Prostate Surgery eguide

Prostate Surgery

Is it the right choice for you?

If you’ve been diagnosed with prostate cancer, you will soon be making a decision with your physician about the treatment plan that is best for you. Surgery to remove the prostate is a common treatment selected by many men. With the evolution of robotic prostate surgery, the procedure is becoming more precise and reducing side effects.

But is robotic prostatectomy the right choice for you?

This guide will help you understand: › I f surgery is right for you ›W hat robotic surgery is ›B enefits of robotic surgery ›H ow to manage side effects ›H ow to choose a surgeon

Table of Contents 1. Choosing a Treatment Plan 2. Is Surgery Right for You? 3. Should You Get a Second Opinion?

4. What Is Robotic Prostatectomy?

5. The Benefits of Robotic Prostatectomy 6. Are You a Candidate for Robotic Prostatectomy?

7. Managing the Side Effects of Robotic Prostatectomy 8. Dealing With ED 9. Controlling Incontinence 10. Choosing Your Surgeon 11. Questions to Ask Potential Surgeons 12. About Foothills Urology 13. Foothills Urology Prostate Specialists 14. Resources 15. Research Studies

Choosing a Treatment Plan One in every seven men will get prostate cancer in his lifetime. While it’s a serious disease, most prostate cancers are diagnosed while they are still confined to the prostate. The five-year survival rate for cancer diagnosed in these stages (called localized or regional) is excellent!

To determine the best treatment plan for you, we will look at characteristics of your cancer as well as personal health factors. But deciding a treatment is not just about statistics and research, we also will talk to you about your goals, preferences, and lifestyle.

Cancer and health factors we will use include: › Your PSA results and Gleason score › The volume of the cancer in the prostate › Whether the cancer has spread outside of the prostate and, if so, where › Your general health and life expectancy Personal factors that we will discuss with you include: › Personal preferences: Are you comfortable with starting with active surveillance and careful follow-up testing, or do you have a strong desire to remove the cancer? › How do various treatment options impact or restrict your lifestyle? › How would the potential side effects of various treatments affect you?

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Is Surgery Right for You? More than 130,000 prostatectomy surgeries are performed in the U.S. annually, making it the most common treatment choice for men with prostate cancer. Whether or not prostate surgery is right for you will depend on the factors listed on the previous page.

In general, surgery is an option if you are generally healthy, without any conditions that restrict surgery.

Surgery is recommended as a treatment option to consider according to your cancer prognosis and life expectancy. But this only determines if surgery is an option — whether or not you choose it depends on all the factors discussed on the previous page.

Surgery is an option if: Cancer Prognosis

and

Life Expectancy

Very low risk

≥ 20 years

Low or intermediate risk

≥ 10 years

High or very high risk

≥ 2 years

Surgery to remove the prostate is not recommended if your cancer is considered advanced metastatic disease, meaning it has spread to other parts of your body.

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Should You Get a Second Opinion?

Obtaining a second opinion for a cancer diagnosis is very common nowadays. In fact, some health insurance plans even require this step before approving certain treatment options.

Second opinions can confirm your prostate cancer diagnosis and support your physician’s treatment recommendations or provide you with additional information. Nearly all physicians support a second opinion if it will help you feel more comfortable.

The physician giving a second opinion will need as much information as possible to provide an accurate diagnosis and treatment recommendation. Ask your physician’s office to compile all test results and records, including: › PSA levels › Biopsy results, including your Gleason score › Any other lab or imaging results, including ultrasounds, CT scans, MRIs, or bone scans conducted to see if your cancer has spread › Your comprehensive medical records, plus details of your family health history

Foothills Urology offers second opinions within five business days, and we will help you obtain your records. To schedule a second opinion appointment, call Foothills Urology at 303-985-2550 or you can request an appointment online at foothillsurology.com.

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What Is Robotic Prostatectomy?

In a traditional or open prostatectomy, the surgeon operates through a single 8- to ten-inch incision. But today, four out of five men who opt for prostatectomy choose to have it done through robotic-assisted laparoscopic prostate surgery,1 according to the National Cancer Institute. This technique allows surgery to be performed through four to five very small incisions, with considerable advantages over traditional surgery.

