Clinical Specialties : Oncology and Robotics

Prostate Cancer

The prostate is a gland, about the size of a walnut, responsible for producing the fluid that makes semen. The prostate is located in the deep pelvis just above the rectum. However, the prostate is part of the urinary tract and sits between the bladder and the rest of the urethra. The prostate has a hole in the middle of it (the prostatic urethra) to allow urine and sperm to pass through it. Some people think of it like a donut, where the urine passes through the donut hole.

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Prostate Cancer is the most common non-skin cancer affecting men in the US. It is the second most common cause of cancer related death in the United States. Almost all prostate cancer is called prostate adenocarcinoma. It becomes exceedingly common as men age. Many risk factors have been looked at, however most have not shown a strong relationship with prostate cancer, except in select patients. A family history of prostate cancer, especially in your father, brother, or close male relatives may confer a higher chance of prostate cancer. A high fat diet has also been suggested to cause prostate cancer as well, although definitive data is lacking.

Signs and Symptoms

Most localized prostate cancer DOES NOT have specific symptoms. This is why screening tests like the PSA blood test is often used to help find prostate cancer. Occasionally, prostate cancer may present with difficulty urination, urinary frequency, or blood in the urine. However, these symptoms are often not related to prostate cancer and are very common in men who do not have prostate cancer.

Localized Prostate Cancer typically causes no symptoms. Urinary frequency (daytime or nighttime), weak flow of stream, and urinary hesitancy are common symptoms among aging men. These symptoms are often not related to prostate cancer, therefore, screening tests, such as PSA or DRE, are crucial in obtaining a diagnosis early in the disease process.

Symptoms of metastatic prostate cancer can include:
Bone Pain
Unintentional Weight Loss

Screening

Prostate cancer is most often suspected on screening tests. There are 2 tests used to screen for prostate cancer and both are very important. It is important to remember, screening tests do not confirm prostate cancer, they only make us aware of the possibility.

1. PSA – this is a simple blood test that looks for specific enzymes that the prostate makes which leaks into the blood vessels. Many PSA tables haves been created which use age and race to determine what are abnormal values. Your PSA trend over time is also helpful in determining the chances of cancer. Your PSA may be elevated for a variety if reasons including benign prostate enlargement, inflammation of your prostate, prostate cancer, or idiopathic (no good reason). Prostate cancer is the cause of an elevated PSA about 30% of the time based on studies.

2. Digital Rectal Exam – This is a very quick exam, where your doctor placed a finger in your rectum to feel the surface of your prostate. If it is abnormal, he or she may recommend further diagnosis.

Diagnosis

The definitive test to see if you have prostate cancer is a biopsy of the prostate.

Transrectal Ultrasound guided prostate Biopsy: If cancer is suspected, a trans-rectal ultrasound-guided biopsy will be performed. An ultrasound probe is inserted through the rectum to visualize the prostate gland. Local anesthesia is then injected into the prostate and 12-16 biopsies, or cores, are obtained with a thin needle. The procedure is uncomfortable but typically not painful. It is done in the office. Afterward, you should expect some blood in your urine, stools and semen.
A pathologist will evaluate the tissue microscopically. The pathologist will then write a report on his/her findings, which usually takes at least 1 week. The

Gleason Score

If prostate cancer is found on biopsy, the pathologist will grade the cancer using the Gleason Score. This score is used to help determine the aggressiveness of the cancer. A pathologist will look at the samples, or cores, of prostate tissue. He/she will determine the grade based on the pattern of the tissue. The grading scale goes from 1-5. The more the tissue looks like a normal pattern of prostate tissue, the lower the grade. The pathologist will then grade the two most common patterns of cancer in each biopsy specimen. The result is a 2 number score which usually reads like 3+3 or 4+5, etc. The Gleason sum is the two numbers added together. We use the highest Gleason scores in your biopsy to determing your final Gleason sum. The lower the score, the lower the aggressiveness. The lowest score given on a prostate biopsy is usually Gleason sum of 6 (3+3).

Risk Groups

Because prostate cancer is so common, we stratify the prostate cancer into risk groups to help you decide which treatment is best. There are three important factors we use to assess the risk of your prostate cancer: DRE, PSA, and Gleason Score

Low Risk: PSA <10 DRE: normal or palpable abnormality in only 1 quarter of the prostate Gleason Sum: 6 or less

Intermediate: PSA 10-20 DRE: palpable abnormality in half of the prostate Gleason sum: 7

High risk PSA >20 DRE: palpable abnormality extending beyond the prostate Gleason sum: 8-10

Treatment

We offer a multi-disciplinary approach in treating prostate cancer. We work closely with Radiation oncology, Medical oncology and pathology to ensure optimal care and treatment for our patients.

