Radical prostatectomy involves surgically removing the prostate gland and the seminal vesicles. It is the most common treatment for localized cancer of the prostate in men under 70 who do not have other health complications.
It is performed through a lower abdominal incision (Open) or laparoscopically. During a laparoscopic prostatectomy, a telescopic instrument called a laparoscope is inserted into the abdomen through a small incision at the belly button. The laparoscope allows surgeons to view inside the abdomen and perform the surgery without having to make a large incision. Usually, four more small incisions are made in the abdomen to accommodate surgical instruments during surgery. This eliminates the need for a large surgical incision to remove the prostate. As a result, the patient may experience less pain and scarring, faster recovery and less risk of infection. In some cases, the surgical procedure may require conversion to the standard open operation if extreme difficulty is encountered during the laparoscopic procedure. Side effects of radical prostatectomy include:
Risk of blood clots
Urinary leakage (incontinence)
If the cancer is small, surgeons try to avoid removing or cutting the nerves that control a man's ability to achieve an erection (nerve sparing). Depending on the patient's age and the stage of tumor advancement, nerve-sparing techniques allow about 40 percent to 65 percent of men who were sexually potent before surgery to remain potent after surgery
ANDROGEN DEPRIVATION (HORMONAL TREATMENT)
Androgen deprivation therapy is the gold standard of care for men whose prostate cancer is advanced and has spread throughout the body. The therapy works by shutting down male hormones, principally testosterone, that promotes prostate cancer growth. It is also used in conjunction with radiotherapy for treating organ confined or locally advanced prostate cancer.
Roughly 95% of the male hormones come from the testis and another 5% from the adrenal gland. Androgen deprivation is achieved in 3 ways:
Bilateral Subcapsular Orchiectomy: Removal of the contents of both testis in a minor day operation. This is a permanent and cost effective method for patients with advanced prostate cancer
LHRH agonists: 3 monthly injections that decrease the levels of testosterone circulating in the blood. This is an effective and reversible form of androgen deprivation, but quite costly. It is often used in conjuction with radiotherapy.
Anti-androgens: Anti-androgens specifically block the action of testosterone at the prostate cells. It also acts the same way in the rest of the body to prevent androgens from working at their target sites. Anti-androgens are used alone or in combination with LHRH agonists.This combination is called total androgen blockade (TAB). TAB has not been shown to be more efficacious in increasing survival from prostate cancer.
Side effects of androgen deprivation are similar to "andropause" or male "menopause" and include decreased libido, erectile dysfunction, hot flashes, fatigue, osteoporosis, high cholesterol, anemia, forgetfulness and insomnia
Radioactive seeds are implanted into the prostate under xray guidance to "kill" the cancer cells. This is only suitable for small, less aggressive cancers. Long term results are still pending but it remains an attractive option to those wanting to avoid surgery.
Also known as active surveillance, this is an option for only the few who have very very "non aggressive" type cancers. It is thought that these are slow growing and therefore unlikely to be lethal. Constant monitoring is still necessary to see if things ever change.
TRUS (TRANSRECTAL ULTRASOUND ) BIOPSY
A Transrectal ultrasound (TRUS) of the prostate gland is performed when
a nodule is felt by a physician during a routine physical or prostate cancer screening exam
an elevated blood PSA test result is noted
evaluating a patient with male infertility
In men, the prostate gland is located directly in front of the rectum, so the ultrasound exam is performed transrectally. The cylinder-shaped ultrasound probe is gently placed in the rectum as the patient lies on his left side with the knees bent
The ultrasound probe allows a needle to be advanced into the prostate gland while the urologist watches the ultrasound images. Your doctor will usually follow a set protocol on the site and number of biopsies to take as the prostate ultrasound image can look perfectly normal in early stage cancer. This ultrasound examination is usually completed within 20 minutes and is performed in the clinic or day suite. Preparation includes having an enema and taking some prescribed antibiotics the day before.
PSA (PROSTATE SPECIFIC ANTIGEN)
The PSA test measures the amount of Prostate Specific Antigen (PSA) in the blood PSA is a glycoprotein (a protein with a sugar attached) found in prostate cells. It can be detected at a low level in the blood of all adult men.
Normal values vary with age. Older men typically have slightly higher PSA measurements than younger men. PSA of 4 ng/ml is considered high for most men and may indicate the need for a prostate biopsy. For men younger than 60, PSA have lower normal limits : Age 40 -49 <2.5 ng/mL ; Age 50 – 59 < 3 ng/mL
A high PSA level does not confirm the presence of cancer. It only identifies patients at higher risk of having prostate cancer. Several conditions besides cancer can cause the PSA level to rise. These include urinary tract infections, an enlarged prostate, prostatitis, recent placement of a urinary catheter or surgery on the urinary tract.
A TRUS biopsy of the prostate is required to confirm prostate cancer. Keep in mind that only 1 in 4 men with a PSA level between 4-10 ng/ml have prostate cancer..
Although PSA testing is an important tool for detecting prostate cancer, it is also not foolproof. 1 in 5 men with prostate cancer have a "normal" blood PSA level.
The PSA level is also used to monitor for recurrence after treatment of prostate cancer. For example, after surgical removal of the prostate (radical prostatectomy) PSA should be near zero.
PROSTATE HEALTH SCREENING
While it has not been conclusively shown that a mass screening program will decrease mortality from prostate cancer, it is acknowledged that early prostate cancer is often without symptoms and that prostate cancers detected by screening are often significant cancers. When detected early, cure rates are excellent. It has therefore been recommended that men over 50 (40 in those with first degree relatives with prostate cancer) have a yearly digital rectal examination and PSA test. Men with suspicious results will be counselled about a TRUS biopsy.
Our prostate health screening consists of a consultation with a urologist, examination including a digital rectal examination, assessment of urinary flow and post void residual volume and a PSA test.
DIGITAL RECTAL EXAMINATION (DRE)
This is performed to determine if the prostate is enlarged or abnormally lumpy (nodular).The patients lies on his left with his knees bent while the doctor inserts a gloved lubricated finger into the rectum. Some patients may find this a little uncomfortable but it is neither painful nor harmful. This examination goes hand in hand with PSA testing to determine if a man is at risk for prostate cancer. Patients with suspicious DREs will often be recommended to undergo a TRUS biopsy.