PROSTATE CANCER - START YOUR TREATMENT NOW

THE BEST DOCTORS, THE BEST HOSPITALS, THE BEST MEDICATIONS and TREATMENTS

Active surveillance

is often used to mean monitoring the cancer closely, with a plan to treat it if tests show it’s starting to grow more quickly. Usually, this approach includes doctor visits with a prostate-specific antigen (PSA) blood test about every 6 months and a digital rectal exam (DRE) about once a year.



Prostate biopsies and imaging tests may be done every 1 to 3 years as well. Exactly how often tests are done can be tailored to some extent, based on each man’s situation and preferences.

If test results change, you have to start with the treatment options to try to cure the cancer on as earlier possible stage.

Observation (watchful waiting)

is sometimes used to describe a less intense type of follow-up that includes fewer tests and that relies more on changes in a man’s symptoms to decide if treatment is needed. This is more likely to be a good option for men who are older and/or have other serious health problems.  

Chemo drugs for prostate cancer are typically given into a vein (IV) as an infusion over a certain period of time. There are some drugs, which are given as a pill.

Sometimes, a slightly larger and sturdier IV might be put into a vein to give chemo.

These are known as central venous catheters (CVCs), central venous access devices (CVADs), or central lines.

They are used to put medicines, blood products, nutrients, or fluids right into your blood.

They can also be used to take out blood for testing. There are many kinds of CVCs available. The most common types are the port and the PICC line.

Chemotherapy is given in cycles, with each period of treatment followed by a rest period to give patient time to recover from the effects of the drugs.

Cycles are most often about 3 weeks long. The schedule varies depending on the drugs used.

Some drugs (the chemo) is given only on the first day of the cycle. With others, it is given for a few days in a row, or once a week.

Then, at the end of the cycle, the chemo schedule repeats to start the next cycle.

How long patient will be given chemo depends on how well it’s working and what side effects patient might have.

Radical prostatectomy

The main type of surgery for prostate cancer is a radical prostatectomy. In this operation, the surgeon (urologist) removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. Sometimes nearby lymph nodes are removed as well.

There are 2 main ways a surgeon can do a radical prostatectomy:

• Open prostatectomy:

the surgeon operates through a single long skin incision (cut) to remove the prostate and nearby tissues.

• Laparoscopic prostatectomy:

the surgeon makes several smaller incisions and uses long, thin surgical tools to remove the prostate and nearby tissues.

Most often, the surgeon sits at a control panel to precisely move robotic arms that hold the tools (known as a robot-assisted prostatectomy or robotic prostatectomy).

The operation can also be done with the surgeon holding the tools directly, although this is less common.

With either type of operation, if there’s a reasonable chance the cancer might have spread to nearby lymph nodes (based on your PSA level, prostate biopsy results, and other factors), the surgeon may first remove some of these lymph nodes (known as a pelvic lymph node dissection).

The nodes are sent to the lab to be looked at right away for cancer cells. If cancer cells are found in any of the nodes, the surgeon might not continue with the surgery.

This is because it’s unlikely that the cancer can be cured with surgery, and removing the prostate could lead to serious side effects.

Prostate cancer is one of the most common types of cancer in men, most often affecting middle-aged and elderly men. Prostate cancer develops slowly and may progress for years without any symptoms; the initial manifestations of the disease appear at stage 2 or later. The primary diagnostic measure for suspected prostate cancer is a PSA blood test. If the result is unsatisfactory, the team of specialists from The Zdenko Kos Foundation and doctors from the hospital where you will be admitted will additionally perform magnetic resonance imaging (MRI) and a transperineally MRI-guided prostate biopsy.

Most clinics perform a transrectal puncture biopsy of the prostate gland. However, it provides doctors with an accurate diagnosis in only 30-35% of cases, so the medical team prefers a transperineally MRI-guided biopsy. With this method, the reliability of diagnostic data reaches 100%. This approach allows the patient to avoid unnecessary invasive procedures.

To detect prostate cancer metastases, the department's doctors use Ga-68 PSMA PET/CT instead of a CT scan and bone scintigraphy, which not so long ago were considered the standard methods of prostate cancer staging. It has already been proven that, among all diagnostic methods, Ga-68 PSMA PET/CT allows for the most accurate detection of prostate cancer metastases in any location.

