The modern management of localised Prostate Cancer

Contents

• Introduction
• Comprehensive treatment programme
• Dealing with the diagnosis of Prostate Cancer
• Radical Prostatectomy
• Laparoscopic Radical Prostatectomy
• Robotic Assisted Radical Prostatectomy (DaVinci)
• Dynamic Intra Operative Prostate Brachytherapy (Potters’ Technique)
• Day case brachytherapy treatments
• Brachytherapy for large prostates and previous TUR surgery
• High Intensity Focused Ultrasound (HIFU) and Cryotherapy
• Conclusion

Introduction

Prostate cancer can be cured or managed in a number of ways. These are: 

• Active Monitoring
• Hormone Therapy
• Radical Prostatectomy
• Open
• Laparoscopic
• Laparoscopic Robotic Assisted
• Prostate Brachytherapy
• External Beam Radiation with Hormones
• High Intensity Focussed Ultrasound (HIFU)
• Cryotherapy

All different modalities, however the management an individual receives will depend on whether the patient has :

• A low, intermediate or high risk for disease progression (dependent on the PSAAn abbreviation for prostate-specific antigen, an enzyme that is produced by the prostate. High levels are present in the blood when the prostate gland is enlarged or inflamed. at presentation, the clinical stage & the GleasonA system used to assess the extent of abnormality of prostate cancer cells. grade of the tumourAn abnormal swelling.)
• The presence or absence of significant lower urinary tractThe channels that carry urine from the kidneys to the outside of the body. symptoms
• The presence of significant co-morbidity, their age and their life expectancy
• Whether they have good erectile function or not
• Access to the resources to deliver the various treatment modalities

Comprehensive treatment programme

A Comprehensive Integrated Localised Prostate Cancer Treatment Programme is essential to ensure that the treatment an individual patient receives is most appropriate for that person and his disease. A dedicated Prostate Service supported by Urology Nurse Specialists, Clinical Oncologists and Urological Surgeons with the back up of Specialist Pathology and Radiological services are the essential components. Unless a centre can offer all the available treatment modalities it cannot consider its service to be comprehensive. Over the last 7 years, with the support of the Guy’s & St Thomas’ Charitable Foundation, we have developed such a programme at Guy’s Hospital. We are prospectively evaluating our experience with Open Radical Prostatectomy and Laparoscopic Radical Prostatectomy, Conformal External Beam Radiotherapy and Dynamic Intra Operative Brachytherapy. In 2005, we purchased the Da Vinci Intuitive Robotic System and have the largest experience in the UK of robotic surgery.

Dealing with the diagnosis of Prostate Cancer

The diagnosis of prostate cancer can be terribly emotive and have a major impact upon relationships and family. An element of depressionFeelings of sadness, hopelessness and a loss of interest in life, combined with a sense of reduced emotional well-being and stressRelating to injury or concern. is a common feature of the normal response to the diagnosis and it is absolutely crucial that you take time to reflect upon your treatment options as explained to you. Decisions should not be taken too quickly and a focused, reasoned, and calm attitude will be an asset in dealing with the pressures you will face.

Remember- if a particular treatment doesn't feel right for you, then it probably isn't suitable. If a treatment feels right, then it probably is. Keep asking questions until you are satisfied. After studying all of your options, and speaking to the appropriate specialists, make use of the knowledge gained and trust your instincts.

Be realistic. If a man is not generally in good health, surgery may not be the best option. Surgery of any kind is hard, and recovery is easiest when a person is in good shape. If a man has bowelA common name for the large and/or small intestines. or bladderThe organ that stores urine. problems already, radiationEnergy in the form of waves or particles, including radio waves, X-rays and gamma rays. of any kind may make them worse. Fortunately, for many patients, there are a number of other options, including various forms of radiation therapy and hormoneA substance produced by a gland in one part of the body and carried by the blood to the organs or tissues where it has an effect. therapy, or a combination of treatments, which may still result in a successful outcome.

