Advanced Treatments for Prostate Cancer

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Enlarged Prostate or Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia is non-cancerous enlargement of the prostate gland. It is often used interchangeably though incorrectly with another term - Benign Prostate Hypertrophy.

Prostate, a walnut shaped gland is a part of male reproductive system and is situated in front of the rectum and below the bladder. It surrounds the urethra.

This condition commonly affects the elderly male population above the age of 60 years and involves an increase in the number of cells of the prostate gland leading to its enlargement. The enlarged prostate gland compresses the urethra leading to interruption of normal urine flow leading to urinary retention.

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Why does it Happen – Causes

The exact cause of this condition is not known yet but there is a strong evidence that dihydrotestosterone which is a metabolic byproduct of testosterone is responsible for this condition. This hormone is present in outer cellular layer of the prostate gland and causes increase in the number of these cells. Because of this the enlarged prostate assumes a nodular appearance. People who are obese or eat very fatty food are seen to be more prone to this condition.

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Signs and Symptoms

A person suffering from BPH will come to the clinician with the following symptoms:

•  Incomplete bladder emptying
•   Night time urination (Nocturia)
•   Prolonged emptying of the bladder
•   Hesitancy
•   Post-urination dribble
•   Urinary urgency
•   Leaking Bladder (Incontinence)
•   Frequent urination
•   Weak urinary stream
•   Abdominal straining
•   Irregular need to urinate
•   Irritation during urination
•   Painful urination
•   Problems with ejaculation

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How to Diagnose

Physical examination: Palpation of the prostate gland through the rectum (Rectal Examination) shows an enlarged prostate.

Blood tests: Show an elevated level of prostate specific antigen. (PSA)

Transrectal Ultrasonography: In this a probe inserted in the rectum which directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen and give an idea on any abnormality. Needle biopsy can also be done along with this to rule out any cancerous growth in the testes, prostate or kidneys.

Cystoscopy: During this procedure the physician introduces a scope into the urethra to visualize the inside of the urethra, urinary bladder and prostate and get information about its size and degree of bladder obstruction. The penile region has to be numbed before doing this procedure.

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Treatment for Advanced Prostate Cancer

BPH: treatment needs a holistic treatment plan and includes lifestyle modification, medications and surgical procedures.

Lifestyle Modification: certain steps like reduced water intake during nighttime, reduction of alcohol and caffeine intake and minimizing the dosage of certain drugs which increase the symptoms like decongestants, opiates, antihistamines, diuretics and antidepressants after due consultation with a medical professional.

Medications: Alpha blockers (like terazosin, doxazosin etc.) are prescribed in this condition as they relax the smooth muscle of the bladder and prostate and hence resolve the urinary obstruction.

The other group of drugs used, are the 5 alpha Reductase inhibitors (finasteride and dutasteride) which reduce the production of dihydrotestosterone hormone which is known to be responsible for prostatic enlargement.

Both these group of drugs have few side effects in some cases like drop in blood pressure, headaches, nasal congestion, ejaculation changes and erectile dysfunction.

Surgical Management: A variety of treatment options are available in prostatic surgery nowadays like Minimally invasive therapies, Transurethral prostatectomy, Laser prostatectomy, HIFU and Robotic prostatectomy

Minimally Invasive Techniques

SPAD – super selective intra- prostatic androgen deprivation: In this procedure, a radiopaque dye is injected into the vein of the leg after which an X-ray of the venous network is carried out (venography). Then a medicine that shrinks the blood vessels is injected into the vein (sclerotherapy) resulting in reduction of prostate volume. This provides relief in cases of nocturia, improves bladder emptying and increases urine outflow. There are minimum sideeffects as compared to traditional surgery.

Transurethral microwave thermotherapy (TUMT):

•  It is a very effective treatment in case of BPH and provides relief from lower urinary tract symptoms after a single procedure.
•   It is a minimally invasive technique performed under local anesthesia.
•   A special microwave urinary catheter is inserted through the urethra into the enlarged prostate. The microwave antennae are then heated up to at least 111 degree Fahrenheit which destroys the surrounding tissues.
•   The procedure takes around 30 minutes to 1 hour after which there is slight swelling and irritation in the prostate. A Foley’s catheter is placed in the bladder to allow bladder emptying without increasing the prostatic irritation and is removed within 3-5 days.
•   There may be a few risks like pain after the procedure, urinary retention and infection but the incidence is very less.
•   The problem of urinary retention resolves within a week’s time, but some patients replace the Foley’s catheter with a temporary prostatic stent to allow volitional emptying of bladder. This improves their quality of life.

Transurethral needle ablation (TUNA) :

•  In this procedure low energy frequency radio energy is delivered through two needles placed inside the prostate by passing through the urethra, creating a high temperature in a small zone, which destroys the excessive prostatic tissue without damaging the urethra.
•   The procedure is performed under local anesthesia on an outpatient basis. It is a single session treatment procedure with the number of needles varying with size of the prostate.
•  It is fairly safe and effective and has minimal side-effects.

Surgical Procedures :

Trans urethral resection of prostate (TURP) :

•  It is the most popular method among patients and doctors for resolving prostate related problems and is considered after medical intervention fails.
•   It involves removing whole or a portion of the prostate gland through the urethra.
•  The procedure is performed under spinal or general anesthesia and involves visualizing the gland using a endoscope.
•  A Resectoscope (which contains an electrical loop to cut the bulging prostate tissue and seal the supplying blood vessels) is introduced inside the penis.
•  The surgery lasts for around 1 and half hours, and cut tissue is carried by fluid into the bladder from where it is washed out.
•  The patient can go home after 3-5 days. Patient is advised to drink lots of fluids and avoid any strenuous activity for a few days (maximum 6 weeks) till the scar heals.
•  He is cured of the symptoms occurring due to urinary pathway obstruction like urinary incontinence, dribbling, nocturia etc.
•  This procedure has very few side effects and a faster recovery period. But sometimes it can cause backward ejaculation of semen (into bladder instead of urethra) during intercourse. This can be managed by certain drugs that keep the mouth of the bladder narrow to reduce backward flow of semen into it.