Standard and innovative prostate cancer treatments are divided in three treatment groups:

• Treatment of prostate cancer and bladder cancer
• Irreversible electroporation (IRE)
• Combination treatment with irreversible electroporation and electrochemotherapy (IRECT)
• Combination treatment with irreversible electroporation and immunotherapy
• Photodynamic therapy (PDT)
• Combination treatment with photodynamic therapy and immunotherapy
• Treatment of benign prostatic hyperplasia
• GreenLight laser therapy
• Rezum water vapor therapy
• Other treatment methods

As for the treatment of prostate cancer, the Zdenko Kos Foundation is proud to offer patients innovative and minimally traumatic methods to combat oncology. The gold standard of prostate cancer treatment is a prostatectomy (prostate removal surgery). For patients with unresectable tumours, doctors offer irradiation. The department's doctors use revolutionary new types of treatment, the effectiveness of which is comparable to prostatectomy and radiation therapy. At the same time, these new treatment procedures help the doctors eliminate the development of complications after the completion of therapy, namely erectile dysfunction and urinary incontinence, which are almost unavoidable with classic prostatectomy or radiation therapy.

NanoKnife irreversible electroporation (IRE):

Is a promising low-traumatic method for prostate cancer treatment, and the medical team working with The Zdenko Kos Foundation have vast experience in its use. The essence of the method consists in the selective ablation (destruction) of cancer cells by the powerful electric field of the NanoKnife device.

The medical team specialists at different hospital working with The Zdenko Kos Foundation around the Europe have successfully performed more than 4,200 IRE procedures. This method provides excellent results and helps patients with advanced stages of prostate cancer.

Irreversible electroporation is performed under general anaesthesia, does not require extensive tissue incisions, and is more than just tolerated. Unlike prostatectomy and radiatiotherapy, IRE practically eliminates the risk of erectile dysfunction. Also, during the entire period of application of this treatment method, none of the patients developed postoperative urinary incontinence. Normal hospital stay for IRE treatment is only 3 days.

Irreversible electroporation and electrochemotherapy (IRECT):

for patients with prostate cancer. In these cases, the effect of the IRE procedure is enhanced by simultaneously applying electrical current and low-dose chemotherapy to cancer cells. Irreversible electroporation increases the permeability of the cell wall, which allows chemotherapy drugs to easily penetrate cancer cells and effectively destroy them. The combination IRECT method may be indicated for patients with high-grade tumours, patients with cancer that has invaded the rectum or bladder wall, and patients with complex focal prostate cancer recurrences after surgery, HIFU, or radiation therapy.

Irreversible electroporation with immunotherapy treatment:

In this case, the effect of IRE is enhanced by activating the patient's anti-cancer immunity. The immune system is "trained" to recognize cancer cells by antigens located on their surface. During irreversible electroporation, tumour antigens are released in large quantities, and it is easier for the immune system to recognize them, subsequently destroying the cancer cells.

Photodynamic therapy (PDT):

Is regularly performed for the treatment of prostate cancer and bladder cancer. This treatment uses photosensitizers and light sources of a certain length. The photosensitizer accumulates in the cancer cells and does not threaten healthy tissues. After the accumulation of the photosensitizer, the tumour is irradiated with light of a certain wavelength. As a result, chemical processes are launched that lead to the formation of active oxygen radicals. Oxygen radicals are toxic to cancer cells, so they can easily destroy them. In addition, PDT triggers an anti-cancer immune response by causing dying tumour cells to release specific antigens that the patient's immune system recognizes, resembling a vaccination mechanism. Tumour antigens allow the natural killer cells of the immune system to recognize and eliminate tumour cells in the patient's body.

Benign prostatic hyperplasia - GreenLight laser therapy and the Rezum procedure:

If untreated, the disease causes serious bladder voiding dysfunction, frequent nocturnal urination, and elevated PSA levels in the blood, which in turn potentially threatens the development of prostate cancer.

Minimally invasive procedures for prostate adenoma treatment are GreenLight laser therapy and the Rezum procedure.

The hospital stay for such treatments is 1-2 days.

Unlike the standard transurethral resection of the prostate, GreenLight and Rezum are bloodless procedures. In addition, innovative GreenLight and Rezum treatments eliminate the risk of developing erectile dysfunction and urinary incontinence.



Laparoscopic prostatectomy (including robotic prostatectomy)

Laparoscopic surgery

is done through several small incisions in the abdomen, rather than one large incision. The surgeon inserts a laparoscope, which is a long, thin tube with a light and tiny video camera on the end, through one of the openings so they can see inside the body. Long, thin surgery instruments are then inserted through the other incisions to perform the operation.

This approach to prostatectomy (particularly robotic prostatectomy) has become much more common in recent years.

Laparoscopic radical prostatectomy

For a laparoscopic radical prostatectomy (LRP), the surgeon holds the handles of the long instruments directly to manoeuvre them inside the belly and remove the prostate. This approach is not used as often as robotic prostatectomy.

Robotic prostatectomy

This approach, also known as robotic-assisted laparoscopic radical prostatectomy or robot-assisted prostatectomy, is the most common way prostatectomy is done in the United States.

