When is surgery the best treatment for prostate cancer?

In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 ng/mL and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation and have a 10-year or more life expectancy. Life expectancy is assessed by both patient age and health.
What types of surgeries are available to treat localized prostate cancer? 

• Open Radical Prostatectomy
• Perinal Radical Prostatectomy
• Retropubic Radical Prostatectomy
• Minimally Invasive
  • Robotic Assisted Laparoscopic Radical Prostatectomy
  • Laparoscopic Radical Prostatectomy

What are the advantages and disadvantages of Active Surveillance/ “Watchful Waiting?”

There are two advantages for utilizing this treatment option – low cost and no immediate complications.    
The risk of active surveillance is that the cancer could grow and spread to other parts of the body between follow-ups, making it more difficult to treat. Not all prostate cancers require active treatment, and not all prostate cancers are life threatening. The decision to implement active treatment is one a man should discuss in detail with a urologists to determine whether active treatment is necessary, or whether surveillance may be an option.

What are the current treatment options for localized prostate cancer?

Because not all prostate cancer is the same and not all are life threatening, it is important to understand the treatment options you choose should be very specific to your personal health history.  It is an individual decision that patients should make together with their doctor and their family. No one treatment is perfect for every man.
Several factors come into play when selecting the best treatment for an individual and they include:

• Tumor stage (extent of local spread) and grade (aggressiveness),
• PSA level (higher levels indicating a greater risk of cancer recurrence after treatment), and extent of disease (number of biopsy cores with cancer), as well as
• competing medical co-morbidities (other diseases that can affect life expectancy) and
• Age at diagnosis (as most prostate cancers take many years to become evident and cause morbidity, the same tumor in an older man may pose a lower risk of causing problems in his lifetime); all play a role in the decision regarding the choice of therapeutic intervention

It is important that you speak to your doctor about which treatment is right for you.
Below is a list of the common medical treatments for localized prostate cancer:

• Active Surveillance
• Surgery
• Radiotherapy
• Cryotherapy

Are there tests to determine if my cancer has metastasized?

To determine if your cancer has spread to other parts of your body your doctor may recommend the following:

• A pelvic CT scan
• MRI scan
• Bone scan

Not all men with prostate cancer need to undergo imaging tests as the risk of spread to other organs can be estimated by PSA levels and cancer grade. It is also standard to omit the bone scan in patients for the following reasons:

• Newly diagnosed, untreated prostate cancer,
• Patients who have no symptoms from their cancer,
• Gleason score of less than 7 and have serum PSA concentrations less than 10 ng/ml
• PSA concentrations less than 15 ng/ml (unless the Gleason score is 7 or higher)

A pelvic CT scan or MRI may not be necessary in men with lower grade cancers, cancers still confined to the prostate, and serum PSA values less than 10 ng/ml.

How do I determine which treatment option is best for me?

Prostate cancer represents a spectrum of disease. Some cancers may grow so slow that treatment may not be needed while others grow fast and are life threatening. Determining the need for treatment can be a complex decision. Initially, the need for treatment should be based on the stage and grade of the cancer as well as the age and health of the patient.
(To determine your risk and need for screening please use the risk assessment tool: Rank Your Risk)
Many physicians have sought to devise risk assessment tools that predict the likelihood of disease recurrence and progression. By combining many types of information (i.e., serum PSA level, clinical stage, Gleason score, extent of cancer in biopsy specimens), patients can be advised of the likely aggressiveness of their cancer and the need for and types of treatment available. However, the longer the patient's life expectancy, the more uncertain the prediction becomes, as most prostate cancers progress with time.
When prostate cancer spreads (metastasizes) it is usually progresses, though not always in such a neat step-wise fashion, first by perforating the capsule and extending into the periprostatic tissues, then to the seminal vesicles, then to the lymph nodes and finally to the bones, lungs, and other organs.

How is prostate cancer staged?

Once prostate cancer has been diagnosed by a prostate biopsy, the physician must stage the disease.  Staging the disease determines the extent of the cancer (i.e., the "T" stage) and whether the cancer has spread from the prostate to other tissues such as the seminal vesicles, the lymph nodes and/or the bones. The T stage is determined by using the DRE and other imaging procedures like the ultrasound scan, CT scan, MRI scan, or MR spectroscopy scan.








