Surgical Treatment of Prostate Cancer

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Almost any actively dividing cell of the human body can become a cancer cell. The prostate gland cells are not an exception, as they produce prostate fluid – part of the semen, which protects spermatozoids and guarantees their viability. This disease is widespread and takes second place among all oncological conditions in men. Special attention should be paid to people over 65 years of age, as they account for more than 70 % of all prostate cancer patients.

The good news is that prostate cancer usually grows slowly and doesn`t affect one’s lifestyle at all. It can be found just by accident during a general examination. Due to this, doctors have multiple choices when deciding on the type of prostate cancer treatment.

In certain cases, active treatment may be substituted with simply being watchful and waiting for further signs or active surveillance. Under all circumstances, a consulting doctor (general physician), urologist (keen on surgical interventions), radiation oncologist, and medical oncologist (keen on chemotherapy and hormone therapy) will give you the information about all appropriate options. We should note that the 5-year relative survival rate after the treatment is close to 100 %.

Content

1. What determines the type of treatment choice?
2. Which treatment tactics offer the best results?
3. Radical prostatectomy: open approach
4. Radical prostatectomy: laparoscopic approach
5. Coping with possible risks and side effects of radical prostatectomy
6. Is it necessary to remove testicles in addition?
7. What happens once the surgery is done?
8. Hospitals and costs of treatment
9. Choosing the best doctor for performing a radical prostatectomy

What determines the type of treatment choice?

Slow growth is a typical feature of prostate cancer, which makes it easier to detect the disease at an earlier stage. Some men with this type of cancer might never need any kind of treatment, especially elderly men or those with other serious health problems.

Another important thing is the total absence of symptoms; signs of cancer usually arise only at more advanced stages of the disease. Having regular preventive examinations is a cornerstone of prostate cancer diagnosis and timely treatment.

The first and most essential aspect of treatment tactics choice is determining the stage of the disease at the time of diagnosis. Usually, the diagnosis starts from a preventive screening examination or examination due to the patient's complaints.

Primary diagnostic procedures include:

• Digital rectal examination (DRE). This manipulation enables the doctor to find the tumor mechanically during assessing the prostate via the patient`s rectum.
• Prostate-specific antigen (PSA) blood test. PSA is produced only by the prostate, and its level reflects the state of the gland. The normal level of PSA is no higher than 4 ng/ml; results from 4 to 10 ng/ml reveal a 25 % possibility of cancer presence, and results over 10 ng/ml shows a 50 % possibility of having this condition. PSA level is significant for staging, planning the further examination, and follow-up after radical treatment.

In case suspicious results of DRE and PSA blood tests are present, further and more profound examination is administered.

In addition to general analyses, a specific diagnostic plan consists of the following investigations:

• Transrectal ultrasound (TRUS) of the prostate gland
• Prostate biopsy under the TRUS control (up to 12 samples of tissue are usually taken)
• Bone scan (to exclude metastases presence)
• CT / MRI scan (to assess the state of nearby organs and exclude metastases in soft tissues)
• Lymphatic nodes biopsy (if signs of oncological process spreading are present)

The diagnosis of prostate cancer is confirmed or excluded only by biopsy. Beyond all doubt, biopsy results are the basis of the future treatment plan.

Besides the normal picture, a biopsy may reveal precancerous conditions of the prostate:

• Prostatic intraepithelial neoplasia (PIN). In PIN, prostate cells are slightly changed but don't grow into other gland parts or the nearby tissues. PIN might be low-grade; this state has no connection to the oncological process. Revealing a high-grade PIN means a 20 % opportunity of having cancer in the other area of the prostatic gland.
• Proliferative inflammatory atrophy (PIA). In PIA, cells are smaller and show signs of the inflammatory process. PIA is not dangerous itself but can progress to high-grade PIN or cancer.
• Atypical small acinar proliferation (ASAP) or glandular atypia. In ASAP, there is a certain suspicion of cancer, but the amount of changed cells is not sufficient to make the conclusion. In this case, the best option is a repeat biopsy within a few months.

Finding pre-cancerous conditions of the prostate doesn`t obligatory mean that prostate cancer will arise in the future, we are talking about only a possibility and certain risk.

The final diagnosis of cancer is confirmed in case of receiving such results:

• Adenocarcinoma. It is the most common type of prostate cancer (more than 90 %). Adenocarcinomas develop slowly, and there is a chance to postpone active treatment.
• Small cell carcinoma and neuroendocrine tumors. These types of tumors tend to have rapid growth and spread to the lymphatic nodes and inner organs.
• Transitional cell carcinomas. We are talking about this type of tumor when cells have features of a few different neoplasms. Transitional cell carcinomas require active treatment.

