Prostate Cancer Surgery & Treatment

The prostate gland is found only in males and is a part of male reproductive system.

It lies below the urinary bladder and in front of the rectum. The gland surrounds the first part of the tube ‘urethra’ that carries urine from the bladder to the penis. The prostate can be divided into right and left “lobes”. The size of the gland changes with age. It grows rapidly during puberty, fuelled by the rise in male hormones (called androgens) in the body. In adult men, a typical prostate is about 3 cm thick and 4 cm wide (about the size of a walnut) and weighs about 20 grams, but it can be much larger in older men.

Functions of prostate gland

  • Produces a thick, clear fluid that makes the semen more fluid and protects and nourishes sperm cells in the semen.
  • It also plays a part in controlling the flow of urine.

What is Prostate Cancer?

Prostate cancer is a disease where some prostate cells have lost normal control of growth and division. They no longer function as healthy cells. A cancerous prostate cell has the following features:

  • Uncontrolled growth
  • Abnormal structure
  • The ability to move to other parts of the body (invasiveness)

Prostate cancer can be slow-growing and some men who develop prostate cancer may live many years without ever having the cancer detected. It is important to get screened regularly so that if you do develop prostate cancer, the appropriate action can be taken.

How can I tell if I have prostate cancer?

Typically, the first symptoms of prostate cancer are difficulty urinating, frequent urination, and blood in the urine. However, symptoms are not always present especially in the early stages of prostate cancer. If detected and treated in its earliest stages (when the cells are only in the prostate), your chances of survival are greatly increased.

The PSA test

The most common prostate cancer test is the PSA, or prostate-specific antigen test. This is a simple blood test that measures the presence of prostate-specific antigen, or PSA, circulating in your bloodstream. This test is usually the first step in any prostate cancer diagnosis. The PSA test is also used to track the effects of prostate cancer treatment such as surgery, radiation, hormone therapy and chemotherapy.

When should I get a PSA test?

Discuss with your physician about your personal risk and make a plan for testing:

Recommendations for PSA testing

  • Age 40: Talk to your physician about testing and your personal risk
  • Age 45–49:If PSA is above 1 ng/mL, repeat at 1–2 year intervals until age 50. If PSA is below 1 ng/mL, repeat PSA at age 50
  • Age 50–70: If PSA is below 3 ng/mL, repeat testing at 1–2 year intervals
  • Age ≥70: Talk with physician and assess general health to decide together if routine PSA testing should continue

The digital rectal exam

In a digital rectal exam (DRE), your doctor will feel the size and shape of the prostate by inserting a gloved and lubricated finger into the rectum. The area where most prostate cancers are found can be felt during this test. A healthy prostate feels soft, rubbery, smooth, symmetrical, regular and even. Any lumps, or hard, woody or irregular areas of the prostate may indicate the presence of cancer and will require further testing.

Further testing and diagnosis

The PSA test or DRE alone cannot diagnose prostate cancer. In order to determine whether or not one has prostate cancer, the doctor will perform one or more of the following exams and tests.

Open Radical Prostatectomy

A surgical treatment for prostate cancer, the open radical prostatectomy procedure removes the entire prostate with an incision in the lower abdomen. With the advent of Laparoscopic Prostatectomy this is becoming rare and used only in select situations.

CT scan

CT scan is often used to check whether enlarged lymph nodes are visible, which is important as prostate cancer can spread through the lymphatic system. The patient will be asked to lie flat on a table inside a doughnut-shaped machine that will take multiple images of different sections of the body. These images are then combined through a computer to produce two and three dimensional pictures from inside the body.

Biopsy

A biopsy removes small samples of tissue for testing. Biopsies can also help your doctor assess how far the cancer has grown. A prostate biopsy is a type of biopsy that removes tissue from the prostate. To prepare for the biopsy, your doctor may say to stop taking some medications and start taking others.

Bone scan

If you have been diagnosed with prostate cancer, and there is a high risk for cancer spreading from the prostate to the bones, so your doctor may recommend a bone scan. For this test, a radiotracer will be injected into your vein. The most common radiotracer used for bone scans is technetium. A special camera will then take pictures of the dye in the bones. The radiotracer can be seen in your bones 2 to 3 hours after it is injected. You may be asked to drink water and empty your bladder to wash out any of the radiotracer that is not in your bones.

Grading of prostate cancer

A cancer’s grade gives information about how fast the cancer is growing and how fast it is capable of spreading. It describes how closely its cells resemble normal cells of the area.

