- What is Prostate?
- What is Prostate Cancer?
- What are the Symptoms of Prostate Cancer?
- Diagnosis of Prostate Cancer
- Prostate Cancer Treatment
- 2. Prostate Cancer Surgery
- Side Effects of Prostate Cancer Surgery
- Operation to Remove the Prostate and Lymph Nodes
What is Prostate?
Prostate is an organ that is located under the urinary bladder and the urinary channel passes through it. Its absence isn’t vital. But, it is nevertheless a vital organ in terms of reproduction and sexual functions. It causes complaints due to two reasons. Enlargements associated and unassociated with cancer. This article will touch upon prostate cancer. Please click here for benign enlargements of prostate.
What is Prostate Cancer?
Prostate Cancer is the malign enlargement of the prostate. The prostate, its shell and the seminal vesicles are removed as a whole during prostate cancer surgeries. It is also mandatory to remove all lymph nodes that are located on both sides of the pelvis as well as all lymph nodes that are located on the main blood vessels of the rear abdominal wall (Radical prostatectomy + Extended lymph adenectomy). When performed duly, prostate cancer surgery is a very sophisticated and difficult surgery. Today, prostate cancer surgeries not accompanied by extended lymph node surgery are considered to be inadequate. One cannot understand the extent of upwards cancer metastasis that has jumped into lymph nodes. For this reason, all lymph nodes should always be removed in order not to leave any cancerous tissues behind.
Is Prostate Cancer Genetic?
Prostate cancer may owe to reasons such as obesity. It is genetically more common in black persons. The familial predisposition of prostate cancer has been proven. Normal persons should be applied PSA test after 50 years of age, which should be after 40 years for those with genetic predisposition. Male children with fathers and uncles having prostate cancer are 2-3 times more disposed to prostate cancer. It is 7-8 times if the disorder exists both in father, uncle and also children.
What are the Symptoms of Prostate Cancer?
Prostate cancer doesn’t manifest any symptoms during the beginning phase. When the prostate cancer causes urination symptoms, this means that it has metastasized to the interior of the prostate. In some cases where it manifests no symptoms, it reveals itself with pains of the back and the torso. When orthopedists take a film due to pain, it is seen that the cancer has metastasized to the bones. It is very difficult to treat in case of metastasis to bones. For this reason, those with familial disposition should be examined by an urologist after 40 years of age, which is after 50 years for others.
Diagnosis of Prostate Cancer
Prostate cancer is diagnosed by blood PSA test, examining the prostate with finger and prostate biopsy. PSA test and finger examination are the initial procedures. A biopsy is taken in cases suspected for cancer. Only after the 3rd procedure we can concretize whether the patient has cancer and whether the cancer requires surgery. Not all prostate cancers are dangerous and require surgery.
Examining the Prostate Cancer with Finger
The prostate is an organ that can be felt at a finger’s distance. A simple examination of the prostate from the anus provides the physician with important clues about the organ’s hardness and dimension. Hardness raises suspicion about cancer.
Prostate Cancer PSA Test
PSA (Prostate Specific Antigen) merges into blood by being secreted from both normal tissue cells and prostate’s cancer cells. We look at the patient’s PSA value for this reason. In diagnosis, PSA is not a definitive cancer indication. PSA follow-up after prostate cancer surgery is important. High PSA after surgery shows that the cancer remains or has repeated. PSA should fall below 0.01 ng/ml 4-6 weeks after surgery. Values higher than 0.01 shows the presence of cancer cells in the body. In such case, we consider supplementary radiotherapy requirement. PSA has more importance in follow-up than in diagnosis.
Prostate Cancer Biopsy
Final diagnosis of prostate cancer should always be pursuant to a pathologic evaluation of 12-15 quadrant biopsy. It is vital that the biopsy is examined by an experienced pathology department. Biopsy may detect no cancer. Meaning that each abnormal PSA and prostate examination isn’t necessarily cancer.
When biopsy detects cancer, it reports the metastatic degree of it. Depending on the metastatic features of cancer, it is defined under low, middle, high and very high risk groups. 45 percent of cancers belong to low risk group. Cancers in low risk group do not require surgery. They are not metastatic. They are not lethal (3+3 and some 3+4 cancers according to Gleason classification). Prostate cancers in low risk group shouldn’t be operated but actively followed-up. Prostate cancers in low risk group are followed-up by measuring blood PSA every 3 months and a biopsy again at the end one year (active follow-up).
