Localised Prostate Cancer :
The testicles
The testicles are two small, oval-shaped organs located below the penis, enclosed in a skin pouch called the scrotum.
Image of the testicles (cruk)
Starting from puberty, the testicles begin producing sperm. Inside the testicle, small tubes come together to form the epididymis, a single tube that becomes wider as it exits the testicle. This wider tube is known as the spermatic cord.
The spermatic cord leads to a short passage called the ejaculatory duct, which opens into the urethra, the tube that carries urine and semen out of the body through the penis.
Testosterone:
The testicles produce the hormone testosterone, which is responsible for developing male characteristics such as:- A deeper voice
- Facial hair growth
- Increased muscle mass
- The ability to achieve an erection
- Male sexual drive (libido)
Where does testicular cancer start:
The testicles consist of various cell types, and the kind of cancer you have depends on the specific cell where it begins. Most testicular cancers arise from germ cells, which are responsible for producing sperm. Doctors classify germ cell cancers into two main types:- Seminoma
- Non-seminoma
Once the biopsy and scan results are available and a diagnosis of localized prostate cancer is made, all the findings will be discussed at a Joint committee meeting (JC). This meeting includes a variety of specialists such as urologists, oncologists (cancer experts), radiologists (imaging specialists), pathologists (experts in tissue analysis), and specialized nurses.
The Joint committee (JC) will propose treatment options depending on the cancer’s clinical stage. This expert team will then go over these treatment options with you. Their recommendations will be grounded in their clinical expertise and national guidelines.
Risk Level | PSA Results | Gleason Score | Clinical Stage |
Low | Less Than 10 | Less than or equal to 6 | T1-T2A |
Intermediate | 10 to 20 | 7 | T2b-T2c |
High | Above 20 | 8 to 10 | T3-T4 |
Treatment Decisions :
Most instances of localized prostate cancer are classified as low or medium grade and fall under clinical stages T1 or T2. Multiple treatment options are available that could potentially result in a cure, including surgery or radiotherapy.
However, certain treatments may not be appropriate due to factors such as an elevated PSA level, the size of the prostate gland, or other underlying health conditions.
Various treatments exist for localized prostate cancer, each offering similar success rates and possible side effects.
Active Surveillance :
Low-grade prostate cancer that does not encompass the entire gland may advance at a very slow pace. For this type of cancer, active surveillance rather than immediate intervention may be advised. It is important to note that active surveillance is different from watchful waiting.
Research indicates that it may take several years for low-grade prostate cancer to become problematic, whereas immediate treatment could lead to side effects that might affect the quality of life.
All treatment options offered to men are initially approved by a joint committee of expert medical consultants. These specialists use global and national guidelines, along with their professional experience, to determine which options should be provided.
Opting for active surveillance instead of immediate treatment is a highly personal decision. This approach has gained popularity in recent years as it helps to delay—or sometimes avoid—the side effects of treatment. However, some men find it difficult to live with the uncertainty and prefer to undergo treatment sooner rather than later.
How does it work:
Active surveillance requires a rigorous schedule of PSA blood tests every three months and a Digital Rectal Examination (DRE) every six months.
Another prostate biopsy might be recommended after 12-18 months to check if the cancer has advanced.
If the cancer shows signs of progression during surveillance, men can transition to cancer treatment without affecting the likelihood of a cure.
Choosing active surveillance is a personal decision, and there is no definitive right or wrong choice.
Watchful Waiting:
This page outlines watchful waiting, a strategy that focuses on observation instead of immediate treatment.
This method is a viable choice for older men diagnosed with prostate cancer who are asymptomatic. It helps to prevent treatments that could lead to side effects and impact future quality of life. The decision to follow this approach also depends on the stage of your prostate cancer.
Watchful waiting might also be suitable for younger men who are asymptomatic and not in good enough health to undergo treatments like surgery or radiotherapy.
It differs from active surveillance.
This approach does not aim to cure the cancer but focuses on managing the disease and addressing any symptoms if they arise.
Surgery : Radical Prostatectomy
Surgical intervention, specifically radical prostatectomy, is frequently employed to address localized prostate cancer. In some cases, it may also be considered for more progressed stages of the disease.
During prostate surgery, the entire prostate gland along with the surrounding seminal vesicles is removed. Prostatectomy is considered a significant procedure, although patients typically stay in the hospital for only a few days.
There are various methods for performing this surgery:
1. Conventional open surgery, where the surgeon makes a single incision in the abdomen.
2. Laparoscopic (or ‘keyhole’) surgery, which is now more prevalent. It involves making several small incisions in the abdomen instead of one large cut.
3. Robotic prostatectomy, a newer technique available in select hospitals or specialized centers. It still involves laparoscopic surgery, but with the assistance of a robotic system controlled by the urologist for making incisions and removing the prostate gland.