The T stage is divided into the following categories:
T1: Doctor is unable to feel the tumor
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed and is low grade (Gleason < 6)
T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed or is of a  higher grade (Gleason > 6)
T1c: Cancer is found by needle biopsy that was done because of an elevated PSA
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still  appears to be confined to the prostate
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate
T2b: Cancer is found in more than half of only one side (left or right) of the prostate
T2c: Cancer is found in both sides of the prostate
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
T3a: Cancer extends outside the prostate but not to the seminal vesicles
T3b: Cancer has spread to the seminal vesicles
T4: Cancer has spread to adjacent organs, such as the urethral sphincter, rectum, bladder, and/or wall of the pelvis
Imaging tests, such as radionuclide bone scan, CT scan, MRI, and MR spectroscopy may help assess whether the cancer is still confined to the prostate or spread elsewhere. To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT or MRI scan of the pelvis. Sometimes follow-up images are needed to evaluate abnormalities found on the bone scan. These tests are not recommended for men with a Gleason grade lower than 7 and a PSA level lower than 10 ng/ml as they rarely show disease. 

How does the Gleason Score work?

The Gleason grading system is the most widely used system. In this system, because often several different tumor patterns are seen, the most common tumor pattern is assigned a score from 1 to 5 and the second most common pattern is similarly assigned a score, using the same scale. The two scores are added together to give a Gleason sum ranging between 2 and 10. Scores of 2 to 6 designate mildly aggressive prostate cancer, 7 moderately aggressive and scores of 8 to 10 are highly aggressive cancers.

How is prostate cancer diagnosed?

Currently, digital rectal examination (DRE) and prostate specific antigen (PSA) are used for prostate cancer detection. The American Urological Association recommends that healthy men over the age of 40 should consider obtaining a baseline prostate cancer screening with a DRE and PSA test. Evidence from research studies suggest that combining both tests improves the overall rate of prostate cancer detection. For more information on the DRE exam, please see the page four of our Prostate Health Playbook.
DRE: The DRE is performed with the man either bending over, lying on his side or with his knees drawn up to his chest on the examining table. The physician inserts a gloved finger into the rectum and examines the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool or rectal masses, which may allow for the early detection of rectal or colon cancer.  Because the DRE by itself is not an effective way to detect early cancer, it should always be combined with a PSA test.
Prostate Specific Antigen Test (PSA): The PSA test is usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream.
The blood test can be done in a clinical laboratory, hospital or physician's office and requires no special preparation on the part of the patient. Ideally, the test should be taken before a DRE is performed or any catheterization or instrumentation of the urinary tract. Furthermore, because ejaculation can transiently elevate the PSA level for 24 to 48 hours, the patient should abstain from sexual activity for two days prior to having a PSA test.
Very little PSA is detected from patients with a healthy prostate, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Inflammation of the prostate, called prostatitis is another common cause of PSA elevation, as is recent ejaculation. Prostate cancer is the most serious possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate.
The American Urological Association (AUA) believes that the decision to screen is one that a man should make with his doctor following a careful discussion of the benefits and risks of screening.  In men who wish to be screened, the AUA recommends getting a baseline PSA, along with a physical exam of the prostate known as a digital rectal exam (DRE) at age 40. A disadvantage of infrequent testing is that it limits the ability to detect a rapidly rising PSA levels that can signal aggressive prostate cancer, though this is relatively uncommon for men with such low PSA values. Recently, several refinements have been made in the PSA blood test in attempts to determine more accurately, who has prostate cancer and who has false-positive PSA elevations caused by other conditions like BPH. These refinements include PSA density, PSA velocity, PSA age-specific reference ranges and use of free-to-total PSA ratios. Such refinements may increase the ability to detect cancer and these should be discussed with your physician.
It is important to realize that in most cases an abnormality in either test is not due to cancer but to benign conditions, the most common being BPH or prostatitis.

What are the causes and risks associated with prostate cancer?

What exactly causes prostate cancer is still unknown; however, the scientific community is conducting research with the hope of finding the answer soon.  The current theory is there are many factors  that can increase a man’s risk for prostate cancer.   The following are some factors:

• Age
• Smoking
• World Region Location
• Ethnicity – being African American doubles your risk
• Family History
• Dietary
• Vasectomy
• Vitamins

