Surgical Therapy

Those patients who, to treat the prostate tumor, must undergo a surgical operation must satisfy the following conditions:

* Good state of health
* Tumor confined to the prostate gland (T1 or T2 stage)
* No older than 70 years
* At least a ten year life expectancy

Depending on the state of diffusion of the prostate tumor, there are various surgical options.

Radical prostatectomy
Radical prostatectomy can be carried out retropubically, a more diffuse operation, through an incision in the lower stomach or in a laparascopic manner, which is carried out with instruments introduced through small incisions, or by means of an apparatus consisting of an optical system (laparoscope) which is inserted through an incision and is used to guide the procedure. The radical laparoscopic prostatectomy causes less loss of blood and less pain, necessitates a shorter post-operation hospital stay and guarantees a quicker recovery. This procedures is not available everywhere and not all patients can be subjected to this type of operation.
With both techniques, the prostate is removed, along with the seminal vesicles, and the pelvic lymph glands are removed. The prostate tumor spreads especially to the lymph glands of the pelvis.
In selective cases some surgeons perform the prostatectomy by way of the perineum, by means of an incision in the perineum (the space between the scrotum and the anus) which, however, does not allow the laparatectomy to be performed.
Normally patients remain in hospital for 3 to 7 days after the operation, and are catheterized for 2 to 3 weeks.
The percentage of survival 10 years after a radical prostatectomy varies from 75 to 97% for patients with well-differentiated tumors (cells little different from the normal ones) and moderately differentiated (containing cells with greater alterations compared to the normal ones) and 60 to 86% for patients with tumors that a little differentiated (that contain cells very different from the normal ones).

Robotized Laparoscopic Radical Prostatectomy
In some cases, in order to perform the radical laparoscopic prostatectomy, there is used an automated surgical system. In this procedure, an automatic chirurg
ic system (Da Vinci® chirurgical system) is used for the operation. This system is very costly and still not widespread. It also needs a long learning curve.
Complications
After the operation there is urinary incontinence, which disappears in most cases and can be cured. During the operation, a technique is used that makes it possible to avoid removing or dissecting the nerves that control erections, and therefore preserve sexual potency in 40 to 65 % of cases, which is also conditioned by the age and local extension of the tumor, when a histological examination shows a greater local extension of the tumor.
If the tumor is limited to the prostate gland, without involving the lymph glands, the illness is usually curable. A certain number of patients with a locally diffused tumor do survive 5 years. If the tumor is diffused to the distant internal organs, the life expectancy is usually less than 3 years.

Ultrasonic sounds focused at high intensity (HIFU)
The technique of ultrasonic sounds focused at high intensity is presently in a clinical trial phase in the United States. HIFU is a non-invasive treatment that uses ultrasonic waves focused to heat and destroy (remove) the prostate tissue without damaging the surrounding healthy tissue. It is indicated in the treatment of localized tumors of the prostate and also for benign prostate hyperplasia (BPH). The Food and Drug Administration (FDA) has not yet approved this treatment in the United States.
In clinical trials, HIFU was performed under anesthesia. It can be repeated when necessary and each treatment lasts from 1 to 3 hours. Following the treatment, it is necessary to apply, for about a week, a catheter. Most patients can resume normal activity in a few days. 1 to 7 % of the cases treated have shown impotence.

Cryosurgery
This “cryoablation” procedure, which is less invasive than other treatments, is reserved for a few selective cases in locally controlling the prostate tumor. It quickly destroys the cells of the tumor, freezing and dissolving the tumorous tissue.
It is suggested for patients who:
* cannot be subjected to surgery or X-ray therapy.
* have a tumor of the prostate at the T3 stage or lower
* do not react to X-ray therapy (of both types: brachitherapy and external radiation)
* are of advanced age.
Freezing-defreezing is repeated twice and then the instruments are removed. The operation lasts 2 hours.
Usually patients can leave the hospital the same day or the day after the operation. A catheter is positioned above the pubis to drain the urine, and is removed after 3 weeks.
To the patient lying on his back, the surgeon inserts a heating catheter in the urethra to protect it from the low temperature.