2. Prostate Cancer

What is the Prostate?

The prostate is a gland which lies just below the urinary bladder in men. It provides fluid to help in male reproductive functions.The prostate gland surrounds a tube, called the urethra through which urine exits the penis. A problem affecting the prostate gland can affect how you urinate and may affect your sexual function.

What is Prostate Cancer ?

Prostate cancer is the commonest cancer in men. Globally, around 1.1 Million men are diagnosed with prostate cancer and more than 300,000 die of prostate cancer in a year.

Prostate cancer is less common in men below the age of 50 years. The average age for diagnosis is 70 to 74 years. The risk is greater for men who have a family history of prostate cancer and in African men.

Prostate cancer is more common in developed, western countries, suggesting that there may be a link with lifestyle factors such as diet.

Prostate cancer can grow very slowly or very quickly. Slow-growing cancers are common and may not cause symptoms or shorten life.

What are the Symptoms of Prostate Cancer?

Many men with prostate cancer have no symptoms related to their cancer. For those that do have symptoms, they could include any of the following:

  • Urinary problems – weak urine stream, difficulty initiating urination, stopping and starting during urination; urinating frequently, especially at night, pain or burning with urination.
  • These symptoms are also often associated with noncancerous enlargement of the prostate, called benign prostatic hyperplasia or BPH.
  • Blood – in the urine and semen.
  • Pain – in the hips, pelvis, spine or upper legs.
  • Pain or discomfort – during ejaculation.

 

How is prostate cancer diagnosed ?

  • Digital rectal examination (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of the gland, you may need further tests.
  • Prostate-specific antigen (PSA) test. 

What is a PSA test?

The PSA test is a blood test that measures the level of prostate specific antigen (PSA) in your blood. PSA is a protein made by the prostate gland. It is released into the bloodstream, depending on your age and the health of your prostate.

A raised level may mean you have prostate cancer. About two out of three men (67%) with a raised PSA will not have prostate cancer. The higher the levels of PSA, the more likely it is to be a sign of cancer. The PSA test can also miss cancer.

Other conditions which are not cancerous (for example, benign enlargement of the prostate, prostatitis, and urinary infection) can cause higher PSA levels in the blood.

The PSA test is often done to detect cancer in men who have problems passing urine. It is also used to help in the treatment of men who are known to have prostate cancer. It can detect early prostate cancer before it causes symptoms or there is any abnormality of the prostate.

When you have a PSA test, you should not have:

  • an active urinary infection or infection within the last six weeks;
  • ejaculated within the last 48 hours;
  • exercised heavily within the last 48 hours;
  • had a prostate biopsy within the last six weeks; or
  • had a digital rectal examination (DRE) within the last week.

Let your doctor decide whether or not a PSA test is recommended for you.If it is done, let him interpret it taking your clinical picture into consideration.

PSA testing combined with DRE helps identify prostate cancers at their earliest stages. 

Multi-parametric Magnetic Resonance Imaging (mpMRI)

This is a type of MRI scan in which three pulse sequences are used, with the results combined and analysed together. An mpMRI cannot diagnose prostate cancer, however if cancer is suspected, your doctor may recommend this test to identify which areas of the prostate may be abnormal. This may reduce the need for a biopsy.

PET scans

These specialised scans are much more sensitive and specific in detecting recurrent or metastatic cancers. The prostate specific membrane antigen (PSMA) PET scan is the most commonly used.

Bone scan

This scan can show whether the cancer has spread to your bones. It can be used for later comparison if needed. A small amount of radioactive material (technetium) is injected into a vein. After 1–2 hours, you will have a body scan. This scan is painless.

How is prostate cancer treated ?

The treatment of prostate cancer depends upon many factors. The type of cancer, whether or not the cancer has spread (metastasized), a patient’s age, general health status, and prior prostate treatments the patient may have undergone.

There are three standard therapies for men with organ-confined prostate cancer :

Deferred treatment (active surveillance/watchful waiting)

Surgery

Radiation Therapy.

Active Surveillance

Active surveillance may be recommended only if a cancer is not causing any symptoms and is expected to grow very slowly.

The cancer is regularly and carefully monitored with PSA, clinical evaluation and intermittent prostate biopsies to ensure that the cancer is not becoming more aggressive. If progression of the cancer is evident, active treatment can be started.

This approach is sometimes suited for older men or those who have other serious health problems. Because some prostate cancers spread very slowly, older men who have the disease may never require treatment. Other men choose active surveillance because they feel the side effects of treatment outweigh the benefits.

Watchful waiting?

Watchful waiting (WW) is also known as deferred or symptom-guided treatment. It refers to conservative management, until the development of local or systemic progression with (imminent) disease-related complaints. Patients are then treated according to their symptoms, in order to maintain quality of life.

In contrast to Active surveillance, no specific tests or markers are used to actively monitor disease. It is used for elderly patients with a short life span.

