Oncology

Prostate cancer Prevention – Treatment

Prostate cancer consists the most frequent malignancy in men and the second cause of death from cancer, after lung cancer. One in six men will develop prostate cancer, while men whose father or brother (first degree relatives) has been affected by cancer are 2.4 times more likely to develop cancer. And if cancer has been diagnosed in this relative at a relatively young age (for example in the 5th decade of their life), chances are doubled. Chances of developing prostate cancer increase with age. Thus, 30% of men will be affected by the age of 50 and 80% by the age of 80.

Although there are no symptoms, it can be effectively treated if diagnosed in early stages. The exact cause of prostate cancer is not known, however there are many ways to prevent it. It is important for someone to know that, given the fact that prostate cancer has no symptoms in early stages, if there are no preventive examinations, the diagnosis will be made from the symptoms of metastases (for example pain from bone metastases), that is, when it will be to late.

Prostate cancer can be detected in time by a preventive medical control, that includes the digital rectal examination and the detection in the blood of the prostate specific antigen (PSA). PSA is a substance which is normally produced by the prostate. The presence of normal or low levels of PSA in the blood does not necessarily rule out the presence of cancer, as, on the other hand, its increase does not necessarily mean that there is prostate cancer.

Thus, attention must be paid because, on one hand, prostate cancer which is accompanied by normal or low PSA levels is more undifferentiated and consequently more agressive and, on the other hand, patients with high PSA levels could undergo useless examinations that cause mental suffering to them and their environment. Thus, PSA is an examination, which must be taken into account correctly, by evaluating in parallel other parameters. The only competent person to carry out this procedure is the specialized urologist and not other doctors of different specializations or the patient, considering only the reference values of the examination.

The detection of prostate cancer in time significantly reduces the mortality of the disease and the danger of development of metastases and of cancer in advanced stage. The instructions of the European Association of Urology recommend the measurement of a reference value of the prostate specific antigen (PSA) at an age of 40-45 years and the individualisation of periodic monitoring, depending on the PSA reference value and the presence of other risk factors.

If the urologist judges that there is a possibility to diagnose prostate cancer, he performs a biopsy by getting prostate particles, with the aid of a thin needle which is directed by ultrasounds, through the rectum. This is the only way to diagnose the disease.

Unfortunately there is no other examination or any other way to absolutely exclude the disease and thus, if the biopsy is negative, the chances of prostate cancer are reduced but not eliminated. Consequently, the monitoring must keep going on and, if it is deemed necessary, the biopsy must be repeated.

When the disease is diagnosed in early stages, it can be treated and it is usually fully cured. The treatment includes three methods. The surgical removal of the whole prostate gland, of the seminal vesicles and, sometimes, of the lymph nodes of the region and then it is called radical prostatectomy, the external radiotherapy and the internal radiation of the prostate, with implants of radioactive material, which is called brachytherapy.

The pharmaceutical treatment is not the proper treatment for prostate cancer in early stages and its application, although that it can be initially effective, will delay the radical treatment of the disease, with possible dangerous results. Although all three techniques present equally good therapeutical results in the relative literature, my opinion is that radical prostatectomy is the optimal treatment for localised prostate cancer because, compared to the external or internal radiation method, it is more advantageous due to the fact that the disease is fully removed from the body, is examined histologically and thus the complete surgical removal or not can be fully confirmed. Besides that, it seems that for younger patients it has the best long-term disease-free survival results.

Today, radical prostatectomy can be performed in three ways: the classical open operation with a moderate incision in the lower part of the abdomen, the laparoscopic operation which is performed with the aid of special instruments and of a camera, that pass through 4-5 small punctures in the abdomen, of a size of 0.5-1cm, after the abdomen has been previously dilated with the aid of an inactive gas and, finally, the robotic operation, which is a laparoscopic operation, where the laparoscopic instruments are moving with the aid of robotic arms, that are directed by the surgeon through a control panel.

The parameters that must be taken into account in the selection of a method include parameters of the tumour (size of the prostate, possibility of metastases to lymph nodes, coexisting local disorders, for example inguinal hernia, pervious operations and therefore symphyses in the area, for example open prostatectomy of benign hyperplasia), parameters of the patient (body type, concomitant aggravating diseases), adequacy of materials for the laparoscopic and robotic operations and experience of the surgeon in each method. It is important to consider that the latest techniques may be more advantageous, in some factors, than the classical operation, but, on one hand, they do not consist a universal remedy and, on the other hand, the selection of the method is finally performed by the doctor, with the agreement of the patient.

