The prostate gland is a part of the male genital (sexual or reproductive) system. It is located immediately below the urinary bladder, which it is joined to in an area known as the bladder neck. The prostate gland is usually described as being the size of a walnut (although it may vary in size from man to man and over a man’s lifetime).
The normal function of the prostate gland is to produce fluid that forms part of semen. The seminal vesicle (which is an additional male sexual gland) and the vas (the tube carrying sperm from the testicle) are joined to the back of the prostate gland. The urethra (the tube which brings urine from the bladder out through the penis) runs through the middle of the prostate gland.
PSA is a substance made within the prostate, which is secreted into semen, where it has an important function in maintaining a fluid environment for sperm. Some PSA gets into the blood-stream, where it can be measured in laboratories by taking a blood sample. The PSA level can be increased by diseases of the prostate including enlargement, infection, inflammation and cancer. The PSA level is decreased, sometimes down to zero, following treatments to the prostate, including surgery, radiation and some medications. (top)
BPH refers to the process of non-cancerous enlargement of the prostate gland. It is a common occurrence with increasing age in many men. The degree of enlargement may vary substantially between men, but is not necessarily related to the extent of symptoms from it.
BPH most commonly causes difficulties in urination as a result of blockage of the urethra as it runs through the prostate gland. This may lead to symptoms such as poor flow of urine, difficulty initiating or maintaining the urine stream, a sense of incomplete emptying of the bladder, frequent day-time or night-time urination and urine leakage (incontinence). BPH may cause urinary bleeding.
In a small proportion of men, blockage due to BPH may lead to complications such as urinary infections, bladder stones, bladder damage or kidney damage. Occasionally, BPH may result in complete blockage of urination (urinary retention), which is a urologic emergency.
Not all patients with BPH need treatment. If symptoms are mild and tolerable, and no complications have occurred, men with BPH may be kept under observation if so advised by a urologist. During observation, it may be advisable to undergo regular checkups including blood and urine tests.
Medications may be used to treat men with BPH who have moderately severe symptoms which are bothersome to them, but no complications. The main group of medications used to treat BPH is the alpha-blockers, which work to relax the smooth muscle of the prostate and bladder neck.
A second type of medication, called 5-alpha reductase inhibitor, works by blocking the effects of the male hormone (testosterone) on the prostate gland. This medication causes gradual shrinkage of the prostate gland over a period of months, and may be useful in combination with alpha-blockers.
Surgery for BPH is required for men with severe symptoms or complications and if medications are no longer effective. Most men with BPH can be treated by a surgical procedure known as TURP (trans-urethral resection of the prostate), which can be performed through an endoscope (without any incisions). If the prostate gland is particularly enlarged, open surgery may be required. (top)
Cancer of the prostate is the commonest internal cancer, and the second commonest cause of cancer deaths among men. It becomes increasingly more common with age, being very rare among men aged below 50, and almost universal in men aged in their eighties and nineties.
In many instances, prostate cancer is silent (i.e. it causes no symptoms), and is diagnosed on the basis of abnormalities found on examination of the prostate or increased levels of PSA. Thus, men aged 50 or more are advised to have an annual check-up which consists of an internal examination (referred to as a digital rectal examination or DRE) and a blood test to measure the PSA. If an abnormality is noted in either case, a biopsy of the prostate gland is required to make a specific diagnosis of prostate cancer.
Sometimes, prostate cancer is diagnosed because men report difficulties with urination or bleeding, although the symptoms may also be caused by co-existing benign prostatic enlargement. If the cancer spreads beyond the prostate, it may result in bone pain, fractures, abdominal pain, generalized weakness, tiredness and weight loss.
Overall, prostate cancer differs from many other cancers in being slow-growing and in many instances is non-lethal. Nonetheless, many men continue to die of prostate cancer, and it causes much suffering. The potential for a particular cancer to behave aggressively can be assessed by a number of different factors:
- Stage: indicates the extent of the cancer, assessed by examination and scans.
- Grade: indicates the microscopic appearance of the cancer, as reported by the pathologist.