The disease predominately affects older men and is rarely found in men younger than 40.  Approximately 1 in 35 men will die of prostate cancer with African American’s twice as likely as Caucasian men to die of the disease.  According to the American Cancer Society prostate cancer accounts for about 10 percent of cancer-related deaths in men between the ages of 60 and 79 and nearly 25 percent in those over the age of 80.
As men age, their risk of developing prostate cancer increases.  If you are a heavy smoker, studies have shown that your risk of prostate cancer may double.  The good news is the risks decreases to roughly that of a non-smoker of the same age within 10 years of quitting.
Worldwide, prostate cancer ranks third in cancer incidence and sixth in cancer mortality among men. There is, however, a notable variability in incidence and mortality among world regions. The incidence is low (but rapidly increasing in recent years) in Japan and other Asian countries and intermediate in regions of Central America and Western Africa. The incidence is higher in North America and Northern Europe. However, the higher rates in North America and Northern Europe can be due to the different screening practices, genetic predisposition, diet and environmental factors.
African-Americans are in the highest risk group, with an incidence of more than 200 cases per 100,000 black men.  While the incidence in Caucasian and Asian men is slightly more than half that of blacks, African-American men tend to present with more advanced disease and have poorer overall prognosis than Caucasian or Asian men.
Men with a family history of prostate cancer are at an increased risk of developing the disease, the more first-degree relatives the higher a man’s risk of developing the disease.  In addition, the age of onset the first-degree relatives was diagnosed can increase a man’s risk of developing the disease.  Men with a family history of disease are 2 to 11 times more likely to develop prostate cancer then men without a family history of prostate cancer.
There is also considerable evidence showing a Western lifestyle is associated with increased prostate cancer risk and increased death from prostate cancer. However, which specific lifestyle factor is unknown.  Engaging in excessive calorie, dietary fat and refined sugar intake with reduced fruit and vegetable and exercise activity is shown to increase the risk of prostate cancer, though the relationship is not entirely clear. However, of those the most commonly cited dietary risk factor is a high intake of dietary fat, though that relationship is still unclear.  Being obese is associated also with an increased risk for death from prostate cancer. Thus, the simplest advice for avoiding death from prostate cancer is to prevent obesity and if you are obese, to lose weight and keep it off.
There is a limited amount of evidence to suggest that the worldwide difference in prostate cancer incidence may be associated with dietary intake of soy proteins in other parts of the world. In Asian countries such as Japan and the Republic of Korea where prostate cancer incidence and mortality are just a fraction of that in North America, soy consumption in the form of tofu, soymilk and miso is up to 90 times higher than that consumed in the United States. In a study of more than 40 nations, researchers found soy, on a per calorie basis, to be the most protective dietary factor. This protective role may be associated with two of soy's components, genistein and daidzein that may act as weak estrogens. Estrogens are female hormones that inhibit prostate cancer growth. Some experts have suggested that the worldwide differences in prostate cancer incidence may also be explained by the high intake of green tea by residents of Asia. However, determining which factors from a complex dietary mix cause prostate cancer is not easy and no clear answers have emerged.
The intake of other certain dietary factors such as lycopene and fish oil may also reduce the risk of developing prostate cancer. Cooked tomatoes are rich sources of lycopene. Lycopenes are antioxidants that may protect cells from becoming cancerous. Several studies have shown that the likelihood of developing prostate cancer is reduced by high intake of lycopene. Researchers found men ingesting two or more servings of tomato sauce per week had a 36 percent reduction in cancer risk compared to those who did not, however again, not all studies have supported this. Fish oils (omega-3 fatty acids) are thought to reduce heart disease due to reducing inflammation. Given the presumed importance of inflammation in causing prostate cancer, it stands to reason that fish oils may prevent prostate cancer. Indeed, some studies have suggested this, though others have failed to find any link with prostate cancer risk.
The correlation of vasectomy and prostate cancer risk remains controversial. Although some studies have suggested that men who have undergone a vasectomy are at an increased risk of developing prostate cancer, many other studies have failed to show such a correlation.
Attention has also focused on vitamin D's effect on the prostate. Epidemiologic evidence shows an inverse relationship between prostate cancer risk and ultraviolet radiation, the primary source for vitamin D production. This observation has led some to suggest that higher rates of prostate cancer in the elderly may be partly due to decreased sun exposure or a decline in the body's ability to make vitamin D with aging. However, several recent studies have found no correlation between vitamin D levels and prostate cancer risk and one even found that men with increased vitamin D had a higher risk of aggressive prostate cancer!
Finally, a word of caution is needed. Based upon very exciting data, the National Institute of Health embarked a large randomized trial of over 30,000 men to test whether vitamin E or selenium would prevent prostate cancer. Unfortunately, the trial was stopped early because there was no evidence either agent alone or in combination prevented prostate cancer. Moreover, there was a suggestion that men who took vitamin E had an increased risk of prostate cancer and men who took selenium had a slightly higher risk of diabetes! This highlights the point that there is no easy substitute for a healthy lifestyle involving eating a balanced diet, avoiding dietary excesses, eating plenty of fruits and vegetables, getting lots of exercise, and most importantly achieving and maintaining a normal body weight.
While there are no exact causes of prostate cancer most doctors agree, if you do things that are heart healthy, you will also keep your prostate healthy.  Eating right, exercising, watching your weight and not smoking can improve your health and help them avoid this disease.

