Macquarie University – Non invasive surgery
Tests involved with prostate cancer treatment:
Digital Rectal Examination (DRE)
Your doctor inserts a gloved finger into the rectum to feel the condition of the prostate that lies close to the rectal wall. If your doctor feels something suspicious such as a lump or bump, further tests will be carried out. Other tests are needed to enable a more accurate diagnosis.
Prostate Specific Antigen (PSA) Test
A blood sample is taken by your doctor to check for prostate specific antigen (PSA), which is produced by the prostate and is increased by cellular abnormalities within the prostate.
As men get older the prostate gland grows and so the PSA is likely to rise. A high PSA may indicate some type of prostate disease. The level can be raised due to inflammation of the prostate (Prostatitis) and enlargement of the prostate gland (Benign Prostatic Hyperplasia or BPH).
PSA is a useful tool for diagnosing and monitoring prostate diseases, but further tests are required to confirm which condition is present.
This is a new urine specimen test to assess the risk of prostate cancer in an individual. It will not tell you if you do or do not have cancer, but will give a likely risk score. Talk to A/ Prof Varol if you are interested or have any further questions.
The most common reason this test is performed is because either a blood test called PSA is abnormally high or the findings on examining the prostate through the back passage are abnormal.
Ultrasound scans use sound waves to build up a picture of the inside of the body. To scan the prostate gland a small probe is passed into the back passage and the image of the prostate appears on a screen. This type of scan is used to measure the size and density of the prostate. A sample of cells (biopsy) can be taken at the same time for examination under the microscope by a pathologist.
The scan may be uncomfortable but it only takes a few minutes.
Preparation for the test
You will have been provided with a prescription for a course of antibiotics. The first tablet should be taken on the morning of the test. The remaining tablets should be taken as directed until completion of the course. Although not critical, but more your own comfort, you should try to open your bowels prior to the procedure. There is no need to fast for the test (that is, you may eat and drink as desired right up until the time of the test).
What actually happens?
A probe like instrument about 2.5 cm in diameter is gently inserted into the back passage. This is in fact an ultrasound probe that allows visualisation of the prostate beyond what can be felt by the finger alone. More importantly, it allows for the placement of a special biopsy needle that collects samples of your prostate. At the time of biopsy you will hear a loud clicking noise that may startle you momentarily. You will feel a slight sting as the needle passes but it literally happens in a split second. A total of 6 biopsy specimens are usually collected. The procedure takes about 20 minutes and you are able to drive home if you desire but it is often a good idea to have somebody with you due to the natural anxiety you may have over
the anticipation of the results.
What risks are associated with the procedure?
Following a prostate biopsy you can expect to see some blood in the urine, bowel motions and in the semen. Any blood in the urine or bowel motions usually settles by a week although brownish discolouration of the semen can last for up to a month. Uncommonly, you may develop an infection but this risk is minimised by the antibiotics administered. If you develop fevers and begin to shake, which is rare, you should go to the nearest Emergency Department to be assessed.
It generally takes up to a week to obtain the results of your biopsy. A copy of the result goes automatically to both your urologist and your referring family doctor. It is critically important that you have a follow up appointment within 7 days of the procedure to follow up on the results of the pathology.
Staging and Grading
The tests performed are used to determine the stage of the prostate cancer. Biopsy specimens are analysed to find out how aggressive the cancer is.
The staging system describes how far the cancer has spread within and/or beyond the prostate capsule.
Stage 1/A: There are no symptoms and the tumour is confined within the prostate. It is usually found during the investigation of a different complaint.
Stage 2/B: Again the tumour is confined to the prostate and although symptoms may not be apparent, it can be felt during a DRE.
Stage 3/C: The tumour has spread just outside the prostate gland and may effect nearby tissue. A common symptom is difficulty in urinating.
Stage 4/D: Also known as Metastatic cancer, the tumour has spread to other parts of the body. Bones and Lymph nodes are commonly afflicted and symptoms may include fatigue, weight loss, bone pain and difficulty urinating.
The Gleason Score indicates how aggressive the cancer is. The Gleason Score (or Sum) is something that the pathologist tells about the cancer in terms of its aggressiveness on the basis of careful inspection under the microscope. The Gleason Score is actually made up of 2 numbers known as Gleason Grades. When a pathologist looks at the prostate cancer under the microscope, a number grade from 1 to 5 is assigned to the areas most representative of the cancer present (the primary Gleason Grade). A second number grade from 1 to 5 is given to the second most representative area within the cancer (The secondary Gleason Grade). These two numbers are added together to give the Gleason Score, the maximum Gleason Score is 10 and the minimum Gleason score is 2. The higher the score, the more aggressive the tumour is likely to be and this will impact on the likely success of treatment.
