Chief, Section of Urology and Director, Minimally Invasive
& Robotic Surgery
Morristown Medical Center
Thorough training, volume of experience, commitment to understanding and treating prostate cancer, and the care to facilitate a good outcome at every step along the way are essential assets your physician must employ in order to see you through this process happily. Dr. Kaynan has these assets, and he’s used them to help many achieve the “trifecta” of prostate cancer care: cancer cure, preservation of urinary control, and preservation of erectile function. His commitment to urologic cancer care, breadth of exposure to maximally and minimally invasive techniques, and level of integrity makes for a unique package. Remember, you are not just choosing a treatment method, you are choosing a doctor. The assets count!
- Surgery
- Radiation Therapy
- Active Surveillance
- Hormone Therapy
- Chemotherapy
- Immunotherapy
- Cryosurgery
- High Intensity Focused Ultrasound (not FDA approved)
Patients who are in good health and could otherwise expect to live ten years or longer are the typical candidates for surgery. There are several types of surgery: open radical retropubic prostatectomy, perineal radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted laparoscopic radical prostatectomy. All may be done with nerve-sparing for purposes of preservation of potency. Robotic surgery has emerged as the preferred standard of care for prostate cancer. It is minimally invasive, the best approach to cancer control, poses the least risk for blood loss or major complication, and provides for the most rapid return of urinary control and sexual function.
Of course, you are not just choosing a procedure type, you are choosing a surgeon. Few surgeons world-wide are fully versed in open, laparoscopic and robotic methods of prostate surgery. Robotics is a form of laparoscopic surgery, and prior laparoscopic experience occasionally makes the necessary difference to handle difficult anatomy – it’s the difference between completing the operation video-telescopically or converting to open surgery (however rare), and the ability to complete the operation well regardless of which method is ultimately employed. Many patients have benefited from Dr. Kaynan’s unique experience with all three methods.
Open Radical Retropubic Prostatectomy:
This is the traditional approach to prostate cancer surgery, and the method most commonly employed until recently. Dr. Kaynan has performed and assisted on several hundred of these surgeries. Compared with the other methods of surgery, this has the largest average blood loss, longer hospital stays, longer catheter time, longest time to return to usual activities (such as driving), longest time to return of urinary control, and longest time to return of sexual function. Pelvic lymph nodes may be biopsied as necessary with this method. Nerve sparing for preservation of potency may also be performed. Currently, the main reason to have a planned open radical prostate surgery is that your operating urologist does not perform robotic surgery. Virtually every prostate cancer patient who is a candidate for surgery is a candidate for robotic prostatectomy.
Perineal Radical Prostatectomy:
In this operation an incision is made in the perineum (between the scrotum and the anus) and it is truly the least invasive of all the surgical options. However, there are multiple drawbacks to this operation: there is no access to the pelvic lymph nodes which are often biopsied in all the other operations; nerve sparing for preservation of potency is not as delicate and access to these nerve bundles is comparatively limited; and the rectal muscles are often stretched which may lead to difficulties with defecation. Very few urologists are trained in this method, and even fewer offer it to their patients. The best candidates for this operation are patients with low-risk disease (who don’t absolutely need lymph node biopsies), who have had extensive prior abdomino-pelvic surgery including placement of mesh material in the pelvis, and have preoperative pronounced erectile dysfunction.
Laparoscopic Radical Prostatectomy:
This is a video-telescopic method of performing radical prostate surgery. It is a non-robotic method. Dr. Kaynan is among the few urologists world-wide who have performed this operation (less than 1% of the world’s urologists have the skill set to complete this technically difficult operation laparoscopically). Compared to open surgery, the benefits include: several tiny incisions instead of one large one; less blood loss; less pain; less risk of infection; shorter hospital stay; shorter catheter time; shorter time to return to usual activities (such as driving); shorter time to return of urinary control; and shorter time to return of sexual function. Pelvic lymph nodes may be biopsied as necessary with this technique. Nerve sparing for preservation of sexual potency may also be performed. This method has served as a model for the performance of robotic surgery, which is currently the method of choice.