Surgery with the da Vinci robotic system may result in better outcomes and fewer side effects due to two key features: › Miniaturized instrumentation with 360-degree rotation › 3-D magnification

Sitting at a console next to the patient, the surgeon views the surgery from a close-up, 3-D perspective. The surgeon then uses controls to manipulate the tiny surgical tools to perform the surgery. The miniaturized size and a range of motion twice that of the human wrist allow the surgeon to perform very delicate movements, which decreases injury to surrounding structures.

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The Benefits of Robotic Prostatectomy Da Vinci surgery gives your surgeon enhanced dexterity and that means minimal impact on nerves, tissues, and surrounding structures. More precise surgical outcomes result in greater cancer control and greater preservation of vital small nerves and blood vessels, according a study published in the Journal of Robotic Surgery.2 Immediate benefits: › Less blood loss and decreased need for transfusions during surgery › Less pain › Lower risk of infection or other complications › Faster return to work and daily activities › Lower chance of hospital readmission › Lower risk of needing follow-up surgery

Long-term benefits: › Lower risk of nerve damage › Faster return of urinary continence and erectile function › Long-term cancer control

Watch a video about robotic prostatectomy.

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Are You a Candidate for Robotic Prostatectomy?

Robotic prostatectomy is typically a good treatment option if: › Your cancer has not spread beyond the prostate › You are able to tolerate general anesthesia › You do not have significant heart, lung, or other disorders that would make surgery high risk › You are not morbidly obese › You have not had a previous prostate surgery

4 out of 5 men who opt to have their prostate surgically removed opt for robotic prostatectomy.

— National Cancer Institute3

Need more information to make your treatment decision? Check out this prostate cancer patient guide from the National Comprehensive Cancer Network at nccn.org/patients/ guidelines/prostate/4

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Managing the Side Effects of Robotic Prostatectomy Every surgical procedure comes with risks, but the enhanced precision and control of da Vinci prostatectomy allows surgeons to perform the procedure with minimal damage to surrounding structures. That means that men today are experiencing fewer side effects that last a shorter amount of time. At the same time, treatments for side effects have advanced considerably.

The most common side effects of prostatectomy surgery, no matter how it is performed, are erectile dysfunction and urinary irritation or incontinence. On the next two pages, we will cover these more in depth.

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Dealing With ED Erectile dysfunction (ED): While all men are likely to experience some degree of erectile dysfunction after any type of prostatectomy, a higher percentage of men choosing robotic prostatectomy will return to presurgery erectile function within 12 months. The younger you are, the more likely sexual function will return. And the more experienced your surgeon is, the lower your risk for postsurgical impotence. If you are over age 60 or had erectile problems prior to surgery, you will have a higher risk of ED following surgery.5 If erectile dysfunction continues, there are now many successful treatment options ranging from medications to penile implants. In fact, 97 percent6 of men who use penile implants report that they are satisfied.

THE BOTTOM LINE Nearly all men will experience some ED immediately after surgery.

Depending on the individual, up to: ď Ź 70-80% resolves within one year postoperatively7 ď Ź 80-90% resolves within two years postoperatively8

For more information about cancer and sexuality, download a free report from the American Cancer Society at cancer.org/acs/groups/cid/documents/ webcontent/002910-pdf.pdf.9

8 Foothills Urology offers comprehensive treatment for erectile dysfunction, including penile implants. Read more about treatment options and success rates at foothillsurology.com/ sexual-health.

Controlling Incontinence Urinary incontinence: Although the majority of men experience some loss of bladder control after prostatectomy, normal control typically returns within a few weeks to a few months, according to the American Cancer Society.10 Some men may end up with stress incontinence, which can cause urine leakage when they cough, sneeze, laugh, or exercise.

If you do experience long-term incontinence, there are many treatments available ranging from medication and behavioral therapy to surgery. One treatment, artificial urinary sphincter, effectively treats up to 90 percent11 of post-prostatectomy incontinence.

