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Androgen Deprivation Therapy: Appropriate Patients, Timing to Initiate ADT, and Complications

Introduction Prostate cancer is the second most frequently diagnosed cancer of men and the sixth leading cause of death in men with close to 258,000 deaths reported worldwide. In the United States alone, prostate cancer is the second leading cause of cancer mortality. Metastatic castration-resistant prostate cancer (CRPC) is almost always associated with death in patients with prostate cancer. The seminal observation that resulted in the…

Management of Locally Advanced (Nonmetastatic) Prostate Cancer

Introduction Locally advanced prostate cancer represents a heterogeneous group of malignancies. Currently, there is no universally agreed definition of what is known as “locally advanced” disease within the urology community, as this disease group of patients is getting smaller due to widespread use of prostate-specific antigen (PSA) testing. However, it remains a common clinical challenge and management is controversial. In this chapter we have summarized some…

Salvage Therapy for Locally Recurrent Prostate Cancer After External Beam Radiation Therapy

Introduction External beam radiation therapy (EBRT) is a commonly applied treatment modality for patients with localized prostate cancer, with up to 35% of patients with prostate cancer undergoing EBRT as first-line therapy. EBRT is associated with excellent outcomes for patients with localized disease, and outcomes associated with the use of EBRT in this patient population are generally thought to be equivalent to those achieved with radical…

Management of PSA Recurrences After Radical Prostatectomy

Introduction Following surgery for prostate cancer, approximately 30–35% of men will develop a rising prostate-specific antigen (PSA) level within 10 years. Considering that an estimated 138,000 radical prostatectomies were performed in the United States in 2010, approximately 41,400–48,300 men would be expected to have experienced a rising PSA after surgery, also known as biochemical recurrence (BCR). Furthermore, Pound et al. found the median time between BCR…

Emerging Modalities in Radiation Therapy for Prostate Cancer

Introduction Radiation therapy techniques and their combination with other modalities have developed rapidly over the past two decades in radiation oncology. This continues today at an ever increasing pace offering considerable hope to the patients with both localized and metastatic disease. This chapter will attempt to highlight the following areas in the treatment of prostate cancer. The areas are better methods for the stratification of patients…

Radiotherapy After Radical Prostatectomy: Adjuvant Versus Salvage Approach

Introduction Over 200,000 men are expected to have been diagnosed with prostate cancer in 2014. Approximately one-third will undergo radical prostatectomy and one-third of these men will have a positive margin. Another 10% are likely to have seminal vesicle invasion. Other variables that increase the patient’s risk for recurrence include high Gleason score, extracapsular extension, positive lymph nodes, and preoperative prostate-specific antigen (PSA). Some patients may…

Proton Beam Therapy

Introduction Particle beam therapy exploits subatomic particles with mass rather than X-rays or gamma rays to deliver radiation dose. It has gained increasing interest, development, and application due to its physical and radiobiologic properties. The physical property allows for precise dose localization and superior depth dose distribution with heavy charged particles such as protons. The advantageous radiobiologic property of heavier charged particles, such as carbon and…

Intensity Modulated Radiotherapy and Image Guidance

Introduction External beam radiotherapy has been accepted as a nonsurgical means of curative treatment for localized prostate cancer since the 1950s and 1960s, coinciding with the advent of cobalt and megavoltage X-ray units that allowed for sufficient energy deposition in the prostate without unacceptable skin toxicity. Since, there have been advances in radiation delivery and treatment planning that has significantly improved the control of cancer as…

Brachytherapy for Prostate Cancer: An Overview

Introduction Patients with localized (i.e., T1–T2) prostate cancer (PCa) have better outcomes if there is local tumor control, even in the presence of high-risk features (e.g., prostate-specific antigen, PSA >20 ng/mL; Gleason score, GS 8–10). Treatment options for localized PCa typically include radical prostatectomy (RP) and radiation therapy, which is delivered either as external beam radiation therapy (EBRT; typically, dose-escalated conventionally fractionated RT (CFRT) ) or…

Radiation with Hormonal Therapy

Introduction External beam radiation therapy (EBRT) is an effective primary treatment for patients with nonmetastatic prostate cancer, and is often used together with androgen deprivation therapy (ADT) in patients with aggressive (intermediate- or high-risk) disease. A large number of randomized trials have been conducted over the past 40 years, which guide clinical practice today. This chapter will summarize results of these trials and other key literature…