The ideal treatment for early prostate cancer would both provide an excellent chance of cure (over 90% of the time) and minimal side effects with regard to urinary continence (leakage) and potency (erectile function). Unfortunately the ideal treatment does not exist (if it did then there would be no question about the benefit of prostate cancer screeningA way to identify people who may have a certain condition, among a group of people who may or may not seem to), they all have significant side effects and an individual’s options are very dependant upon a number of interrelated factors:

Radical Prostatectomy

The open radical prostatectomyThe surgical removal of the entire prostate gland. is a well-described and reproducible technique with very few major complications reported. The indications for an open radical are predominantly for patients with extensive but localised disease, where the need to feel the extent of the disease is required to best assure a complete excisionThe removal of a piece of tissue or an organ from the body.. This procedure is often combined with an intra operative frozen section of the excision margins to achieve a complete removal of the tumour. The need for bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. transfusion, post-operative pain relief and the risk of wound infectionInvasion by organisms that may be harmful, for example bacteria or parasites. remain significant issues. Nonetheless it remains the Gold Standard against which all other treatment modalities must be compared

Urinary continence rates overall are excellent (95% complete control, no pad), 50% of patients may expect to have immediate urinary control with 30% of patients having incontinenceThe involuntary passage of urine or faeces. for between 6 to 12 weeks. The remaining 15% regain urinary control over a longer period. The degree of incontinence varies with the extent of surgery. Those with high risk disease requiring a wide excision may have urinary leakage for longer but in the long term continence rates are the same. Artificial Urinary Sphincters can be used to achieve continence but this is rarely required.

Erectile Function after radical prostatectomy will always be compromised and although important, it is not the priority, cancer control and continence are paramount. Increasing experience of the nerveBundle of fibres that carries information in the form of electrical impulses. sparing approach and oral treatments has improved long term outcomes. Patients will often have significant improvement up to 3 years following surgery. Outcomes with regard to return of erectile function are best when surgery is combined with an intensive penile rehabilitationThe treatment of a person with an illness or disability to improve their function and health. programme involving the use of regular oral medication such as cialis, the use of a vacuum pump daily to promote penile blood flow and prevent shortening and injection therapy if necessary. With this regime up to 70% of patents can regain function at 1 year.

Laparoscopic Radical Prostatectomy

Laparoscopic Radical Prostatectomy has a long learning curve and the need for specialist training in the technical aspects of the surgery before embarking on a programme is essential. 

Although preservation of erectile function seems better because of improvements in visualisation and nerve sparing techniques, surprisingly the immediate and early continence rates are no better than in open surgery. In the long term however urinary continence rates are comparable. The major advantage is the more rapid recovery from surgery and reduced length of stay. There is less blood loss , a reduced  need for blood transfusion, post operative analgesia, and risk of wound infection are considerably reduced when compared to open surgery; however there is a greater risk of significant complications such as a urinary leak or rectalRelating to the rectum, the lowest part of the bowel leading to the anus. injury during the early part of a surgeon’s learning curve which can result in greater morbidity. This experience seems to be a reflection of the learning curve during the first 120 cases and is common to all surgeons irrespective of the approach.

Robotic Assisted Radical Prostatectomy (DaVinci)

Robotic Assisted Radical Prostatectomy has been popularised by the Vattikuti Institute in Detroit and offers the advantages of the laparoscopic approach (better vision, reduced bleeding, better nerve preservation, less analgesia and reduced length of stay) with the enhanced dexterity of the endowrist offering 360 degree intuitive movement. This allows surgeons trained in predominantly open surgery to translate their pelvicRelating to the pelvis. surgical skills to a laparoscopic environment. For this reason this procedure is gaining increasing popularity in the USA and now in Europe & the UK. 

The department’s experience in open and laparoscopic radical prostatectomy and laparoscopic urology, combined with the mentoring programme supported from Detroit and the Cleveland Clinic, fulfilled the clinical governance requirements for the introduction of new surgical procedures into the UK. This surgery has now become routine in our department and we now carry out over 150 of these procedures each year at Guy’s Hospital, with the majority of patients discharged within 48 hours of the surgery. There is no doubt that Robotics is the surgery of the future and our experience confirms this.