The next step to determining treatment tactics is staging the tumor. A comprehensive approach to the assessment of prostate cancer stage includes:

• Level of the PSA at the time of diagnosis.
• TNM classification. “T” reflects the clinical (detected by DRE) and pathological (based on the results of imaging investigations or surgical treatment) extent of the primary tumor. “N” reflects the spreading of the tumor to lymphatic nodes. “M” reflects the presence of remote metastases.
• Grade group. The grade group takes into account the Gleason score and predicts the tumor`s speed of growth and spreading. Gleason score is calculated once biopsy results are ready and the degree of atypia can be assessed under the microscope. Grade I is given to almost normal cells, grade 5 – to highly abnormal ones. Scores are summed for two of the most typical prostate areas. Gleason score under 6 means that the tumor is well-differentiated or low-grade, from 6 to 10 – that the tumor is moderately differentiated or intermediate-grade, and over 10 – that tumor is poorly differentiated or high-grade. The higher the score is, the quicker the treatment should start.

Which treatment tactics offer the best results?

In case symptoms are absent, the small size of the initial tumor and its slow growth (low Gleason score), low level of PSA, and age over 60 years doctor may advise postponing active treatment.

According to the data from clinical trials, more than 70 % of all patients with prostate cancer will never need to go through surgical intervention, radiation therapy, or drug therapy.

In this situation, a doctor may offer you two options:

• Active surveillance. You will visit your general practitioner every 6 months and have a PSA blood test and DRE. Biopsy of the prostate will be repeated each year, if necessary. The results of the examination will influence further treatment options.
• Watchful waiting (observation). It is a type of follow-up with fewer tests; attention, therefore, is focused on complaints and clinical symptoms.

The opinion of the patient is important as well. Some people may strongly prefer radical treatment, regardless of its risks and side effects. They have the right to such a point of view, as active surveillance may give cancer a chance to grow and spread that restrict possible treatment options. Other people may like the idea of postponing active treatment because surgery may not help them live better, or they don`t want to face numerous side effects.

Surgical removal of the prostate gland is the only option for radical treatment. Taking into consideration all benefits and risks of such intervention, surgery is recommended in such cases:

• The good general state of health
• Estimated expectancy of life over 10 years
• High risk of cancer progression
• The localized form of cancer without spreading to lymphatic nodes and other organs
• No previous radiation therapy

In certain cases, prostatectomy may be performed before radiation therapy to reduce the volume of the tumor mass and increase the effect of the following treatment. Such an approach may be somewhat useful even in case of the presence of a few metastases.

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Radical prostatectomy: open approach

Radical prostatectomy implies total and irreversible removal of the prostate gland, seminal vesicles, part of the urethra, and vas deferens. There are few techniques of this intervention, but the first stage, preparation for surgery, is common.

To make surgery and postoperative period as safe and comfortable as possible, patients should follow these rules:

• Visit the hospital 5-7 days before the surgery to have preliminary tests done and see related specialists
• Stop taking certain drugs (warfarin, nonsteroidal anti-inflammatory drugs, etc.) 1-2 weeks before the procedure
• Lose weight
• Quit smoking and using other tobacco-related products
• A few days before the surgery, take medication to ensure normal stool and prevent constipation
• Do pelvic floor muscle exercises to prevent urinary problems (incontinence)
• Take a vacation for 4-8 weeks before being admitted to the hospital
• Prepare comfortable clothes
• Study information about using a urinary catheter or ask your doctor about it
• Ask somebody to stay with you and help with activities of daily living for the first few days after the surgery

The first technique of radical prostatectomy was open prostatectomy, which requires a long skin incision. Nowadays, the open approach is used less often, only when the prostate volume is more than 100 gr or the laparoscopic approach is impossible due to certain reasons.

In radical retropubic prostatectomy, skin incision starts from the belly button and goes down to  the pubic bone. Of course, the intervention is performed under general anesthesia, so the procedure is painless. Another variant is providing spinal or epidural anesthesia in combination with sedative drugs. This approach allows lymphatic node revision (during the surgery or afterward), as the field of view is vast. After the surgery completion, a urinary catheter is put into the penis to ease urination. Use of the catheter will be helpful during the first 1-2 weeks after the procedure.

When radical perineal prostatectomy is performed, the skin incision is half-round and is located between the anus and scrotum. This technique is performed under the same types of anesthesia but is less traumatic and requires less time. Negative moments are a high risk of erection problems development and bad access to lymphatic nodes (actually, they can`t be removed via this approach). Use of the urinary catheter is necessary as well.

