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Prostate Cancer

Prostate cancer is one of the most common forms of cancer in men. Over 230,000 American men are diagnosed with prostate cancer each year. In recent decades, there has been a steady increase in the incidence of prostate cancer but doctors are making progress in treatment and survival rates are improving. What are its symptoms? How do you know if surgery is the best treatment for you? The following information should help you better understand this condition.


What happens under normal conditions?

The prostate gland is about the size of a walnut. It is located between the bladder and the penis, and surrounds the urethra (the tube that carries urine from the bladder out through the penis). The prostate gland is part of the male reproductive system. The prostate is responsible for the production of semen, the milky white substance which nourishes the sperm. The semen is stored in small pouches, called seminal vesicles, which are attached to the prostate gland.


What is prostate cancer?

Prostate cancer is a disease that affects the cells of the prostate. It occurs when the normal process of cell growth within the prostate becomes abnormal. This causes uncontrolled cell growth resulting in a mass of tissue called a tumor. Like many cancers, the cause of prostate cancer is unknown. But doctors do know that it is more common as men age, in African-American men and men with a family history of the disease. Its growth is also enhanced by the male sex hormone testosterone. Prostate cancer is very common, with every man having a one in six chance of getting prostate cancer within their lifetime. Thanks to widespread knowledge about prostate cancer which has resulted in increased efforts at early detection (prostate cancer screening), about 80 percent of the men who are found to have prostate cancer have a disease which seems to be confined to the prostate and is therefore responsive to treatments, including surgery.


What are the symptoms of prostate cancer?

In its early stages, prostate cancer may not cause any symptoms. But as the cancer grows, the following symptoms may appear: frequent urination (especially at night), problems with urination (inability, weakened flow, pain, burning, etc.), painful ejaculation, blood in urine or semen and/or frequent pain or stiffness in the back, hips or upper thighs.


How is prostate cancer diagnosed?

Ideally, prostate cancer should be detected when it is so small that there are no symptoms. Early detection can be achieved by a digital rectal examination (DRE) and a PSA test. If either the DRE and/or the PSA is abnormal, a prostate biopsy is recommended. This biopsy uses an ultrasonic probe that is inserted into the rectum and a biopsy needle that is directed into various areas of the prostate gland. Believe it or not, this procedure is relatively painless and does not require hospitalization.

Once prostate cancer has been diagnosed by a prostate biopsy, the physician seeks to stage the disease; that is, to determine the extent of the cancer (i.e., the "T" stage) and whether it has spread to the lymph nodes and/or the bones. The clinical T stage is determined by the DRE and can be divided into the following categories:

  • T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed

  • T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed

  • T1c: Cancer is found by needle biopsy that was done because of an elevated PSA

  • T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate

  • T2a: Cancer is found in one half or less of only one side (left or right) of the prostate

  • T2b: Cancer is found in more than half of only one side (left or right) of the prostate

  • T2c: Cancer is found in both sides of the prostate

  • T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles

  • T3a: Cancer extends outside the prostate but not to the seminal vesicles

  • T3b: Cancer has spread to the seminal vesicles

  • T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis

To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT scan of the pelvis, an MRI of the pelvis, and/or a bone scan.

In addition to clinical staging, the physician seeks to determine the so-called "aggressiveness" of the cancer. This is done in two ways. The first way is by determining the grade of the cancer; that is, how "angry" it looks under the microscope. Briefly, the most popular prostate cancer grading system is the Gleason system. Each area of cancer in the biopsy is assigned a Gleason grade between 1 and 5. The two most common Gleason grades within a biopsy are added together to give the Gleason score which is designated between two and 10. Gleason scores of two to four designate well differentiated cancers that tend to be slow growing. Gleason scores of five or six are moderately differentiated while Gleason scores of seven to 10 are poorly differentiated. The second sign of aggressiveness is the PSA level before biopsy. In general PSA levels less than 10 are ideal, levels between 10 and 20 are somewhat worrisome for more extensive disease while levels greater than 20 are worrisome though cure is still sometimes possible.


What is a radical prostatectomy?

A radical prostatectomy is the removal of the entire prostate, the seminal vesicles, and the tissue immediately surrounding them. Because prostate cancer may be scattered throughout the prostate gland in an unpredictable way, the entire prostate must be removed so that cancer cells are not left behind. The pelvic lymph nodes, small oval or round bodies located along vessels that filter lymphatic fluid, are usually the first site of any spread of the cancer beyond the prostate gland. Normally, these lymph nodes are also removed during the operation. Fortunately, you have many other lymph nodes, so your body will not miss these few.


When is surgery the best treatment for prostate cancer?

In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Finally, prostate cancer surgery is usually restricted to men who have a 10-year or more life expectancy. Life expectancy is assessed by both patient age and health.


What are some risk factors associated with prostate cancer surgery?

Radical prostatectomy has the potential for both early and late complications. Early complications occur either at the time of surgery or shortly thereafter. Bleeding can occur in any major operation including radical prostatectomy. Some surgeons will recommend that the patient donate their own blood before surgery or to receive a hormone (epogen, EPO) that boost the patient's blood count to reduce the risk of the patient requiring blood from an anonymous donor. Injury to nearby structures like the rectum and ureters (tubes that drain urine from the kidney to the bladder) is uncommon. Infection in the incision site and/or urinary tract is also rare. Lastly, deep venous thrombosis (blood clot) and pulmonary embolism (blood clot that goes to the lung) occur in approximately 2% of patients after radical retropubic prostatectomy.