- PSA: the level and rapidity of increase (if known)
- Amount of cancer: assessed as a measurement or proportion of the biopsy
The above parameters may be combined in various tools (e.g. Partin tables, Kattan nomograms or D’Amico risk groups) to assess the probability of spread of cancer, and therefore the likely success of treatments. Your urologist should be able to provide you with further information specific to your situation.
In simpler terms, an initial distinction needs to be made between localized prostate cancer (i.e. the cancer is contained within the prostate gland, and may be treated for cure) and metastatic prostate cancer (i.e. the cancer has spread beyond the prostate gland, and is no longer amenable to cure).
Treatment of localized prostate cancer
Multiple options are available for the treatment of localized prostate cancer, with the final choice dictated by the type of cancer, other co-existing problems (such as prostatic enlargement or bowel disease), availability of treatment facilities and to some extent patients’ preferences. For aggressive varieties of prostate cancer, the use of more than one type of treatment may be recommended.
Surgery (radical prostatectomy) for prostate cancer consists of the removal of the prostate gland along with the seminal vesicles (additional male sexual glands) and the ends of the vasa (which bring sperm from the testes to the back of the prostate). The surgery may be carried out by a conventional incision or via laparoscopy with or without the assistance of computerized robotic technology (for more information on robotic prostatectomy, please refer to this information sheet or go to www.melbourneroboticprostatectomy.com).
Radiotherapy for prostate cancer can be administered as external radiation (similar to having an X-ray) or internal placement of radioactive seeds (known as brachytherapy). Compared to surgery, each of the forms of radiotherapy have some advantages and disadvantages, and a thorough discussion with a urologist and/or a radiation oncologist is required to decide the best treatment in an individual case.
Newer treatments for localized prostate cancer include high-intensity focused ultrasound (HIFU) and cryotherapy (freezing of the prostate). At present they are under assessment, and are of limited applicability.
Some localized prostate cancers may be kept under observation, with the intention of selectively applying curative treatment at a delayed time if the cancer seems to need it. This approach is usually suitable only for very early and non-aggressive cancers, and particularly in older or frailer men. Although it may avoid treatment related problems, observation may also lead to a missed opportunity for cure, and potentially may cause anxiety and difficulty coping.
Treatment of metastatic prostate cancer
Metastatic prostate cancer is treated non-curatively by removing the male hormones (known as androgens, e.g. testosterone), which the cancer depends upon for growth. This leads to shrinkage of the cancer and slowing of its growth, for a variable length of time (typically months or even years). Hormonal therapy may be carried out by surgically removing the testicles (which produce most androgens) or by administering drugs (by injection) which shut down the testicles from producing androgens. Sometimes, other drugs (in tablet form) may also be used, which block the effects of androgens. Hormonal therapy is usually well tolerated, but some side-effects may occur, including tiredness, hot flashes, loss of libido and sexual function, weight gain, loss of muscle and bone strength.
Ultimately, the cancer begins to grow despite the hormonal therapy, in which case it is said to be hormone-refractory, and is likely to be fatal within subsequent months. At this stage, chemotherapy or alternative drug therapy may be recommended. Various treatments are available for the control of cancer-related symptoms, which should be discussed with your doctor. Palliative care services may be put in place to help facilitate these treatments. (top)
This is a surgical procedure in which the prostate gland along with the seminal vesicles (additional male sexual glands) and the ends of the vasa (tubes carrying sperm from the testicles), which are both attached to the back of the prostate. Lymph glands near the prostate may also be removed at the same time. The surgery is performed for men with localized prostate cancer, with the aim of curing the cancer. Consultation with a urologist is required to determine whether you are a suitable candidate for radical prostatectomy.
Radical prostatectomy may be carried out by making an cut in the lower part of the abdomen (i.e. open surgery) or by laparoscopic instruments through multiple small punctures. Laparoscopic surgery requires the surgeon to work using a two-dimensional image on a monitor screen and specific instruments that are somewhat restrictive in their movements, and is therefore more challenging. Laparoscopic radical prostatectomy may be assisted by a computerized robot, known as the da Vinci surgical system, which provides the surgeon with a three-dimensional image and jointed instruments, thus allowing easier and more precise surgery.