THE BOTTOM LINE Nearly all men will experience some urinary incontinence immediately after surgery. ď Ź 81% resolves in the first three months12 ď Ź 93-98% resolves within one year postoperatively13

For more information on urinary incontinence and treatment options, download a helpful guide from the National Institute of Diabetes and Digestive and Kidney Diseases at niddk.nih.gov/health-information/ health-topics/urologic-disease/urinary-incontinence-in-men/ Documents/uimen_508.pdf.14

9 Foothills Urology specializes in successfully treating urinary incontinence with a variety of options. Read more about treatment options at foothillsurology.com/conditions/urinary-incontinence.15

Choosing Your Surgeon If, after reviewing your treatment options with your physician, you decide robotic prostate surgery is best for you, the next step is choosing a surgeon. Here are a few things to consider: Experience: Robotic surgery has a longer learning curve than traditional surgery, so you should make sure the surgeon you select has performed at least 100 robotic surgeries.

Board certification: Board-certified surgeons have received additional training in their area of specialty, have passed certification tests, and engage in continuing education to learn about advances in their specialty. You also should look for specialized training, including fellowship training, in robotic surgery.

Personal connection: Consider how your surgeon makes you feel. Bedside manner, communication style, and approach to your treatment should make you feel comfortable and confident.

Other factors: You also want to search for a surgeon who accepts your health insurance or is part of your health plan’s network, as well as one who has admitting privileges at a hospital you feel comfortable with.

Foothills Urology Experience The board-certified surgeons at Foothills Urology specialize in robotic prostatectomy using the da Vinci robotic surgical system. They have performed more than 500 robotic prostatectomies and more than 800 robotic surgeries for all types of urological conditions.

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A study in the Journal of the National Cancer Institute 16 found that patients whose surgeons had performed at least 250 robotic prostatectomies were less likely to have patients whose cancer recurs or who develop tumors that spread beyond the prostate.

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Another study in the Journal of Robotic Surgery 17 found that surgeons who have performed more than 300 robotic prostatectomies experience better outcomes, including less risk of incontinence and erectile dysfunction.

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Questions to Ask Potential Surgeons › Which type of surgical procedure are you recommending, and how long have you been performing this specific surgery? › How many total procedures of this type have you performed? › How many of these surgeries do you perform each year? › How do you measure outcomes, and what are your rates? › Are you board-certified? What type of ongoing education are you involved in? › What was your formal training in robotic prostatectomy? › Will I need radiation or hormone therapy before or after surgery? › Walk me through the day of my surgery: How long will it take; will I be in pain afterward; how long will I need to stay in the hospital?

SECOND OPINION

Foothills Urology can provide you with a second opinion within five business days. Call 303-985-2550 to schedule an appointment or request an appointment online at foothillsurology.com/ second-opinion.

› What side effects should I expect after surgery? What is my risk of experiencing incontinence or impotence? › What other side effects might I experience? › How soon can I return to my regular activities after surgery?

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About Foothills Urology Foothills Urology offers patients the option of being treated by one of four boardcertified urology surgeons, each of whom has extensive experience in treating prostate cancer. We believe that the best medical care is a combination of providing the latest treatments that are supported by research in a small, caring personalized practice.

Prostate cancer is a complicated disease, and there is no one-size-fits-all treatment.

We will work closely with you to ensure that you understand your cancer and your treatment options thoroughly. Together, we will help you choose a treatment that is best suited to your cancer and your lifestyle.

Foothills Urology surgeons accept most major insurance plans and perform da Vinci robotic prostatectomies at: ›S t. Anthony Hospital

›P resbyterian/St. Luke's Medical Center

Foothills Urology offers three offices to more conveniently serve patients.