If the PSA level exceeds 10, surgeons may opt to surgically remove nearby lymph nodes to examine whether cancer has spread beyond the prostate.
After Surgery :
Men can usually resume eating and drinking immediately after surgery, and they will receive regular painkillers as needed.
Following the operation, a small plastic tube known as a ‘drain’ might be placed in the abdomen temporarily. This drain is utilized to gather any surplus blood draining from the surgical site, which could otherwise accumulate and hinder the healing process.
Urinary Catheter:
To facilitate healing of the surgical site, men will have a urinary drainage tube known as a catheter inserted, which will remain in place for approximately 10 days.
Possible Side effects :
Erectile disfunction ( ED):
The nerves responsible for controlling erections are located very close to the prostate gland. During prostate surgery, these nerves can be affected.
In cases where only a small amount of prostate cancer is detected, the surgeon may opt for a nerve-sparing technique. This approach aims to preserve the nerves, increasing the likelihood that men will fully regain their erectile function, although recovery may take a year or longer.
When there is a greater extent of cancer, it becomes more challenging for the surgeon to preserve these nerves, as the main focus is to ensure that all cancerous tissue is removed.
Post-prostatectomy, various treatments are available to enhance erectile function and aid in recovery. ( Erectile disfunction therapies – go to surgery – erectile disfunction in orchid surgery page )
Urinary continence :
During prostate cancer surgery, the structures that aid in controlling urinary continence will be removed. As a result, men who undergo this procedure might experience a type of urinary incontinence known as stress incontinence. This condition makes it difficult to control urination, leading to occasional urine leakage and the need to wear protective pads for a short period after surgery.
Performing pelvic floor exercises can help alleviate stress incontinence after surgery. The details of these exercises are explained below.
Urinary symptoms typically improve rapidly post-surgery and usually return to normal within two to three months. However, a small percentage of men may still experience minor stress incontinence after a year. This often occurs during activities such as laughing, coughing, sneezing, or making sudden movements. Wearing a small pad can help manage these minor accidents and prevent embarrassment.
Pelvic floor exercises:
The ‘pelvic floor’ refers to the layers of muscle that provide support to the bladder and bowel, extending from the tailbone at the back to the pubic bone at the front. Performing pelvic floor exercises can aid in improving erections as well as maintaining urinary continence after surgery.
1. Lie down comfortably, ensuring your thigh, buttock, and stomach muscles are relaxed.
2. Tighten the ring of muscle around the anus without clenching your buttocks. Think about what it feels like to stop diarrhea or gas. Avoid holding your breath.
3. Relax.
4. Picture yourself halting the flow of urine mid-stream, then restarting it. If done correctly, you should feel the base of your penis move slightly upwards towards your abdomen.
5. Relax.
6. Tighten and pull in the muscles around your anus and urethra, lifting them internally. Count to 5, then release and relax. You should distinctly feel a ‘letting go’ sensation.
7. Repeat this up to a maximum of 8 to 10 squeezes, pausing for 10 seconds after each muscle tightening.
8. Perform 5 to 10 short, strong squeezes in rapid succession.
9. Repeat the slow and quick squeezes approximately 3 to 4 times daily.
1.6 : Results of Surgery :
After the prostate gland is removed, it is meticulously examined under a microscope by scientists known as histo-pathologists. They will determine if the cancer was confined to the prostate and if the surgeon successfully removed it all.
The tissue edges removed during the surgery are referred to as ‘margins,’ and ideally, these margins should be free of cancer cells. If some cancer cells are found at the margins but haven’t spread beyond them, the medical team will refer to this as a positive margin.
If the prostate and all cancer cells have been completely removed, the PSA level should remain low (below 0.1). If the PSA level is higher than this, additional treatment, usually radiotherapy, may be necessary.
1.7: Bladder Neck Stenosis and Urethral Stricture:
The removal of the prostate gland results in a gap between the urethra and the bladder. This gap is surgically closed by stitching the urethra back to the bladder.
Occasionally, the surgery can lead to the development of scar tissue at the site of the operation, which can cause the urethra to narrow. This condition is known as a urethral stricture and can make urination difficult. If this occurs, a minor surgical procedure can be carried out to widen the urethra.
Next Steps:
After the surgery, your Multi-Disciplinary Team (MDT) will review the outcomes of the operation. If there is a concern that some cancer may remain, they may recommend additional treatment, such as radiotherapy.
Men will have follow-up appointments, typically every three months, to monitor PSA levels. Over time, these appointments will become less frequent, moving to every six months and eventually once a year.
Daignosis
If you have any symptoms, your first step is usually to visit your GP. They will discuss your symptoms with you and conduct an examination. Based on their findings,
Treatment options
A team of healthcare professionals (multidisciplinary team) will determine your treatment plan. Most people undergo surgery to remove the affected