This operation is done using a robotic system. The surgeon sits at a control panel in the operating room and moves robotic arms to operate through several small incisions, usually in the patient’s abdomen (although it can also be done with a perineal approach). The robotic system helps the surgeon move the instruments more precisely than if they were holding the laparoscopic tools directly in their hands.

ROBOTIC v OPEN RADICAL PROSTATECTOMY (Things you should know)

Robotic prostatectomy is the most common surgery to treat prostate cancer in quite a few countries around the Europe. That is largely because this operation has some short-term advantages over open radical prostatectomy. Normally results in:

• Less blood loss during the operation
• Less pain after the operation
• A shorter hospital stays
• A quicker recovery time
• Less time the urinary catheter needs to stay in place
• A lower risk of some rare but potentially serious side effects

However, the results of robotic and open prostatectomy seem to be about the same when it comes to the long-term side effects that many men are most concerned about, including erection problems and trouble holding urine (incontinence). (These are described below.)

There also doesn’t appear to be much difference between robotic and open prostatectomy when it comes to long-term outcomes. That is, studies haven’t shown that either approach is clearly better than the other when it comes to how likely the cancer is to return after surgery or how likely a man is to die from prostate cancer. Both approaches generally result in good outcomes when done by experienced surgeons.

In some instances, there might be clear reasons to favour one approach over the other.

Make no mistake, doesn’t matter which prostatectomy approach you choose, the biggest factor in the success of your surgery is likely to be the experience and skill of your surgeon. Therefore, it’s very important to go with an experienced surgeon whom you’re comfortable with and whom you can trust.

Risks of prostatectomy

The risks with any type of radical prostatectomy are much like those of any major surgery. Problems during or shortly after the operation can include:

• Reactions to anaesthesia
• Bleeding from the surgery
• Blood clots in the legs or lungs
• Damage to nearby organs
• Infections at the surgery site
• Rarely, part of the intestine might be injured during surgery, which could lead to infections in the abdomen and might require more surgery to fix. Injuries to the intestines are more common with laparoscopic and robotic surgeries than with the open approach.

If lymph nodes are removed, a collection of lymph fluid (called a lymphocele) can form and may need to be drained.

Your risks depend, in part, on your overall health, your age, and the skill of your surgical team.

Side effects of prostatectomy

The major possible side effects of radical prostatectomy are:

• Urinary incontinence (being unable to control urine)
• Erectile dysfunction (problems getting or keeping erections)
• These side effects can also occur with some other forms of prostate cancer treatment.
• Other side effects are also possible (see below).

Urinary incontinence

You may not be able to control your urine, or you may have leakage or dribbling after your surgery. Being incontinent can affect you not only physically, but also emotionally and socially. These are the major types of incontinence:

Men with stress incontinence might leak urine when they cough, laugh, sneeze, or exercise. Stress incontinence is the most common type after prostate surgery. It’s usually caused by problems with the valve that keeps urine in the bladder (the bladder sphincter). Prostate cancer treatments can damage this valve or the nerves that keep the valve working.

Men with overflow incontinence have trouble emptying their bladder. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.

Men with urge incontinence have a sudden need to urinate. This happens when the bladder becomes too sensitive to stretching as it fills with urine.

Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence.

After surgery for prostate cancer, bladder control usually improves slowly over several weeks or months. But doctors can’t predict for sure how any man will be affected. In general, older men tend to have more incontinence problems than younger men. Large cancer centers, where prostate surgery is done often and surgeons have a lot of experience, generally report fewer problems with incontinence.

Incontinence can be treated. Even if your incontinence can’t be corrected completely, it can still be helped. To learn about managing and living with incontinence, see Bladder and Bowel Incontinence.

Erectile dysfunction (impotence)

This means you can’t get an erection sufficient for sexual penetration.

Erections are controlled by 2 tiny bundles of nerves that run along either side of the prostate. If you can have erections before surgery, the surgeon will try not to injure these nerves during the prostatectomy. This is known as a nerve-sparing approach. But if the cancer is growing into or very close to the nerves, the surgeon will need to remove them.

If both nerves are removed, you won’t be able to have spontaneous erections, but you might still be able to have erections using some of the aids described below. If the nerves on only one side are removed, you might still have erections, but the chance is lower than if neither were removed. If neither nerve bundle is removed, you might have normal erections at some point after surgery.

Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut. Most men will probably have at least some loss of ability to have an erection, but the younger you are, the less likely you are to be seriously affected.

Surgeons who do many prostatectomies tend to report lower rates of erection problems among their patients than those who do the surgery less often. A wide range of rates have been reported in the medical literature, but each man’s situation is different, so the best way to get an idea of your chances for recovering erections is to ask about your doctor’s success rates and what the outcome is likely to be in your case.

