Advanced Imaging, Robotic Surgery Propel Prostate Cancer Management

The global incidence of cancer is increasing. In 2050, more than 35 million people around the world are expected to be diagnosed with cancer, representing a massive 77% increase from the estimated 20 million diagnoses in 2022.¹

Among the cancers driving this increase is prostate cancer, which is the most common cancer among men in the US and the second-most common among men globally.² Prostate cancer incidence is expected to double worldwide by 2040 to nearly 3 million diagnoses per year.³

Accurate diagnoses and effective treatment for prostate cancer is a clear priority in medicine, and recent news about the diagnosis of former US President Joe Biden with aggressive metastatic prostate cancer is driving even greater attention to this common disease.⁴

As with most cancer care, management of prostate cancer is a multidisciplinary effort, and surgeons share a position at the forefront of treatment.

The ubiquity and sometimes unique nature of prostate cancer necessitates high-quality, proven treatment, while also providing continuous opportunities for evolution. This reality makes prostate cancer management a microcosm of broader conversations in surgery, which includes advanced imaging, optimal surgical or nonsurgical treatment, and decisions regarding whether surgery—or any treatment—is necessary in each case.

Advanced Imaging Guides Diagnosis, Treatment

Effective management of solid tumor cancer relies on accurate information, and prostate cancer imaging has experienced several advancements in recent years that are helping to make diagnoses and treatment decisions more impactful.

The prostate-specific antigen (PSA) blood test continues to be the mainstay of contemporary prostate cancer screening and monitoring after treatment, with its high sensitivity that is useful for detecting disease (though it has low specificity). Other newer blood-based and urine-based biomarkers are enhancing the initial point of entry for identifying patients who are at risk for prostate cancer, as well. And once cancer is suspected, advanced imaging techniques come into play.

“We typically use prostate–focused magnetic resonance imaging (MRI) for diagnosis,” according to John G. Pattaras, MD, FACS, the James C. Kennedy Chair of Prostate Surgery, director of minimally invasive surgery, and associate professor of urology at the Emory University School of Medicine in Atlanta, Georgia.

“Individuals can still go and get a biopsy done if their PSAs are elevated or the urologist feels they’re at risk for prostate cancer, but the standard in 2025 is getting the MRI before the biopsy to look for suspicious areas and allow us to target those biopsies,” he said. 

The idea of targeted biopsies for prostate cancer represents a sea change for gaining diagnostic information compared to the mid-1990s and early 2000s when the PSA was introduced and gained traction.

“Historically, the way we would identify prostate cancer is the patient would get a PSA test, and if it was high, they would use a template biopsy of the prostate where the surgeon, like playing a game of Battleship, would essentially map out the prostate in a 4-by-3 grid and just hope that they catch the cancer,” said M. Minhaj Siddiqui, MD, FACS, director of urologic oncology and robotic surgery at the University of Maryland Medical Center in Baltimore. 

“Now with these MRIs, we can see areas most concerning for cancer, and we have the ability to perform a targeted biopsy that provides much more accurate information,” he noted.

The MRI has a relatively high sensitivity and specificity for localizing the index lesion or the most dominant focus of clinically significant cancer in the prostate. It also is reasonably useful for local staging, including involvement of seminal vesicles, lymph nodes, or extracapsular extension.

However, there are accuracy limitations when extending beyond the local area into broader regional or further metastatic areas of concern—and it is in these instances that the prostate-specific membrane antigen positron emission tomography (PSMA PET) scan has entered the conversation.

“PSMA PET has really changed the landscape of staging and advanced imaging for prostate cancer,” said Kara L. Watts, MD, director of the prostate screening program at Montefiore Einstein Medical Center in the Bronx, New York.

“Traditionally, we obtained a computed tomography (CT) and bone scan to stage men who have intermediate, or high-risk prostate cancer at time of diagnosis. But PSMA PET has been shown to have a much higher accuracy for predicting lymph node involvement compared to CT scan, and a higher sensitivity and specificity for other distant spread compared to bone scan. In addition, it delivers less than half the total radiation of the CT/bone scan combination,” she said.

As a result, PSMA PET has largely replaced CT and bone scans for determining oligometastatic and metastatic disease (when insurance and access are available). And it is worth underscoring that this scan is specifically designed to enhance prostate cancer management.

“These are very specific PET scans. They’re not fluorodeoxyglucose PET scans, which are used for breast, colon, and other types of cancer,” Dr. Pattaras said. “This is for prostate cancer, and it has become our standard for working up patients prior to surgery or radiation for unfavorable intermediate-risk and high-risk patients.”

