a) Surgical Therapy
The surgical approach is bilateral orchiectomy or the removal of both testicles which the main source of androgen (testosterone) production. Typically, this procedure can be performed as a minor surgical procedure under local anesthesia.
Bilateral orchiectomy can performed through a single incision in the middle of the scrotum or through two incisions, one on each side of the scrotum. The blood vessels that supply the testis and the sperm duct (vas deferens) are tied off, and the testes are removed.
Some urologists perform a subcapsular orchiectomy, whereby the testicular tissue is removed from within the outer coat (the capsule), and the capsule remains in the scrotum, leaving some fullness to the scrotum.
To minimize swelling and bleeding in the scrotum, the scrotum is often wrapped to compress it or a scrotal supporter is used to elevate it. The incision is closed with dissolvable sutures so that the stitches need not be removed.
The advantages of bilateral orchiectomy are that it causes a quick drop in testosterone level about 8 hours after the procedure. Being a one-time procedure, it is more cost effective than the shots.
However, there may be bleeding, infection, permanence and scrotal changes. Patients who are bothered by an empty scrotum may use bilateral testicular prostheses.
Most men who undergo bilateral orchiectomy lose their libido and have erectile dysfunction after the testosterone level is lowered. Other long term side effects include hot flashes, osteoporosis, fatigue, loss of muscle mass, anemia, and weight gain.
b) Medical Therapies
There are three types of medical therapies: luteinizing hormone-releasing hormone (LHRH) analogues, antiandrogens, and gonadotropin-releasing hormone (GnRH) antagonists. These prevent the action of testosterone on the prostate cancer and on normal prostate cells (antiandrogen), or prevent the production of adrenal androgens.
Luteinizing hormone-releasing hormone analogues are chemicals produced in the brain that in turn stimulate the production of another chemical produced by the brain, the luteinizing hormone. Luteinizing hormone tells the testicles to produce testosterone.
Initially, when a man takes an LHRH analogue, there is an increased production of LH and of testosterone. This superstimulation in turn tells the brain to stop producing LHRN and, subsequently, the testicles stop producing testosterone.
It takes about 5 to 8 days for the LHRH analogues to drop the testosterone levels significantly. The increase in testosterone that may occur initially with LHRH analogues may affect patients with bone metastases, and there may be a worsening of their bone pain called the flare reaction.
Such men with metastatic disease will be given another medication, an antiandrogen, for two weeks or so before starting the LHRH analogue to block the effects of the testosterone and to prevent the flare phenomenon.
LHRH analogues are given as shots either monthly, every 3, 4 or 6 months, or even yearly. There are five forms of LHRH analogues: leuprolide acetate for intramuscular injection (Lupron Depot), triptorelin pamoate suspension for intramuscular injection (Trelstar Depot and Trelstar LA), leuprolide acetate for subcutaneous injection (Eligard), histrelin acetate for subcutaneous implant (Vantas) and goserelin acetate implant (Zoladex).
All five LHRH analogues work the same way, and differ only in how they are administered. The advantage of hormone treatment for prostate cancer is that it does not require removal of the testicles. However, it is expensive and requires more visits to the doctor’s office.
You can’t afford to miss a shot because when the testosterone level rises, the prostate cancer cells may grow. Get the shots on a regularly scheduled basis. If you are traveling, plan ahead and contact doctors in the areas where you will be to arrange for the shots.
LHRH analogues have side effects that may affect your quality of life. Side effects such as hot flashes, erectile dysfunction, anemia and osteoporosis can be treated. Erectile dysfunction occurs in about 80% of men taking LHRH analogues and is associated with decreased libido.
The widely prescribed drug siladenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are effective in most of these men if they had normal erectile function before starting hormone treatment for early stage prostate cancer. Unfortunately there is no medication to restore libido.