Gleason score

The grading system for prostate cancer is called the Gleason score. The Gleason score is used by doctors to plan treatment. The chart describes what the scores mean.

  • 2–6: The cancer is likely to grow and spread very slowly. If the cancer is small, many years may pass before it becomes a problem. Thus, you may never need cancer treatment.
  • 7: The cancer is likely to grow and spread at a modest pace. If the cancer is small, several years may pass before it becomes a problem. To prevent problems, treatment is needed.
  • 8 – 10: The cancer is likely to grow and spread fast. If the cancer is small, a few years may pass before the cancer becomes a problem. To prevent problems, treatment is needed now

Staging of prostate cancer

A cancer’s stage gives information on how far the cancer has spread. It is determined by considering three factors:

  • Size of tumor, and whether the cancer has spread beyond the prostate capsule or covering
  • Whether the cancer has spread to the lymph nodes close to the prostate
  • Whether there are any distant metastases

TNM staging system

The TNM staging system provides information about the cancer’s size and how far it has spread.

  • T = Tumor The T score is a rating of the size and extent of the primary tumor
  • N = Nodes The N reflects if the cancer has spread within nearby lymph nodes
  • M = MetastasisThe M tells if the cancer has spread to distant sites

Treating prostate cancer

To determine the best treatment option for you, work with your healthcare team and consider the following factors:

  • Age
  • The stage and grade of your cancer
  • Your general health
  • Your values and preferences

Questions for your doctor

  • What treatment options might be right for me?
  • What are the major side effects of the treatments available to me?
  • What are the chances I will have problems with incontinence, erectile dysfunction or rectal issues?
  • How would the various treatments affect my quality of life?
  • What is your experience with this treatment?
  • How frequent are complications?
  • What happens if the cancer spreads beyond my prostate?
  • When will my treatment begin and how long is it expected to last?
  • How often should I come for follow-up?
  • What are tests that should be repeated and how often?
  • Will I be able to lead my normal sexual life?
  • What are the options for managing pain on a long-term basis?

Treatment options

Active Surveillance

What is it?

May be recommended if:

  • Your cancer is small and low-grade
  • The possible side-effects of other treatments are felt to outweigh the benefits at this time

What is done?

  • Your doctor will track your PSA levels over time, and any changes in DRE findings
  • Repeat biopsies will be required to determine if there has been a significant change or progression of the cancer

Radical prostatectomy

What is it?

  • Surgery that completely removes the prostate gland and surrounding tissue, as well as the seminal vesicles and part of the urethra
  • Potentially removes all cancer cells
  • May be recommended if your cancer has not spread outside the prostate
  • May be used in combination with other treatments e.g., radiation

What is done?

There are 3 main types:
Open: One cut, 3 to 4 inches long, is made from the belly button to the pubic bone
Laparoscopic: Several small cuts are made in the abdomen and a video camera is inserted to view the prostate. The surgeon operates the instruments by the bedside
Robot-assisted: Similar to laparoscopic surgery except that the video camera and instruments are connected to a robotic system that is controlled by the

Radiation therapy – External beam

What is it?

  • External beam radiation delivers therapeutic X-rays to a localized area in order to kill cancer cells
  • Often a good option if age or general health makes surgery too risky
  • Can be used in combination with other treatments although surgical removal of the prostate is very difficult after radiotherapy

What is done?

  • Radiation works by interfering with cell division. Because normal cells are affected along with cancerous ones, radiation is given in small doses over a period of eight weeks
  • Usually treatment is given Monday–Friday, with a break on weekends to give the healthy cells some time to recover

Radiation therapy – Brachytherapy

What is it?

Brachytherapy delivers radiation internally. The two main types include: low-dose seed implant brachytherapy and high-dose rate brachytherapy (HDR)

What is done?

Low-dose seed implant brachytherapy

  • The seeds are inserted through the skin in the perineum (the area between the anus and scrotum)
  • Procedure is performed under either general or spinal anesthesia and lasts approximately 1 hour

HDR

  • Under anesthesia, approximately 15 needles are inserted through the perineum.
  • These needles are wired to the radiation source that delivers a high radiation dose to the prostate
  • The needles are then removed
  • The treatment takes 10–20 minutes

Hormone therapy

What is it?

  • Hormone therapy works by depriving cancer cells of androgens (the male hormones) they need to grow

Most often used to treat:

  • Cancer that has spread outside the prostate
  • Recurrence of prostate cancer after another therapy has been used

What is done?

