Introduction: What is it and how widespread prostate cancer is
Prostate cancer is the most common cancer in men. Its incidence is very low under the age of 40, but increases progressively with increasing age. The prevalence of this type of tumor doubles for each decade of age, from 10% in men aged 50 to 70% in the eighties.
The causes that promote the development of prostate cancer are not yet fully known, although genetic, environmental and diet (high-calorie diet) factors are definitely involved. The most common malignant prostate cancer is the prostate adenocarcinoma (PCA).
In the early stages the prostate adenocarcinoma is confined to the gland. Being generally characterized by a very slow growth, it can remain asymptomatic and undiagnosed for years; in some cases, it is not able to alter, even if not cured, the quality and life expectancy of the patient.
Some prostate cancers can be rather aggressive and spread quickly to other parts of the body (especially at the level of the lymph nodes and bones): in these cases, early diagnosis and proper treatment can be vital. If caught and diagnosed early, these tumors may benefit from more conservative treatments in order to have an effect (the least) on the future quality of life of patients. Early diagnosis allows for a healing treatment.
Early diagnosis is made through an initial urological visit, determination of PSA values or of potential new more accurate markers like -2proPSA and subsequently, if the suspicion is relevant, prostate biopsies are performed. At our center we are currently analyzing the new tumor marker -2proPSA with excellent preliminary results shared with the global scientific community as demonstrated by the following links:
Our outpatient service of prostate biopsies also provides the ability to have the report in one day. In selected patients the transperineal biopsies can also be performed as in-patient treatment with "template" or complete mapping of the prostate for any indication as to perform focal therapy of the prostate.
How can you treat prostate cancer?
Relative to the time it was diagnosed, the possible therapeutic alternatives for prostatic cancer include:
§ Active surveillance and watchful waiting
§ Medical therapy (HRT)
§ Focal treatment (cryotherapy, brachytherapy)
§ Radical surgical treatment (open prostatectomy, laparoscopic, robotic)
The decision on possible treatments in the case of prostate cancer depends on many factors such as age, the patient’s life expectancy and the clinical stage (severity of disease). Therefore, it requires a careful analysis and discussion with the patient about the different therapeutic possibilities.
Open radical prostatectomy
The term traditional radical prostatectomy (open air surgery) refers to the operation to remove the prostate through an incision under the navel around the pubis area. At our center this type of surgical technique is indicated mainly in the most aggressive tumors that do not require saving the nerves deputies to erectile function, but rather an extended oncological radicalism. The surgery can be performed under general or spinal anesthesia and lasts an average of 2-3 hours. The possible disadvantages of this type of surgical approach are related to major blood loss, more postoperative pain, prolonged hospital stay with resumption of normal daily life and convalescence.
Robotic radical prostatectomy
Our experience in terms of minimally invasive treatment for prostate cancer began in the 90s with laparoscopic surgery. After more than 500 laparoscopic procedures the evolution of surgical techniques has led us to the robotic treatment; therefore, laparoscopy on prostate cancer has now been abandoned by our center.
The robotic surgery is the highest indication in all those patients with less aggressive tumors for which it aspires for full functional recovery (urinary continence and sexual potency). The intervention of robotic radical prostatectomy is performed with the Da Vinci robotic system under general anesthesia. The patient is positioned on the quarters to approximately 35° of Trendellemburg (head down). The procedure lasts an average of 3 hours during which time an intraoperative histological examination of the prostate is usually performed in order to evaluate the extent of disease, and to decide whether to preserve the nerves for erectile function or not. This type of investigation, performed at a few centers in Italy and Europe, are granting this type of surgical technique with a better result than oncology.
While waiting for the result of this intraoperative examination, the removal of the lymph nodes is typically performed when the severity of the illness requires it. The aid of robots also typically provides among its advantages a better quality of suture that is made for joining the urethra and bladder.
The rapid recovery in the postoperative process allows us to discharge the patient only 3 days after surgery with a bladder catheter in place or otherwise 6 days after removal of the bladder catheter. This type of surgical technique is currently considered a first choice as it offers all the advantages related to minimally invasive laparoscopic procedures (reduced bleeding, better aesthetic results) and all the advantages in the postoperative period (reduced pain, reduced hospital stay and faster return to normal daily activities) associated with typical advantages of robotic surgery thus faster recovery of sexual function and urinary continence.
Clearly all of these benefits are directly related to the quality of the robotic system that offers a magnified three-dimensional vision of the operative field and the possibility of using more sophisticated surgical instruments, including an involuntary tremor filter resulting in better anatomical dissection of tissue during surgery and consequent better functional results.