Prostate cancers in medium and high risk groups should always undergo treatment. Gleason 4+4, 5+4, 4+5, 5+5 cancers are aggressive ones. The higher its aggressiveness, the more lethal it becomes. Medium and high risk group cancers of the prostate follow an arithmetic sequence in metastasis. They initially spread to the nearby lymph nodes through the white blood vessels (lymph channel) surrounding them, later to the main vessels above, remote lymph nodes and later primarily to bones and other organs through blood. Bone scintigraphy, computerized tomography and MRI imaging may also be needed for determining the treatment method.
Prostate Cancer Treatment
1. Active Follow-Up in Prostate Cancer
Active follow-up is the non-surgical treatment of prostate cancer. Active follow-up is only applied to the low risk group cancers of the prostate. PSA test is performed at quarterly periods. The biopsy is repeated at the end of the 1st year if there is no excessive rise in the PSA value. We don’t wait 1 year if there is an excessive rise in the PSA value. An inexperienced pathologist may report low risk group as middle, and middle risk group as low risk group cancer (pathologic examination error). During active follow-up, the principle purpose of the biopsy taken one year after is to reveal the possible pathologic error in the first biopsy. The treatment type is determined according to the pathologic evaluation of the second biopsy. We recommend multi-parametrical MR screening biopsy instead of the traditional method for the second biopsy. That is because it is beneficial to perform the secondary biopsy in the company of MR screening, which yields better results for diagnosing cancer. 10-15% of those diagnosed as low cancer group during the first biopsy are reported as middle risk group cancer during the second biopsy. This owes to the previous pathologic evaluation error. Low risk group of prostate cancers don’t evolve into medium or high risk groups. Studies have shown that this one year’s delay in the 10-15% patient group has no impact of the life expectancy of patients (Filippou et al., European Urology 2015.06.011).
Although not required, some patients under active follow-up insist on undergoing surgery due to fear of cancer. Patients should be explained that this unnecessary operation might disrupt sexual performance and cause urinary incontinence. Today, patients are given better information and physicians are trained according to contemporary guidelines. Prostate cancer patients of the lower risk group, who were operated unnecessarily in the past, are today being followed-up without surgery (PIVOT; Prostate Cancer Intervention and Observation Trail).
2. Prostate Cancer Surgery
There are 3 separate techniques in prostate cancer surgery;
• Open Surgery • Laparoscopic Technique • Robotic Surgery
ong-term results of these 3 surgeries are similar. Success depends on the experience of the surgeon on this technique rather than the technique itself. If the principle of leaving no cancerous cells is applied (removing the prostate, seminal vesicles and all lymph nodes), this means that the cancer surgery has been applied in accordance with the rules regardless of the surgical method chosen. It is not sufficient to remove the prostate with the seminal vesicles and peripheral tissues as a whole. One should always remove all lymph nodes and the channels thereof that are located the main blood vessels (aorta - vena cava), which start from the periphery of the prostate and extend on both sides along the pelvis and the lower walls of the abdomen, which is called Extended Lymph Adenectomy.
The surgical principle in all cancers is to remove the cancer inclusive of all peripheral tissues and organs in a manner to leave no cancerous tissue behind. In cases where cancer has spread to the peripheral tissues and organs, leaving cancerous tissue for preserving the penile function will serious imperil the patient’s life. Meaning that in order to evade problems in penile erection, leaving the cancer, which has spread to the nerves and blood vessels that erect the penis, is a grave mistake. This will entirely imperil the patient’s live as cancerous cells are left behind.
After the prostate cancer grows within the organ, it begins to spread into the peripheral tissues. It spreads to the nerves and blood vessels that erect the penis, seminal vesicles and the outer surface of the large intestine. This is called prostate cancer that has exceeded the organ. Even in such cancers that have exceeded the organ, a sophisticated surgery performed by experienced surgeons may relieve patients completely from cancer.
Why should lymph nodes be removed during prostate cancer surgery?