A variant of partial prostate removal is transurethral resection of the prostate (TURP). The primary indication for this procedure is benign prostatic hyperplasia and concomitant urination problems due to the narrowing of the urethra. In addition, TURP may be performed for relieving the same symptoms in men with advanced prostatic cancer. During this procedure, the inner part of the prostatic gland is removed with the help of a laser or electricity via the urethra, so the skin remains undamaged. Surgery is painless, as general or spinal anesthesia is applied. It takes no longer than an hour to perform the whole procedure. The doctor puts in a urinary catheter, but it is no longer needed in 1-2 days.

Despite minimal damage, TURP side effects include the presence of blood in the urine, infection, slow urine flow due to scar tissue, erectile dysfunction, and retrograde ejaculation. However, the good qualification of the surgeon minimizes these risks.

Radical prostatectomy: laparoscopic approach

Laparoscopic radical prostatectomy, or keyhole surgery, is the new approach to prostatectomy performing. This technique involves removing the prostate via several small incisions. It is why the surgery is less traumatic, blood loss is minimal, pain syndrome is significantly less pronounced, staying in the hospital is reduced to 1 day, and fast recovery is provided. One possible restriction is the inability to convert the surgery into the open one and make the intervention more comprehensive in the case of necessity.

We should note that the result of laparoscopic prostatectomy depends to a great extent on the qualification of the surgeon. Beyond all doubt, high-technology equipment ensures certain advantages, but a surgeon is still the one who performs the intervention. No equipment will help in the absence of skilled and experienced healthcare professionals.

Robotic-assisted laparoscopic radical prostatectomy is the newest technique, which was implemented into clinical practice during the last two decades. This kind of intervention is performed with the help of the da Vinci Surgical System. Specific high-quality equipment, a four-armed robotic system, makes it possible to perform minimally invasive prostatectomy. As was mentioned before, the surgeon's qualification is of primary importance in this case. The surgeon must be an expert in laparoscopic procedures and using the da Vinci Surgical System. A doctor is skilled enough once he has performed more than 100 surgeries. The rate of successful surgeries is usually available on the hospital's website.

Prostatectomy with the help of the da Vinci Surgical System starts with the introduction of microsurgical instruments and high-definition cameras inside the patient's body. General anesthesia is provided in advance so the patient doesn't feel any pain. After that doctor goes to the operation room, and connects to the system. The Da Vinci Surgical System transforms movements of the surgeon's hand into the precise movements of the inserted instruments. It is a real-time procedure, so the surgeon feels involved in the process.

We should note that the system is working only under the surgeon's control. That is why choosing the right specialist is extremely important. Automatic surgery or preliminary programming of the system is impossible. The procedure finishes with the removal of the instruments and suturing of tiny skin incisions.

During the prostatectomy with the help of the da Vinci Surgical System, the surgeon works in a comfortable position, sitting in front of the control panel. He sees a magnified high-definition 3D view of the prostate and the whole surgery area.

The benefits of such a procedure are obvious:

• Greater precision and better dexterity when separating blood vessels and nerves
• Improved visualization, invisible for the naked eye aspects are perfectly seen
• Increased range of motion, access to hard-to-reach areas
• Ability to spare healthy tissues not affected by cancer in a proper way
• Ability to spare nerves and thus reduce risk of complications development

When prostatectomy is completed, additional investigation of removed material starts. Pathologist specifies the type of the tumor, its growth outside the prostate, and, the most important aspect, the presence of cancer cells on the margins of removed tissue (so-called “positive or negative surgical margins”).

Revealing positive surgical margins means that the tumor may not be removed completely. The percentage of operations with negative surgical margins is as important for a surgeon`s qualification as the number of performed interventions.

Coping with possible risks and side effects of radical prostatectomy

As with each surgical intervention, radical prostatectomy has certain risks:

• Abnormal reaction to anesthesia drugs
• Bleeding during the surgery and afterward
• Thrombosis of legs and lungs
• Injury to nearby organs (this mainly happens during robotic interventions, when the surgeon is not skilled enough)
• Infection
• Abnormal collection of lymph in case of removal of lymphatic nodes

These risks can be successfully avoided by appropriate preparation, which was mentioned above, and with a careful selection of the surgeon. Side effects of radical prostatectomy mainly depend on the surgeon's qualification as well. Some of them are temporary and will disappear over time; others are stable and need additional treatment. The most typical side effects of radical prostatectomy are described below.

Urinary incontinence. It is a complete or partial loss of ability to control urination or leakage.