Active Surveillance (AS) is only a treatment option in select patient with low volume, low risk cancer. This is not a curative treatment and will not treat the prostate cancer. However, this may defer or delay (definitely or indefinitely) the need for definitive treatment for prostate cancer. This is supported by the fact that localized cancer has a low risk for clinical progression within the first 10-15 years after diagnosis. (AUA) Complications include growth and spread of the cancer. Before you can join active surveillance, you need to have a second confirmatory prostate biopsy to ensure there are no aggressive components to the cancer. If you are still eligible for AS, you will have your PSA blood tests checked every 3-6 months, and a repeat prostate biopsy every 12-18 months. A prostate MRI may also be used as an adjunct to monitor your cancer. If your cancer does not progress, you can maintain surveillance. If your cancer progresses, you may be recommended for active treatment.

Radical Prostatectomy (RP) is indicated in patients in good health, with a life expectancy greater than 10 years, with a diagnosis of localized prostate cancer. RP is performed with intent to cure the disease. Through this treatment approach, the entire prostate is removed, including the prostatic urethra, seminal vesicles, and adjacent pelvic lymph nodes. The bladder is then sutured to the urethra to ensure the flow of urine. A foley catheter is placed to help this area heal. The Foley catheter stays in place for 7-10 days. Most patients spend 1 day in the hospital. RP can be performed through an open incision or with a robotic approach, although 85% of prostatectomies are performed robotically in the current era.

Robotic Assisted Laparoscopic Prostatectomy (RALP)
The robotic system allows for a more meticulous dissection of the prostate gland through greater magnification and maneuverability. Benefits to the robotic approach include smaller incisions, less blood loss, less pain, and shorter hospital stays. It does however involve typical risks of surgery.

Possible Long term complications:
1. Stress Incontinence: most men will leak some urine after the Foley catheter is removed. IT will take some time for men to strengthen the muscle which restores their urinary control. Most often it may take one to twelve months. Until the continence is restored, most men will use a pad to help control any urine leaks. You will learn special exercises (Kegel Exercises) to help strengthen your muscles starting about 1 month after surgery.

2. Erectile Dysfunction (ED): The nerves that help produce erections lie on the sides of the prostate. During RP, these nerves are typically spared in the dissection of the prostate gland, as long as the cancer is not close to the nerves.

Three factors influence long term ED: 1. Age (younger men fare better) 2. Sexual function prior to surgery 3. How well the nerves were spared during surgery

ED following prostatectomy is addressed at follow up appointments. Return of sexual function is gradual and may take 1 month to 12 months and is different for each man. However, most young men who undergo nerve sparing are able to recover erections.

External Beam Radiotherapy (EBRT) involves approximately 6-8 weeks of daily treatments in which a beam of energy is directed at the prostate. This treatment approach is also used with intent to cure the disease. In patients with high-risk disease, hormone therapy is sometimes used simultaneously with EBRT. Intensity-modulated radiotherapy is a technique to avoid radiating healthy tissue in the surrounding area. Complications include erectile dysfunction, bladder irritation, urinary incontinence, GI disturbances, and small chance of development of a secondary cancer (most commonly bladder cancer).

Brachytherapy (prostate seeds) is a form of radiation therapy that is administered inside the body. Only patients with low risk prostate cancer should consider this treatment. An ultrasound is inserted through the rectum to implant radioactive pellets, seeds, into the prostate. This approach requires anesthesia. Complications include bladder irritation, urinary incontinence, and urinary retention.

Focal Therapy

HIFU (High Intensity Focused Ultrasound) involves heating the prostate tissue, enough to cause death to the tissue. A device is inserted through the rectum to deliver this high energy and usually requires anesthetic. Complications include urinary retention, and incontinence. Long- term effects have not been determined and it is not yet FDA approved.

Cryotherapy involves freezing the prostate with liquid nitrogen or argon to allow for cell death within the prostate. This outpatient treatment usually requires anesthetic and can be repeated. Complications include erectile dysfunction, incontinence, and bladder irritation.

Hormone Therapy involves administration of oral medications and/or injections used to block production or activity of male hormones with the goal to prevent growth of cancer cells. Side effects include fatigue, low libido (sex drive), hot flashes, development of breast tissue, and osteoporosis.

Resources:
http://www.cancer.org/treatment/supportprogramsservices/mantoman/index
http://www.cdc.gov/cancer/prostate/index.htm