Medium and high risk group cancers of the prostate follow an arithmetic sequence in metastasis. It initially spread to lymph nodes and later to the bones and other organs. If the prostate cancer cell is aggressive, it may jump to lymph nodes through lymph channels even it has not exceeded the organ. As prostate cancer first spreads to lymph nodes, it is very important to remove all lymph nodes alongside the pelvis and the rear abdominal walls during prostate cancer surgery (extended Lymphadenectomy). No screening method shows the extent of cancer spreading to lymph nodes.
The extent of cancerous spreading can only be understood by a pathologic examination after the lymph nodes are removed. The probability of leaving cancerous tissue behind is high in operations where the lymph nodes aren’t removed. Operations where the prostate is removed without extensively removing the lymph nodes are deficient operations.
Studies have shown that even no cancer is detected in lymph nodes, there can be cancerous cells at molecular level that cannot be detected by a normal microscope. Removing lymph nodes ensures that possible cancerous nodes, which cannot be shown by microscope, are also eliminated. (Extended lymph node dissection).
####Closed Surgery in Prostate Cancer;
Carbon dioxide gas is administered the patient’s abdomen during laparoscopic technic and the robotic surgical technique and an area is therefore created for easily using the tools. The difference between these two techniques is that during laparoscopy, the surgeon personally uses the tools at the operating table. The doctor is not at the table during robotic surgery. Robotic arms, which operate as the hands of the surgeon, detect the hand movements of the surgeon and perform the surgery. Both techniques represent closed surgery.
Enlargement and three-dimensional view, absence of tremor filtration (robotic arms don’t shake), ability to apply sutures with robotic arms from different angles, ability to use both robotic arms (ability to use the right and left hands), movement in seven planes and cosmetic view (hole trace instead of an incision on the abdomen) are the advantages of robotic surgery.
Prostate and lymph node nodes are located outside the peritoneum (extraperitoneal). This method requires entering the peritoneum and exiting the peritoneum again for reaching the prostate. It is like showing the ear from the reverse. Surgeries performed outside the peritoneum are advantageous in terms of rehabilitation and patient comfort. Absence of touching sensation for the physician (tactical stimulus), inability to change the patient’s position, requirement for more experience especially for lymph adenectomy, long operating time and high-costs are the disadvantages of closed method. Cleaning lymph nodes during closed surgery requires more experience than removing the cancerous prostate and takes longer compared to open operation. That is because lymph nodes are located on the main blood vessels and represent dangerous layouts.
Also during surgery, one may need switching to open surgery owing to situations such as bowel perforation, hemorrhage etcetera. Post-operative complications may occur due to the carbon dioxide gas administered to swell the abdomen. The cost of a single robot is nearly 2 Million 500 Euros (a single robot will set off its costs with nearly 350 surgeries per year). Costs further increase when robot’s annual maintenance expenses and per-surgery expenditures are added.
####Open Surgery in Prostate Cancer
By a 7-8 cm incision on the lower abdomen, the surgeon directly accesses the area behind the peritoneum (retroperitoneal area) without incising any muscles. Surgeon doesn’t enter the peritoneum as opposed to closed surgery. He can reach the prostate and lymph nodes that are located outside the peritoneum (extraperitoneal) from the exterior of the peritoneum. Presence of touching sensation, ability to change the patient’s position, short operating time, and an easy surgical view up to 4-5 cm above the main blood vessels (aorta vena cava) can be listed amongst its advantages.
An experienced surgeon can apply the advantages of robotic surgery also using his own hands instead of using robotic arms. He can make incisions and apply futures in 5-6 planes using wrist movements. With the lateral working method, surgery can be performed within a narrow area by making a small incision. With supported wrist movement techniques, tremor can be entirely controlled just like in robotic surgery. The tool operates and the hand prides. One shouldn’t forget that the hand is also a tool. The hand reduces technological requirement during surgery. The importance of touching sensation is obvious during the coordination between the hand and the brain. Hemorrhages even in small blood vessels can be easily brought under control with subtle hand movements and suture technique. (Manipulation on a parallel plane without pulling or tensing any tissue and without exerting force on suture lines during suturing and binding). With our surgical technique, patients can be discharged from hospital within 1-3 days. Post-operative rehabilitation is fast as we operate entirely outside the peritoneum. It is easily to remove lymph nodes during open surgery.
