Many patients are undergoing non-surgical therapies of their prostate cancer with curative intent.
These include seeds, external beam radiation, and cryosurgery. What are their alternatives if they fail therapy?
The first thing to assess after failure is the type of failure. Is it metastatic (spread away from the prostate), locally advanced (spread away from the prostate in an area that can not be removed), or localized (contained to the prostate or seminal vesicles)?
All of the patients history needs to be assessed including:
PSA BEFORE radiation
Timing of PSA failure
Any hormonal therapy- will drastically lower the PSA, but not curative
Current PSA and exam- A PSA after treatment is much different than a similar PSA before therapy.
Bone Scans and CT Scans
Possibly endorectal MRI and Prostascint scan
The main issues with prostate removal after radiation are that the surgical planes are a little glued together. This may lead to an increased risk of injuring the rectum, which will likely need a temporary colostomy if injured- this risk is about 5% vs 1% with no radiation (and likely no colostomy).
The other main problem is a 30% chance of significant urinary incontinence that doesn’t get better. This is due to the effect of radiation on the urinary muscles.
I believe that the robotic approach visualizes the rectum better and limits the rick of injury.
The urinary muscles may be less effected than open surgery, but a higher incontinence rate must be expected.
For cryosurgery these risks should not be as high since the rectal plane should be less effected and the muscles for urination should be less effected by cryo than radiation.
The main options that need to be discussed for the treatment of radiation failures is cryosurgery, which probably has less side effects, but is probably not as curative.
Radiation sometimes leads to severe urinary incontinence and a small bladder. In this case the bladder and prostate are both removed and a urinary diversion is performed. I had one patient where this happened after cryosurgery and radiation 10 and 8 years prior. I performed open surgery which went well, although the cancer was much more aggressive at this point than originally and was locally advanced at the time of surgery.