There are a few types of urinary incontinence:

• Stress incontinence is the most typical form of the disorder. It is connected to the damage to bladder sphincter muscles or nerves. In this case, urine is released when a person is coughing, laughing, or doing physical activity.
• Overflow incontinence feels like a complication when emptying the bladder. It arises when scar tissue blocks or narrows the upper part of the urinary tract and disturbs the natural flow of the urine. In acute cases, it should be corrected surgically.
• Urge incontinence means that the bladder is hypersensitive. Minimum amounts of urine irritate it and result in the passing of urine.
• Continuous incontinence is a rare but serious complication. It is characterized by a total loss of ability to control urination.

Usually, it takes several weeks or months to return the process of urinating back to normal. During this time, a patient may use absorbent pads or pants. It should be noted that doing pelvic floor exercises before the surgery strengthens muscles, which are used during urination and helps to fight against urinary incontinence.

Erectile dysfunction (impotence) is the absence of  a good-quality erection enough for normal sexual intercourse. This side effect is important for many men, so nerve-sparing surgery is always performed once nerves are not affected by cancer. The ability to be responsible for the erection nerves depends to a great extent on the experience of the surgeon. Nevertheless, erection with certain medicinal help is still possible even in the case of removing both nerves.

As it may take anything from months to years to restore erectile function completely, these measures can help improve sexual intercourse:

• Drugs of phosphodiesterase-5 (PDE-5) inhibitors group (e.g., Viagra, Sialis, Levitra). These drugs are effective in the case of the viability of at least one nerve.
• Vacuum devices create the erection mechanically.
• Penile implants restore the erection in most complicated cases. It is a kind of surgical intervention as well.

To be precise, erectile dysfunction might be connected not only with nerve damage but also with psychological problems and general fatigue after the surgical treatment.

Changes in orgasm. Orgasm does not disappear after the treatment, but it changes – becomes “dry”. It is connected with the removal of seminal vesicles and the prostate, which produce fluid for the semen.

Loss of fertility. Radical prostatectomy destroys connection between testicles (source of sperm) and urethra, so the sperm doesn't leave the body and there is no ejaculation. Produced sperm is reabsorbed inside the body; this is completely safe for the body. Option of fathering a child is still available in such a situation. Patients should “bank” sperm before the intervention, so it can be used for artificial insemination in the future. Regardless loss of fertility, patients should continue using condoms for prevention of sexually transmitted diseases.

Lymphedema. In case of removing many lymphatic nodes around the prostate, the lymph might start collecting in the genital region or legs. It results in edema and pain. The most effective way of treatment for such conditions is physical therapy.

Change in penis length. Not significant shortening or shrinkage of the penis may arise due to urethra cut and low level of androgens. Nevertheless, these changes usually don`t influence sexual function dramatically.

Inguinal hernia. Patients after radical prostatectomy have an increased risk of inguinal hernia development. It can be somewhat prevented with the help of regular physical activity and the strengthening of muscles.

Is it necessary to remove testicles in addition?

Orchiectomy, or surgical castration, may be helpful in the treatment of prostate cancer. To understand the mechanism of its positive action, we should know that androgens (male hormones) make the prostate grow and, at the same time, promote the progression of prostate cancer.

Androgens (testosterone and dihydrotestosterone) are produced by testicles and adrenal glands (tiny amounts). With decreasing androgens levels, we can slow down the growth of the tumor or even reduce it in size. Such a treatment option is called “hormone therapy”. Sole hormone therapy is not a cure for prostate cancer but is an appropriate component of complex treatment schemes.

Hormone therapy is administered in such circumstances:

• When surgery and radiation therapy are contraindicated or not effective (e.g., in advanced cancer cases)
• When the relapse after surgery and radiation therapy is diagnosed
• To reduce tumor size before radiation therapy
• Along with radiation therapy or as an additional treatment if the risk of relapse is high

There are two main types of conducting hormone therapy:

1. Medical treatment with several groups of drugs. The first one is LHRH agonists and antagonists. These drugs suppress the production of androgens in testicles. Regardless, it has a great effect at a high cost, and shrinkage of testicles (as they don`t work anymore) should be noted. The second common group of drugs is anti-androgens, which block androgen receptors in the prostate, so the gland becomes “blind” and can't see hormones. Anti-androgens should be taken daily to support the effect. The third group of drugs is estrogen drugs. Estrogens are female hormones, so they have opposite actions. This group of drugs is prescribed rarely due to the presence of serious side effects.
2. Orchiectomy. It is the irreversible surgical removal of testicles. Orchiectomy is a simple outpatient procedure during which the doctor makes a small cut in the scrotum, removes testicles, and fixes skin incisions with absorbable stitches. If it is important for the patient, artificial testicles (prostheses) might be inserted into the scrotum to restore a natural look. This treatment option is deprived of risks and side effects of medicinal treatment but may be hard psychologically. In the end, both treatment options have the same result - the patient should understand this clearly.

