6 March 2019 Author : Kris Maes The prostate is an exclusively male gland located around the urethra (the channel that allows urine to come from the bladder to the outside of the body), which is responsible for the production of part of the seminal fluid. Prostate cancer mainly affects the peripheral area of the gland and is the second-most common type of cancer in men, after lung cancer. What are the risk factors associated with prostate cancer? Several factors increase the risk of developing this disease, the most significant of which are: Age (most men diagnosed are over 50 years old); Family history of prostate cancer; Ethnicity - it is more common among black men. How is prostate cancer diagnosed? Unlike benign hyperplasia, which is more likely to limit urine output from the bladder and lead to symptoms, prostate cancer is generally asymptomatic. Diagnostic assessment of this neoplasia thus depends on: Measuring PSA (prostate specific antigen) levels; Digital rectal examination; Imaging examinations (transrectal ultrasound and, more recently, multiparametric magnetic resonance imaging). PSA is a molecule produced by the prostate that contributes to the liquefaction of the semen. It is also circulating in the body, which makes it possible to measure it in the blood. Prostate cancer is associated with increased PSA. However, it also occurs in other benign conditions, which makes this parameter insufficient when considered on its own. The digital rectal examination allows the peripheral region of the prostate gland to be assessed by looking for suspicious nodules in the area most frequently affected by malignancy. The final diagnosis depends on a transrectal or transperineal prostate biopsy. Developments in diagnosis Until the 1980s, prostate cancer was not usually diagnosed until it had reached a late stage. It was almost always the appearance and symptoms of metastases (mainly in the bone) that led to diagnosis. However, with the introduction of an effective blood test, the possibility of measuring the prostate-specific antigen (PSA) began a new era of early diagnosis . In most cases, it became possible to diagnose the disease while it was still at a localised stage (confined to the prostate) and was therefore susceptible to curative treatment. It should be noted that PSA is not a tumour marker, but it is an indicator of the organ’s state of health. Many prostate diseases, such as infection, inflammation, trauma and cancer can alter PSA values. As such, high levels of PSA are not synonymous with the existence of prostate cancer but merely draw attention to the possibility of it being present. Periodic (annual) determination of PSA levels and palpation of the prostate with digital rectal examination are the pillars of early diagnosis for this cancer. In the diagnosis of prostate cancer, transrectal ultrasound of the prostate has come to be widely used as a supplementary method in addition to the digital rectal exam. This method has been used in patients with elevated levels of PSA or with anomalies detected in the digital rectal examination. However, definitive diagnosis depends on histopathological confirmation . The recommended method for most cases where prostate cancer is suspected is ultrasound-guided prostate biopsy. With the developments in diagnostic technology, it is now also possible to undergo multiparametric magnetic resonance imaging. This has the capacity to assess not only the anatomical characteristics of the prostate, but also its molecular behaviour. What is the treatment for prostate cancer? Once diagnosed, the disease must be characterised in accordance with the risk of progression. This should be linked to the age of the patient and the available therapeutic options considered. You should talk to your doctor about the most appropriate option for your clinical condition and the possible complications and benefits with regard to the cancer. Treatment for localised prostate cancer with low risk of progression: Active surveillance: the patient is kept under regular clinical surveillance with PSA testing and prostate biopsy, and the onset of curative therapy is delayed while oncological disease control is maintained; Surgery: radical prostatectomy (prostate removal), which can be performed conventionally (with a vertical incision below the navel), laparoscopically (through 5 small holes) or robotically (also through small holes but with the help of a robotic structure controlled by the surgeon); Radiotherapy: by placing radioactive seeds inside the prostate (brachytherapy) or by extracorporeal administration. Treatment for advanced stage prostate cancer: Neoplasms diagnosed at a more advanced stage may require a combination of the above therapies or pharmacological treatment such as hormone therapy or chemotherapy. Treatment progression In most cases, the preferred choice for localised prostate cancer is surgical treatment; more specifically, radical prostatectomy. Radical prostatectomy, regardless of the approach used (open, laparoscopic or robotic), has systematically shown better results and has enabled greater survival. Open radical prostatectomy In open radical prostatectomy the entire prostate and all seminal vesicles are removed through a mid-line abdominal incision. Afterwards, the neck of the bladder is sutured to the urethra. If necessary, the pelvic lymph nodes are also removed. All efforts are made to preserve the muscle of the external sphincter in order to avoid incontinence, and the neurovascular bundle in order to maintain erectile function, wherever possible. However, with radical prostatectomy there is always a considerable risk of incontinence and impotence following surgery. Minimally invasive surgery Traditional minimally invasive surgery started being used in radical prostatectomy in the late 1990s. Using very small incisions, the surgeon operates in an abdominal cavity inflated by carbon dioxide, with two-dimensional visualisation and using rigid instruments. With this laparoscopic approach, oncology control and functional outcomes have improved in comparison with open surgery, but it takes a long time for the surgeon to learn to perform the procedure. Therefore, only in centres with large volumes of patients can the necessary experience be acquired in order to achieve the best results. Da Vinci robotic surgery system More recently, the development and introduction of the da Vinci robotic surgery system has profoundly changed the approach to prostate cancer treatment around the world. This equipment enables the surgeon to operate under excellent ergonomic conditions, with 3-dimensional, amplified visualisation of the operating field. It uses articulated instruments that simulate the movements of the human fist and filter out tremors. As such, robot-assisted laparoscopic prostatectomy (RALP) results in: Shorter hospital stays; Less blood loss during surgical procedures; Less post-operative pain; Faster overall recovery. Current scientific literature also points to the advantage of robotic surgery in terms of continence and erectile function , in comparison with laparoscopy and open surgery. It also provides comparable oncological control. Carrying out radical prostatectomy by robotic surgery enables: Better visualisation of anatomical structures, particularly the apex of the prostate and the urethra, and of the lateral neurovascular bundles; Effective traction and contraction of the prostate, bladder and adjacent anatomical structures, with a very positive impact on the precision with which the prostate and adjoining structures can be dissected; Precise, hermetic vesicourethral anastomosis. Robotic radical prostatectomy has also shown better functional results in relation to: Percentage and degree of recovery of erectile function; Rapid return to urinary continence. At the hospitals and clinics of the Hospital da Luz network, you will find urology specialists who can carry out all the examinations and procedures that you may need in this area. Meet the urology team from Hospital da Luz network and book your consultation The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
