When a malignant tumor appears in the tissues of the prostate gland, it is referred to as prostate cancer. This condition is very common in elderly men. Prostate cancer symptoms are usually missing until the cancer is in the advance stage. Prostate cancer treatment depends on multiple factors and ranges from non-invasive active surveillance to surgical removal of prostate (robotic prostatectomy). Below we are going to review this condition, symptoms it may cause, its diagnostic services, as well as prostate cancer treatment options in more detail.
The prostate gland is a walnut-sized gland situated below the urinary bladder. It produces prostatic secretion that forms part of semen. Prostate cancer develops when cells in the prostate gland turn malignant, i.e. uncontrolled growth, and forms a lump. This cancer grows out of the prostate capsule and invades surrounding tissue, e.g. seminal vesicles, bladder neck. It can also spread to lymph glands in the pelvis. It also often spreads via the blood stream to the backbone.
This disease is one of the most common cancers amongst men. It normally grows at a slow rate and remains confined to the prostate gland in the initial stages. If this cancer is detected early, it has a higher success rate of treatment.
ARE YOU AT RISK?
These are the identified risk factors:
- Family history of prostate cancer
- Age. 96% of patients are above 55 years old
- Diet rich in animal fat
- Previous vasectomy
Note: sexual activity is not a risk factor
HOW TO PREVENT PROSTATE CANCER?
Prostate cancer can be detected at an early stage by:
- Digital Rectal Examination (DRE)
- Blood level of Prostate-Specific-Antigen (PSA). PSA of more than 4mg/ml is abnormal.
By combining these two tests, the accuracy of early detection is improved.
HOW CAN ONE DETERMINE THE SEVERITY OF PROSTATE CANCER?
Two parameters are used to determine the severity of Prostate cancer.
STAGE that measures the extend of spread
Stage 1 – Localized. Cancer is confined to the prostate gland.
Stage 2 – Locally invasive:
- Capsular invasion
- Invasion of adjacent organs such as seminal vesicles
- Spread of pelvic lymph organs
Stage 3 – Metastatic. Widespread cancer, which includes bone involvement.
GRADE which measures the aggressiveness of the cancer cells.
Grade 1 – well differentiated
Grade 2 – moderately differentiated
Grade 3 – poorly differentiated – most aggressive
PROSTATE CANCER SYMPTOMS
In the early stages of prostate cancer, there may be no signs and symptoms. However, as the cancer grows, the signs and symptoms can include:
- Difficulty urinating
- Force of urine stream weakens
- Semen contains blood
- Discomfort in pelvic area
- Pain in bones
- Erectile dysfunction
- Elevated PSA in the blood test results
- A lump detected during a Digital Rectal Examination performed by a doctor
PROSTATE CANCER TREATMENT OPTIONS
Treatment may not be necessary right away for patients with early stage prostate cancer. In some cases, patients never need treatment. Instead, regular check-ups for symptoms will be recommended. For serious cases, the treatments options are:
- Active surveillance: If your cancer characteristics have a very low risk of spreading, active surveillance (AS) is considered to be one of the possible treatment options. Active surveillance is a strategic treatment that can be given if you have early low risk prostate cancer as opposed to immediate curative treatment. It aims to minimize unnecessary treatment and the side effects until clinically indicated. This treatment aims to achieve the right timing for curative treatment.
During this treatment, close follow-ups are necessary and your serum PSA levels are checked once every six months. An annual prostate biopsy and digital rectal exam is also necessary to confirm that the prostate cancer cells haven’t turned aggressive over the course of treatment.
If any of these markers indicate aggression of the disease, you will be advised to proceed with curative treatment. Curative treatment may be delayed for several years in younger men until the cancer becomes clinically worrying of aggressive spread.
WILL ACTIVE SURVEILANCE CAUSE PATIENTS TO MISS THEIR “WINDOW OF CURE”?