Enhancing Surgical Planning

Prostate MRI and PSMA PET scans provide invaluable data for a multidisciplinary care team to understand the severity of disease and create a map for treatment. For surgeons, both can aid in pre- and perioperative planning.

The MRI of the prostate is exceptionally good at characterizing the behavior of the cancer within the prostate as well as prostate anatomy, which has allowed surgeons to map and treat the cancer better surgically, according to Dr. Siddiqui.

Modern MRI can provide clear images of vital structures the cancer is near, such as important nerve bundles.

“In certain situations, you must be more aggressive in the way you resect the cancer in the prostate, and you may not be able to spare some of these structures to get all the cancer out. In other situations, you can see that the cancer is not really near some vital structure,” Dr. Siddiqui said.

“So, even though the patient may have aggressive cancer in some areas, you can consider a more extensive surgical approach when performing a nerve-sparing prostatectomy to save the neurovascular bundle or manage the bladder neck to help with continence recovery,” he said.

Dr. Pattaras echoed the utility of MRI and added that PSMA PET has a place for optimal perioperative treatment.

“I can use MRI to know the anatomy when I’m opening the bladder, and I’ll know the size of the prostate and locations of adjacent structures; then I use PET to determine my lymph node dissection. I’m using these imaging techniques not just for diagnostics; I’m using them as surgical planning techniques,” he said.

Despite newly available patient data from PSMA PET, caution should be taken, according to Dr. Watts, because it has the potential to identify lymph nodes or small lesions on bones that look positive but may not be metastatic.

“In some cases, this does carry a risk of upstaging a patient where they may no longer be offered a surgical option for curative intent, or the amount of therapy offered to them may be changed from what was originally recommended to them based on the MRI,” she said, adding that such possibilities must be considered when reviewing PET scans and holding multidisciplinary consultations.

Robotic Prostatectomy Dominates Surgical Treatment

Many different prostate cancer treatments exist, but when diagnostics and imaging confirm that surgery is appropriate for primarily localized disease, the approach is clear—a patient will almost invariably have a robotic prostatectomy.

Robotic-assisted prostatectomy has been the standard surgical treatment for prostate cancer for at least a decade, and today approximately 95% of prostatectomies are performed using a robotic approach.⁵

This is a noteworthy figure in an era where considerable research is dedicated to determining the efficacy of robotic versus laparoscopic approaches to a variety of procedures, from hernia repair to cholecystectomy to transplant surgery.^6-8 Both pathways have varying outcomes that sometimes trend toward less favorable results for robotics in terms of outcomes and costs. 

Fortunately, the prostate presents an operative environment that favors the robotic-assisted approach and, specifically, disfavors laparoscopic and open approaches.

“The location of the prostate is particularly challenging. You’re deep into the narrower male pelvis, and it’s surrounded by the rectum and bladder,” Dr. Pattaras said, which limits working and visualization space with traditional laparoscopic tools.

“When we were attempting these laparoscopically, you couldn’t see in three dimensions, but with modern robots, there are two 1080p cameras providing 3-D visualization that allows you to see small nuances of the prostate and surrounding tissue,” he said.

When weighed against open prostate surgery, which is the primarily used alternative approach, there are similar advantages to using a robot.

“The prostate is surrounded by a plexus of vascular structures that could make it a fairly bloody case historically,” Dr. Minhaj said. “The robot really helps with visualization access to these spaces and has made the case much less bloody compared to open surgery.”

This approach represents a significant improvement from the 1990s, when US Food and Drug Administration approval of the PSA test led to a substantial increase in prostate cancer surgery.

With open surgery, “patients would lose 500 ml to a liter of blood very easily in a prostatectomy, and the transfusion rates were quoted to be anywhere between 10% and 40%,” Dr. Pattaras said. “Now, because of the pneumoperitoneum and improved visualization, most patients lose probably less than 100 ml of blood, and the transfusion rate is down to less than 1%.”

Overall, the general advantages for patient recovery after surgery with the minimally invasive, robotic approach are similar to most other procedures in contrast to open surgery—reduced pain, less time in the hospital, and quicker return to functional status.

It is important to note that the oncologic outcomes for robotic and open surgery appear to be roughly equal at a moderate follow-up interval,⁹ but where the robotic approach has shown a clear advantage is in noncancer outcomes, such as continence and erectile function.

The intraoperative precision of a robotic approach makes nerve-sparing prostatectomy more of a possibility, which can dramatically improve these important quality of life outcomes. Other advances continue to be made in robotics, such as the development of single-port robots that make only one incision to perform the prostatectomy versus multiple, which introduces new minimally invasive possibilities.

