What Is The Prostate Gland?
The prostate is a small gland found only in men. It is situated between the neck of the bladder and the urethra (see above).
Although the prime function of the prostate gland is to add secretions to the seminal fluid during ejaculation, removing the prostate gland completely has no permanent effects on a man’s health.
During a man’s lifetime the prostate can be subject to a number of diseases but the two commonest are:
Benign enlargement of the prostate or benign prostatic hyperplasia (BPH)
In this condition the epithelium and the fibrous tissue of the prostate undergo proliferative growth, causing enlargement of the prostate gland. It is extremely common, being found to some degree in most men beyond middle age.
BPH can cause various urinary symptoms, known collectively as lower urinary tract symptoms (LUTS) but obstruction to the neck of the bladder usually results in:
- difficulty in starting
- slowing of the urinary stream
- dribbling at the end of the stream
- bladder irritability
These symptoms are non-specific and can also be caused by locally-advanced prostate cancer. The symptoms of BPH do not always require treatment but they an be relieved by a number of drugs. If there is no response to drugs, symptoms can be improved by trimming away the lining of the prostate gland (a transurethral prostatectomy or TURP) or by other minimally-invasive and laser treatments; many of these treatment are available at Addenbrooke’s Hospital.
Prostate cancer
Prostate cancer is the commonest cancer in men in England. It is an extremely slow-growing cancer and there is evidence that it can be found, in its very early stages, in men as young as 20 or 30.
We do not know what causes prostate cancer but, in some men, there is a familial component. Men whose fathers, uncles and brothers have had prostate cancer or whose mothers have a history of breast cancer may be at increased risk. We believe that diets rich in red meat may also increase prostate cancer risk.
Prostate cancer can sometimes be detected at an early stage by a blood test (prostate specific antigen or PSA). However, the PSA test is not entirely accurate. There is no real safe lower limit. Even in men with "normal" levels of PSA (less than 3 to 4 ng/ ml) around 15% may have small prostate cancers. Conversely, the PSA level may be increased by conditions other than the presence prostate cancer; BPH or prostate inflammation can increase PSA levels.
What Is The Risk of Progression In Localised Prostate Cancer?
The clinical staging of prostate cancer is shown above.
In many men, some small prostate cancers of low Gleason grade (6 or less) and low stage (T1 & T2a) may remain dormant throughout the patient’s lifetime. For this reason, careful active monitoring (AM) or active surveillance (AS) is sometimes recommended in certain men, especially in those who have other medical conditions or in those who are more elderly. In younger men, an initial conservative approach using AM or AS can be used to enable them to think about surgery or radiotherapy in more detail.
For men who have been diagnosed with an early prostate cancer, we work hard with you to ensure that you have all the necessary information to work out what treatment is best for you, given your own approach to things, your own values about cancer cure and the importance of retaining sexual function.
Some information about cancer risk is available from nomograms; these allow us to calculate the risk of your cancer being confined to the prostate gland (organ-confined) and the likely outcomes of various treatments. One such nomogram can be found on the web-site of the Memorial Sloan Kettering Hospital in New York.
You will need to know:
- your own PSA level
- the primary Gleason score (1 to 5)
- the secondary Gleason score (1 to 5)
- the total Gleason sum score (the sum of the previous two scores: = 2 to 10)
- the T-stage of your tumour
Tumours can be stratified into degrees of risk. Low risk cancers are those with a PSA less than 10, a Gleason grade of 6 or less and a clinical stage of T1 or T2a. However, younger men with a family history or those with a large amount of cancer in the biopsies may be at increased risk.
What Treatments Are Available For Prostate Cancer?
Localised prostate cancer (T1 & T2)
- Active monitoring
- Open surgery
- laparoscopic surgery
- robotic surgery
- Radiotherapy
- conventional external beam
- brachytherapy
- Other treatments
More advanced, locally-confined prostate cancer (T3)
With more advanced (but still locally-confined) prostate cancer, radiotherapy can still be helpful, usually in combination with hormone treatment. Occasionally, in some younger men, surgery in combination with other treatments can be used.
Advanced (T4) or metastatic prostate cancer
For men with more widespread disease, hormone treatment is the mainstay although there are new chemotherapy regimes available at Addenbrooke's Hospital and new research treatments are being trialled all the time.