Dynamic Intra Operative Prostate Brachytherapy (Potters’ Technique)

Brachytherapy for early and low risk prostate cancer is a very attractive alternative to radical surgery and radiotherapyThe treatment of disease using radiation. for many patients, with comparable relapseA return or worsening of the symptoms of a disease after a period of remission. free survival rates as radical surgery at 10 years. Simplistically, this is the targeted insertion of titanium seeds impregnated with radioactive Iodine (I125) directly in to the prostate to achieve a high dose to the cancer. We have been the first group in the UK to introduce a Single Stage dynamic approach with seed implantation carried out under real time ultrasoundA diagnostic method in which very high frequency sound waves are passed into the body and the reflective echoes analysed to build a picture of the internal organs – or of the foetus in the uterus. with intra-operative dosimetryThe measurement and calculation of the correct dose of ionising radiation.. This provides immediate feedback on the quality of the implant and allows us to maximise the dose to the prostate whilst minimising the dose to the urethraThe tube that carries urine from the bladder, and in men also carries semen during ejaculation., bladder and rectumThe last part of the large intestine, where faeces are stored before being passed.. Louis Potters, the American, who developed the technique at the Memorial Sloane Kettering Cancer Center  has mentored our own programme. We have treated over 400 patients between December 2003 and October 2009

Day case brachytherapy treatments

The procedure is conducted as a single visit day case or overnight stay, no catheterA tube used either to drain fluid from the body or to introduce fluid into the body. is required and patients can return to work in a day or two. Urinary control is excellent although most patients will experience some frequencyApplied to urination, needing to urinate more often than normal, for whatever reason. and urgency this is rarely a significant problem and is minimised by careful patient selection. Erectile function is very well preserved when compared to the alternative options such as nerve sparing radical surgery or hormone radiation. 

It makes use of the principle of Inverse Planning and uses modern hardware and software developments to deliver a Dynamic Real Time Implant with Intra- operative Dosimetry. Thus allowing dose optimisation to maximise treatment of the prostate cancer whilst minimising the dose to the urethra, rectum and bladder.

The procedure has been extremely well tolerated and 96% of patients have been discharged within 16 hours of the implant. The urinary side effects can take up to 3 – 6 weeks to develop and so many patients experience no immediate morbidity and can work or travel as they please. 

Brachytherapy for large prostates and previous TUR surgery

The other major advantage of Potters’ intra-operative dynamic approach is the ease with which it can be adapted and applied to patients with large prostates. Many centres would have difficulty treating these cases and would have to give many months of hormones to shrink the prostate beforehand, with a consequent worsening of the side effect profile. We have also successfully implanted, with out any difficulty or early complications over 50 patients who have previously had trans-urethralRelating to the urethra, the tube that connects the bladder to the genitals. prostate surgery (TURPtransurethral resection of prostate).

High Intensity Focused Ultrasound (HIFU) and Cryotherapy

These are minimally invasive approaches to treating prostate cancer which uses ultrasound guidance to deliver a high intensity of focused ultrasound to the prostate in segments (HIFU) or the placement of cryoprobes to freeze the prostate or part of it (Cryotherapy). They can be used as both a primary treatment and as salvage treatment after radiotherapy. Patients will generally require a limited resectionThe surgical removal of part of the body. of the prostate (TURPAn abbreviation for transurethral resection of the prostate, a procedure to shave away some of an enlarged prostate. This eases the pressure from the prostate on the urethra, the tube that carries urine from the bladder.) at the time of the procedure to prevent urinary retention with HIFU. The catheter is removed the next day. The long term data with these treatments are limited to 5 years but the best available suggest that about 70% of patients with “low risk” disease will be free of disease at 5 years, compared to over 90% of patients treated with radical surgery or brachytherapy. Nonetheless it is an option to be considered in selected patients who would be unfit or unsuitable for these other treatments. 

Conclusions

Treatment advances in prostate cancer are dependant upon a multidisciplinaryRelating to a group of healthcare professionals with different areas of specialisation. approach and the resource to invest in new technology. Our department has been more fortunate in this regard than others and we have a comprehensive and integrated treatment programme. In some respects, this makes it harder to advise patients when the choice is so broad but I would rather that my patients were well informed on their options. Most often, it is not which treatment would be best for an individual but why one particular choice would be a bad idea.