Our center offers a counselling service for all patients who have to undergo this type of intervention enabling Our patients to be properly informed before being hospitalized. The patient is then assisted by Our team, thanks to free health centers for the rehabilitation of Andrology and pelvic floor rehabilitation.
Our results: open surgery vs robots
Our series included more than 1100 interventions of robotic radical prostatectomy from 2006 to present time.
Our large series allowed the direct comparison between the robotic radical prostatectomy and the traditional surgical technique, highlighting what are the real benefits guaranteed by the use of the Da Vinci robot. From the oncological point of view of the two techniques are fully superimposable surgical techniques, guaranteeing control of the tumor independent of the technique used.
The great advantage of robotic surgery emerges in terms of functionality, referring to early recovery of urinary continence and sexual activity. For one year after the procedure, Our patients who underwent robotic radical prostatectomy have a chance of urinary continence recovery (defined as the absence of diaper) by about 90%, compared to only 70% of those who underwent traditional surgery.
This difference becomes even more apparent when we consider the recovery of sexual function: the Da Vinci robot allows the resumption of satisfactory sexual activity in 70% of patients who underwent a bilateral saving of nerves for erectile function (illness permitting), compared with approximately 50% of patients operated on with traditional technique; a percentage that can rise if vaso-active drugs are used.
Our results, confirmed by further studies at international centers, suggest that robotic surgery provides a much better quality of life for patients.
Active surveillance is abstaining from any type of care from diagnosis to the time when the disease can become clinically significant. It may be a "reasonable" option for patients with prostate cancer with a disease defined at "low risk of progression", thus clinically insignificant and indolent. However, there is no certainty about the prognosis and the identification of the "type" of patient candidate for active surveillance; it must still be a case of "indolent" cancer and it is also important to consider the psychological aspect because the patient has to bear the idea of living with cancer.
The patient who decides for this therapeutic option should be well aware of the need for regular and frequent checks concerning the status of their disease. It is therefore necessary to perform periodic prostate biopsies in patients with stable or advancing PSA for assessing the progression of cancer, or increasing its biological aggressiveness.
Focal therapy (brachytherapy)
Permanent brachytherapy is a form of radiotherapy where capsules in the size of a grain of rice, containing radioactive sources of Iodine-125 or Palladium-103, are implanted into the prostate under ultrasound guidance or fluoroscopy. It is one of the validated therapeutic treatments for the treatment of clinically localized prostate cancer.
The procedure is generally carried out in loco-regional anesthesia and lasts about 90 minutes, with a brief hospitalization of a couple of days. Brachytherapy can be used as monotherapy or in combination with external beam radiation therapy, depending on the clinical situation, and in accordance with the guidelines of the main European and US urological associations.
Recent advances in technology have led to a drastic reduction in morbidity and a consequent improvement in quality of life in terms of maintenance of urinary continence and erectile function. The urinary incontinence rate after brachytherapy in patients who have not previously undergone prostate interventions is around 0%. The percentage of maintenance of sexual potency ranges from about 50 to 90% and it is a function of variables such as age and comorbidities present.
Focal therapy (Cryotherapy)
Prostatic cryotherapy is a procedure that allows the destruction of cancer cells by freezing. The procedure consists of a double cycle of freezing and heating performed through thin probes placed into the prostate through transperineal approach (the area between the scrotum and anus) and under continuous ultrasound guidance. The gases used are argon for freezing (with attainment of temperatures of -30, -40 degrees) and Helium for heating. Before starting the procedure, a urethral catheter is inserted in which a heating fluid circulates in order to protect the urethra. The treatment is usually performed under spinal anesthesia and lasts about 2 hours with a hospital stay of 2-3 days.
Cryotherapy is a recognized therapy by leading international urological associations and the FDA (Food and Drug Administrator). The elective indication is local recurrence after external radiotherapy, or brachytherapy. In such a case it is referred to salvage cryotherapy, as applied after the failure of a primary therapy.
Cryotherapy is sometimes first-line therapy in patients who for various reasons cannot be subjected to conventional therapies (comorbidities etc.) A further use of cryotherapy is for the locally advanced forms of prostate cancer for a symptomatic purpose or debulking (tumor shrinkage). The recent use of cryotherapy in the focal treatment of prostate cancer is of great interest, in which only a portion of the prostate gland is treated, with a consequent reduction of side effects. The risks of this type of procedure are mainly characterized by: hematuria, hemospermia, peno-scrotal edema, micturition disorders such as increased urinary frequency, urgency and difficulty emptying the bladder, erectile dysfunction (impotence) for around 80% of patients, urinary incontinence (more common in rescue treatments), and fistula formation between the rectum and the bladder.