The radical prostatectomy
Why prostate surgery (also known as radical prostatectomy, surgical removal, robotic surgery, keyhole surgery, or Da Vinci surgery) cannot “cure” prostate cancer.
It is often claimed that for prostate cancer, surgical removal of the prostate – radical prostatectomy (also referred to as prostate surgery, prostate removal or Da Vinci surgery) – is the only “safe” treatment method. Since the cancer is located in the prostate, it would be completely removed from the body, along with the prostate. Prostate gone, cancer gone.
At first glance plausible, but wrong.
Because even after the removal of the prostate, the cancer can come back, exactly where the prostate was removed. Radical with or without da Vinci robot. This is referred to as a local recurrence.
Local recurrence after prostatectomy
No contradiction but quite normal
In addition to biochemical recurrences and metastases which are traditionally blamed on the “missed time” before spreading, there are also the so-called local recurrences. And these local recurrences occur frequently after prostate surgery. After removal of a relatively harmless prostate carcinoma, the cancer regrows within 5 years in 2 – 17% of all men operated on, and in 10 to 60% of all cases for dangerous carcinomas (for exact data and a self-test, see: Han Tables, Johns Hopkins University). And this is when the cancer is still confined to the prostate, so the surgeon has removed the “entire” cancer along with the prostate (this is also called “negative incision margins”).
Prostate cancer, like all cancers, is always systemic.
distributed throughout the body – never just locally
At the latest since the availability of the so-called “liquid biopsy”, we know that the old idea of cancer as a local ulcer is wrong. Cancer cells and their secretions and exosomes are always distributed throughout the body – and can therefore also be detected in the blood, precisely as a “liquid biopsy” by taking and analyzing blood or other body fluids. Individual cancer cells are therefore also embedded in the connective tissue around the prostate. Normally, these cancer cells are kept in check (dormant state) or killed by the immune system. If the immune defense fails, these individual cancer cells can grow into recurrences or metastases, small local cancerous tumors. Only when these growths consist of millions of cells, i.e. reach macroscopic sizes of at least a few millimeters, and have found a connection to the bloodstream can they be detected by MRI or PET.
Local therapies such as
reduce the tumor mass
only the immune system can heal
Because doctors have not yet been able to locate or reliably destroy the individual cancer cells scattered throughout the body, physicians cannot cure cancer patients. The treatment of cancer is limited to a reduction of the tumor mass – “tumor mass reduction” – an important therapeutic concept that makes it easier for the immune system to attack the remaining tumor cells in the body. The type of treatment thus becomes less important: whether radical or nerve-sparing surgery with or without da Vinci robot, radiotherapy, HiFU or irreversible electroporation, is irrelevant; what counts is the reduction of tumor mass. This makes it all the more important to minimize these and to keep the possibility open for follow-up therapies. This is the reason why we currently mainly use Irreversible Electroporation (IRE). It is the first therapy that has tissue selectivity but is repeatable and does not block subsequent therapies.
as nonsensical as Halsted’s radical breast surgery
At the end of the 19th century, the American surgeon Halsted tried to cure women of breast cancer by increasingly radical operations; he removed not only the breast, but finally also larger parts of the chest and shoulders of the affected women. Without success. Today, usually only the tumor is removed from the breast (possibly in combination with chemotherapy or radiotherapy), and the breast is preserved. And the affected women live longer. The history of prophylactic removal of all lymph nodes in breast cancer was similar. Fortunately, this has also been abolished and lymph nodes are selectively removed, if at all, only according to scientifically proven guidelines.
These tragic experiences continue to be ignored in the treatment of prostate cancer. Men with prostate cancer are still mutilated, 70% become impotent, 10 to 50% incontinent – most with no significant survival benefit: operated and non-operated men live the same length of time in many cases.
This fact forms the basis for focal therapy but also the background for the Watchful Waiting and Active Surveillance recommendation of some subgroups, which however is often not sufficiently pointed out to the patient.
At the VITUS PRIVATKLINIK, we provide you with comprehensive information about all treatment options for prostate cancer and also inform you about possible alternatives.
Get in touch with us. We will be happy to advise you.
Conclusion for men with prostate cancer:
- Surgical removal of the prostate does not guarantee a cure. Whether a cure occurs or the cancer returns depends on the tumor biology and thus whether the immune system keeps the cancer cells scattered throughout the body in check or kills them.
- Reducing tumor mass in the body has a positive effect on survival, as it helps the immune system fight the cancer.
- Radical treatment strategies have proven to be a dead end throughout the history of medicine: With few exceptions, they are no better than the gentler focal therapies.
- In particular, follow-up therapies after a radical treatment strategy are only possible to a very limited extent and are usually then associated with even more massive effects on quality of life.
- Immunotherapies are playing an increasingly important role in the targeted therapy of cancer with few side effects; many patients can already benefit from them today.