ProstRcision vs. Radical Prostectomy:

The Radiotherapy Clinics of Georgia team has laid out a comparison of both treatment options in this section. See how the two approaches differ in:

* Long-term cure rates
* Side effects such as sexual function and urinary leakage
* Recovery

It’s a lot of information to take in at once. Download our brochure for future reference.

Question 95:
Compare ProstRcision with radical prostatectomy, whether open, laparoscopic or robotic. (See Figure 18.)

Answer:
The goal of ProstRcision and radical prostatectomy is the same: destroy all prostate cancer cells and normal prostate cells. The PSA goal of ProstRcision and radical prostatectomy is also the same: achieve PSA 0.2 ng/ml or less after treatment and remain at PSA 0.2 ng/ml forever with cure rates measured 10 years following treatment. However, there is considerable difference in how ProstRcision and radical prostatectomy work to achieve these goals. With radical prostatectomy, the entire prostate gland is surgically removed with critical dissection at the apex, while striving to leave the muscles that control urination and preserve sex nerves. In contrast, ProstRcision destroys all prostate cancer and normal prostate cells without removing the urethra or damaging muscles that control urination. Additionally, the sex nerves often remain intact. A wider area around the prostate is treated with ProstRcision than with radical prostatectomy. Consequently, there is a difference in results, especially with regard to three issues: microscopic capsule penetration (particularly at the apex), urinary leakage and the rate of PSA fall after treatment. See Figure 18.

Question 96:
How does ProstRcision differ from radical prostatectomy when treating microscopic capsule penetration?

Answer:
As stated earlier, a cause for failure of cure after radical prostatectomy is because cancer cells are left behind in the area of the prostate, which is due to microscopic capsule penetration especially if the surgical margins are positive, which indicates the cancer was cut across.43 See Figure 18 where the dotted line shows the cut line of surgery with cancer cells left behind at the apex and one side of the prostate. This is called positive surgical margin. In contrast, with ProstRcision, microscopic capsule penetration and positive surgical margins are a non-issue. The follow-up IMRT beam radiation of ProstRcision destroys microscopic capsule penetration cancer cells.

Question 97:
Since the apex (bottom) of the prostate is the most common location for microscopic capsule penetration, is this location a problem for ProstRcision as with radical prostatectomy? (See Question 88.)

Answer:
No. Although dissection of the apex is the most critical part of surgical removal of the prostate and where prostate cancer is located 67% of the time, the apex is the easiest area to treat with ProstRcision. Seeds can be placed at and below the apex. The beam irradiation can reach even further below the apex, including the sphincter muscle. In fact, the apex is the area that can be irradiated with the widest margin. Thus, cancer at the apex is the worst location for radical prostatectomy but is the best location for ProstRcision.

 Question 98:
How would you compare cure rates between ProstRcision and radical prostatectomy? (See Table 7.)

Answer:
Radical prostatectomy is an excellent way to treat men with early stage prostate cancer. Most men with early stage prostate cancer do not have microscopic capsule penetration, and men with very small amounts of cancer cell leakage can still be cured with surgery. Therefore, the cure rates with radical prostatectomy are high (76–80%, refer to Table 1). However, a substantial number of men who have radical prostatectomy have significant microscopic capsule penetration to the point that 11–27% (depending on how well patients are selected for surgery) will have microscopic capsule penetration cancer cut across, leaving positive surgical margins.33,39,17,44 Unfortunately, a patient cannot know whether he has microscopic capsule penetration or positive surgical margin until three to four days after surgery when the pathologist examines the specimen. Since with ProstRcision, microscopic capsule penetration is not an issue, the overall cure rates should be better than with surgery. The overall 10-year cure rate for ProstRcision is 83% for men with early, intermediate and advanced cancer. Radical prostatectomy is typically performed only on men with early to intermediate prostate cancer. In contrast, with ProstRcision, we treat not only men with early and intermediate cancer, but also men who have advanced cancer who could not be cured with radical prostatectomy. For a more accurate comparison, cure rates after ProstRcision were calculated for men with early and intermediate cancer only. Table 7 compares the cure rate of ProstRcision with radical prostatectomy for men with early and intermediate cancer.

