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Prostate Cancer

Prostate cancer is the most common cancer in men, accounting for 30% of all new cancer diagnosis and over 13% of all male cancer deaths in Australia.

Not all prostate cancers are the same; they are generally classified based on grade, severity and extent of the cancer. Low-grade cancers could often be safely monitored in majority of patients if safe and feasible through a protocol called ‘active surveillance’. Whereas intermediate and high grade cancers often need definitive treatment with intention to remove the prostate and the pelvic nodes to cure the disease.

A variety of treatment options exist, each with their pros and cons, and the treatment is often tailored and individualized to the patients based on the extent of disease as well as individual patient factors. The previous approach of ‘one treatment for all patients’ is now outdated and during consultation and thorough assessment with the patient’s active involvement, we tailor the treatment to the patient. The main focus of our practice is to achieve first and foremost cancer control, while preserving the urinary continence as well as erectile function.

What is active surveillance?

Active surveillance is often offered to patients with low-grade and low-volume disease, where the risk of cancer spread is low. In this protocol, the prostate cancer is monitored over time with a combination of digital rectal examination, PSA testing, imaging modality such as MRI scans as well as interval prostate biopsy. If the cancer shows signs of progress or more aggressive behaviour, definitive treatment is instituted.

What is prostate biopsy and how is it performed?

Prostate biopsy is indicated for men with high index of suspicion of prostate cancer. This includes:

  • Abnormal digital rectal examination
  • High or rising PSA levels
  • Abnormal areas seen on MRI of prostate

Prostate biopsy is performed using an ultrasound and could be performed either through rectal passage (called Trans-Rectal Ultrasound Biopsy) or via perineum, the area behind the scrotum and in front of the anus (called trans-perineal biopsy). The main advantages of Trans-Perineal Ultrasound biopsy includes significantly lower rates of biopsy related infections.

Accurate targeting of the suspicious areas in the prostate improves the detection of cancer, and subsequently the decision making regarding the treatment options. In patients where MRI shows an abnormal area, we perform MRI/Ultrasound Fusion Targeted Biopsy, where the MRI images and the real-time US images are fused using a computer software and the lesion is accurately targeted and biopsied.

What is radical prostatectomy?

Radical prostatectomy is the procedure where the prostate, as well as seminal vesicles, are removed with intention of curing prostate cancer; it remains the gold standard of treatment for organ-confined prostate cancer. Following removal of the prostate, the bladder and urethra are re-joined. In our practice, this surgery is often performed using the da Vinci Robot and is customized and individualized to the patients. In rare circumstances, open surgery is preferred to robotic surgery.

The five main objective of this surgery involves:

  • To cure the cancer, which is the first and foremost priority
  • Preservation of the urinary continence (continence-preserving surgery)
  • Preservation of erectile function nerves (nerve-sparing prostatectomy) if indicated
  • Minimally invasive approach (da Vinci Robotic Prostatectomy)
  • Achieving complication free recovery

What are the advantages of da Vinci Robotic prostatectomy?

Robotic surgery is a type of keyhole procedure, where surgeons are able to control the da Vinci robotic instruments, as well as the camera, to perform the operation through very small incisions. The key advantages are mainly attributed to the improved ability to access deep spaces in the abdomen and pelvis without the need to make a large incision. The robotic camera provides the surgeon with a high-resolution 3D vision and the robotic surgical arms, controlled by the surgeon, are able to provide highly precise movements, which mimics the surgeon’s hands. Consequently, surgeons are empowered to do complex surgery and replicate open surgery, avoiding large and morbid incisions.

The main advantages of da Vinci robotic surgery include:
  • Reduced pain
  • Reduced blood loss and transfusion
  • Reduced complications after surgery
  • Faster recovery and return to normal activity
  • Minimised scarring

Furthermore, emerging evidence indicates that patients undergoing da Vinci robotic prostate surgery have greater improvement in erectile function preservation and recovery as well as earlier return of urinary continence, compared to open prostate surgery. This is in addition to maintaining the same cancer outcomes when compared to open surgery.

Robotic surgery does require dedicated training and the surgical outcomes are highly dependent on the surgeon’s level of training and experience. Dr Ahmadi underwent a 2-year da Vinci Robotic Urological Oncology Fellowship overseas at the prestigious University of Southern California in Los Angeles. During this time he was trained and mentored by Professor Inderbir Gill and his team in advanced robotic cancer surgery. Dr Ahmadi is a da Vinci accredited robotic surgery instructor and since his return to Australia has provided training and mentorship for surgeons in NSW and Victoria.

What are the complications of surgery?

The main complications specific to this procedure are: urinary incontinence and erectile dysfunction.

The the incontinence is often temporary and over 95% of patients will regain full continence a few week to months after surgery. During robotic surgery, we have successfully used a variety techniques such as bladder neck preservation, sling procedures or suspension sutures to reduce the rates of incontinence.

The rates of erectile function recovery depends on the degree of nerve-sparing procedure as well as base line erectile function prior to surgery. Patients with good baseline erectile function, who have had nerve-sparing robotic prostatectomy, have a very good chance in regaining their erectile function.

Other complications of the surgery includes but not limited to infection, bleeding, deep vein thrombosis and other anaesthetic complications.  You will need to discuss these risks with you doctor prior to making a decision regarding surgery.

What are the other options of definitive therapy for prostate cancer?

Radiotherapy, also known as external beam radiotherapy (EBRT), is an effective treatment for prostate cancer. Patients often require to have approximately 30-40 treatments over 6 -7 weeks. Often patients are required to be on hormones therapy prior, during and after their treatment.

Seed Brachytherapy is a form of radiotherapy where radioactive seeds are placed in the prostate gland. This treatment is often more suitable in men with low-risk prostate cancer. Men who have enlarged prostate gland (>40gr) or bothersome urinary symptoms are not suitable candidates for this treatment.

High Dose brachytherapy is another radiation based treatment, where under anaesthesia in two sessions, multiple rods are placed in the prostate and radiation is delivered to the prostate gland. Following this treatment, often some EBRT is also delivered to the prostate. Patients with more advanced cancers may require hormone therapy during this treatment.

What are the complications of radiotherapy?

  • Bladder and rectal bleeding; this is the most common side effect of radiotherapy and it could range from mild and sporadic episodes to severe bleeding requiring surgical intervention and catheterization. Some patients may experience significant bladder dysfunction, mainly characterized as reduced bladder capacity and symptoms of urinary frequency
  • Erectile dysfunction; almost half of men will develop ED by 5 years
  • Urethral stricture; this is when the urinary passage is significantly narrowed and resulting in difficulty passing urine.
  • Secondary malignancies secondary to radiation including bladder cancer, rectal cancer and hematological cancers (e.g. Leukemia)
  • In patients with recurrence of cancer who have had prior radiation, surgery (salvage prostatectomy) is very risky and carries a very high-risk of urinary incontinence, rectal injury and almost always erectile dysfunction.

Where can I get more information on prostate cancer?

Understanding Prostate Cancer

Localised Prostate Cancer

Advanced Prostate Cancer