The PSA Test
Prostate specific antigen (PSA) is a protein which is secreted largely by the prostate. Men with advanced prostate cancer have high levels of PSA but men with localised disease usually have PSAs of < 10 ng/ml. In these men, the levels in the blood stream have no clear normal cut-off point between cancer and non-cancer; there is almost a continuous distribution of risk.
In the UK, the “normal” cut-off point is taken at ~4 ng/ml, depending on age, but, in the USA, it is now recommended that biopsies of the prostate should be undertaken in younger men (between 50-60) when the PSA is more than 2.5 ng/ml. Biopsies are frequently recommended in men over 60 when their PSA reaches 3.0 to 3.5 ng/ml.
PSA levels can also be raised by inflammation of the prostate or by BPH; this will need to be excluded by your urologist.
In practice, what this means for men aged 50 to 69 is that, if you have a normal feeling prostate and your PSA is in the region of 3.5 to 10 ng/ml, you have a 25% chance of having cancer found on prostate biopsy.
The risks of your having a small prostate cancer related to the level your PSA are shown in the table above. We would stress that many of the cancers found in the low PSA range (< 2 ng/ml) are very small and well-differentiated, posing an extremely low risk to yoour future health.
Biopsy Of The Prostate
The only way of being sure a prostate cancer is present or not is to carry out a prostate biopsy using transrectal ultrasound (see above). We know that taking at least 10-12 biopsies is more accurate than doing sextant (6) biopsies. Even so, in some instances, we may need to repeat the biopsy to be sure.
Local anaesthetic is given around the prostate to minimise any pain during the biopsies. We will give you a full information sheet about the side-effects and expected outcomes of a transrectal ultrasound scan if this is what you agree to have.
Go to the information sheet for transrectal ultrasound.
Prostate Cancer Staging & Grading
When we carry out a biopsy of the prostate we find out how much tumour is present in the biopsies and where the biopsies are positive; this helps to work out the risks of the prostate cancer involving the capsule (outside) of the prostate gland. It also enables us to work out the extent to which sparing of the nerves which produce penile erection might be possible if you elect to have surgery.
In addition to the amount of tumour found in the biopsies, we also get information on the grade of the cancer. We use the term Gleason grade to describe how aggressive the cancer looks. This is stated as primary, secondary and sum (the total of the primary and secondary grades).
- Gleason grade 6 cancers, or less, we describe as well-differentiated cancers.
- Gleason grade 7 cancers are somewhere in the middle; some behave aggressively but others less so. These are moderately-differentiated cancers.
- Gleason grade 8-10 cancers are the most aggressive and are known as poorly-differentiated cancers.
Imaging of the prostate & skeleton
We frequently carry out cross-sectional imaging with magnetic resonance imaging (MRI) or computerised tomography (CT); see MRI image above. These techniques allow us to see if the cancer has advanced locally. However these investigations are not entirely accurate in predicting the extent of local invasion. They are better in determining whether the local lymph glands are enlarged and this will determine what kind of treatment it might be possible to advise you to have.
T1 cancers
If the prostate feels entirely normal on rectal examination and we find a cancer inside it, this is termed a T1c prostate cancer. Such cancers are suitable for most forms of treatment including active monitoring, radiotherapy (external beam or Brachytherapy) or surgery (conventional open surgery, laparoscopic or robotic prostatectomy).
T2 cancers
Radical local treatments are also sometimes appropriate for men with more locally advanced cancers (T2 or even sometimes T3 cancers) but may need to be supplemented by radiotherapy and/or hormonal treatment.
T3 cancers
T3 cancers are those where we feel the tumour might have breached the capsule of the prostate, may be involving the seminal vesicles (the sperm sacs) or may have invaded other parts of the bladder. In general, T3 cancers are not ideal for surgical treatment but we will discuss their management with you in terms of surgery versus radiotherapy or hormonal treatment.
T4 cancers
T4 cancers are those where the cancer has involved other structures and these are not generally suitable for radical local treatment.
Active Monitoring (AM) or Active Surveillance (AS)
This describes one method of management where we carry out frequent, careful observation of your prostate gland by means of digital rectal examination and by measuring the level of PSA in the blood. The reason we sometimes recommend this method of management is because not all cancers are at high risk of progression. In more elderly men with low volume Gleason grade 6 cancers, the risks are very low and active monitoring can be a very good form of treatment.