Fundamentals of Radiation Treatment for Prostate Carcinoma – Techniques, Radiation Biology, and Evidence Base

Introduction Radiation therapy was used to fight cancer within a few years of the discovery of X-rays in 1895. By 1902, Emil Grubbe had published an article outlining the conclusions from his own experience and that of dozens of writers for the treatment of cancer with radiation therapy. His conclusions were that the X-ray is a most remarkable therapeutic agent, in properly selected cases of so-called…

Reimbursement for Prostate Cancer Treatment

Introduction Prostate cancer (PCa) is the most common solid organ malignancy in men with over 200,000 new cases diagnosed each year. The long life expectancy of most men diagnosed with PCa has led to a burgeoning prevalence of the disease. An estimated 2.7 million men currently live with PCa in the United States, and the prevalence is only likely to increase in the future with the…

Management of Bladder Neck Contracture in the Prostate Cancer Survivor

Introduction Bladder neck contracture (BNC) is an infrequent but commonly recognized complication encountered by the urologist in patients following prostate surgery. While the number of patients seeking surgery or radiation therapy for prostate cancer has increased in the prostate-specific antigen (PSA) era, the number of bladder neck contractures has decreased due to advancements in surgical methods and the introduction of robotic surgery. Nonetheless, there exists a…

Clinical and Pathologic Staging of Prostate Cancer

Introduction Cancer staging criteria are designed to characterize the extent of a tumor and the burden of disease. Staging criteria serve several purposes, including defining patient prognosis, helping to determine appropriate treatment, facilitating the exchange of information among treatment centers, and serving as a basis for cancer research. The Whitmore–Jewett classification was the original system used to stage prostate cancer. This system has since been supplanted…

The Technique of Robotic Nerve Sparing Prostatectomy: Extraperitoneal Approach

Introduction Prior to the advent of robotics, a consensus panel of expert urologic surgeons judged laparoscopic radical prostatectomy to be “extremely difficult,” and the highest level of urologic surgical complexity in their ranking system. The robotic approach has certainly facilitated the performance and dissemination of laparoscopic radical prostatectomy throughout the United States. Once the transperitoneal approach to the prostate was perfected laparoscopically, some of the initial…

Posterior Approach to Robotic-Assisted Laparoscopic Radical Prostatectomy

Introduction The introduction of the prostate-specific antigen (PSA) test led to an unprecedented increase in the number of men diagnosed with prostate cancer. With that rise in rate of diagnosis came a rise in men found to have localized disease. As the concurrent adoption of minimally invasive surgical approaches progressed, laparoscopic techniques began to be applied to radical prostatectomy performed for prostate cancer with initial marginal…

Anterior Approach to Robotic Radical Prostatectomy

Introduction Robot-assisted radical prostatectomy (RARP) has become a common approach to surgical management of prostate cancer (PCa). By some reports, this approach has become more common than open radical prostatectomy (RP) over the last several years. As a result of the wide and rapid adoption of this technology, multiple different approaches have emerged. These approaches include the anterior transperitoneal prostatectomy (ARARP), the posterior RARP (PRARP), and…

The Technique of Robotic Nerve-Sparing Prostatectomy

Introduction The following chapter will describe the evolution of radical prostatectomy with a special concentration on the technique of robotic-assisted radical prostatectomy (RARP) that was developed and established at the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan. Historical perspective Radical prostatectomy was considered a morbid procedure, marred by blood loss, poor visualization, as well as high rates of postoperative urinary incontinence and erectile…

Open Versus Robotic Prostatectomy

Introduction Prostate cancer is the most common solid malignancy among men in the United States and the second most common cause of death, with an estimated 233,000 new cases and 29,480 deaths in 2014. The “gold standard” for surgical management for prostate cancer has been a radical prostatectomy, dating back to the first perineal prostatectomy described by Hugh Hampton Young in 1905. Several advances have been…

Prognostic Significance of Positive Surgical Margins and Other Implications of Pathology Report

Introduction With the adoption of widespread prostate-specific antigen (PSA) screening, prostate cancer (PCa) is increasingly diagnosed at a younger age and at an earlier stage of the disease. For patients managed with radical prostatectomy (RP), the opportunity to perform pathologic evaluation of the specimen offers valuable prognostic information and directs informed decision-making regarding surveillance and secondary therapies. For patients with localized disease, RP has demonstrated excellent…