Long-term complications after surgery are primarily urinary incontinence (urine leakage) and erectile dysfunction (impotence). Short-term incontinence after radical prostatectomy is common. Many men will require a protective pad for several weeks to months after surgery. Fortunately, most men will recover urinary control. Long-term (after 1 year) incontinence is rare with occurrence in less than 5 percent of all surgical cases. However, when it does occur, there are procedures that can solve the problem.

Erection of the penis occurs because of the stimulation through the cavernous nerves, which send signals to dilate the blood vessels in the penis, allowing it to fill with blood and become rigid. The two nerve bundles responsible for erection run along either side of the prostate, only a few millimeters away from the area where prostate cancer most commonly arises. Although preserving these nerves at the time of surgery is always possible, it is not always wise. The less tissue removed around the prostate, the greater the chance that cancer cells will remain. Since the primary goal of the operation is to remove all of the cancer, one or both of these nerves may have to be completely or partially resected. Unless both nerves are resected, the chance of recovering erectile function exists, but recovery may be slow. The average time until recovery of erections sufficient for intercourse is four to nine months, but in some men it takes longer. Erections usually improve with time, for as long as two to three years after the operation, because nerve fibers recover slowly. Of course, the operation will not make your erections better than they were before surgery, even if both nerves are spared. Even with full recovery, most men find the erections are a bit less firm and durable than before surgery. Younger men recover sooner than older men and those with stronger erections before the operation have a better chance of recovery than if the erections were weak.

Impotence, if experienced post-surgery, can also be treated by a variety of medications and/or technical devices like penile prostheses.


What are the different types of prostate cancer surgery?

Retropubic prostatectomy: During this procedure, the surgeon makes an incision through the lower abdomen that is about 3 to 4 inches in length. The surgeon can remove the prostate, surrounding tissue and pelvic lymph nodes (if necessary).

Perineal prostatectomy: During this procedure, the surgeon removes the prostate through an incision in the skin between the scrotum and the anus. In general, the perineal surgery is a little easier on the patient, but it may be somewhat inefficient if the cancer is serious and the lymph nodes need to be examined before the prostate is removed.

Laparoscopic prostatectomy is a type of 'minimally-invasive' surgery that uses several small incisions rather than one larger incision to remove the prostate. Through the small incisions surgical instruments, including a camera, are inserted. The camera allows the surgeon to view inside the abdomen and perform the surgery. Because the surgery uses smaller incisions, the patient may experience less pain and scarring and a faster recovery than with the retropubic approach. This procedure is technically demanding and requires a surgeon with special training to perform the operation successfully.

Robotic-assisted laparoscopic prostatectomy is similar to laparoscopic prostatectomy but rather than the surgeon directly holding the instruments, a robot serves as an interface between the surgeon and the instruments. Advantages for the patient are similar to laparoscopic surgery.


What can be expected after surgical treatment?

At the time of surgery, the urinary tract is sutured back together over a catheter, a thin flexible tube to drain urine. This gives the anastomosis, or union between the bladder and the urethra, time to heal completely. The catheter will remain in place for one to two weeks after the surgery. The catheter is removed on a return visit to the surgeon's clinic, and exercises (called Kegel exercises) are begun by the patient to strengthen the urinary control valve. Urinary control (continence) can be immediate but usually takes several weeks to months to recover.

One or two suction drains are left beside the bladder, deep in the pelvic cavity, to drain any fluid that accumulates. The drains will exit from a small incision in your lower abdomen (or pelvic area). They help to decrease the risk of infection and pressure from fluid in the operated area. The drains are usually removed before you are discharged from the hospital.

While in the hospital, the patient begins his physical recovery. After the operation you will be in the Post-Anesthesia Care Unit (PACU) for a recovery period of several hours. You can have ice chips and water as soon as you are fully awake. Family members may also visit you in the PACU. You will be taken to your hospital room after the recovery period.

Fluids will be given to you through an intravenous (IV) line in a vein. The IV line will remain in place until you can tolerate fluids and food by mouth and you begin to eat a regular diet. You can progress to a clear liquid diet that evening or the next morning after the surgery. When your intestinal activity begins to recover, about 24 - 36 hours after the operation, you can eat solid food. Most people do not pass flatus (intestinal gas) for one to two days and do not have a bowel movement for four to five days. The goal during the first few days after your operation will be to prevent the breathing and circulation problems that can develop after any surgery. You must walk at least three to four times a day to help your breathing and circulation.

After the surgery, the surgeon reviews the final assessment of the removed prostate and (if applicable) the lymph nodes. Based on this "final pathology," a follow-up plan is developed. If the pathology is especially serious (e.g., spread to the seminal vesicles or lymph nodes) additional therapy may be recommended. This may include radiation therapy and/or hormone treatment. If the pathology is not especially serious, the follow-up plan entails regular visits to a physician and a regular PSA test. The PSA level should be non-detectable.

Erectile function may recover soon after the operation or may take up to one year to return. Usually, if erections are not sufficient for intercourse at one month, additional therapies are used until the erections become sufficient. One does not lose the ability to have an orgasm. However the orgasm is "dry"—very little (if any) ejaculation comes out—so the ability to procreate is generally lost.


Frequently asked questions:

When can I resume normal activity after the surgery?

The time varies, but usually it is between three to six weeks.


Will I know if I am cured after surgery?

Not completely and it certainly varies depending on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for ten years before cure is certain.


I worry about potency but I am most afraid of incontinence. What are the odds?

That depends mostly on the surgeon and his/her experience. But age and your current level of continence and potency are also key factors. Usually, incontinence is temporary and does not last long although it can persist for as much as six to twelve months. With more experienced surgeons, the risk of permanent incontinence is rare after prostate cancer surgery.

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