In the early 1990s, roughly 30 percent
of prostate cancer patients in the United States were treated
by surgery, 30 percent by radiation, and 20 percent by watchful
waiting. (Most of the rest were treated with a combination
of therapies). In Europe, by contrast, watchful waiting
constitutes the standard treatment for asymptomatic prostate
The popularity of surgery in this country
has grown tremendously in recent years. A study of Medicare
patients' records found that the number of men nationwide
receiving radical prostatectomy by 1990 was six times greater
than the number recorded for 1984, and the increase was
seen in all age groups, from the youngest (that is, age
65) to men in their eighties.
The growth of the popularity of surgery
has corresponded with the advent of minimally invasive surgical
options that reduce side effects and promote faster recovery
times. Two surgical options touched on in this section are
radical prostatectomy and cryosurgery.
An operation called radical prostatectomy
completely removes the prostate and nearby tissues. A radical
prostatectomy is further described in terms of the incisions
used by the surgeon to reach the gland. In a retropubic
prostatectomy, the prostate is reached through an incision
in the lower abdomen; in a perineal prostatectomy, the approach
is through the perineum, the space between the scrotum and
In radical prostatectomy, the surgeon
excises the entire prostate gland, along with both seminal
vesicles, both ampullae (the enlarged lower sections of
the vas deferens), and other surrounding tissues. The section
of urethra that runs through the prostate is cut away (and
with it some of the sphincter muscle that controls the flow
of urine). Pelvic lymph node dissection is done routinely
as part of a retropubic prostatectomy; with a perineal prostatectomy,
lymph node dissection requires a separate incision.
Cryosurgery uses liquid nitrogen to freeze and kill prostate
cancer cells. Guided by TRUS, the doctor places needles
in preselected 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 2 hours, requires anesthesia
(either general or spinal), and requires 1 or 2 days in
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.
A suprapubic catheter is placed through a skin incision
on the abdomen into the bladder so that if the prostate
swells after the procedure (which usually occurs), it won't
block the passage of urine. The catheter is removed 1 to
2 weeks later.
After the procedure, there will be some bruising and soreness
of the area where the probe was inserted. You will likely
stay in the hospital for 1 or 2 days. Cryosurgery is less
invasive than radical prostatectomy, so there is less blood
loss, a shorter hospital stay, shorter recovery period,
and less pain than radical surgery. But compared with surgery
or radiation therapy, doctors know much 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 cryotherapy among the options they
routinely consider for initial treatment of prostate cancer.