This option consists merely of close observation of the cancer, looking for any signs of progression with blood tests, scans and physical examinations. Specific cancer treatment will be undertaken only when problems arise from the cancer growth. While this approach may seem out of the question in most cases, withholding treatment is appropriate and justifiable in certain circumstances. The treatments might be more risky than the disease. For instance, an older man with localised cancer, and with no symptoms, might be better left alone. In the absence of symptoms, and in the presence of other medical situations which are more threatening, observation is correct.

Increasingly no treatment has become a common approach to early prostate cancer. This is because in some patients the disease will grow so slowly that radical treatment is unnecessary. In older patients whose prostate cancers start to grow quickly, medical treatment may be instituted although this may not be curative. In contemporary urological practice there is now a very strong focus on avoiding over-treatment of harmless cancers to avoid complications of radical surgery or radiotherapy.

This is different to observation in that active treatment is deferred but regular PSA testing, MRI scans and repeat biopsies are required to determine whether it is still safe to defer treatment. In young fit patients there is a concern that even with a rigorous followup protocol, up to 25% of patients may have progression of their cancer by the time they have definitive treatment. However many patients may be happy to accept this option if they are concerned about the side effects of treatment. Because there are strict criteria for active surveillance, not all patients are suitable. In most surveillance programs the criteria include PSA less than 10, Gleason score less than 7 and only a small amount of cancer seen on the biopsies.

Chemotherapy is the use of medicines or drugs to stop the growth of cancers. Chemotherapy is used for the most part in patients whose disease has spread to other parts of the body (metastases) and is resistant to other forms of treatment. Chemotherapy is very unlikely to cure prostate cancer and is therefore not used for localised disease.

The prostate gland is uniquely male. Its very existence is due to the presence of male hormones, which the prostate, and most prostate cancers require to grow. This observation led urologists to use surgery or oestrogen like drugs to reduce the production of testosterone to treat prostate cancer. Currently the usual way of effecting hormone reduction is an intramuscular or subcutaneous injection. Oral medications may also be required. Because hormone therapy is not curative, we usually do not recommend this for localised cancer in patients with a reasonable life expectancy.

Surgical removal of the prostate is a commonly used treatment for localised prostate cancer. This is known as a radical prostatectomy. The entire prostate is removed together with the seminal vesicles and the bladder is reconnected to the urethra (water pipe). Broadly speaking the surgery can be done through a single incision called an open radical prostatectomy or by laparoscopic (key hole) surgery. Laparoscopic radical prostatectomy is a difficult operation but the use of a robotic system has made the procedure easier to perform.

Open Radical Prostatectomy

This is performed through a small incision in the lower abdomen. Removal of the pelvic lymph nodes is usually performed in addition to removal of the prostate. The hospital stay is about 3 days and a catheter is left draining urine for one week.

Robot-assisted Radical Prostatectomy

The same procedure is performed in this operation, the main difference being that a number of small incisions are used instead of one incision. Hospital stay is usually 2 days but the catheter does need to stay in for one week. In general key hole surgery has the advantage of reduced discomfort and earlier return to full activities. There is minimal difference in the discomfort compared to the open radical prostatectomy but full activities can be started 1-2 weeks earlier. With regard to the long-term outcomes including cancer control, urinary control, and erectile function, there is still some uncertainty whether laparoscopic surgery confers a major benefit.

The benefit of total surgical removal of the prostate is that if the cancer is localised to the prostate, as we would hope, then removal of the prostate will cure the cancer. If surgery cures the disease then other treatments such as radiotherapy, hormonal therapy and chemotherapy will not be required.

Possible side effects include:

Incontinence
Most patients will have excellent control within 3-6 months but a very minor degree of leakage not requiring protection can occur. Only 2-3% of men may have permanent troublesome problems with urinary control – they will require some form of protection (such as pads). If this occurs, surgical treatments are possible to correct the problem. These include the insertion of a tape to support the urethra (as used in female incontinence) or for more severe cases the insertion of an artificial urinary sphincter.

Impotence
The nerves that stimulate erections run adjacent to the prostate on their way to the penis. If both of these nerves are removed during total prostatectomy, impotence (inability to achieve an adequate erection) will result. However, in nearly all cases the nerves that create erections remain intact, but may cease functioning on a temporary or permanent basis depending on the extent of the tumour, technical issues and any pre-existent erectile dysfunction.

