Screening, diagnosis and treatment by Mr Shiv Bhanot
Cancer of the prostate is the most common cancer in men in the UK - a quarter of all new cases of cancer diagnosed in men are prostate cancers. Around 300,000 new cases are diagnosed in Europe each year.
Of the men diagnosed, almost 60% are aged over 70 years.* With the help of an expert oncology team at Spire Roding Hospital – which includes radiologists, oncologists and specialist nurses – Mr Bhanot can support prostate cancer patients throughout their entire diagnosis, treatment and recovery process. In fact, with early diagnosis, the vast majority of prostate cancer patients at Spire Roding under the care of Mr Bhanot are cured and return to normal life quickly.
*Statistics courtesy of www.cancerresearchuk.org - November 2009
Mr Bhanot is at the forefront of delivering an excellent service to patients from Essex and East London who come to Spire Roding for private prostate cancer screening, diagnosis and treatment.
Screening and diagnosis
Early screening and diagnosis is important for the successful treatment of prostate cancer and to ensure the best possible outcome. Mr Bhanot can carry out a number of screening and diagnostic tests at the clean and comfortable, private Spire Roding Hospital.
PSA test for Prostate Cancer
A PSA test is a blood test that measures the level of PSA - Prostate Specific Antigen – in a man’s blood. PSA is a protein made by the prostate which naturally leaks into the bloodstream. After testing, if a man’s levels of PSA are said to be ‘raised’, it could be a sign that he has prostate cancer. However, a raised PSA level can also indicate that another, non-cancerous prostate condition exists, such as benign enlargement of the prostate and prostatitis (inflammation of the prostate). Following a raised PSA test result, often the only way to definitely determine whether prostate cancer exists is through a biopsy.
Read more about what Mr Bhanot has to say about PSA testing on the Macmillan website.
Because of the uncertainties that are often associated with PSA testing, and the need for a biopsy, Mr Bhanot now offers his patients the PCA3 test.
PCA3 test for prostate cancer
This test helps to diagnose prostate cancer more accurately, often without the need for a biposy. The PCA3 tests the urine for the presence of PCA3, the prostate cancer-specific gene, which is present in much higher levels in prostate cancer tissues than in normal prostate tissues. The PCA3 test is specific in determining the presence of the prostate cancer gene, and, unlike the PSA test, will normally NOT pick up genes relating to benign prostate conditions. This gene-based test can be used to diagnose new cases of prostate cancer, and also for men who have had back previous biopsies with a negative result who want further reassurance.
(NB: The PCA3 test has not yet been approved by NICE within the NHS, so please check with your insurers if you are covered for this procedure.)
Surgery for prostate cancer
Mr Bhanot consistently strives to deliver the very best and most advanced surgery to prostate cancer patients at Spire Roding. In 2005, he introduced the laparoscopic (keyhole) radical prostatectomy procedure (LRP) to the Essex and East London area, and has since carried out more than 300 of these operations for patients with prostate cancer.
Prostate cancer specimen, caught just in time
The LRP procedure is now routinely offered at Spire Roding to all newly diagnosed patients. Mr Bhanot is a major advocate of LRP – find out why by reading more below about its advantages as a treatment for prostate cancer, including the many benefits for patients.
What is the difference between ‘open’ and ‘keyhole’ prostatectomy?
As the name suggests, the major difference between the two types of surgery lies in gaining access to the prostate. Open prostatectomy requires a large incision, whereas the keyhole technique requires only tiny holes in which to insert the camera and access the prostate.
Both techniques treat prostate cancer by removing the entire prostate gland, then attaching the urethra directly to the bladder.
During surgery, a scope is passed through the hole that provides uniform lighting everywhere, including the far reaches of the narrow male pelvis. The scope used in laparoscopic prostatectomy transmits dynamic, magnified images to a monitor that can be simultaneously viewed by everyone involved in the operating theatre. A very precise and well-illuminated view of live surgery is presented to everyone, which promotes greater control of the anatomy and excellent coordination among team members.
Read more detail of the surgery in an article written by Mr Bhanot.
What are the benefits of laparoscopic radical prostatectomy?
In short, the advantages of LRP surgery are
- reduced blood loss
- less pain
- quicker recovery
- better preservation of potency and urinary continence functions
Because this method of surgery allows the surgeon a magnified and illuminated view, the process of dissection is much more gentle and precise. As a result, blood loss is very low (typically 100 to 400ml per case), therefore reducing the chance of transfusion, blood pressure fluctuations, and risks of post-operative complications such as heart attack.
Apart from minimal blood loss, the laparoscopic operation is associated with very little surgical pain because it is performed through very small incisions. In fact, most patients recover without narcotic medication. The reduction of pain also permits most patients to be up and about fairly quickly.
Following LRP, your potency stands a very good chance of being preserved where nerves have been spared, although this depends on lots of other factors such as hypertension, diabetes, obesity, smoking history and anxiety.
Who is suitable for laparoscopic prostate cancer surgery?