Robotic-Assisted Laparoscopic Radical Prostatectomy:
Also known as daVinci Prostatectomy or Robotic Prostatectomy. Dr. Kaynan has observed, assisted, performed and taught hundreds of these operations. This method, considered minimally invasive, incorporates a state-of-the-art computerized surgical system that facilitates the performance of laparoscopic surgery. It provides a magnified and brighter image than standard laparoscopic telescopes, and unlike the 2-dimensional image seen with standard laparoscopy, the daVinci system is stereoscopic (3-dimensional). The instruments have Endowrist technology which provide for multiple degrees of freedom of motion, much like a normal wrist and elbow, but with greater range of motion than what the human hand is capable of. The robot has a motion-scaling feature which eliminates hand tremor entirely and gives the operating surgeon greater finesse than what is natural. The standard use of gas under pressure to create the working space in the abdomen has made this procedure virtually bloodless. These features have collectively made it much easier to perform radical prostate surgery laparoscopically. As a result, we have realized the best outcomes all around, and robotic prostatectomy is now standard of care for the treatment of prostate cancer:
- Reduced margin positive rates (ie, better chances for cancer cure)
- The worst complications (including death, heart attack, stroke, and blood clots) have been reduced in frequency to virtually case reports
- Least blood loss (typically less than 150cc) – blood transfusions are now extremely rare
- Shortest hospital stay (95% of patients are discharged after only one night in the hospital)
- Least pain
- Least chance of infection
- Shortest catheter time (1 week instead of 2)
- Least chance of internal scars impeding the flow of urine (less than 5% instead of 10%)
- Fastest return to activities of daily living (driving a car in 1 week instead of 4-6)
- Fastest return of urinary control (median 3 months instead of 6)
- Fastest return of erectile function (median 6 months instead of 1 year)
Radiation therapy is generally reserved for patients who can expect to live more than five years, but carry diagnoses or illnesses that preclude them from the rigors of surgery. Its ability to cure prostate cancer for patients with low-risk disease (ie, PSA level less than 10, non-palpable disease, Gleason’s score of 6 or less) is about the same as radical surgical removal. There is little immediate risk to overall health and function, however there are small risks which are cumulative over time (long after radiation therapy is finished). Potential side effects include: urinary urgency, urinary frequency, pain or burning with urination, urinary incontinence, urinary retention, urinary bleeding, rectal bleeding, diarrhea, urethral stricture, impotency and lethargy. Very few patients have a severe or life-threatening side-effect in the short run, and almost all of these side-effects subside. In the long-run, about half of patients who receive radiation therapy for prostate cancer become impotent. Very few suffer from urinary incontinence (leakage) in the long-run, though the type of incontinence these patients get are typically difficult to correct. Some patients develop severe bleeding from the bladder, prostate or rectum many years after radiation therapy, and this may prove very difficult to control.
On the whole, radiation is a safe and standard method of treatment for prostate cancer. There are two main types of radiation treatment: external type, whereby radiation is delivered outside in; and internal type (brachytherapy), whereby radiation is delivered inside out. Three dimensional conformal radiation therapy (3DCT), image-guided radiation therapy (IGRT), intensity modulated radiation therapy (IMRT), Cyberknife, proton beam, volumetric modulated (VMAT / Rapid Arc), and Tomotherapy are examples of external radiation. Seeds, and high dose rate radiation therapy (HDR or rods) are examples of internal type radiation therapy. The goal of all these treatments is to maximize the dose of radiation aimed at the prostate cancer cells, and minimize the amount of radiation delivered to the organs around the prostate.
The internal types of radiation require placement under general anesthesia. Seeds are delivered as a one-time event on an outpatient basis (no admission to the hospital). Rods require placement in the operating room, which are then used as portals for the delivery of high dose seeds three times over the course of 36 hours. The rods are then removed just prior to your discharge from the hospital.
The external types of radiation require frequent short visits to the radiation oncology center but don’t require anesthesia. At Garden State Urology, we have a state-of-the-art Tomotherapy unit, and a radiation oncology team dedicated to the treatment of prostate cancer only. Radiation oncologists and physicists help to calculate the proper dose regimen appropriate for you.
Also known as “observation” or “watchful waiting”. Prostate cancer is typically a very slow-growing form of malignancy. On average, it takes over 2 years for prostate cancer volumes to double in size. For those who die from prostate cancer, the median time to death is 12 years from the time of diagnosis, and few die from prostate cancer within five years. For patients who have no symptoms from prostate cancer, carry other potentially life-threatening disease(s) and are expected to live less than five years, active surveillance is clearly recommended. Patients with minimal volume, low-grade disease are also good candidates for active surveillance.
You must first get a sense of your risk of death from prostate cancer, as well as competing risks for death, if simply observed to the end. This has been mapped out by large epidemiological studies.