It can also be used whilst men are making up their minds about different forms or treatment and it can be used to monitor how aggressive the tumour might be. The reason is that, if a cancer does not progress on monitoring, you will not need more radical forms of treatment. In younger men we sometimes carry out further biopsies over time to ensure the cancer has not changed in nature.
The advantage of active monitoring is that it involves no aggressive intervention and there are, of course, no side-effects. The disadvantage is that PSA level is not entirely reliable in predicting when a tumour has grown and sometimes further biopsies of the prostate gland are required.
Some men find that they become very anxious whilst on active monitoring and worry all the time about the prostate gland; for such patients, this is not a good form of management.
Radiotherapy
If you wish to consider having radiotherapy, we will refer you to one of our clinical oncology colleagues who specialises in radiotherapy treatment for the prostate gland.
Brachytherapy
We have recently established brachytherapy (see picture above) at Addenbrooke’s Hospital, led by Dr Rob Thomas & Dr Simon Russell (Clinical Oncologists) and Mr Andrew Doble (Consultant Urologist). Brachytherapy is ideal in a man with no symptoms of BPH (no difficulty in passing water or urinary frequency) and where the prostate cancer is small (T1C), of Gleason grade 6 or less and low volume. Brachytherapy involves two treatments under a general anaesthetic.
In the first, an accurate estimate of the size, shape and position of the prostate gland is made.
Go to the information sheet on brachytherapy planning
During the second, longer anaesthetic, a number of seeds are placed throughout the prostate gland under ultrasound control using a special template. These seeds contain radioactivity and provide a high local dose of radiation to the prostate gland.
Go to the information sheet on brachytherapy treatment
Conventional external beam therapy
This involves a total of 32 treatments over several weeks with the radiotherapy being given in low doses to minimise side effects.
Sometimes we advise you to have three months of hormone treatment before starting the radiotherapy in order to shrink the prostate gland and to improve the effectiveness of the radiotherapy. In men with higher stage cancers, hormonal treatment is continued for 12 to 24 months after the radiotherapy is completed.
Once again if you wish to have further information about this we will provide you with a detailed information sheet.
In general terms, radiotherapy, whether provided by external beam or by brachytherapy, can be an effective treatment in some men with early prostate cancer. It has side effects, including irritation to the bladder (blood in the urine) and bowel (rectal bleeding). These are usually mild in nature and frequently settle after a period of time. More severe, permanent, side-effects occur in about 5-10% of people.
Radiotherapy can continue to produce damage over time. Its immediate effects on sexual function are less than surgery. Generally, about 15% of people who were sexually active before radiotherapy lose their erectile function immediately after radiotherapy and this proportion will increase over a 5-year follow up. Severe urinary leakage is an infrequent complication of radiotherapy.
After radiotherapy you will be followed up carefully by means of PSA testing. Surgery or cryotherapy can sometimes be given to those people where the radiotherapy has not completely eliminated the prostate cancer but the side-effects of surgery after radiotherapy are more severe and you will need to discuss this with your radiotherapist or surgeon before making your decision to have radiotherapy.
More aggressive, locally-confined cancers
In the past, the general view was that patients with more locally-advanced or high risk cancers should undergo external beam radiotherapy with hormonal manipulation, rather than be subjected to surgery. This remains a standard of care for such men.
However it has become clear that surgical treatment can offer continued and sustained cure rates in such patients even if they require hormonal treatment post-operatively for evidence of positive lymph nodes at the time of surgery.
There is also good evidence from randomised clinical trials that, following surgery for more locally aggressive cancers, a short course of radiotherapy has minimal side-effects but improves the long-term outcome of surgical treatment.
Primary surgery for such locally-aggressive cancers may now be feasible because it is possible, after initial surgery, to carry out further treatment, including hormone manipulation and radiotherapy. It is, however, difficult to offer surgical treatment to men who have failed radiotherapy treatments.
Conventional Surgery
Surgical treatment of prostate cancer involves removal of the whole of the prostate and seminal vesicles (sperm sacs). In Addenbrooke’s Hospital we can offer you a choice between open surgery or robotic prostatectomy although most men now choose the robotic approach.