If your ability to have erections does return after surgery, it often returns slowly. In fact, it can take from a few months to 2 or more years. During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments.

Many doctors feel that regaining potency is helped along by trying to get an erection as soon as possible once the body has had a chance to heal (usually several weeks after the operation). Some doctors call this penile rehabilitation. Medicines (see below) may be helpful at this time, although it’s not clear if they work better if taken daily or just on an as-needed basis. Be sure to talk to your doctor about your situation.

Options for treating erectile dysfunction:

Phosphodiesterase-5 (PDE5) inhibitors, such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra), are pills that can help with erections. These drugs won’t work if both nerves that control erections have been damaged or removed. Common side effects of these drugs include headache, flushing (skin becoming red and feeling warm), upset stomach, light sensitivity, and runny or stuffy nose. Rarely, these drugs can cause vision problems, possibly even blindness. Some other drugs such as nitrates, which are used to treat heart disease, can cause problems if you are taking a PDE5 inhibitor, so be sure your doctor knows what medicines you take.

Alprostadil is a man-made version of prostaglandin E1, a substance naturally made in the body that can produce erections. It can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or placed into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You might have side effects, such as pain, dizziness, and prolonged erection, but they are not usually serious.

Vacuum devices are another option to create an erection. These are clear, plastic tubes connected to pumps that are placed over the penis. The pump sucks the air out of the tube, which draws blood into the penis to produce an erection. After the device is removed, the erection is maintained by placing an elastic ring around the base of the penis, which keeps the blood from draining out. The ring is then removed after sex.

Penile implants might restore your ability to have erections if other methods don’t help. An operation is needed to put them inside the penis. There are several types of penile implants, including those using silicone rods or inflatable devices.

For more on coping with erection problems and other sexuality issues, see Sexual Side Effects.

Changes in orgasm

After surgery, the sensation of orgasm should still be pleasurable, but there is no ejaculation of semen – the orgasm is “dry.” This is because the glands that made most of the fluid for semen (the seminal vesicles and prostate) were removed during the prostatectomy, and the pathways used by sperm (the vas deferens) were cut. In some men, orgasms might become less intense. Less often, men report pain with orgasm.

Loss of fertility

During a radical prostatectomy, the surgeon cuts the vas deferens, which are the pathways between the testicles (where sperm are made) and the urethra (through which sperm leave the body). Your testicles will still make sperm, but they can’t leave the body as a part of the ejaculate. This means that a man can no longer father a child the natural way.

Often, this is not an issue, as men with prostate cancer tend to be older. But if it is a concern for you, you might want to ask your doctor about “banking” your sperm before the operation. To learn more, see Fertility Problems.

Lymphedema

This is a rare but possible complication of removing many of the lymph nodes around the prostate. Lymph nodes normally provide a way for fluid to return to the heart from all areas of the body. When nodes are removed, fluid can collect in the legs or genital region over time, causing swelling and pain.

Lymphedema can usually be treated with physical therapy, although it may not go away completely. You can learn more on our lymphedema page.

Change in penis length

A possible effect of surgery is a small decrease in penis length. This can result from a shortening of the urethra when a portion of it is removed along with the prostate.

Inguinal hernia

A prostatectomy increases a man’s chances of developing an inguinal (groin) hernia in the future.

Transurethral resection of the prostate (TURP)

This operation is more often used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). But it is also sometimes used in men with advanced prostate cancer to help relieve symptoms, such as trouble urinating. (It is not used to try to cure the cancer.)

During this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra (the tube through which urine leaves the bladder). The skin is not cut with this surgery. An instrument called a resectoscope is passed through the tip of the penis and into the urethra to the level of the prostate. Once it’s in place, either electricity is passed through a wire to heat it or a laser is used to cut or vaporize the tissue.

This operation is done with either spinal anaesthesia (which numbs the lower half of your body) or general anaesthesia (where you are in a deep sleep), and it usually takes about an hour.

After surgery, a catheter (thin, flexible tube) is inserted through the penis and into the bladder. It remains in place for about a day to help urine drain while the prostate heals. You can usually leave the hospital after 1 to 2 days and return to normal activities in 1 to 2 weeks.

You will probably have some blood in your urine after surgery.

Other possible side effects from TURP include infection and any risks that come with the type of anaesthesia used.

Orchiectomy (castration)

In this operation, the surgeon removes the testicles, where most of the androgens (male hormones) are made. Although this is a type of surgery, its main effect is as a form of hormone therapy. To learn more about this operation, see Hormone Therapy for Prostate Cancer.