The laparoscopic and the robotic surgery are more advantageous, firstly, due to the use of camera for the operation. This allows a singificant magnification (zoom in) and consequently a better vision and, therefore, the minimalisation of injury of the nearby healthy tissues. Particularly in a robotic operation, the surgeon has the capacity of tridimensional (3D) vision. At the same time, the use of robotic arms allows the execution of movements that cannot be made by the human hand, with a high precision and stability. This helps avoiding pointless injuries of the nearby tissues. In parallel, due to the excellent vision and to the high manipulation precision, the surgeon can save the erection nerves, which lie in parallel to the prostate capsule, so that the patient could maintain his erection postoperatively, at least with the use of adjuvant pills. Furthermore, the mechanism of the urethral sphincter can be more easily protected and thus the postoperative urinary incontinence can be partially or completely prevented.

The verification of the aforementioned logical conclusions from the use of newer techniques must be also confirmed by the relative literature in order to be accurate. Thus, the latest data from the most recent guidelines of the European Association of Urology show that the robotically assisted laparoscopic radical prostatectomy is accompanied indeed by a smaller blood loss and need for blood transfusion, a shorter hospitalization time and a smaller need for painkiller treatment, in comparison to the open operation.

The catheter can be removed postoperatively more fastly and the patient can return sooner to his activities. Regarding the oncologic result, which is the main concern of the doctor and the patient, it seems that regarding the excision of the tumour on healthy tissues, it is equivalent with the open radical prostatectomy. However, regarding the recurrence of the disease and the overall survival of the patients, there are no comparable data yet, because the robotic operation is a new procedure and has not been yet evaluated. Finally, regarding the long-term complications of the radical prostatectomy, that is incontinence and erectile dysfunction, it seems that there is some superiority of the robotically assisted operation, but many more properly designed studies are needed, so that this can be proven.

In order to select the appropriate method of radical prostatectomy must be also considered some other factors. Thus, the cost of the robotically assisted operation primarily is much higher, and the one of the simple laparoscopic operation is relatively higher, compared to the cost of open operation. This is due to the cost of investment and maintenance of the expensive robotic device, of the laparoscopic instruments, but also to reasons of medical competition, since the robotic operation can be performed only by few specialized surgeons.

Furthermore, the patient for whom is decided to undergo a laparoscopic or robotic operation must always be informed that this operation may become an open operation, if this is deemed necessary, for safety reasons and in order to get the right oncological result.

Furthermore, incontinence and erectile dysfunction occur frequently with the aforementioned operations too, and it is not possible to predict in advance the possibility of their occurrence and, thus, to assure the patient that they will not occur. Moreover, the protection of the nerves of the erection and of the mechanism of the urethral sphincter can take also place in an open operation, folllowing specific surgical steps. It must be remarked that the first neuroprotective radical prostatectomies that were performed by Patrick Walsh were open operations, with excellent results regarding erectile dysfunction and incontinence.

The laparoscopic operations, either the simple, or the robotically assisted ones, have also complications, some of which are specific complications of these operations only, while some others – that also occur in the open operations – are more frequent, more severe and more difficultly treatable. Thus, the use of carbon dioxide for the dilatation of the abdomen and the longest duration of the laparoscopic operation, compared to the open one, presents specific metabolic, but also cardiovascular and respiratory risks.

Recently, Kavoussi et al. analyzed the complications in a large series of 2,775 laparoscopic urologic operations, that have been performed in a period of 12 years. The most common complication is the injury of the vessels. Intraoperatively, there can be hemorrhage at any point during a laparoscopic operation. In an open surgical operation, the identification of the hemorrhage point and its control is clearly easier and faster, compared to a laparoscopic operation.

Therefore, in conclusion, regarding the patient and his environment, and in order to select the proper method of radical prostatectomy, someone should consider the following:

-The laparoscopic and particularly the robotically assisted laparoscopic radical prostatectomy consist an evolution of the classical open operation and are accompanied by good therapeutical results, and they consist lower gravity operations for the patient, having a faster recovery

-They cannot be applied in all cases.

-The robotically assisted operation has a much higher cost.

-The laparoscopic and the robotically assisted laparoscopic radical prostatectomy are not free of intraoperative complications, neither of a subsequent incontinence or erectile dysfunction; however these occur less frequently than in the case of classical open operation.

-They are considerably overestimated and are frequently presented in a over-optimistic way on the Internet, but also by the surgeons who perform them.

-As in the case of every new method, their value must be proven with accurate and long-term clinical studies.