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Postradical Prostatectomy Incontinence

Introduction There was an estimated 233,000 new cases of prostate cancer in the United States in 2014 and many of these men would have been treated with radical prostatectomy. Incontinence is a well-documented complication of this procedure and, regardless of a robotic or open approach, incontinence rates seem to be similar, ranging from 1% to 40% of all patients at one year. Various definitions of postradical…

Radiation-Resistant Prostate Cancer and Salvage Prostatectomy

Radiotherapy for prostate cancer Radiation therapy (RT) for the treatment of prostate cancer (PCa) has been utilized in the United States and Canada since 1915. The first radiotherapy devices used radium applicators that were positioned adjacent to the prostate gland. Unfortunately, this technique resulted in significant morbidity including unwanted dose to adjacent critical structures. Low-penetrating electron beam X-rays were then applied in the palliative setting as…

Radical Retropubic Prostatectomy

Introduction The concept of removal of the entire prostate to treat prostate cancer was first introduced by Irish urologist Dr Terence Millin in the late 1940s. The procedure did not develop widespread popularity until Dr Patrick Walsh performed detailed studies of the anatomy relating to the procedure and popularized the nerve-sparing open radical retropubic prostatectomy in the early 1980s. This dramatically improved outcomes with decreased blood…

The Surgical Anatomy of the Prostate

Anatomical principles underpin optimal oncological and functional outcomes in the surgical management of prostate cancer. Therefore, an in-depth understanding of pelvic anatomy is prerequisite for all prostate cancer surgeons. Recent technology development, such as the advent of 10-times magnification, high-definition video, and 3D video systems in robotic and laparoscopic surgery, enables the surgeon to identify subtle anatomical structures like never before, ever increasing the precision of…

Indications for Pelvic Lymphadenectomy

Introduction The introduction of prostate-specific antigen (PSA) screening during the 1990s has decreased the incidence of prostate cancer lymph node metastasis in contemporary surgical series. This observed stage migration coupled with improvements in axial imaging has largely obviated the need for pelvic lymph node dissection (PLND) as an independent staging procedure. As a consequence, current practice patterns largely integrate PLND simultaneously with open or minimally invasive…

Is Surgery Still Necessary for Prostate Cancer?

Stage migration: increased incidence of localized prostate cancer In the prostate-specific antigen (PSA)-based early detection era, approximately 81% of men with prostate cancer (PCa) have disease considered confined to the prostate gland (clinically localized PCa), and only 4% present with distant disease. Survival has improved and disease-specific mortality has declined with overall 5-year survival rates now at 99%. With better understanding of the biological behavior of…

Preoperative Risk Assessment

Introduction There was an estimated 233,000 cases of prostate cancer diagnosed in the United States in 2014. There are a variety of therapeutic options for men with clinically localized prostate cancer including radical prostatectomy, radiation therapy, and active surveillance. Multiple variables ultimately factor into a patient’s decision on which therapeutic avenue to pursue including overall health status and life expectancy, tolerance of side effects, and oncologic…

Active Surveillance: Rationale, Patient Selection, Follow-up, and Outcomes

Introduction The last century has witnessed a shift from invasive to minimally invasive surgery, and it has been proposed that the next century may bring the elimination of invasion altogether. For the management of localized prostate cancer, this is a very apt expectation. Active surveillance represents a major advance at the noninvasive end of the treatment spectrum and offers the critically important promise of reducing the…

Decision Support for Low-Risk Prostate Cancer

Introduction Over the past decades, increasing numbers of men have been faced with the diagnosis of prostate cancer. Conversely, prostate cancer mortality rates have decreased. In addition, men are more often diagnosed at an earlier stage of the disease. The obvious reason for these profound changes is the introduction of the prostate-specific antigen (PSA) test for the early detection of prostate cancer. Early detection of prostate…

Level-1 Data From the REDUCE Study and the PCPT Data

Introduction Alternatives to waiting for the clinical signs of a disease to become apparent are screening and prevention. These approaches may make treatment more effective and safer. Prostate cancer is seemingly an ideal disease for these approaches as it has a long latent period driven not just by mutation but also by many epigenetic variables, particularly those relating to the action of cell-signaling regulatory molecules, which…