What is the prostate?

The prostate is part of the male reproductive system and is a small, walnut-sized gland that sits below the bladder and in front of the rectum.  The prostate gland secretes a fluid that makes up part of the semen.
Men should discuss with their physicians about their need to have a prostate cancer screening; which helps maintain proper prostate health.  For more information please refer to our prostate cancer screening brochure:

Prostate Cancer

Prostate Cancer is the second-leading cause of cancer deaths among men in the United States and a significant health-care problem due to its high incidence. . It is estimated that in the United States (U.S.), there will be more than 240,890 new cases and 33,720 deaths from prostate cancer in 2011. The natural history and progression of this disease is not clearly and consistently understood. An analysis of autopsy studies has shown that approximately one in three men over the age of 50 years had histologic evidence of prostate cancer, with up to 80% of these tumors being limited in size and grade and, therefore, clinically insignificant. However, a recent study of incidental prostate cancer diagnosed in organ donors found prostate cancer in 1 in 3 men age 60-69, and this increased to 46% in men over age 70. 
The number of men diagnosed with prostate cancer remains high. However, 5-year relative survival rates have increased dramatically over the years.  There also has been at least a 25% reduction in the age-specific prostate cancer mortality rate since the beginning of the PSA era. It is estimated that 99 % of men diagnosed with localized or regional prostate cancer survive at least five years, while only 33% of those with metastases at diagnosis survive 5 years.
For African American men, however the statistics are more dramatic.  African American men when diagnosed are more likely to be diagnosed at a later stage and 2.4 times more likely than white men to die of prostate cancer.  In addition, if you have a family history the risk is even greater.
Thus, it is still important for men to know the facts abut prostate cancer and have an informed discussion with their doctors about prostate cancer testing.  For information on prostate cancer please visit the page for our Know Your Stats About Prostate Cancer® campaign, in partnership with the National Football league.

How can kidney stones be prevented?

Unfortunately kidney stones are a recurrent disease, meaning that if you have one stone you are at risk for another stone event. In general, the lifetime recurrence risk for a stone former is thought to approach 50%. Stone prevention, therefore, is essential. Your doctor or urologist may follow up with several tests to determine which factors e.g., medication or diet should be changed to reduce your recurrence risk.
A good first step for prevention is to drink more liquids and water is the best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two liters of urine in every 24-hour period. People who form calcium stones used to be told to avoid dairy products and other foods with high calcium content. However, recent studies have shown that restricting calcium may actually increase stone risk.  High doses of calcium, Vitamin D, or Vitamin C may increase the risk of developing stones, especially in people with a family history of stones. These people need to be careful and should calcium supplementation be needed, calcium citrate is best.
If you are at risk for developing stones, your doctor may perform certain blood and urine tests to determine which factors can best be altered to reduce the risk. Some people can decrease their risk with dietary changes while others will need medicines to prevent stones from forming.
Other general recommendations for stone formers is that they consume a low sodium and low animal protein diet.
Do not be surprised, if you are asked to collect urine for 24 hours after a stone has passed or been removed to measure volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate and creatinine. This information will be used to determine the cause of the stone. A follow-up 24-hour analysis may be used to find out the effectiveness of treatment.

How are kidney stones diagnosed?

Sometimes "silent" stones, those that cause no symptoms are found on X-rays taken during a general health examination. These stones would likely pass unnoticed. If they are large, then treatment should be offered. More often, kidney stones are found on an X-ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests also help detect any abnormal substance that might promote stone formation.
If your doctor suspects a stone but is unable to make a diagnosis from a simple X-ray, he or she may scan the urinary system with computed tomography (CT). CT is an imaging technique that is the gold standard for stone diagnosis as it is an extremely accurate diagnostic tool that can detect almost all types of kidney stones painlessly. Historically intravenous pyelorgram (IVP) was used but this requires prep as well as intravenous contrast dye and serial X-rays.
The abovementioned tests give your doctor information about the size, location and number of stones that are causing the symptoms. This allows the urologist to determine appropriate treatments.

What happens under normal conditions?