Anyone diagnosed with localized prostate cancer may benefit from the laparoscopic approach; however, this decision to have prostate cancer treated surgically depends upon numerous considerations. Most importantly, the severity of the prostate cancer and the severity of other illnesses. The following variables are taken into account for pre-operative evaluation:
- pre-biopsy PSA levels
- previous prostate cancer treatments
- other illnesses
- smoking history
- current medications
Laparoscopic radical prostatectomy can be performed on men of all sizes and who have had other operations such as appendectomy, laparoscopic hernia repair, repair of abdominal trauma, transurethral prostatectomy (TURP) etc.
Preparing for the operation
Prior to surgery, you will be advised to keep active and start doing regular pelvic floor exercises. These will strengthen your continence mechanism.
Standard blood and other tests will be taken and you will be given a laxative and an enema before the operation.
The operation of laparoscopic radical prostatectomy
LRP is performed under a general anaesthetic. Just before surgery commences, a cysto urethroscopy (examination of the urethra, prostate and bladder) is carried out before while you are under the anaesthetic. Patients who have had previous prostatic surgery may require temporary stenting of tubes (ureters) from their kidneys.
Depending upon your PSA test result, tumour stage and grade, you may also need biopsies of your lymph glands at the time of your operation.
The operation is carried out through 5 keyholes below the level of the belly button. The whole of the prostate including its true capsule and both seminal vesicles are normally removed during the operation. The urethra is sutured to the bladder to keep the continuity of urinary tract.
What are the risks associated with LRP?
Laparoscopic radical prostatectomy carries the general risks of any major operation. It also associated with the risks of infertility, impotence, and incontinence.
Does Laparoscopic Radical Prostatectomy require a catheter, drain, dressings, or stitches?
Yes. Like any radical prostatectomy, LRP requires reconstruction of the bladder-urethra connection. A catheter is left in the urethra, connected to a drainage bag, and used to align the healing suture line and drain the bladder. In the immediate post-op period, LRP also requires a drain. The drain assures the collection of blood and urine that may accumulate immediately after surgery and is removed when the output drops, usually the morning after surgery. There are stitches, but these dissolve by themselves and require no special care. The surgical dressings for LRP are five band-aid dots used to cover the instrument entry sites. These dressings are generally removed 48 hours after surgery. Most patients are able to shower within 24 hours of surgery.
How would I feel immediately after LRP?
Patients leave the operating room with an intravenous line, a urethral catheter, and a small rubber drain in their lower abdomen.
After recovering from anesthesia, almost all patients start to drink clear liquids. In the first few hours, depending on strength and motivation, most patients get out of bed and stretch their legs. Most have walked around the nurse's station by next morning. Patients are discharged with a catheter connected to a leg bag, which fits under their pants. Loose clothing and shoes that don't require tying are appropriate to wear in the first few hours and days following surgery. The catheter is usually removed within a few days of the operation.
What can I expect after returning home?
The single most common complaint after hospital discharge seems to be sleep deprivation and fatigue. Relative to open surgery, the LRP is generally a less physically demanding procedure, but it is still a major pelvic operation. Most patients are anxious about going into surgery, get little sleep the night before, arrive at the hospital very early on the morning of surgery, and get very little sleep the following night. Accordingly, on returning home, most patients seem most interested in a good, long nap and a shower!
The other complaint following LRP seems to be a sense of bloating, with clothes fitting very tight. This bloating seems related to the effects of surgery, anaesthesia and bedrest.
What can I expect after the catheter comes out?
Almost all patients have some incontinence when the catheter comes out. Continence function returns with time. While recovering this function, you’d be wise to carefully consider your fluid intake, as a full bladder is much more likely to leak than an empty bladder.
How will I be followed-up after LRP?
Depending on the pathologist’s report of the LRP specimen, a patient may or may not consider additional cancer treatments. In most cases, but not all, the wise course of action is surveillance.
Every operation has certain associated complications and LRP is no different. These complications are similar to the complications associated with open operation, but much less frequent. Serious complications involving bowel injury with this technique are rare as this operation is performed through the extra peritoneal route.
The statistics below relate to cases of LRP performed by Mr Bhanot’s - where possible, relating to his last 100 cases:
- Infection - 4 UTIs in last 100
- Delayed wound and anastamosis healing - 1 in last 100
- Bleeding and need for blood transfusion - 1 in last 100
- Injury to big blood vessels - 0 in last 100
- Injury to nerves; ilio-inguinal (nerve to groin area), obturator (nerve to inner side of thigh and knee) and cavernosal nerves (used for erectile function) - 0 in last 100
- Injury to urinary sphincter causing urinary incontinence* - 0 in last 100
- Injury to ureters - 0 in last 100
- Injury to rectum - 0 in last 100
- Injury to other abdominal viscera - 0 in last 100
- Tumour positive surgical margins (18% T2 and 60% T3)**
- Scarring of bladder neck - 1 in last 100
- Some shortening in length of penis in all patients
- Lymphocoele formation (collection of tissue fluid) - 0 in last 100
- Complications related to anaesthesia and positioning during operation - 0 in last 100
- Conversion to open surgical operation - 0 in last 100
* At three months after surgery 80% patients have either no incontinence or use one pad/day for minor stress leakage
** Positive surgical margins depend upon the presenting PSA, T stage, Gleason Grade and surgical technique. Laparoscopic surgery in experienced hands has lesser chance of positive surgical margins.
Read more about Spire Roding's prostate cancer service