotherapy or radical prostatectomy). Urology. 2006 Dec;68(6):1268-74.
  2. 2.Tewari A, Raman JD, Chang P, Rao S, Divine G, Menon M. Long-term survival probability in men with clinically localized prostate cancer treated either conservatively or with definitive treatment (radiotherapy or radical prostatectomy). Urology. 2006 Dec;68(6):1268-74.
  3. 3.Tewari A, Divine G, Chang P, Shemtov MM, Milowsky M, Nanus D, Menon M. Long-term survival in men with high grade prostate cancer: a comparison between conservative treatment, radiation therapy and radical prostatectomy–a propensity scoring approach. J Urol. 2007 Mar;177(3):911-5. Erratum in: J Urol. 2007 May;177(5):1958.
  4. 4.Tewari A, Divine G, Chang P, Shemtov MM, Milowsky M, Nanus D, Menon M. Long-term survival in men with high grade prostate cancer: a comparison between conservative treatment, radiation therapy and radical prostatectomy–a propensity scoring approach. J Urol. 2007 Mar;177(3):911-5. Erratum in: J Urol. 2007 May;177(5):1958.
  5. 5.Di Blasio, C. J., A. C. Rhee, et al. (2003). Predicting clinical end points: treatment nomograms in prostate cancer. Semin Oncol 30(5): 567-86.
  6. 6.Baxter NN, Tepper JE, Durham SB, Rothenberger DA, Virnig BA. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology. 2005 Apr;128(4):819-24.
  7. 7.Boorjian S, Cowan JE, Konety BR, DuChane J, Tewari A, Carroll PR, Kane CJ; Cancer of the Prostate Strategic Urologic Research Endeavor Investigators. Bladder cancer incidence and risk factors in men with prostate cancer: results from Cancer of the Prostate Strategic Urologic Research Endeavor. J Urol. 2007 Mar;177(3):883-7; discussion 887-8.
  8. 8.Litwin MS, Sadetsky N, Pasta DJ, Lubeck DP. Bowel function and bother after treatment for early stage prostate cancer: a longitudinal quality of life analysis from CaPSURE. J Urol. 2004 Aug;172(2):515-9.
  9. 9.Miller, D. C., M. G. Sanda, et al. (2005). Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy. J Clin Oncol 23(12): 2772-80.
  10. 10.Buron, C., B. Le Vu, et al. (2007). Brachytherapy versus prostatectomy in localized prostate cancer: Results of a French multicenter prospective medico-economic study. Int J Radiat Oncol Biol Phys 67(3): 812-22.
  11. 11.Di Blasio, C. J., A. C. Rhee, et al. (2003). Predicting clinical end points: treatment nomograms in prostate cancer. Semin Oncol 30(5): 567-86.

2. Long-Term Survival in Men With High Grade Prostate Cancer: A Comparison Between Conservative Treatment, Radiation Therapy and Radical Prostatectomy—A Propensity Scoring Approach

Ashutosh Tewarin, George Divine, Peter Chang, M. Mendel Shemtov, Matthew Milowsky, David Nanus and Mani Menon
The Journal of Urology, Volume 177, Issue 3, March 2007, Pages 911-915

Outcome

da Vinci

Open surgery

Laparoscopy

Cancer control
T2 margin status

2,51

5,92

7,73

Complications
estimated blood loss (ml)

1094

13555

3806

length of stay

1,24

35

2,513

major

1,7%4

6,7%5

3,7%6

minor

3,7%4

12,6%5

14,6%6

Urinary function
3 month

92,9%7

54%8

62%9

6 month

94,9%7

80%8

77%9

12 month

97,4%7

93%8

83%9

Sexual function
12 month

86%10

71%11

76%12

Purpose:

We performed a retrospective cohort study using propensity score analysis to calculate long-term survival in patients with prostate cancer with Gleason score 8 or greater who were treated with conservative therapy, radiation therapy and radical prostatectomy.