Its disadvantage is leaving a 6-7 cm suture mark on the lower abdomen. The surgeon should be very experienced as reaching and applying sutures on deep organs such as the prostate is more difficult. Reconnecting the urinary channel with the bladder after the prostate is removed is a difficult procedure.
3. Radiotherapy in Prostate Cancer
Radiotherapy in prostate cancer is applied in two ways.
Premier (first treatment)
With the modern techniques and applications today, post-radiotherapy side effects have significantly lessened. Radiotherapy that was administered with 39-day intervals in the past can today be administered at 20-day intervals. But one cannot say that it has replaced surgical treatment. That is because even modern screening methods cannot concretize the spreading extent of cancer. It can be applied on patients that have low life-expectancies and that don’t consent to surgery. Radiotherapy also disrupts sexual functions. Surgery is more beneficial for young patients. Hormone treatment is applied to the patient for 18-24 months in order to increase the effects of radiotherapy. This treatment suppresses testosterone. It has side effects such as bone thinning, depression and losses in conceptual skill. These can be partially prevented by increasing the physical activities of patients. One should explain radiotherapy option instead of surgical treatment to patients who apply for prostate cancer surgery.
It is applied in high-risk surgeries as a supplemental procedure when cancer remains or when cancer repeats later on after surgery. Effects of radiotherapy are increased by hormone (TAB) application.
Side Effects of Prostate Cancer Surgery
A comprehensive operation, which is performed in accordance with the principles of cancer surgery, may have some complications (side effects). Some of such complications may disappear over time. They can be treated if the contrary occurs. These complications and post-operative methods to be pursued should be explained to the patient and his close relatives.
1) Urinary incontinence 2) Sexual problems 3) Stricture in the urinary channel 4) Cyst formation** (accumulation of liquid called lymphocele in the region where lymph nodes are removed).
As the prostate’s location in the body is a critical region that hosts blood vessel-nerve and other formations that erect the penis, patients may suffer urinary incontinence and penile erection problem (impotence) after the surgery. Two main mechanisms that retain urine (bolts) are located beneath and over the prostate. Urination control is provided by these two urine retention mechanisms (sphincters). In all kinds of prostate surgeries, the internal involuntary sphincter (bolt) is always removed with the prostate. The patient may achieve urine control with the voluntary sphincter (bolt) only remaining. If this bolt leaks even a little, control can be achieved in a short period by the hold-leave exercises given to the patient. It can be treated with artificial sphincter (artificial bolt) surgery. During this surgery, the artificial bolt manufactured only by one company in the world is installed into the patient and represents a conclusive solution to urinary incontinence (artificial sphincter). In the simultaneous existence of impotence and urinary incontinence, penile prosthesis and urine retainer bolt can be installed by a single incision at the same time.
The prostate closely neighbors the nerves and blood vessels that erect the penis. These formations are in close contact with the prostate. It is possible that after surgery, the nerve and blood vessel network that erect the penis sustain damage. Removing such nerves and blood vessels may emerge as a requirement when the cancer spreads to the periphery of the prostate tissue. Erection problems in the penis may be corrected with some drugs. And in situations where erection is completely disrupted, penile prosthesis represents a conclusive solution.
During prostate cancer surgery, the prostate is removed with its capsule, the seminal vesicles and the peripheral tissues. The rear section of the urethra, which is the channel discharging the urine from the bladder, is also removed completely. The 3-5 cm gap occurring in the urinary channel is re-added to the bladder (urethro-vesical anastomose). Stricture may occur at this joint at later times. When this stricture advances, the patients have difficulties while urinating. Most of such strictures can be remedied by simple closed operations. In rare cases where the patient may not urinate at all, the patient is initially installed an apparatus to discharge the urine from the bladder, which procedure is called cystostomy. This is the only means for the patient to discharge his urine. Later an operation to rejoin the urinary channel to the bladder is performed (Perineal Re-Do Uretro-Vesical Anastomose). Even in the entire world, only a limited number of centers can perform this operation. We successfully perform this sophisticated surgery. The integrity of the urinary channel is re-ensured after this operation and the patient begins to urinate comfortably.
In cases where the lymph nodes are removed, there may occur cystic formations that are called lymphocele. Most of these disappear over time without treatment. One should avoid hasty, unnecessary interventions. It may require drainage in rare cases.
We successfully repair all complications mentioned above.