Prostate cancer usually affects men between the ages of 60 and 80 with a peak of frequency occurring during the seventh decade of life. There is a significant difference between clinical incidence and anatomical – pathological incidence: at 80 years of age, clinical signs of the illness are manifested in approximately 25% of men, whereas autopsy reports on men of the same age showed the presence of the pathology in more than two thirds of cases.
Prostate cancer is the second most frequent cause of cancer mortality in men of all ages and the most frequent cause in men over 75 years of age; it is rare in men under 50 years of age with incidence of the pathology increasing by 3-4% for each year of life thereafter; afro-caribbean men are more likely to develop the illness and enough is known about prostate cancer to suggest a genetic component.
The risk of contracting prostate cancer is equal in identical twins.
The oncogenetic cause is obviously unknown but the relationship between tumours and both male and female sexual hormones (androgens and estrogens) is well known.
The cancer always originates at the periphery of the prostate even though it can also be found in fragments of central (glandular) adenomatous tissue.
Histology – seat – Gleason score
Initially there are no symptoms given that the pathology occurs at the periphery of the prostate away from the urethra. Therefore the obstruction syndrome is usually manifested in subjects where prostate cancer is already at an advanced stage.
The feature which distinguishes urinary obstruction resulting from a tumour as opposed to other causes (urethral stenosis, prostate adenoma, bladder neck sclerosis, etc.) is rapid development in a few weeks or months from the initial stages to the full-blown pathology. Perineal pain, acute urine retention and even macroscopic haematuria can all occur at the same time.
The aforementioned local symptoms can be accompanied by painful and slow urination due to infiltration of the trigone, obstruction of the upper urinary ducts due to an obstacle in the ureteral passageways and colic-type pain. Other symptoms can include haematospermia and problems with defecation caused by compression on the rectal lumen.
Local spreading of the cancer occurs towards the prostatic capsule. The caudal prostate is affected first and then the cranial prostate. In a more advanced stage the prostatic urethra is affected giving rise to the urinary symptoms. In the next phase the cancer spreads towards the seminal vesicles and the trigone of the bladder, often affecting the ureteral openings, and then towards the rectum
Metastasis is frequent and rapid and occurs via the lymph system and bloodstream. This type of metastasis occurs in part due to the affinity of cancer with lymphatic cells and in part due to the extensive network of intraprostatic lymphatic cells. The most frequent type of metastasis is that affecting bone tissue and this must be assessed in the follow-up to the disease. Symptoms of the metastasis include aching bones and radicular pain, problems with walking and even paraplegia caused by pathological fractures of vertebrae
As with all tumours, diagnosis must assess the existence of the disease and the stage it has reached.
The objective examination must always include inspection of the rectum which can show the presence of an enlarged nodule compared to the surrounding gland which is often painful when touched.
Laboratory tests often suggest the presence of neoplastic tissue; specifically total PSA (prostate-specific antigen) and free PSA and their relationship (free/total), PSA growth velocity, the PCA3 urine test and the pro2psa test all help the urologist to decide whether to defer or make a more detailed diagnosis.
In expert hands the transrectal ultrasound to evaluate the bladder and prostate is the most reliable tool to diagnose the existence of the pathology.
The prostate TRIMprob test assesses the functionality of prostate tissue and indicates whether the tissue is inflamed, hyperplasic or cancerous (see slide 18 showing a state of the art TRIMprob test).
Certain diagnosis can only be achieved using perineal prostatic ago-biopsy utilising transrectal ultrasound as a guide. The process requires a local anaesthetic and involves removal, using a special needle, of suspect prostate tissue and healthy tissue from the other parts of the prostate
A scan of the abdomen and pelvis or NMR of the prostate not only highlight the pathology but are also useful to assess satellite and distant lymph node structures. Bone scintigraphy highlights the presence of metastasis affecting bone tissue.
A fundamental requirement of obtaining a good result is for the tumour to be located inside the prostatic capsule and the documented absence of metastasis. The gland must be removed completely together with the seminal vesicles (prostatovesiculectomy) where possible using the nerve-sparing and neck-sparing technique. This procedure spares the nerves used to obtain an erection and the bladder neck which, together with the urethral sphincter, helps to prevent or limit urinary incontinence.
Depending on the case surgery requires lymphadenectomy of the valve, hypogastric and common iliac stations up to the bifurcation of the aorta.
Radical prostatectomy procedures can be performed using the traditional open technique (Fig. 88) or minimally invasive keyhole surgery.
TNM tumour classification system
Palliative surgical treatment
This is required in all cases where the prostatic neoplasm, often at an advanced stage, has affected the bladder neck, the urethra, ureters and is causing an obstruction making it difficult to empty the bladder. Often the urination dynamic can be restored using transurethral resection (TUR).
This is used for forms of cancer which do not respond to hormone therapy. Doxorubicin, Epirubicin, Mitoxantrone, Taxanes, etc. can all be used at the discretion of the oncologist.
Sexuality after radical prostatectomy
Having performed and assisted in many radical prostatectomy procedures, on the basis of worldwide re-evaluation of the issue and assessment of patients months after the operation, I always recommend an early sexual rehabilitation programme following radical prostatectomy, given that it is still possible to achieve orgasm!!!
Obviously ejaculation is no longer possible given that the prostate is no longer able to produce the liquid required.
The programme involves sexual assessment prior to the radical prostatectomy and methods aimed at restoring sexual functions after the operation.
The procedure forms part of the programme and where possible the nerves used to obtain an erection are spared (nerve-sparing technique) or at least one of the nerves is spared (unilateral nerve-sparing).
An important factor is the age of the person; the younger the patient the easier it is to achieve an erection. On the other hand if the patient already suffers from erectile dysfunction before the operation then the less chance there is of restoring sexual functions.
I personally recommend that the rehabilitation programme begins a few weeks after the surgical procedure.
The first stage of the programme involves re-establishing intimate contact with the partner which is followed by the oral administration of drugs and, if necessary, the use of intrapenile drugs (this assists in the oxygenation of the penile vessels and represses fibrosis of these vessels).
A penile prosthesis can be implanted in the event that normal functioning of the penis cannot be restored. This usually results in the considerable satisfaction of patients and their partners.
Individual assessment assists in the selection of the correct therapeutic strategy.