by Dudley S. Danoff, MD, FACS
INTRODUCTION:
Prostate cancer is one of the most serious health problems in the United States today. It has touched almost everyone by involving either a family member or a friend. Approximately 240,000 new 
cases of prostate cancer will be diagnosed in the United States this year. It is the most common male malignancy. In the past 30 years, the number of prostate cancer cases detected each year has dramatically increased due to the rising median age of our population, as well as our ability to detect tumors at an earlier, more curable stage.
To ensure the preservation of normal life expectancy and high quality of life, early diagnosis and treatment of prostate cancer is essential. Once the diagnosis of prostate cancer is made, the key to treatment is based on the underlying stage of the disease. Differentiating between prostate cancers that are confined to the prostate and those that have spread beyond the margins of the prostate gland is necessary. The development of magnetic resonance imaging (MRI) has revolutionized prostate imaging and has allowed practitioners to visualize the internal architecture of the prostate and map all the fatty connective tissue around the prostate, including the neurovascular bundles, the vessel complexes, and the regional lymph nodes, to make a precise diagnosis. If detected while still confined to the prostate, the prostate cancer can usually be cured surgically. In general, patients with disease that is confined to the prostate, and who have an actuarial life expectancy of at least 10 years, are ideal candidates for extirpative (removing all cancerous tissue) nerve-sparing, continence-preserving laparoscopic (also known as minimally invasive) robotic surgical removal of the diseased organ.
Today, among the most active and skilled urologic surgeons dealing with prostate cancer, the preferred surgical technique is the laparoscopic da Vinci robotic method. In our hands, this method has an especially good outcome with regard to maintaining urinary continence and erectile function. The enormous success of this technique is based upon an improved understanding of prostate anatomy, including groupings of nerves and blood vessels (neurovascular bundles) and the mechanism that controls urinary continence. The da Vinci robotic system also provides significant magnification of the operative field, and the robotic arm is able to rotate, move, and bend with infinitely more efficiency than even the most skilled surgeon’s appendage.
In appropriately selected patients, the laparoscopic da Vinci robotic prostatectomy can provide a disease-free survival rate comparable to the expected survival rate of similarly aged, healthy men, for up to 30 years of observation. With early diagnosis and appropriate surgical treatment by a skilled team, even young men diagnosed with prostate cancer can look forward to living a full and rich life. Despite the new and improved techniques afforded by the da Vinci robotic system, surgery is suited only for patients whose cancer is completely confined to the prostate, without any evidence of extension.
In addition to surgical treatment, a number of other options are available for the treatment of prostate cancer, each with its negative and positive features. After diagnosis of prostate cancer, all options of treatment must be shared, and the decision-making process must flow freely between the physician and the patient.
Other treatment methods that can be considered include pinpoint external beam radiation (IMRT) and/or the implantation of radioactive seeds (also known as internal radiation therapy). Even with more advanced cancers, including cancers that have spread beyond the confines of the prostate gland, there is still hope for fully curing the disease. These patients may not be suitable candidates for surgery, but well-established treatment utilizing hormonal manipulation, radiation, and chemotherapy, often in combination, offers excellent results.
The good news is that, provided the diagnosis of prostate cancer is made early enough to allow maximal effective treatment, life after prostate cancer and surgery (or other treatment options) can be full, rich, and rewarding and allow a man to be confident, sexually active, and vigorous in all areas of his life.
If you are diagnosed with prostate cancer, the following dos and don’ts will help you move forward.
DOS:
DO #1. Educate yourself.
Do everything you can to educate yourself as much as possible about the disease. For example, searching the Internet will reveal much information regarding the treatment options for and prognosis of prostate cancer.
DO #2. Have your urologist stage the cancer.
Once the diagnosis of prostate cancer has been made, you must allow your urologist to stage the disease, that is, determine if the prostate cancer is confined to the prostate or has spread. The staging procedure will usually include MRI, computed tomography (CT) scan, bone scan, and perhaps cystoscopy. Knowing the stage of your cancer will help determine the appropriate treatment.
DO #3. Modify your diet.
The recommended diet for prostate cancer includes extremely low fat intake, high protein intake (tofu, fish oil), and the avoidance of all carbohydrates and processed foods. These diet changes will benefit your overall health and may slow the growth of prostate cancer.
DO #4. Discuss your options with a urologist.
Once your particular disease is appropriately and properly staged, a full discussion with your treating urologist is needed. Among the options to be considered are laparoscopic robot-assisted removal of the prostate; radiation, either external beam radiation or radioactive seed implant or a combination of the two; or watchful waiting, sometimes called active surveillance. Many prostate cancers are very small, low grade, and low stage and do not have a tendency to progress to advanced cancers. These can easily be managed by your urologist with periodic examinations requiring no aggressive treatment. This option should be explored.