Side effects of hormone therapy mainly arise due to higher levels of female hormones. Possible complications of the treatment include erectile dysfunction, reduced sexual desire, shrinkage of the testicles and penis, reduction of muscle mass, gaining weight, osteoporosis, anemia, depression, and breast enlargement and tenderness. Additional medicinal treatment is prescribed to ease the side effects of the main treatment.

What happens once the surgery is done?

In absence of surgical complications, it usually takes about 6 weeks to completely get back to normal life. Long-distance driving is allowed in approximately 4 weeks, but you should additionally clear up this question with your insurance company. Also, there might be some restrictions on going back to work; it depends on the nature of your duties.

You will visit your general practitioner 4-6 weeks after the surgery. Follow-up visits will not be frequent – you will see a doctor every 3-6 months. The frequency of visits is individually determined and depends on the stage of disease, results of treatment (e.g., results of prostate pathological examination and presence of positive or negative surgical margins), administration of additional drug treatment, and its side effects.

You may discuss with the doctor options for fighting against relapses, such as regular physical activity, reducing excessive body mass, quitting smoking, and correcting nutrition habits. Also, your general practitioner will always help you in coping with prostatectomy side effects. Emotional support is no less significant than the physical state is, so you may be advised to visit a psychotherapist if necessary.

Hospitals and costs of treatment

Surgical treatment of prostate cancer is carried out at large multidisciplinary hospitals and small medical centers that specialize in urological oncology. Among the hospitals that demonstrate high success rates in the treatment of prostate cancer are:

1. Helios Hospital Berlin-Buch, Department of Urology
2. University Hospital of Ludwig-Maximilian University of Munich, Department of Adult and Pediatric Urology
3. University Hospital Ulm, Department of Adult and Pediatric Urology
4. Urology Hospital Munich-Planegg Munich, Department of Adult and Pediatric Urology
5. Charite University Hospital Berlin, Department of Adult and Pediatric Urology

The cost of prostate cancer treatment is determined for each man individually. The average costs of the main surgical treatment options are as follows:

• Nerve-sparing radical prostatectomy – €25,090
• Radical prostatectomy with da Vinci robot – €24,418
• High-intensity focused ultrasound ablation (HIFU) for prostate cancer – €25,266
• Transurethral electroresection for prostate cancer – €12,378
• Cancer rehabilitation – €1,576 per day

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Choosing the best doctor for performing a radical prostatectomy

As noted above, choosing a skilled surgeon determines a good outcome of the intervention, provides the absence of complications in the early postoperative period, and minimizes the risk of serious side effects, such as incontinence and erectile dysfunction. The best up-to-date and high-technology equipment will never replace the experience of the doctor. Moreover, doctors should be keen to work with such equipment, otherwise, it will cause more harm than good. One more important aspect is the quality of nursing care. It may seem less significant, but competent nurses will ease your state in the postoperative period and help in quick recovery.

Taking into consideration all of the abovementioned factors, many men seek medical help abroad. In the modern world rating, and qualifications of urological surgeons can easily be found online, as well as patient`s reviews and stories about treatment experience. In this scope, patients often decide to have surgery in Germany- as hospitals in Berlin, Cologne, and Leverkusen are famous worldwide in this relation. Applying directly to the hospital will put you at the end of a long queue of international patients. It is natural, as German citizens have higher priority when it comes to receiving high-technology surgical treatment. In addition, administrative workers, who receive these applications, may have difficulties with medical documents, as some information is clear only to doctors.

The most appropriate option for arranging treatment abroad is using the trusted help of the Booking Health company. Booking Health is a medical tourism company that annually helps thousands of patients with treatment abroad.

Booking Health offers help in such significant aspects as:

• Recommending the best doctor and clinic for your case
• Booking an appointment on the convenient date
• Organizing comprehensive preoperative examination
• Providing you with a transfer, interpreter, and medical coordinator if necessary
• Providing you with obligatory medical insurance
• Preparing for you all the medical reports and further recommendations
• Providing help in further urological rehabilitation, if necessary
• Providing help in further communication with your treating physician

To start planning your treatment, you should leave a request on the website of Booking Health. Our reliable case manager or medical advisor will contact you the same day to discuss all the details. Our work aims to help you have a better chance at improving and maintaining your health.

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Choose treatment abroad and you will for sure get the best results!

Authors:

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk, Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Sources:

American Cancer Society

Cancer Research Institute

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