THE STAGING GUIDE VIDEO SERIES | TRANSCRIPTION:

Hi, I’m Dr. Scholz.  Let’s talk about prostate cancer.

This video is about radical prostatectomy for Basic-Teal prostate cancer, that is intermediate risk prostate cancer.  There are a number of options on how to treat Basic-Teal prostate cancer including seed implants, SBRT, proton therapy, cryotherapy—all kinds of things, but in this video we’ll just cover surgery. Surgery—the old stand by—radical prostatectomy is the oldest and most established type of therapy for the treatment of prostate cancer.  In general, I would say that it compares pretty poorly with the other options that are available. Everyone is always surprised because surgery has been called the gold standard in the past. It turns out that technology in the forms of different types of radiation has advanced so much whereas surgery stayed about the same [so] that men who choose some of the other options are more likely to be cured and less likely to have problems with long-term side-effects.  

So what are the disadvantages of surgery?  Well it’s an operation for one, and you have to undergo anesthesia.  More and more there are concerns these days about long-term memory problems with anesthesia and with the other options—the radiation options—you can avoid that risk altogether.  Major issues in the treatment of Basic-Teal are preservation of urinary and sexual functions, and on both those fronts surgery scores poorly compared to the other options.  The risk of erectile dysfunction is much higher; in fact after surgery everyone is impotent and a minority or a percentage of men slowly recover over the next year or so.  Unfortunately it's very rare for men to recover to their original baseline. Only about 5-10% of men describe their erections as being like before when they’ve had a radical prostatectomy.  The other major problem of course if leaking urine which is pretty uncommon—almost non-existent—with radiation options. But men who have surgery, they all become incontinent after surgery.  They require catheters and pads for several months. The majority will recover fairly good control, but maybe 5-10-15% (depending on your age) are going to be left with long-term incontinence after surgery.  Another problem of course is what’s called stress incontinence. So even though people are dry most of the time, if they laugh, jump, cough they have squirts of urine, this is called stress incontinence. Lastly, sexual activity, when men have orgasms about 20% of men have ejaculation of urine.  

So there are a lot of things that aren’t talked about with surgery that people put up with in the past because they thought anything was necessary to save their lives, but now we realize that men who have these very curable types of prostate cancer, the Basic-Teal category are generally going to be served better by one of the radiation options.  

So do I have anything good at all to say about surgery?  There are a few small advantages to surgery and I think that the profile of an individual who might benefit from surgery is a Basic-Teal patient who has a very large prostate and a lot of serious pre-existing urinary blockage symptoms from the large prostate.  Not all large prostates block, but when you give radiation to very large prostates you’re going to increase the side-effects of the radiation, whereas if men undergo surgery and have a lot of blockage symptoms, it’s quite possible those blockage symptoms will improve a lot.  So the subgroup of people that might be a good candidate for surgery would be men with really big prostates and a lot of serious urinary blockage problems that could be corrected by the surgery and have their cancer cured at the same time. Another small advantage for surgery is more accurate staging.  Staging has become so accurate now with multi-parametric MRIs that this is not the problem that it used to be, but when the gland is removed surgically, and a pathologist fine slices the whole prostate and looks at it in great detail, you get a little bit more information and precision with the prediction of the Gleason score and whatnot.  I don’t think that’s a big enough upside to consider all the other detrimental effects of surgery, but it is a small advantage of doing surgery.

As we go through and talk about the different treatment options for Teal, surgery in my opinion should only be considered for the men who are in the subgroup Basic-Teal.  High-Teal patients should have a combination of seed implants, IMRT, and hormones; Low-Teal patients should considered active surveillance.  So we are talking about select, single substage of prostate cancer that I would consider a potential candidate for surgery.  Let me address one common myth that I hear over and over that was actually true ten years ago or fifteen years ago when radiation therapy was in its infancy, and the side-effects were worse and the cure rates were unacceptable. In fact in the 1990s, in my practice which was full time prostate cancer, we never referred people for radiation because radiation technology was very poor honestly.  But one myth that continues to this day which is no longer true is the “sequence argument,” as I call it, that men who have surgery first can have a follow-up chance at a cure by having radiation afterwards if the cancer comes back; whereas if you have radiation first you can’t do surgery after the radiation if the cancer came back. That was a problem when cancers were coming back frequently after radiation in the past because radiation wasn’t very good.  These days the cure rates with radiation for the most part are as good or better than surgery. So the likelihood of the cancer coming back especially at Basic-Teal is very small, probably 5%.  So to structure a whole treatment plan over a 5% possibility doesn’t make a lot of sense.  But people also should realize that if the cancer were to come back in the prostate after radiation there are a number of options that you can consider that can be a substitute for a radiation failure such as HIFU, electroporation, and cryotherapy. Surgery shouldn’t be considered because it would have a lot of side-effects.

So in summary, when talking about all the many options for Basic-Teal, ( we have a short video that just addresses comparing these options which you should also look at) surgery at my view comes out at the bottom of the list—more side-effects, and cure rates which are no better, plus you need to have an operation with all the attendant risks.  Men that are in this situation with Basic-Teal should carefully look at all the pros and cons of each of the options before jumping into any specific treatment as these treatments, once they’re done, are irreversible.  As with every other treatment, if you do decide to have surgery, it’s very important to be selective in the kind of surgeon that you use. Surgery and all the other treatment options as well are skilled procedures, that means that the doctor has to have a special talent and a lot of practice.  So don’t just go to any doctor to do these types of procedures or operations; do a lot of research about which doctor is best.

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