Prostate cancer

Prostate cancer is cancer that starts in the prostate gland. The prostate is a small, walnut-sized structure that makes up part of a man’s reproductive system. It wraps around the urethra, the tube that carries urine out of the body.

Causes, incidence, and risk factors

Prostate cancer is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40. People who are at higher risk include:

  • African-American men, who are also likely to develop cancer at every age,
  • Men who are older than 60
  • Men who have a father or brother with prostate cancer
  • Men who use too much alcohol
  • Farmers and Painters
  • Men who eat a diet high in fat, especially animal fat
  • Tire plant workers
  • Men who have been around cadmium

Prostate cancer is less common in people who do not eat meat (vegetarians). A common problem in almost all men as they grow older is an enlarged prostate. This is called benign prostatic hyperplasia, or BPH. It does not raise your risk of prostate cancer. However, it can increase your PSA blood test results.

Symptoms

The PSA blood test is often done to screen men for prostate cancer. Because of PSA testing, most prostate cancers are now found before they cause any symptoms. The symptoms listed below can occur with prostate cancer, usually at a late stage. These symptoms can also be caused by other prostate problems:

  • Delayed or slowed start of urinary stream
  • Dribbling or leakage of urine, most often after urinating
  • Slow urinary stream
  • Straining when urinating, or not being able to empty out all of the urine
  • Blood in the urine or semen
  • Bone pain or tenderness, most often in the lower back and pelvic bones (only when the cancer has spread)

Signs and tests

A biopsy is needed to tell if you have prostate cancer. A sample of tissue is removed from the prostate and sent to a lab. Your doctor may recommend a prostate biopsy if:

  • You have high PSA level
  • A rectal exam shows a large prostate or a hard, uneven surface

The results are reported using what is called a Gleason grade and a Gleason score.

Treatment

Treatment depends on many things, including your Gleason score and your overall health. Your doctor will discuss your treatment options. For early-stage prostate cancer, this may include:

  • Hormone therapy (medicines to reduce testosterone levels)
  • Surgery (radical prostatectomy)
  • Radiation therapy, including brachytherapy and proton therapy

If the prostate cancer has spread, treatment may include:

Nerve-Sparing Robotic Radical Prostatectomy:

Nerve-sparing laparoscopic radical prostatectomy is a well established, minimally invasive procedure that is performed through 4 to 5 small 1-cm keyhole incisions across the mid abdomen. Through these small incisions, the surgeon uses fine laparoscopic instrumentation to precisely dissect the prostate gland, seminal vesicles, and vasa deferentia from the urethra and bladder. The instruments can be placed transperitoneally (through the abdomen) or extraperitoneally (under the rectus muscles and in front of the bladder) depending on which approach is more suitable for the patient.

The surgery is performed adhering to the same anatomic principles of open surgery, but without the surgeon’s hands entering into the patient’s body cavity. A robotic arm is also used to control the telescopic lens. The high-definition telescopic lens is attached to a camera device that projects the image onto a video monitor. This provides the surgeon with excellent visualization and details of the prostate gland and the surrounding neurovascular structures, allowing for precise dissection of the prostate and suturing of blood vessels. Once the prostate gland is dissected free from the bladder, rectum, and urethra, it is placed in a small plastic bag and eventually removed by extending one of the keyhole incisions to accommodate the prostate. The bladderneck is sewn back to the urethra to restore continuity of the urinary tract using laparoscopic suturing techniques inside the body. A Foley catheter is placed through the penis to drain the bladder and allow healing of the bladder-urethra connection. In addition, a small drain is placed around the surgical site, exiting one of the keyhole incisions.

Nerve-Sparing Laparoscopic Radical Prostatectomy:

Anatomic radical prostatectomy, or open surgery, is the most commonly performed surgical procedure for treatment of localized prostate cancer. A less invasive option, laparoscopic radical prostatectomy has its basis in traditional open surgery, with less blood loss and better cosmetic results. Laparoscopic instruments improve visualization, enabling precise dissection of the prostate and neurovascular structures. Additionally, laparoscopic suturing techniques allow for a meticulous connection of bladder to urethra following removal of the prostate. This offers the potential for less scarring of the urethra following surgery.

Advantages over open surgery

  • Significantly less blood loss
  • Better cosmetic result
  • Quicker return to normal activity
  • Improved visualization of surgical field

Perineal Prostatectomy:

Radical perineal prostatectomy is a surgical procedure wherein the prostate gland is removed through an incision in the area between the anus and the scrotum (perineum). It is typically performed to remove early prostate cancer. Radical perineal prostatectomy is less commonly used than another surgery such as the open radical retropubic prostatectomy or the robot assisted laparoscopic radical retropubic prostatectomy. When the cancer is small and confined to the prostate, radical perineal prostatectomy achieves the same rate of cure as the retropubic approach but less blood is lost and recovery is faster. One downside to the perineal approach is an increased risk of fecal incontinence.
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