The urinary tract, or system, consists of the kidneys, ureters, bladder and urethra. The kidneys are two bean-shaped organs below the ribs in the back of the torso (area between ribs and hips). They are responsible for maintaining fluid and electrolyte balance by removing extra water and wastes from the blood and converting it to urine.
The kidneys keep a stable balance of salts and other substances in the blood. They also produce hormones that build strong bones and help form red blood cells. Urine is carried by narrow muscular tubes to the ureters, from the kidneys to the bladder, a triangular-shaped reservoir in the lower abdomen. Like a balloon, the bladder's walls stretch and expand to store urine and then flatten when urine is emptied through the urethra to outside the body.  Normally, urine contains chemicals that prevent crystals from forming.

What are stones and the difference between kidney stones and ureteral stones?

Normally, urine contains many dissolved substances. At times, some materials may become concentrated in the urine and form solid crystals. These crystals can lead to the development of stones when materials continue to build up around them, much as a pearl is formed in an oyster.
Stones formed in the kidney are called kidney stones.  Ureteral stone is a kidney stone that has left the kidney and moved down into the ureter.
The majority of stones contain calcium, with most of it being comprised of a material called calcium oxalate. Other types of stones include substances such as calcium phosphate, uric acid, cystine and struvite.
Stones form when there is an imbalance between certain chemical urinary components such as calcium, oxalate and phosphate.  These chemical components either promote crystallization while others inhibit it.
The most common stones contain calcium in combination with oxalate and/or phosphate.
A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Much less common are the pure uric acid stones. Much rarer is the hereditary type of stones called cystine stones and even more rare are those linked to other hereditary disorders.

KIDNEY STONES & URETRAL STONES

 

Stone disease is among the most painful and prevalent urological disorders.  More than a million kidney stone cases are diagnosed each year with an estimated 10 percent of Americans destined to suffer from kidney stones at some point in their lives.
The incidence of urolithiasis, or stone disease, is about 12% by age 70 for males and 5-6% for females in the United States.  Additionally, the gender gap may be decreasing as more women are being diagnosed and treated for kidney stones.  The reason for the change is of the dietary and climate changes in our population.  The debilitating effects of kidney stones is quite substantial, with patients incurring billions of dollars in treatment costs each year.
Fortunately, most stones pass out of the body without any intervention. If you are not so lucky, the following information should help you and your doctor address the causes, symptoms and possible complications created by your kidney stone disease.

Is there a screening test for early detection of bladder cancer?

Not at this time, although periodic check of the urine for microscopic blood may promote earlier detection.

Bladder Cancer

Bladder cancer is the sixth most common cancer in the United States. About 65,000 Americans are diagnosed with bladder cancer each year and 12-14,000 die annually of the disease. In recent decades there has been a steady increase in the incidence of bladder cancer. However, doctors are making progress in treatment, and survival rates are improving. But what are its symptoms? How should it be treated? The following information should help you talk to an urologist about this condition.
What happens under normal conditions?
The bladder is a hollow balloon-shaped mostly muscular organ that stores urine until ready for release. The urine is produced in the kidneys. It flows through tubes called the ureters into the bladder and is discharged through the urethra during urination. The bladder muscle aids urination by contracting (tightening) to help force out the urine.
A thin surface layer called the urothelium lines the inside of the bladder. Next is a layer of loose connective tissue called the lamina propria. Covering the lamina propria is the bladder muscle. Outside of the bladder is a layer of fat.

What is Urology?

Urology is a surgical specialty which deals with diseases of the male and female urinary tract and the male reproductive organs. Although urology is classified as a surgical specialty, a knowledge of internal medicine, pediatrics, gynecology and other specialties is required by the urologist because of the wide variety of clinical problems encountered. In recognition of the wide scope of urology, the American Urological Association has identified seven subspecialty areas:

• Pediatric Urology
• Urologic Oncology (cancer)
• Renal Transplantation
• Male Infertility
• Calculi (urinary tract stones)
• Female Urology (urinary incontinence, pelvic outlet relaxation disorders)
• Neurourology (voiding disorders, urodynamic evaluation of patients and erectile dysfunction or impotence)

Dr. Bruder, MD is a board certified urologist practicing in New York City.

Bruder graduated from the New York Medical College in 1982. He completed his surgical residency training at New York Medical College, final leaving the institution in 1988 as Urology Chief Resident. Since 1988, Dr. Bruder has maintained his own practice.

Recently, he co-established the Luzato Medical Group combining his urology practice with board certified cardiologists, internists and neurologists to give patients the comprehensive coverage they deserve. Additionally, Dr. Bruder retuned in 2004 to his alumarter, New York Medical College, as a Clinical Assistant Professor of Urology.