Minimally Invasive Treatment Options for Clinically Localized

Prostate Cancer

Jeffry Twidwell, MD

Prostate Anatomy

Prostate Cancer Detection

• Digital rectal exam – nodule, assymetry, firmness

• Prostate Specific Antigen (PSA) – normal range, age adjusted, rate of change

• Prostate Cancer Antigen 3 (PCa3 urine)

Prostate Ultrasound and Biopsy

Prostate Cancer Staging

• Bone scan• CT scan• MRI scan• “risk stratification” – multiple factors

evaluated to place patients into low, intermediate and high risk groups.

Treatment Options for Localized Prostate Cancer

• Observation• Active Surveillence• Radical Prostatectomy• Radiation Therapy• Cryosurgery• High Intensity Focused Ultrasound (HIFU)

Observation / Active Surveillence

• Good option for ---• Patient with multiple medical issues• Elderly• “Low risk” patient• Follow patient with psa AND periodic

prostate biopsy• 15% 10 year cancer specific mortality; 20%

risk of metastasis at 10 years

Radical Prostatectomy

• Conventional / Open Radical Prostatectomy

• Da Vinci Robotic Radical Prostatectomy

Radiation Therapy

• External beam• Brachytherapy / seed

implant

Prostate Cryosurgery

• Freezes tissue to produce cell death

• Individual needles placed into tissue

• Overlapping “iceballs” freeze entire gland

Prostate Cryosurgery

• Procedure performed in operating room with general or regional anesthesia

• Small needles placed throughout prostate under u/s guidance

• Argon gas used to freeze; helium gas used to thaw

• 2 “freeze – thaw” cycles• Target /kill temp -40 C

Prostate Cryosurgery

Prostate Cryosurgery

• Outpt procedure• Catheter 4-5 days post op• Side effects---• Perineal pain / fullness• Erectile dysfunction 80%• Incontinence uncommon• Great option for older men, ED not an issue

High Intensity Focused Ultrasound (HIFU)

• NOT FDA approved for use in the US• Considered “investigational”• Phase III trials underway• Presently used throughout the world including

Europe, Asia, Canada

High Intensity Focused Ultrasound

• Uses focused sound waves to create heat

• Heat creates a precise lesion to destroy tissue

• No damage to tissue before or after focal point

High Intensity Focused Ultrasound

High Intensity Focused Ultrasound

• Imaging and treatment ultrasound energy delivered through transrectal probe

• General anesthesia in OR• SP catheter until voiding • Outpatient• Normal activities in 4-5 days

High Intensity Focused Ultrasound

High Intensity Focused Ultrasound

• Early data looks encouraging• Early studies show psa recurrence rates similar to

radical prostatectomy (suarez et al)• Long term follow up needed (10, 15 yr data)• Favorable side effect profile---• ED - <20% • Incontinence 1%• Improving technology – tissue change

monitoring, NVB mapping

High Intensity Focused Ultrasound

• May be FDA approved by 2012 / 2013• NOT covered by insurance• Expensive• US patients presently travel to Mexico,

Carribean, Canada for treatment