Open surgery has been established for many years and is well-standardised. It involves a small cut in the lower part of the abdomen and takes about three hours to perform. We first remove the lymph glands around the prostate gland and, following the removal of the prostate and seminal vesicle, we stitch the bladder neck to the urethra, producing a watertight anastomosis (see picture above). You will sometimes have a drain placed in position for 24-48 hours and a urinary catheter will be left in place for 2-3 weeks while the anastomosis heals.
The operation involves a stay in hospital of 5-8 days and the risks of requiring a blood transfusion are in the order of 15-20%. It will take you 2-3 months to recover your full strength and to return to normal working.
Go to the information sheet on open surgery
The special complications of open prostatectomy are those of urinary incontinence and sexual dysfunction:
Continence
A year after open prostatectomy, 80-85% of patients report that they are completely dry or only need to wear one small pad a day. About 2% of men are very wet and may require further surgical treatment. Those between these two extremes may need to wear more than one pad per day for continence. We minimise this by attention to detail and also by ensuring that you are trained in pelvic floor exercises before and after treatment.
Sexual Function
The nerves that produce penile erection run very close to the prostate gland. In open surgery, we try to preserve the neurovascular bundles if this is compatible with removing all the cancer. We try to estimate the risk of impotence based on the PSA level, the Gleason grade and the proportion of the biopsies affected by the cancer. This will be discussed in greater detail with you when you come up to the clinic.
Robotic Prostatectomy
The DaVinci Robot was devised by Intuitive Surgical at Sunnyvale in California.
It allows surgeons to carry out very fine and precise manipulations of the prostate gland using robotic assistance. In essence, it is a type of minimally-invasive, laparoscopic surgery with the advantage that the surgeon can control the movements much more precisely and delicately.
Robotic prostatectomy involves the insertion of five small openings (ports) in the abdominal wall, each around 1-2 cm in length. Through these ports, a variety of different instruments can be introduced to allow clear visualisation of the prostate and careful manipulation.
We will give you a detailed information sheet about the operation of robotic prostatectomy if this is what you decide to have done.
Download the information leaflet about surgery.
Training for robotic prostatectomy
The whole theatre team, including theatre sisters, anaesthetist (Dr Vishal Patil) and two surgeons (Mr Nimish Shah and Professor David Neal) have trained in several different centres in the USA and Europe. Before establishing the program, we went to New York and New Jersey to work in laboratories and operating theatres. In addition, Professor Neal and Mr Shah have both visited Professor Mani Menon in the Henry Ford Hospital Systems in Detroit at the Vaticuti Urology Institute.
Once we started carrying out robotic prostatectomies at Addenbrooke’s, a team from Detroit (Dr Jim Peabody and Mr Sanjeev Kaul) came and mentored Professor Neal and Mr Shah in their first few cases. Since then Professor Neal has again visited Cornell and Detroit to refine further the operative technique.
Our Results for Robotic Prostatectomy
We have now done over 300 operations and have been impressed with our initial results. In our first 40 operations, we have not had to convert the patient to a conventional open operation. The average length of stay has been less than 24 hours after the operation, with over 80% of men going home after the first post-operative day. Less than 1.5% of men have required a blood transfusion. In our hands, recovery time has been much improved over open surgery.
We have been impressed by the ability to carry out a careful anastomosis (join) between the bladder neck and the urethra); we believe this will improve urinary control compared with an open operation. In addition we have been able to preserve the delicate neurovascular tissue around the prostate; we believe this will improve the ability of patients to retain erectile function and a sense of orgasm after the operation.
The cancer removing results have been good in that less than 15% of men have had what we call a positive margin. The risks of positive margins are dependent on the stage and grade of the cancer.
The most recent results for continence are shown above. In our last 108 men, over 85% required no pad at all after 10 months of follow-up.
We now have a dedicated team including a cancer specialist nurse (Claire Johnston) and a surgical care practitioner (Gillian Basnett) who take a particular interest in patients having robotic prostatectomy, counselling them carefully before the operation, training them to do pelvic floor exercises before and after the operation and following them up after the procedure.
Download the leaflet about post-operative recovery.