Surgery

Surgical treatment of prostate cancer involves removing the entire prostate as well as the seminal vesicles (small glands near the prostate), with or without the removal of lymph nodes -  a procedure called radical prostatectomy.

Radical prostatectomy – can be done by various approaches.

1) Open radical prostatectomy

entails an incision on the lower half of the abdomen and removal of the prostate.

Although it is the oldest procedure, it entails a longer hospital stay, bigger wounds and greater chances of infection.

2) Laparoscopic Radical Prostatectomy

is done by making small holes in the anterior abdomen.

It is a technically challenging operation requiring advanced laparoscopy skills by the surgeon.

The hospital stay is shorter, the recovery of the patient is faster and the chances of infection are lesser.

3) Robotic assisted laparoscopic prostatectomy/Robotic radical prostatectomy

        The three goals of surgery, in order of importance, are cancer control, preservation of urinary control, and preservation of sexual function.Great skill and experience in the selection of surgical candidates and operative technique are necessary to achieve all three. With the advent of robotic surgery, improvements have been made in the surgical technique.

RARP is now the most preferred and most advocated surgical technique for Radical prostatectomy.

What happens during the procedure ?

  • A full general anaesthetic is normally used and you will be asleep throughout the procedure. You will usually be given an injection of antibiotics before the procedure, after you have been checked for any allergies. The anaesthetist may also use an epidural or spinal anaesthetic to reduce the level of pain afterwards. During the surgery you will be given antibiotics by injection. If you have any allergies, be sure to let the anaesthetist know. The Da Vinci® Xi Robot is used at my hospital. It is the state of the art robot with the most cutting edge technology available today. It helps remove the prostate using “keyhole” techniques but with small incisions to remove the gland. We use a robotic console which is placed beside you in the operating theatre (pictured). Each console has four robotic arms; three for instruments and one for a high-magnification 3-D camera. The robotic arms can hold a variety instruments which allow the surgeon to carry out your ?operation. The instruments are 7mm or so wide. Because they are small, they have a greater range of movement than the human hand and they allow the surgeon to carry out the operation in 3-D, within a small space in the body.With robotic surgery, the instruments are placed on to the robotic arms through small port holes into your abdomen. The operating surgeon sits in the same room but away from you. The surgeon is able to carry out controlled & precise movements using robotic assistance. The robot does not, of course, do the operation; the instruments are controlled by the surgeon because the robot cannot work on its own.

Are there any side-effects? Most procedures have possible side-effects. But, although the complications listed below are well-recognised, most patients do not suffer any problems.

Common (greater than 1 in 10)

- Temporary difficulties with urinary control.

- Impairment of erections even if the nerves can be preserved (20 to 50% of men with good pre-operative sexual function).

- Inability to ejaculate or father children because the structures which produce seminal fluid have been removed (occurs in all patients).

- Discovery that cancer cells have already spread outside the prostate, needing ?further treatment. 

 

Occasional (between 1 in 10 and 1 in 50) 

- Scarring at the bladder exit resulting in weakening of the urinary stream and needing further surgery (2 to 5%).

- Severe urinary incontinence (temporary or permanent) needing pads or further surgery (2 to 5%).

- Blood loss needing transfusion or repeat surgery.

- Further treatment at a later date, including radiotherapy or hormone treatment.

- Lymph fluid collection in the pelvis if lymph node sampling is performed.

- Some degree of mild constipation can occur; we will give you medication for this but, if you have  a history of piles, you need to be especially careful to avoid constipation.

- Apparent shortening of the penis. 

- Development of a hernia related to the site of the port insertion. 

- Development of a hernia in the groin area at least 6 months after the operation. 

 

Rare (less than 1 in 50) 

- Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including  chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death).

- Pain, infection or hernia at incision sites.

- Rectal injury needing a temporary colostomy.

 

Radiation Therapy

Radiation therapy is either a non-invasive, or minimally invasive treatment for prostate cancer that uses x-rays or gamma-rays to eradicate prostate cancer cells.

Prostate cancer treatments have several forms of radiation therapy that may be recommended. Each patient receives a customized treatment plan depending on the nature of the cancer, the patient’s unique symptoms and overall health.

 

Prognosis

Prognosis means the expected outcome of a disease. Generally, prognosis is better when prostate cancer is diagnosed while it is early stage, and at a lower grade.

You will need to discuss your prognosis with your doctor. However, it is not possible for any doctor to predict the exact course of the cancer. Test results, the extent of the spread of the cancer, and factors such as your age, level of fitness, medical and family history are important in assessing your prognosis. These factors will also help your doctor advise you on the best management or treatment options and tell you what to expect.

Prostate cancer often grows slowly and even the more aggressive prostate cancers tend to grow more slowly than other types of cancer. Compared with other cancers, prostate cancer has one of the highest five-year survival rates. For many men, the prostate cancer grows so slowly that it never needs treatment. Many men live with prostate cancer for many years without any symptoms and without it spreading.

 

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