Environmental and Occupational Exposures and Prostate Cancer

Introduction Prostate cancer is the most common solid organ malignancy diagnosed in men and the second leading cause of cancer deaths in American men. The etiology and risk factors for prostate cancer are largely unknown. Some theories suggest that environmental carcinogens or occupation-related exposures may be associated with prostate cancer. In particular, research efforts have focused on the interplay between environmental exposures and hormonal aspects of…

Effects of Smoking, Alcohol, and Exercise on Prostate Cancer

Introduction Multiple studies have been performed in an effort to determine the cause of cancer. Certainly, both genetic and environmental factors play a role in the pathogenesis of malignancies. Patients often wish to know what lifestyle behaviors can be modified to decrease their risk of developing cancer. One of the most common questions asked by patients with a new diagnosis of cancer is, “What caused this…

Heart Healthy = Prostate Healthy and S.A.M. are the Ideal “Natural” Recommendations for Prostate Cancer

Key points Cardiovascular disease (CVD) preventive strategies via lifestyle, dietary supplement, and pharmacologic agents appear to have the best current evidence for prostate cancer prevention, especially aggressive disease. Obesity, dyslipidemia, glucose intolerance, lack of exercise, caloric excess, and even metabolic syndrome should be considered prostate cancer risk factors. Dietary supplements in high-doses that have not been found to prevent CVD and could increase the risk of…

Breast and Prostate Cancers: A Comparison of Two Endocrinologic Malignancies

Introduction Prostate and breast cancers are two common malignancies that have some striking and surprising similarities. As we know, they are both tumors of accessory sex organs and both are characterized primarily by being epithelial, hormone-driven malignancies, which respond to so-called “endocrine therapy.” They constitute the second leading cause of cancer-related mortality in the United States for men and women, respectively. In both cancers, there is…

Neuroendocrine Prostate Cancer

Introduction Carcinoma of the prostate represents the most common cancer diagnosis in American men and is the second leading cause of deaths from cancer. The large majority of prostate cancers are histologically adenocarcinomas. The development and implementation of serum prostate-specific antigen (PSA) screening among at-risk men lead to the high incidence of prostate cancers discovered in the late twentieth and early twenty-first centuries. While far more…

Hereditary Prostate Cancer

Introduction The McKusick catalogue (1990) lists 66 Mendelian disorders that involve cancer or a predisposition for cancer as a component of the phenotype. The genetic loci of 21 of these 66 traits have been mapped by genetic epidemiological investigations. Prostate cancer has a well-established familial clustering, including both dominant and recessive syndromes similar to those found in breast and ovarian cancer syndrome families. However, extensive research…

Race, Ethnicity, Marital Status, Literacy, and Prostate Cancer Outcomes in the United States

Epidemiology African-Americans (AA) have a 25% greater cancer mortality rate compared to Caucasians, and prostate cancer is a significant contributor to the overall cancer mortality gap in men. There will be an estimated 220,800 new cases of prostate cancer in 2015, with AA men having the highest incidence of prostate cancer among men in the United States. Asian-American/Pacific Islanders have the lowest incidence, whereas Hispanic men…

International Trends in Prostate Cancer

The world population climbed over 7 billion in 2011. Over the next 40 years, the predicted growth in population will almost all come from the less-developed world. This is due to its higher birth rate and younger current population compared to those in the more developed world. The world population will continue to change at an exponential rate; in particular, the more developed world will account…

Cancer of the Prostate: Incidence in the USA

Introduction Prostate cancer is the most common noncutaneous cancer diagnosed in the United States. In 2014 it was estimated that 233,000 men will be newly diagnosed with prostate cancer. Prostate cancer represents 14% of all new cancer diagnoses in the United States during 2014. Only skin cancer affects more men than prostate cancer in the United States. Prostate cancer is the second leading cancer killer of…

Prostate-Specific Antigen Screening Guidelines

What is PSA? Prostate-specific antigen (PSA) is a serum protease inhibitor produced only by prostate tissue following androgen stimulation. PSA typically forms a complex with α1-antichymotrypsin and plays a role in semen liquefaction. Serum PSA values usually correlate with prostate volume. Several conditions elevate PSA including benign prostatic hypertrophy (BPH), prostate cancer, prostate infection, prostate manipulation, and ejaculation. Androgen deprivation or castration, certain medications including 5α-reductase…