Materials and Methods:

Between January 1, 1980 and December 31, 1997, 3,159 patients in the Henry Ford Health System were diagnosed with clinically localized prostate cancer. Of these patients 453 had a Gleason score of 8 or greater in the biopsy specimen and they were the cohort. The end points were overall and prostate cancer specific survival. Propensity score analysis was used to more precisely compare the 3 treatments of observation, radiation and radical prostatectomy. Median patient followup was longer in the radical prostatectomy arm than in the conservative treatment and radiation therapy arms (68 months vs 52 and 54, respectively).

Results:

Of the 453 patients 197 (44%) were treated conservatively, 137 (30%) received radiation therapy and 119 (26%) underwent radical prostatectomy. Using propensity scoring analysis median overall survival for conservative therapy, radiation and radical prostatectomy was 5.2, 6.7 and 9.7 years, respectively. Median cancer specific survival was 7.8 years for conservative therapy and more than 14 years for radiation therapy and radical prostatectomy. The risk of cancer specific death following radical prostatectomy was 68% lower than for conservative treatment and 49% lower than for radiation therapy (p <0.001 and 0.053, respectively).

Conclusions:

Survival of men with high grade prostate cancer can be improved by radical prostatectomy or radiation therapy.

 

References for Chart 2:

  1. 1.Patel VR, Thaly R, Shah K.Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May;99(5):1109-12.
  2. 2.Scardino PT. Open Radical Retropubic Prostatectomy. Presented at the American Urological Association’s Carcinoma of the Prostate Course, San Francisco, California, Sept. 30 – Oct. 1 2005
  3. 3.Touijer K, Kuroiwa K, Saranchuk JW, Hassen WA, Trabulsi EJ, Reuter VE, Guillonneau B. Quality improvement in laparoscopic radical prostatectomy for pT2 prostate cancer: impact of video documentation review on positive surgical margin. J Urol. 2005 Mar;173(3):765-8. p. 766 (Results)
  4. 4.Bhandari, A., McIntire, L., Kaul, S.A., Hemal, A.K., Peabody, J.O., and Menon, M. (2005). Perioperative complications of robotic radical prostatectomy after the learning curve. J Urol 174, 915-918.
  5. 5.Brown, J.A., Garlitz, C., Gomella, L.G., McGinnis, D.E., Diamond, S.M., and Strup, S.E. (2004). Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy. Urologic oncology 22, 102-106.
  6. 6.Guillonneau, B., Rozet, F., Cathelineau, X., Lay, F., Barret, E., Doublet, J.D., Baumert, H., and Vallancien, G. (2002). Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. The Journal of urology 167, 51-56.
  7. 7.Locke, DR, Klimberg IW and Sessions RP. Robotic Radical Prostatectomy With Continence And Potency Sparing Technique: An Analysis Of The First 250 Cases. Submitted To Journal Of Urology, Publication Date TBD. p. 5 table 4.
  8. 8.Walsh PC. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. J Urol. 2000 Jul;164(1):242. p. 59 table 1.
  9. 9.Goeman, L., Salomon, L., La De Taille, A., Vordos, D., Hoznek, A., Yiou, R., and Abbou, C.C. (2006). Long-term functional and oncological results after retroperitoneal laparoscopic prostatectomy according to a prospective evaluation of 550 patients. World J Urol 24, 281-288.
  10. 10.Kaul, S., Bhandari, A., Hemal, A., Savera, A., Shrivastava, A., and Menon, M. (2005). Robotic radical prostatectomy with preservation of the prostatic fascia: a feasibility study. Urology 66, 1261-1265.
  11. 11.Parsons JK, Marschke P, Maples P, Walsh PC. Effect of methylprednisolone on return of sexual function after nerve-sparing radical retropubic prostatectomy. Urology. 2004 Nov;64(5):987-90.
  12. 12.Su, L.M., Link, R.E., Bhayani, S.B., Sullivan, W., and Pavlovich, C.P. (2004). Nerve-sparing laparoscopic radical prostatectomy: replicating the open surgical technique. Urology 64, 123
  13. 13.Dahl DM, L’esperance JO, Trainer AF, Jiang Z, Gallagher K, Litwin DE, Blute RD Jr. “Laparoscopic radical prostatectomy: initial 70 cases at a U.S. university medical center.”Urology. 2002 Nov;60(5):859-63.

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