Your doctor may want to see if the cancer has metastasised and has affected you bones. A small amount of radioactive material is injected into your arm, which is then absorbed by your bones as they heal. Your arm will then be scanned an hour later to view the activity of the bone and ascertain whether the cancer has spread.
A new Pet scan – F14 pet ct scan
A/Prof Varol is currently involved in the evaluation of a new pet ct scan for use in staging of prostate cancer. The F14 is thought to be the most sensitive imaging tool for use in staging cancers, especially for prostate cancer. A/Prof Varol may consider this test to be of useful in certain individuals.
Robotic Prostate Cancer Surgery
The prostate is a small walnut sized gland found below the urinary bladder in men. During sexual climax, it releases fluid into the urethra that forms a part of the semen and energises the sperm as well as reduces the acidity of the vaginal canal.
Prostate cancer is a malignant cancer that can spread to the lymph nodes, bones and other parts of the body. It is the most common cause of death in elderly men over 75 years of age.
The treatment of prostate cancer depends on the stage of the cancer and the overall health status of the patient and may include surgery, radiation therapy, chemotherapy and hormone therapy. Surgery is the gold standard for the treatment of prostate cancer. It involves the complete removal of the cancerous prostate gland and also helps confirm the diagnosis, by biopsy, and ascertain the need for any additional therapy.
Surgery for prostate cancer can be done either through open approach (a large incision over the abdomen) or through laparoscopy (few small holes over the abdomen). However, a common problem faced by the patient after surgery, with either of the approaches, is a loss of bladder control and erectile dysfunction.
Robotic prostate cancer surgery is a new advanced laparoscopic approach that overcomes the limitations of the traditional open as well as improving the laparoscopic approach. It enables the A/Prof Varol to perform complex surgery through tiny incisions, with precision and ease, improving the outcome and reducing complications. A/Prof Varol has had more than 800 case experience in laparoscopic / robotic prostate cancer surgery.
He pioneered minimally invasive bladder cancer surgery in australia and has one of the largest series in australia. Bladder cancer surgery is much more complex operation compared with prostate cancer surgery. There are therefore very few surgeons performing this operation or who have any experience in this field at all. Robotic bladder cancer surgery is considered the gold standard surgical approach in major international cancer units, and also at macquarie urology centre.
Robotic prostate cancer surgery involves two machines, a unit that is controlled by A/Prof Varol and a patient unit. A/Prof Varol sits at the control unit, away from the operating table, and controls the movement of the four robotic arms of the patient unit, present near the operating table. One of the robotic arms holds and positions a 3d high definition camera through the incision in the operated area providing images of the operation site to the surgeon at the control unit. These images are high resolution 3d images, superior to the 2d images in the laparoscopic approach. Moreover, the images can also be magnified by 10 to 12 times. The other three robotic arms are used to hold small miniature instruments, which are used for the surgery. These instruments are introduced through the tiny (1-2cm) incisions over the patient’s abdomen. These miniature instruments are more flexible compared to the long handled rigid instruments of the traditional laparoscopic surgery. A wide range of these instruments are available to A/Prof Varol to perform various specialized surgical tasks.
The robotic arm cannot be programmed to do the surgery on its own. Instead, it translatesA/Prof Varol hand movements,,at the control unit, into precise movements of the micro-instruments in the operation site, minimizing tremors that may occur from unintended shaking of the surgeon’s hands. The enhanced vision and superior control of the micro-instruments helps in precise removal of the prostate without damaging the nerve fibres and the blood vessels near it, which are critical for the maintenance of bladder control and erectile function. Nerve sparing, however, is not possible in patients with an advanced cancer that has spread beyond the prostate. Precise removal of the cancerous tissue with a border of healthy tissue reduces the chances of recurrence of the prostate cancer. Thus robotic prostate cancer surgery provides a novel treatment approach for the management of prostate cancer with a quicker recovery and control of sexual and urinary function, in most patients. It also provides additional benefits of less blood loss, less pain, shorter hospital stay, faster return to normal routine activities and a lower incidence of complications.
Talk to A/Prof Varol for any unanswered queries on robotic prostate cancer surgery and what to expect from the surgery in individual cases.