DO #5. Consider your age.
Do consider your age when evaluating your treatment options for prostate cancer. Be aware that the older you are at the time of the diagnosis, the less likely you are to die of this disease. Incidental prostate cancer is often found in older men, and many of these cancers are insignificant, do not progress, and require no treatment other than active surveillance.
DO #6. Discuss other medical problems with your urologist.
Your doctor needs to be aware of any other condition, including simultaneous diseases (comorbidities) such as hypertension, coronary artery disease, diabetes mellitus, liver disease, and any other condition that might shorten your actuarial life expectancy. Discuss your lifestyle and sexual activity with your urologist prior to making a treatment decision as your choice of treatment may negatively impact both lifestyle and sexuality.
DO #7. Encourage male family members to get screened.
There is a strong family connection between male relatives with prostate cancer. If you have been diagnosed with prostate cancer, your son, brother, or other male relative is 30 percent more likely to develop a prostate cancer than a similar patient in the normal population. If such a relative exists, he should be encouraged to start prostate cancer screening at age 40 to detect any cancer at an early and treatable stage.
DON’TS:
DON’T #1. Do not despair.
A prostate cancer diagnosis is not the kiss of death. Most men who are diagnosed with early prostate cancer and who are appropriately treated by a qualified urologist have a life expectancy equal to men without prostate cancer of a similar age and medical condition. Most men diagnosed with prostate cancer live a normal, productive, sexually active, and fulfilling life following successful treatment.
DON’T #2. Do not fear surgery.
Don’t fret if your treating urologic surgeon recommends surgical removal of the prostate, if the staging indicates that to be the best treatment. Today’s modern da Vinci robotic laparoscopic prostatectomy, utilizing nerve-sparing and continence-sparing techniques, will require a single day in the hospital, no abdominal incision, minimal pain or discomfort, and a full recovery, including the ability to get an erection firm enough for penetration in most cases.
DON’T #3. Do not ignore scheduled follow-up appointments.
Your urologist will schedule follow-up recommendations if you are in the active surveillance group, that is, a patient with focal, low-grade and nonaggressve prostate cancer who is being followed with watchful waiting and no aggressive treatment. To be certain that your tumor does not progress, meticulous and periodic examinations are essential, and they are not to be missed.
DON’T #4. Do not ignore the diagnosis of prostate cancer.
Prostate cancer is a silent disease and will only become symptomatic when at an incurable stage. Most men, as they age, develop symptoms of benign prostatic enlargement. This enlargement, which has nothing to do with prostatic malignancy, will manifest itself in various symptoms including a slow and narrow urinary stream, incomplete bladder emptying, the necessity to get up at night to urinate, and occasional urinary incontinence. These are not necessarily the symptoms of prostate cancer and are more often a sign of benign enlargement of the prostate. But, if you are diagnosed with prostate cancer, don’t ignore your doctor’s advice and wait for symptoms because, if you do, you may be untreatable.
DON’T #5. Do not fear the loss of your sexuality.
Many patients, when they learn they have prostate cancer, assume that they will end up permanently impotent. In almost all cases, this fear is totally unwarranted. As far as sex is concerned, the prostate is a secondary organ. A man’s sexual organs can perform perfectly well without a prostate. All treatment options must be discussed with your treating urologist, and the right treatment must be carefully selected and best suited to your overall general health, age, stage of disease, sexuality, and lifestyle.
DON’T #6. Do not doubt your treating urologist.
If you do not have 100 percent confidence in what your doctor is telling you and his or her recommendations, skill, judgment, or character, you must find another doctor that you believe in. The diagnosis and treatment of prostate cancer is very nuanced. Great judgment and experience are required to pick the appropriate treatment for any particular patient and his disease. You must have complete and full confidence in your treating urologist, and then you must follow his or her recommendations precisely. As medical doctors, urologists have vast clinical experience and years of training that enable us to sort out all of the variables. You must have your urologist explain exactly what your condition is and what the benefits and risks are with each of the treatment methods that are applicable to your particular case.
DON’T #7. Do not hold your life hostage to sex.
If those vital nerves must be compromised in surgery to ensure complete removal of the cancer, you can still be helped with any postoperative erectile dysfunction by utilizing the “pills” (Viagra, Cialis, or Levitra), a prosthetic penile implant, or an injectable medication. A surgeon’s first obligation is to cure your cancer. A surgeon will try to preserve your sexual function, but not at the risk of shortening your life.
SUMMARY:
In conclusion, the takeaway message if you are diagnosed with prostate cancer is don’t despair, and do find a skilled physician you believe in and follow his or her advice to the letter.