West Denver Office 400 Indiana Street, Suite 300 Golden, CO 80401 Presbyterian/St. Luke’s Office 1721 E. 19th Avenue, Suite 454 Denver, CO 80218 Evergreen Office 28000 Meadow Drive, Suite 210 Evergreen, CO 80439 For more information or to schedule an appointment at any of our offices: Phone: 303-985-2550 Fax: 303-985-2586 foothillsurology.com

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Foothills Urology Prostate Specialists Foothills Urology offers four board-certified urology surgeons who have extensive experience in prostate treatment and robotic prostatectomy.

Dr. Derek Zukosky

Dr. Diane Hartman

One of the most highly trained and experienced robotic surgeons in the Denver area, Dr. Zukosky specializes in robotic prostatectomies and is the medical director of robotic surgery at St. Anthony Hospital. Dr. Zukosky was fellowshiptrained in urological laparoscopic (minimally invasive) surgery and earned his certification in da Vinci robotic surgery. He has performed more than 500 robotic prostatectomies.

One of the most experienced female urologists in the Denver area, Dr. Hartman’s expertise and personalized, comprehensive care led to her being named a Top Urology Doctor by 5280 magazine in 2012. Dr. Hartman specializes in urological surgery, including minimally invasive da Vinci robotic surgery.

Dr. David Cahn Dr. Cahn brings years of extensive experience to complex urological conditions, including advanced prostate care. In addition to his board certification in urology, Dr. Cahn completed a fellowship in neurourology.

Dr. Thomas Facelle Recognizing that prostate cancer patients have several treatment options that work equally well, Dr. Facelle’s approach is to offer his patients a multimodal approach customized to each patient’s individual cancer and lifestyle. Dr. Facelle strives to see most patients, particularly in cases of second opinions, within 24 hours.

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Resources If you would like to learn more about robotic prostatectomy, here are some reliable resources: American Cancer Society: cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-surgery American Urological Association: urologyhealth.org/educational-materials?topic_area=717| urologyhealth.org/urologic-conditions/prostate-cancer/treatment/surgery da Vinci Surgery: davincisurgery.com/assets/docs/prostatectomy-prostate-cancer-en-870033.pdf National Cancer Institute: cancer.gov/publications/patient-education/understanding-prostate-cancer-treatment cancer.gov/publications/patient-education/wyntk-prostate-cancer National Comprehensive Cancer Network: http://www.nccn.org/patients/guidelines/prostate/

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Research Studies This guide was developed in April 2016. Sources used in this guide include: 1. “Tracking the Rise of Robotic Surgery for Prostate Cancer.” National Cancer Institute.

National Cancer Institute, 9 Aug. 2011. Web. 12 Apr. 2016. http://www.cancer.gov/ about-cancer/treatment/research/rise-robotic-surgery 2. Coronato, Eric E., Justin D. Harmon, Phillip C. Ginsberg, Richard C. Harkaway, Kulwant Singh, Leonard Braitman, Bruce B. Sloane, Jamison S. Jaffe. “A Multi-Institutional Comparison of Radical Retropubic Prostatectomy,” Radical Perineal Prostatectomy, and Robot-assisted Laparoscopic Prostatectomy for Treatment of Localized Prostate Cancer. Journal of Robotic Surgery, 1 Oct. 2009. Web. 12 Apr. 2016. http://link.springer.com/article/10.1 007%2Fs11701-009-0158-2#/page-1 3. “Tracking the Rise of Robotic Surgery for Prostate Cancer.” National Cancer Institute.

National Cancer Institute, 9 Aug. 2011. Web. 12 Apr. 2016. http://www.cancer.gov/ about-cancer/treatment/research/rise-robotic-surgery 4. “NCCN Guidelines for Patients; Prostate Cancer.” NCCN Guidelines for Patients®.