Question 99:
Robotic radical prostatectomies have been performed for less than 10 years. How can a doctor calculate a 10-year ICR for robotic surgery?

Answer:
There is no difference in cure rate between an open radical prostatectomy and robotic radical prostatectomy. Since the cure rate is the same urologists can calculate a 10-year ICR based on all the radical prostatectomies they have performed.

Question 100:
Is there a difference in urinary leakage between ProstRcision and radical prostatectomy?

Answer:
Yes. Since the most critical part of a radical prostatectomy is removing the apex of the prostate where microscopic capsule penetration is most common, and one of the large muscles that control urination is located there, this muscle could be cut out at surgery. This is the primary cause for 8–17% of men experiencing leakage after radical prostatectomy, including the robotic or da Vinci technique.34,35,36,37 With ProstRcision, there is no urinary leakage because the muscle at the apex of the prostate is not removed. The only exception to this observation is if men, prior to ProstRcision have had a TURP (roto-rooter operation) where the other large muscle (the bladder neck muscle) has been removed, or in men who have severe urinary urgency such that they leak urine before they get to the toilet.

Question 101:
Is there a difference in preserving sexual function between radical prostatectomy, including the robotic technique and ProstRcision?

Answer:
Although difficult to compare, there appears to be approximately the same degree of preservation of sexual function between ProstRcision and radical prostatectomy, when surgery is performed by highly-skilled urologists. However, a study from Duke University showed that 24% of men who had a robotic radical prostatectomy regretted their decision to have this surgery.45 The reason for their regret was that men were told sexual function would be preserved, but this did not happen. Instead, many men lost sexual function after robotic prostatectomy.

Question 102:
I have been told that if you are not cured with radical prostatectomy, you can be treated with irradiation; but if you are not cured by irradiation, you cannot have a radical prostatectomy. Is this true?

Answer:
No. Men can receive beam irradiation after radical prostatectomy, which helps some men who are not cured with surgery.46 However, you can also have a radical prostatectomy after irradiation, which can also help some men not cured by irradiation.47 Either way, a man gets two treatments instead of one; however, the chance of complications is increased, whether you are treated with salvage irradiation or salvage prostatectomy. It is best to make a well-informed, practical decision regarding your treatment method and doctor BEFORE any treatment, rather than counting on salvage treatment where you risk still not being cured and increased chances for urinary, sexual and rectal complications.

Question 103:
An undetectable PSA (0.2 ng /ml) is the goal after both ProstRcision and radical prostatectomy. Is there a difference in how fast the PSA falls after each of these treatments? (See Figure 19.)

Answer:
Yes. Since all normal prostate cells and, hopefully, all cancer cells are suddenly removed with radical prostatectomy, a man’s PSA should fall to 0.2 ng/ml within six weeks of surgery.1 In contrast, after ProstRcision, the average time to achieve an undetectable PSA is 27 months. The hallmark of cancer is growth — cancer cells reproducing and making more cancer cells. Irradiation primarily kills cancer by preventing cancer cells from reproducing. Thus, cancer cells may live for a period of time and make PSA. However, these cells will not be able to reproduce and will eventually die. This is measured by the slower time for PSA to achieve PSA 0.2 ng/ml after ProstRcision.

Question 104:
If you see a man with early prostate cancer in consultation at Radiotherapy Clinics of Georgia, do you recommend ProstRcision over radical prostatectomy?

Answer:
No. We recommend he conduct research and make a personal decision about treatment. After all, this is a decision he will live with for the rest of his life. This brochure is designed specifically to inform men of a decision-making process. If a man is less than 70 years old and has early prostate cancer, we recommend he focus on cure (along with urinary leakage and loss of sexual function), instead of focusing on treatment. He should ask his urologist for a graph of his 10-year ICR with robotic radical prostatectomy, or any radical prostatectomy, and compare that with the 10-year Individual Cure Rate with ProstRcision that we give him. If a man is older than 70 or has advanced prostate cancer, we do the same, but recommend that he consider ProstRcision because it is easier to undergo for older men. Additionally, men with advanced prostate cancer will have a much better chance for cure with ProstRcision than surgery. For the few men who cannot have anesthesia for medical reasons for ProstRcision or radical prostatectomy, we recommend IMRT beam radiation.