There are two methods of hormone therapy:

  • Surgical removal the testicles to prevent testosterone production
  • Medication

Chemotherapy

What is it?

  • The use of specific drugs to treat cancer
  • Normally used to treat recurring or metastatic prostate cancer if hormone therapy does not work anymore

What is done?

Chemotherapy is usually given through the vein but some forms can be taken as a pill

Emotional support

Being diagnosed with prostate cancer may feel lonely. Try to remember that you do not have to deal with everything on your own.

Support options:

  • Family and friends
  • Spiritual groups
  • Your doctor and specialist(s)
  • Private counselling through a psychologist or social worker

For family, friends and caregivers

Caring for a man who has prostate cancer is a challenging experience. Here are some suggestions to help you through your experience and provide the best level of support, not only for your loved one, but for you as well.

  • Learn about prostate cancer
  • Focus on communication
  • Participate in the patient’s treatment
  • Look after yourself

Managing treatment side effects

Most treatments for prostate cancer can cause both short-term and long-term side effects. There are four main categories of side effects:

  • Trouble with urination
  • Bowel problems
  • Side effects of hormone therapy
  • Problems related to sexual function

Urinary difficulties

Urinary incontinence is a relatively common side-effect of radical prostatectomy. Incontinence is the loss of the ability to control urination. Any treatment that removes the prostate or destroys prostate tissue can affect urination. This is because the prostate is close to the bladder and it surrounds the tube that allows urine to flow outside the body (the urethra). Leakage of urine may occur without warning, or only with heavy lifting or sudden physical movement e.g., sneezing. Other urinary difficulties may occur with radiation therapy e.g., frequent urination, burning and pain, blood in the urine or an intense urge to urinate.

Management of urinary difficulties

Bowel side effects

Radiation therapy to the prostate also affects the wall of the rectum and can cause bowel inflammation, urgency to go to the toilet, diarrhea, cramps, blood in the stool and faecal incontinence (loss of regular control of the bowels). Treatment may include dietary changes, medication, bowel training, local remedies such as steroid suppositories, and in rare cases, surgery.

Hormone therapy side effects

Hormone therapy can cause a wide variety of side effects including hot flashes, fatigue, weight gain, loss of muscle or bone mass, erection difficulties, loss of sex drive and lower blood counts.

Treatment and management of hormone therapy side effects

Hot flashes:These can be controlled with medication or by making dietary and lifestyle changes.

Fatigue and weight gain:Exercise (both aerobic and weight-bearing) and proper nutrition are good ways to reduce fatigue and weight gain.

Loss of muscle or bone mass:Men using hormone therapy are at particular risk of muscle loss and mineral loss in the bones that can make them fragile and vulnerable to fractures – a condition called osteoporosis. This can be slowed or even prevented through regular exercise and healthy eating. Get yourself evaluated for bone health with your healthcare provider and you might need to check on your Calcium and Vitamin D levels periodically.

Side effects related to sexual function

Whether you are single or in a relationship, changes in how you perceive yourself, family role, and patterns of sexual intimacy often occur during and after prostate cancer treatment.

The various side effects related to sexual function include:

Treatments for erectile dysfunction

There are certain oral medications and injectable drugs that can help in the treatment of erectile dysfunction.

What happens after treatment?

Treatment for prostate cancer is often successful in removing cancer cells and tumors. This is both exciting and relieving, but can also be scary and stressful. Many men worry about the cancer returning and how to get back into their daily routines.

Follow-up care

Once you have completed treatment you will still need to be monitored closely by your doctor. It is natural to worry about the cancer coming back and to have anxiety about follow-up testing; however, it is important not to let this stop you from attending your regular appointments. The doctor should give a follow-up plan that will include regular appointments and possibly additional exams, lab tests or imaging tests to give you the best chance at remaining cancer-free.

Fatigue

Fatigue, or extreme tiredness, is common among people treated for cancer. For some, fatigue may last for a long time after treatment and can make it difficult to get back to “normal life”. Exercise has also been shown to reduce stress and improve mental health.

Nutrition after prostate cancer

Good nutrition may reduce the incidence of prostate cancer and help reduce the risk of prostate cancer progression. Take the help of a good dietician to plan the most suitable diet on your preferences and local availability.

Diet tips for prostate health

Physical activity after prostate cancer

Regular physical activity is shown to have a number of health benefits, including

  • Improving cardiovascular health
  • Reducing anxiety and depression
  • Maintaining a healthy weight
  • Improving muscle strength
  • Reducing fatigue and improving energy levels