Because the seminal vesicles are removed there will be no semen production but orgasm can still be possible even if there is erectile dysfunction. Some patients report loss of penile length. On rare occasions some scarring of the penis may occur which can cause curvature of the erection.

If necessary, patients can be treated with a variety of modalities including medications such as Viagra, vacuum pumps, self injections of medications, and placement of prostheses – all of which work, and work well in selected patients.

Blood loss
Most patients undergoing radical prostatectomy will not require a blood transfusion.

Surgical complications
Pain, infection, anaesthetic problems, pneumonia, blood clots, and heart problems can occur with any major operation.

Unique to prostatectomy are injury to the rectum (adjacent to the prostate), and scarring of the new connection between the bladder and urethra, which might require dilatation at a later stage. Fortunately these types of complications are rare.

Recovery time

Hospitalisation is usually two to three days. All patients go home with a catheter in place, continually draining the urine into a special leg bag. You will be seen one week after surgery to have the catheter removed. Urinary control may be poor at the beginning and some form of protection, such as a pad might be required. Within 3-6 weeks, most men have achieved reasonably good control requiring minimal protection and have resumed their normal activities. Sometimes the recovery is slower taking up to 12 months.

It is recommended that pelvic floor physiotherapy is started prior to surgery so you know how to effectively contract the correct muscles. This will speed up recovery of continence.

a) External beam

External beam radiation therapy is by far the simplest of the radiotherapy options. Over a six to seven week period, the patient will receive a radiation treatment lasting about 15 minutes, five days a week. The radiation is aimed at the prostate from many different angles in an attempt to reduce the dosage to the surrounding tissues while maximising the dosage to the prostate and the cancer.

The advantage of external radiation therapy is its ease of administration. No surgery, no anaesthesia, no blood loss. The biggest disadvantage is that the cancer is left in place and one must hope that the amount of radiation delivered is enough to cure the cancer. In addition, surgical removal of the prostate although possible is not usually performed after radiotherapy because of the high incidence of complications.

During the last two to three weeks of treatment, diarrhoea and urinary urgency and frequency can occur. These symptoms usually resolve two to three weeks after the radiation treatments have ceased. Permanent radiation injury to the rectum may occur causing diarrhoea and or bleeding. The risk of radiation damage to the rectum can be reduced by injecting a gel to separate the rectum from the prostate (thus reducing the radiation dose to the rectum). There may also be radiation damage to the bladder causing a number of symptoms. Difficulty with erections (impotence) can also occur in some 50% of patients who were having no problems pre-treatment.

b) Seed Implantation

In this procedure radioactive seeds are implanted directly into the prostate. The radiation treatment is given from within over the next 6-9 months. There is a much reduced chance of affecting surrounding structures, especially the bowel. The normal procedure is for a planning study to be done to ensure that the prostate is small enough for implantation. Hormone therapy may need to be given to shrink the prostate down to the appropriate size. Once this is achieved, the seeds are ordered and implantation is performed as an overnight stay in hospital. Advantages are reduced side-effects, including bowel irritation and impotence. Patients do have to be selected very carefully as normally only very localised low-grade tumours are suitable and seed implantation in patients who have obstructive BPH (benign enlargement in addition to cancer) may result in troublesome long term urinary symptoms. Other problems include the technical difficulties implanting the seeds into exactly the right position, as once they are inserted the position can not be changed. Sometimes external radiation may be needed to treat the prostate if seed position is not acceptable.

c) High Dose (needle) Brachytherapy followed by External beam radiation:

The rationale for this approach is that side effects following external beam radiation usually only occur if more than five weeks of treatment is given. With this technique a high dose of radiation is delivered to the prostate via needles inserted through the perineum into the prostate. This involves several days in hospital. Two weeks later a five week course of external beam radiation is commenced. The advantage of high-dose brachytherapy is that a high dose of radiation can be delivered to the prostate with a reduced chance of harming the surrounding tissues, especially the rectum. We have been performing high dose brachytherapy at the Mater Hospital for over 10 years and have been very happy with our cancer control rate, even in patients with locally advanced aggressive tumours.

Side effects may include bowel or bladder irritation, but this is usually mild. Urethral scarring (known as a stricture) can occur after any form of radiation therapy. It can develop early or much later and at times can be very difficult to manage. Any form of surgery following pelvic radiation is made more complex.

Note that high dose brachytherapy may also be used in selected patients who have locally advanced prostate cancer without evidence of distant spread.