According to a recent review of over 3,900 patients, active surveillance is safe for the majority of patients with low-risk cancer characteristics.
2.8% of AS patients with the longest follow up reported incidences of developing bony metastases during follow-up. On the other hand, 27% of patients who underwent curative treatment (surgery or radiation) developed worrying characteristics during follow-up PSA testing and repeat prostate biopsies.
- Radiation therapy: Radiation beams are directed at the body to kill cancer cells. This is used to ablate the cancer cells in the prostate.
- Robotic assisted laparoscopic radical prostatectomy: The da Vinci® Surgical System is used to perform surgery through small incisions. This robotic prostatectomy has gained popularity worldwide since its inception in 2002. This technology consists of a surgical cart that is placed next to the operating table to small ports placed through the incisions of less than a centimetre in the abdomen.
Robotic wristed instruments are inserted in these small ports into the abdomen. A binocular camera lens allow the surgeon a three dimensional view of the operating field that can be magnified up to twelve times. The instruments are specially designed to give the surgeon excellent precision and dexterity of surgical movement.
WHAT HAPPENS DURING ROBOTIC PROSTATECTOMY?
First, you will be put under general anaesthesia. Then, six keyhole incisions less than a centimetres are made in the abdominal wall where the robotic instruments will enter. The prostate, bladder and seminal vesicles are dissected from the surrounding tissues.
The seminal ducts will then be disconnected on either side. Next, the prostate and seminal vesicles will be removed after securing the blood vessels supplying these organs. The bladder will then be sewn to the urethra using sutures. A urinary catheter will be left in the bladder for about five to seven days for adequate healing.
If you have low-risk prostate cancer, your surgeon will normally attempt to spare the nerves controlling erectile function and urinary control to facilitate for faster recovery of these vital functions. Patients who are under sixty five will benefit most from curative prostate cancer surgery.
HOW LONG TO STAY IN HOSPITAL AFTER ROBOTIC PROSTATECTOMY?
Patients are normally discharged after two to three days with an indwelling catheter. This will be removed around a week after surgery. Patients can go back to most normal activities and work two to three weeks after surgery.
Most of the time, patients who undergo robotic surgery will experience less bleeding and pain compared to conventional open surgery. Normally, patients will return to the general ward upon waking up. Due to the small incisions, there is usually little pain post-surgery and you will be able to walk the following day.
WHAT ARE THE SIDE EFFECTS OF ROBOTIC PROSTATECTOMY?
There will be some degree of urinary leakage after the catheter is removed. This will mean that patients will be required to wear pads or diapers until their pelvic floor muscles become strong enough to resume adequate urinary control.
Improved robotic surgery allows most patients to recover full urinary control within three to four months. Another common side effect is erectile dysfunction. This tends to take about nine months or longer to resolve. This is due to injury to the nerves during pelvic surgery.
CAN ROBOTIC PROSTATECTOMY BE USED TO TREAT AGGRESSIVE PROSTATE CANCER? OR IS CONVENTIONAL OPEN SURGERY OR RADIATION THE ONLY OPTION?
Recently, many centres have reported positive results with robotic surgery with surgical margin and PSA recurrence rates similar to or better than open surgery for aggressive prostate cancer.
Extended removal of the pelvic lymph nodes during surgery in high-risk patients helps to significantly reduce the chances of recurrences. Patients with lab reports that show the cancer has spread outside the prostate capsule or involved the attached seminal vesicles will require a short course of adjuvant radiation to completely kill off cancer cells in the
DIAGNOSING PROSTATE CANCER
The following tests can be used to diagnose prostate cancer:
- Prostate-specific antigen test (PSA): This test measures the protein that is produced by the prostate gland.
- Ultrasound: Sounds waves are used to produce images of the prostate gland. A small probe will be inserted into the rectum during this procedure.
- US guided needle biopsy: This procedure is conducted to confirm or exclude the presence of malignant cells in the prostate.