Issues related to therapy

• Side effects of surgery are incontinence and impotence There is some decrease in impotence with nerve sparing procedure which can be performed on selected patients.There are newer surgical techniques being investigated including cryosurgery.
• Side effects of irradiation are often GI, including diarrhea and proctitis. Also acute and chronic cystitis. "Scarring" of the pelvis increases the difficulty of performing future surgeries should these be necessary. Impotence is a late complication in less than half the patients. Some centers use implants (brachytherapy). There is a very high local relapse rate after radiation therapy if biopsy is performed, but the clinical significance of positive biopsies is not always clear.
• There is no evidence that neoadjuvant hormonal therapy (LHRH analog predominantly) can increase survival in patients undergoing curative radiotherapy.
• Are there patients with palpable localized disease who don't need therapy? Scandinavian studies in well-differentiated patients suggest that not all patients need therapy.