There is a dichotomy in prostate cancer in that while 1 in 7 men in the United States will be diagnosed with this disease in their lifetime, only 2.7% of all male deaths are from prostate cancer. It is often a disease that patients die with but not from. To address this dichotomy, some patients elect to undergo active surveillance, rather than immediate definitive treatment for cure, with the notion that such definitive treatment may be deferred until acceleration of disease is apparent. In this scheme, patients would undergo periodic digital rectal examination, PSA checks, and occasionally a repeat biopsy. An increase in nodularity of the prostate, PSA level, or worsening biopsy characteristics would then trigger definitive treatment for cure. Data is evolving to demonstrate the safety of such an active surveillance program. The potential benefit is that a clinically insignificant prostate cancer would not be over treated, and patients could avoid the risks of these treatments entirely. The potential downside of this plan, however, is that the window of opportunity for cure is lost over time.
Also known as androgen deprivation therapy (ADT). Prostate cancer thrives on testosterone. The use of agents that block the production or effectiveness of testosterone kills off prostate cancer cells. This effect is only temporary, however, maybe months or years. Prostate cancer cells which grow independent of testosterone will eventually flourish in time. Therefore, androgen deprivation therapy is not used as a definitive treatment modality, but rather as a temporizing measure when other primary treatments have failed. It is also used, often, to improve the effectiveness of various radiation treatments: it shrinks very large prostate glands which narrows the radiation zone, and it assists in the kill effect radiation has on prostate cancer cells. Its most common use is in long-term management of patients with disseminated disease.
Typical side effects include lethargy, weakness, breast enlargement, decreased libido, impotency or hot flashes. Most men have at least one side effect but tolerate it.
Some urologists give ADT to “stabilize” prostate cancer, or reduce the size of a very large gland, when it is clear that the patient is going to seek a second opinion. Dr. Kaynan generally recommends against ADT as a preoperative measure because the reaction around the prostate gland may frustrate some of the technical aspects of surgical removal.
This is generally reserved for patients with very high risk prostate cancer, failed hormone therapy (or other treatments), or patients demonstrating evidence of spread of disease outside the prostate. Chemotherapy typically kills prostate cancer cells during their division. Taxotere is an example, often used in prostate cancer. These agents are theoretically attractive because they disseminate with the blood stream everywhere in the body (so called systemic treatment). They have been demonstrated to provide a small but significant survival advantage for prostate cancer patients compared to similar patients who did not receive such treatment. However, they have significant side effects, some of which may be dangerous. These agents are, therefore, used in the more desperate circumstances. Dr. Kaynan works closely with medical oncologists who have experience with the administration of these drugs. Further, they collaborate for the placement of qualifying patients into national research protocols. Ask Dr. Kaynan about this!
Immunotherapy:
Provenge (Sipuleucel-T) is a form of cellular immunotherapy, used in patients with disseminated prostate cancer failing androgen deprivation therapy. It has been shown to improve survival. Patients donate their own blood in order to extract white blood cells, a process known as leukapheresis. These antigen presenting cells are then incubated with the antigen prostatic acid phosphatase (PAP) and an immune signaling factor granulocyte-macrophage colony stimulating factor (GM-CSF). The activated blood product is then infused back into the patient.
Also known as freezing of the prostate. Cryosurgery has been approved by the FDA as a salvage treatment for patients failing radiation therapy. It has also been used for the focal treatment of prostate cancer (as opposed to treatment of the entire gland). However, 80% of patients with prostate cancer have cancer cells in both lobes of the prostate, even if biopsies only demonstrated cancer in one lobe or a nodule. Such focal therapy would not address the likelihood of leaving some of the cancer untreated.
Cryosurgery has the advantage of being a minimally invasive procedure without removal of the cancerous gland. The likelihood of injury to the surrounding structures (ie, bladder, rectum, etc.) has been minimized with advances in cryo technology, and it is unlikely to cause urinary incontinence (leakage). However, the chance of impotency after this treatment is about 50%. More importantly, there is no long-term data to demonstrate that this is an effective cure for prostate cancer.
High Intensity Focused Ultrasound:
Also known as HIFU, this method entails heating the prostate. This energy method was just approved by the Food & Drug Administration for the treatment of prostate cancer in the United States. Like cryosurgery, it has the advantage of being a minimally invasive procedure without removal of the cancerous gland. However, there is no long-term data to demonstrate that this is an effective cure for prostate cancer.
