Prostate cancer

CANCER OF THE PROSTATE

Diagnosis

Prostate-specific antigen (PSA) testing

It is known that prostate cancer increases the production of prostate-specific antigen (PSA). Therefore the PSA test, which measures the level of PSA in your blood, may be able to detect prostate cancer in its early stages. However, PSA levels tend to rise in all men as they get older, so an elevated PSA level will not necessarily mean that you have prostate cancer.

Digital rectal examination

The next step to confirming a diagnosis of prostate cancer is a digital rectal examination (DRE). This can be done by your GP.

During a DRE, your GP will insert a finger into your rectum (back passage). The rectum is close to your prostate gland, so your GP is able to check to see if the surface of the gland has changed. This will feel a little uncomfortable but it should not cause you pain.

Prostate cancer can cause the gland to become hard and bumpy. However, in some cases, the cancer causes no changes to the gland and a DRE may not be able to detect the cancer.

DRE is also useful in ruling out benign prostatic hyperplasia, as this causes the gland to feel firm and smooth.


Prostate biopsy

Prostate biopsy is a procedure designed to establish whether there is a cancer in your prostate. It is usually done by imaging the prostate with a specially designed ultrasound probe, which is inserted into the rectum via the back passage. Samples of the prostate are then taken with a needle, which makes a clicking noise as it is operated. Up to 10 samples are taken depending on the size of the gland, which is measured at the beginning of the procedure. It carries a small risk of introducing infection, so you will be given an antibiotic at the time of the procedure, together with a prescription for a short course of antibiotics to continue over the subsequent days.

It is also quite common to see blood in both the urine and the motion over the subsequent few days, but this is very rarely anything to worry about, and usually stops very promptly. Some men may also see blood in their semen afterwards, and this can take a few days to settle completely.

The most worrying thing of course is the result, and this can take up to 2 weeks to come back. If the biopsy does show the presence of cancer, then the implications of this will be fully discussed with you. If no cancer is found, this means that there is either no cancer, or if there is, it is so small as not to be detectable, so further follow up will be arranged so that if a cancer does subsequently grow, it may be caught in good time.

Further testing

If it is felt that there is a significant chance that the cancer has spread from your prostate to other parts of the body, further tests may be recommended. Two tests that are commonly used are:

• A magnetic resonance imaging (MRI ) scan - which uses magnetic waves to build up a detailed picture of the inside of your body. A MRI scan can tell if the cancer has spread beyond the prostate to the surrounding tissue.

• An isotope bone scan - this test uses radiation to detect any abnormalities in your bones. An isotope bone scan can tell if the cancer has spread to your bones.  

Radical prostatectomy

If you have already looked at the paragraph about prostate cancer, you will already know that we cannot unreservedly recommend this treatment for all men with prostate cancer; but if after careful thought you have decided to go ahead with surgery, then maybe a few words about the operation may be helpful. Surgery to remove the whole prostate in cases where the cancer appears not to have spread is widely practised, and in the majority of cases is successful.

There are 3 main approaches to carrying out the operation

1. Open surgery through an abdominal incision

2. Open surgery through a perineal incision ( a cut made between the anus and scrotum)

3. Laparoscopic surgery

All surgery can carry a risk of serious complications, including a very small risk of dying as a direct result of the operation and the need for an anaesthetic, so should not be undertaken lightly; but the overall risk of developing life threatening complications is very small.

At the practice, we are unable to directly offer the perineal approach, but can make the necessary referral if this is the desired operation. Likewise, if a laparoscopic approach is preferred, we do not use the robot assisted method, as this is considered a costly and unnecessary refinement.

The surgery is carried out under general anaesthetic, and usually takes between 2 and 4 hours. The main problems that can be encountered during the operation are bleeding (for which a blood transfusion may occasionally be required) â€" please make sure that you tell your surgeon if you have any serious misgivings about this.  Secondly, and fortunately, very rarely, it is possible to injure the rectum, and whilst this is usually easily dealt with, on very rare occasions a colostomy becomes necessary, and whilst this would always be a temporary solution, it obviously could have ramifications.

After the operation, recovery is usually fairly straightforward, although a catheter is required to help the bladder to heal. Most patients will go home after about 2 days if they have had the laparoscopic operation, or about 5 if they have had the abdominal operation, and the catheter is removed a week or so later.  You can expect to be back at work (or on the golf course!) after a further 3 weeks for the laparoscopic patients, or about 2 months for the open patients.

When the catheter is first removed many patients do experience difficulties with urinary control, but with gentle exercises, and a certain amount of patience, control gradually returns in the majority, but a few unfortunate men will never regain complete control, and in these circumstances, further surgery may be required, but fortunately this is fairly unusual. Erectile function may also take some time (up to a year) to return, and may never be satisfactory â€" this is unfortunately rather more common, and may affect about 50% of those men undergoing this type if surgery. It is a problem that affects people in different ways, but almost always can be helped to some degree, so don’t be embarrassed to ask for help if you need it.

The final problem that may be encountered in the months following surgery, is that the join up between the bladder and urethra can become scarred and narrow, a condition known as bladder neck stenosis. This will slow the urinary stream down, and may hinder return of continence, but fortunately it is very easily treated, although will probably require a further anaesthetic.

After the operation, the whole prostate, and any lymph nodes removed, are sent for analysis, and thus a lot more information is gained regarding the cancer â€" indeed, in a very small number of patients, no cancer can be found in the specimen, which does not mean that the biopsy that had previously been taken was wrongly read.

On the basis of the information gained from the lab, further treatment in the form of radiotherapy and/or hormone treatment may be considered necessary, but in most people, it is simply sufficient to monitor the PSA levels every few months over the following years, as these are a good indicator of the success of the treatment in dealing with the cancer â€" it is worth pointing out that the level of PSA never goes down to absolutely nothing, and a low level is entirely acceptable.

TURP

This stands for trans urethral resection of the prostate, and is probably the commonest operation performed in urology. It is not the only treatment for prostate trouble - indeed most men with prostate trouble will require either no treatment, or tablets, but when removal of the prostate is required it is an extremely effective and safe operation, with side effects only occasionally occurring. It should not be confused with radical prostatectomy, the operation done for cancer of the prostate.

During the operation, a camera is passed up the penis, and the lower urinary tract is inspected. This is done under either general or spinal anaesthetic, depending on the anaesthetist's assessment of what is best. Once it is confirmed that the prostate is the cause of the trouble, the prostate is removed using a loop on the end of the camera that cuts it away in small strips, thus opening up the channel through which you pass water. A catheter is then placed to allow healing to take place. The catheter is removed after a day or two, after which you can usually go home, though it may be a few days or even weeks before urinary symptoms settle down.

The main complications of the operation are bleeding and infection, neither of which are usually severe, and can be treated effectively without long term consequences. Some men notice a loss of ejaculation after the operation, but in the age group usually having the operation, the need to continue to be able to father children is not usually a major consideration. Loss of ejaculation does not usually affect a man's enjoyment of intercourse, as orgasm is usually maintained. A word of warning though - the loss of ejaculation does not cause complete sterility, and it is still possible to father a child, albeit not so easily.

The ability to maintain an erection is not usually lost after this operation, although it may sometimes be affected. In the long term, most men who have TURP will be delighted with the result, but it is possible for scarring and regrowth of the prostate to cause further problems in the future.

Because the operation is not perfect, there are alternative procedures available, and the urological community are very optimistic that the new hybrid laser may at last be a potential improvement, but the next 5 years should confirm or refute this optimism. The holmium laser is already available locally, but surgically the technique is hard to learn, and not all the local surgeons have received training in the techniques.