Multimodal and Nonoperative Approaches

While surgeons are likely to focus on how technologic and technical leaps are impacting the care they provide, robotic-assisted surgery is just one piece of the overall treatment plan for prostate cancer.

Whether a patient has advanced metastatic disease that makes surgery a less effective option or they are physiologically unable to bear surgery-related stress, there are multiple nonoperative approaches that can effectively treat prostate cancer in the right circumstances.

The most familiar option is likely external and internal radiation therapy, which is a common alternative to surgery. In fact, Dr. Pattaras said he and a radiation oncologist see all new patients together to offer additional options and more information on potential follow-up radiation after surgery. 

Other treatment modalities include hormonal therapy to block the action of androgens, which can spur prostate cancer growth, as well as standard chemotherapy and immunotherapy for metastatic disease.¹⁰

But there is one area of increased focus that is aimed at minimizing side effects while providing quality outcomes for localized diseases—focal therapy.

“The most commonly available forms of focal therapy are cryotherapy, which involves freezing the prostate with needles, and transrectal HIFU [high-intensity focused ultrasound], which involves heating the prostate to a lethal temperature through a transrectal probe. There is also irreversible electroporation, or NanoKnife, which uses needle-based electrical pulses that destroy only the tissue in between the needle points. Other treatments are also offered in select centers or are in development in current clinical trials,” explained Dr. Watts.

“The benefit of this type of approach is that it minimizes the side effects that may result from whole-gland therapy, like surgical removal of the prostate or radiation therapy, while still achieving in, appropriately selected cases, an effective cancer control outcome,” she said.

These treatments are not currently the standard of care for prostate cancer, and because some prostatic tissue remains untreated, their use necessitates additional monitoring after the procedure. “But in the properly selected patient, with an experienced surgeon, these can offer a really effective alternative with much fewer side effects than whole-gland therapy,” Dr. Watts said.

Active Surveillance Helps Avoid Unnecessary Treatment

Underlying all discussions of surgery, alternate therapies, and advanced imaging is a clinically significant fact—prostate cancer is, in many cases, a slow-growing or indolent disease. It often does not require immediate treatment after a patient is analyzed using the Gleason score or the more recently developed grading on Grade Groups.

And because most prostate cancer diagnoses occur in men in their late 60s to 70s, conversations are increasingly taking place regarding whether treatment is the right decision when weighing the side effects of surgery, radiation, chemotherapy, and so on against the extended life expectancy, which is typically 10–15 years for prostate cancer patients. 

After all, there is a reason that the medical maxim of “more men die with prostate cancer than because of it” still holds true.¹¹ Resultantly, the concept of active surveillance has found a foothold in prostate cancer management.

“These patients can range the spectrum of age, health, and baseline status. But their cancers are characterized based on their PSA, imaging, biopsy, and Gleason score or Grade Groups score, as having a low-grade and a low-stage cancer. If all these things line up, and it’s a low-risk cancer, or in some cases even a favorable intermediate risk of cancer, then a process of active surveillance begins,” he said.

True to its name, active surveillance requires regular testing and patient engagement, with 6-month visits that include PSA tests and repeat MRIs and biopsies to make sure that the cancer is not progressing into a more aggressive subtype.

Evidence shows that the protocol works in the right patient. When the studies examined individuals who were randomized to either getting immediate treatment versus being monitored closely with active surveillance and only treated when they were found to have a progression, the cancer-related outcomes were identical.

“More than half of the time, patients under active surveillance never require treatment,” Dr. Siddiqui said.

He also noted that the efficacy of active surveillance has been substantiated with enough data that this approach has become part of guideline statements from the American Urological Association and the National Comprehensive Cancer Network; it also has become a part of best practices at ACS Commission on Cancer (CoC)-accredited treatment centers, where Dr. Siddiqui managed updating the urologic cancer measures.

“The CoC measure that was adapted and is now live states that for patients who are diagnosed at CoC institutions with low-risk prostate cancer, the preferred method for management should be active surveillance, not treatment, as an initial strategy,” he said, demonstrating that the ACS plays a meaningful role in whole-patient management, and not just surgery.

Ultimately, the decision to pursue active surveillance speaks to the nature of modern prostate cancer. It is a well-understood, generally slow-growing disease that has several effective treatment modalities, but it also affords the possibility of no treatment at all for appropriate patients. And looking forward, genomics and artificial intelligence may play a role in enhancing treatment decisions even further.

As with all cancer, it is incumbent upon surgeons, oncologists, and other members of cancer care teams to regularly communicate with the patient so they understand the course of action that will provide the best outcomes for their individual circumstances.

Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.

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