Radical Prostatectomy :

•   It is the traditional open surgery method used when TURP cannot be performed due to reasons like highly enlarged prostate or bladder injury etc.
•   It involves removing whole or a portion of the prostate gland through the urethra.
•  The surgery is performed under general anesthesia and an incision is made in the lower abdomen just above the pubic bone (Retropubic approach). At times the incision can be made between the scrotum and the anus depending on the enlargement of the gland or spread of the tumor (Perineal approach). The incision of perineal approach is smaller and has lesser blood loss as compared to retropubic approach and hence has a faster recovery period.
•  On reaching the prostate gland, the gland and extra tissue is scooped out and in case of any injury to surrounding organ like the bladder; a tissue repair is carried out. The urethra is reattached to the bladder and a catheter is left in the bladder to drain out urine.
•  In case prostate cancer is suspected, then surrounding lymph nodes are also removed and sent for biopsy.
•  The patient stays in the hospital for a week and is discharged with the urine catheter in place that has to be kept for 1-3 weeks’ time.

Laser Prostatectomy :is the latest trend in BPH and prostate cancer surgeries because they have lesser blood loss and quicker recovery period. But long term effects of this surgery are yet to be determined.

There are four Types of Laser Surgeries:

1. Green Light PVP Laser: This procedure uses green light to vaporize the prostate and useful for majority of patients with enlarged prostate. A tube with light and lens called the cystoscope is inserted into the penis. The laser beam is introduced through the cystoscope and directed towards the prostate. It creates high energy which vaporizes the excess tissue and relieves the urethral blockage. The procedure is done in a short time and the patient can go home the same day and resume daily non strenuous activities within a couple of days.

The image on the left shows an enlarged prostate constricting bladder flow. The image on the right shows the prostate after laser PVP surgery.

2. Holmium Laser: This is the most commonly used technique and is performed under general anaesthesia. The laser of 2140nm wavelength and 0.4mm penetration is introduced through the cystoscope that is inserted into the penis at the start of the procedure. The laser cuts and vaporises the enlarged prostate tissue and relieves urinary blockage. Some tissue pieces are directed to the bladder from where they are flushed out. The procedure is done in a short time and the patient can go home the same day or the next day and resume daily non strenuous activities within a couple of days. The procedure is relatively bloodless.

3. VLAP: This procedure has many disadvantages and has become virtually obsolete with the coming of Holmium Laser. The technique uses neodymium:yttrium-aluminum-garnet (Nd:YAG) laser which has a wavelength of 1064nm. The laser beam is directed towards the prostate gland via the cystscope. The beam generates a lot of heat which coagulates the gland tissue. The surgery is performed under regional or general anaesthesia. The technique was not popular among patients as the coagulated portion caused irritation. Also the urine catheter had to be kept for long. Soon this was replaced by Holmium Laser.

4. ILC: Interstitial Laser coagulation therapy was used to coagulate tumours which could not be cut and removed especially in the brain, neck, liver, pancreas etc. in this procedure the laser probe is in direct contact with the prostatic tissue and generates temperature of 60 degrees Celsius which destroys the cell protein. The destroyed cells are absorbed in due course of time and a shrunken prostate gland remains. The urethra is not affected. The procedure is performed under general or regional anaesthesia. The rigid laser probe is inserted through the cystoscope and pushed till it enters the prostate after which it is activated to produce the heat. The effect is localised to the prostate tissue only.

Robotic Prostatectomy: This procedure is carried out using the computer and is an advanced form of minimally invasive surgery. In this technique, small incisions are made in the lower part of the abdomen and the entire surgery is carried out using Tele-manipulator. The surgeon performs actions, which moves the Tele-manipulator which in turn is connected to the robot’s arms which replicate the surgeons hand movements and perform the surgery. The surgery is controlled remotely but involves great precision because of which it is soon becoming very popular. The procedure has resulted in favourable outcome as there is less blood loss, faster recovery and shorter hospital stay.

Surgeons also perform laparoscopic robot assisted surgeries using the Da Vinci system which uses miniature surgical tools to carry out the surgery through the keyhole incisions. This method is gradually gaining popularity in treatment of prostatic cancers as there is great precision involved while removing the prostate gland without affecting the other tissues.

HIFU: High intensity focused ultrasound is the new treatment approach that has evolved for the treatment of prostate cancer. The focused high energy ultrasound beam is targeted towards the cancerous cells which may be very small or very big which results in intense heating up of these cells causing their death. Since this treatment does not involve any side effects that are seen with chemo and radiotherapy, it is fast gaining popularity among the patients. The patients can go home after a single night stay in the hospital. The surgery is carried out under general or spinal anesthesia. The ultrasound probe is inserted through the rectum and emits high energy ultrasound towards the prostate gland which destroys the cancer tissue. The chance of recurrence is very less and side effects like erectile dysfunction and urinary incontinence are rarely seen. Hifu has been used successfully in Europe but is still in the clinical trial stage in United States.

After surgery, the patient is advised not to lift heavy weights or do strenuous work for 2-3 weeks and drink plenty of water. Regular physician checkup should be done as advised. Patients attain their pre-surgery status sooner in laparoscopic, laser assisted or robotic surgeries as compared to traditional open surgeries.

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