National Comprehensive Cancer Network, 2015. Web. 13 Apr. 2016. http://www.nccn.org/patients/guidelines/prostate 5. Stanford, PhD, Janet L., Ziding Feng, PhD, Ann S. Hamilton, PhD, Frank D. Gilliland, MD, Robert A. Stephenson, MD, J. William Eley, MD, Peter C. Albertsen, MD, Linda C. Harlan, PhD, and Arnold L. Potosky, PhD. “Urinary and Sexual Function After Radical Prostatectomy for Clinically Localized Prostate Cancer.” JAMA Network. The Journal of the American Medical Association, 19 Jan. 2000. Web. 13 Apr. 2016. http://jama.jamanetwork. com/article.aspx?articleid=192307 6. Bernal, Raymond M., and Gerald D. Henry. “Contemporary Patient Satisfaction Rates for Three-Piece Inflatable Penile Prostheses.” Advances in Urology. Hindawi Publishing Corporation, 2012. Web. 13 Apr. 2016. http://www.hindawi.com/journals/ au/2012/707321 7. Coughlin, G., K. J. Palmer, K. Shah, and V. R. Patel. “Robotic-assisted Radical Prostatectomy: Functional Outcomes.” National Center for Biotechnology Information. U.S. National Library of Medicine, May 2007. Web. 13 Apr. 2016. http://www.ncbi.nlm.nih.gov/ pubmed/17626533 8. Ahlering, Thomas E., MD. “Sexual Function or Potency.” Sexual Function. University of California, Irving, Department of Urology, 4 Aug. 2010. Web. 13 Apr. 2016. http://www.urology.uci.edu/prostate/Potency_info.html

9. “Sexuality for Men with Cancer.” American Cancer Society. 19 Aug. 2013. Web. 13 Apr. 2016. http://www.cancer.org/acs/groups/cid/documents/webcontent/002910-pdf.pdf 10. “Surgery for Prostate Cancer.” Surgery for Prostate Cancer. American Cancer Society, 11 Mar. 2016. Web. 13 Apr. 2016. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-surgery 11. Herschorn, Sender. “The Artificial Urinary Sphincter Is the Treatment of Choice for Post–radical Prostatectomy Incontinence.” Canadian Urological Association Journal.

Canadian Medical Association, Oct. 2008. Web. 13 Apr. 2016. http://www.ncbi.nlm. nih.gov/pmc/articles/PMC2572249 12. El-Hakim, Assaad, and Ashutosh Tewari. “Robotic Prostatectomy — A Review.” Medscape General Medicine. Medscape, 25 Oct. 2004. Web. 13 Apr. 2016. http://www.ncbi.nlm. nih.gov/pmc/articles/PMC1480556/#R31 13. Finkelstein, Julia, Elisabeth Eckersberger, Helen Sadri, Samir S. Taneja, Herbert Lepor, and Bob Djavan. “Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience.” Reviews in Urology. MedReviews, LLC, 2010.

Web. 13 Apr. 2016. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859140 14. “Urinary Incontinence in Men.” Annals of Internal Medicine 132.7 (2000): 547. National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health, June 2007. Web. 13 Apr. 2016. http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-incontinence-in-men/Documents/ uimen_508.pdf 15. “Urinary Incontinence.” Urinary Incontinence. Foothills Urology, 2015. Web. 13 Apr. 2016. http://www.foothillsurology.com/conditions/urinary-incontinence 16. Vickers, Andrew J., Fernando J. Bianco, Angel M. Serio, James A. Eastham, Deborah Schrag, Eric A. Klein, Alwyn M. Reuther, Michael W. Kattan, J. Edson Pontes, and Peter T. Scardino. “JNCI: Journal of National Cancer Institute.” The Surgical Learning Curve for Prostate Cancer Control After Radical Prostatectomy. Journal of the National Cancer Institute, 13 June 2007. Web. 13 Apr. 2016. http://jnci.oxfordjournals.org/ content/99/15/1171 17. Lavery, Hugh J., David B. Samadi, Rahul Thaly, David Albala, Thomas Ahlering, Arieh Shalhav, Peter Wiklund, Ashutosh Tewari, Randy Fagin, Anthony J. Costello, Geoff Coughlin, and Vipul R. Patel. “The Advanced Learning Curve in Robotic Prostatectomy: A Multi-Institutional Survey.” Springer Link. Journal of Robotic Surgery, 4 May 2009. Web. 13 Apr. 2016. http://link.springer.com/article/10.1007/s11701-009-0154-6#/page-2

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