The da Vinci robotic prostate surgery leads to less bleeding and a quicker recovery (including less pain, shorter hospital stay and an earlier return to work and other activities). The surgical outcomes, including cancer removal and preservation of important structures, such as the urinary sphincter (a muscle controlling urine flow) and nerves providing sexual function, are similar to or better than for open surgery. In specific instances (e.g. previous surgeries, large prostates or advanced cancers), these techniques may not be suitable, and open surgery may be recommended.
Whichever approach is used, after removal of the prostate, the bladder is joined back to the urethra (the tube which drains urine to the outside), and a catheter is placed to protect the join. The catheter is usually left in place post-operatively for a period of one or two weeks. A drainage tube is placed into the abdomen, to lie outside but adjacent to the bladder. This tube is usually removed after a day or two. Most patients are able to drink and eat within one or two days after surgery, and discharge from hospital is usually after about 3 days after laparoscopic or da Vinci robotic surgery, and about 5 days after open surgery.
After removal of the catheter, most men initially experience some leakage of urine, but this improves over time, and can be helped by undertaking exercises of the internal muscles controlling urine flow. By two or three months after surgery, most men are dry most of the time. The surgery also causes the loss of erections, which may take up to 12 to 24 months to recover. The chances of recovering sexual function depend on many factors, such as the patient’s age, the stage of the cancer and the extent to which the erectile nerves can be separated from the prostate. A number of specific treatments are available to help the return of erections, and your urologist will be able to provide further advice on which of these may be most suitable. (top)
This is a surgical procedure usually performed to relieve urinary blockage due to an enlarged prostate. It is performed without any cuts, using endoscopic instruments passed through the eye of the penis. A spinal anaesthetic (local anaesthetic injection into the lower back) is often used. The surgery removes the central portion of the prostate gland, using electro-cautery.
A catheter is left in place for two or three days after the surgery, during which time the patient is usually in hospital. Upon removal of the catheter, the flow of urine is usually much improved, but there may be quite significant irritation of the bladder, leading to frequent and uncomfortable urination. This usually improves over a four to six week period, with further improvement of bladder function over three to six months.
On occasion, bleeding or swelling may cause blockage of urine flow, and require a catheter to be re-inserted for a temporary period. If urine was completely blocked before surgery, and a catheter was in place, most but not all patients will become free of catheter after surgery. After successful relief of blockage by surgery, symptoms may re-appear due to scar formation (which may occur at any time, but most often within a year or two) or fresh growth of the prostate (which typically occurs after ten years or more). (top)
This is a form of radiotherapy in which radioactive material within small metal seeds is placed within the prostate gland, in order to treat cancer of the prostate. The radioactivity is present for a period of a few months, although the seeds remain in place for ever.
Brachytherapy is administered in conjunction between a urologist and a radiation oncologist. The initial step for brachytherapy involves a careful assessment of the prostate gland, the type of cancer within it, and types of symptoms experienced by the patient. Based on these assessments, only some patients will be identified as being suitable for brachytherapy.
In a subsequent step, scans are taken of the prostate gland, and using measurements from these scans, the number and pattern of seeds is planned. Finally, a small procedure is performed to place the seeds within the prostate. This is usually a day-case procedure performed under anaesthesia. After-effects of the procedure may include bleeding or irritation of the bladder. Occasionally, a catheter may be required due to blockage of urine. Irritable urinary symptoms may be bothersome for a few months after the procedure, as the radiation has its effect on the prostate gland and bladder.
Following brachytherapy, the PSA may fluctuate for a period of time, but usually gradually reduces. Regular assessments, including measurement of the PSA, are necessary to monitor the response of the prostate cancer to brachytherapy. On occasion, brachytherapy may be combined with external radiation or hormonal treatment.
Brachytherapy aims to maximize the radiation dose within the prostate gland, while minimizing radiation to structures around the prostate. Thus, harmful effects on the bowel and bladder are reduced. Similarly, the risk of impotence, although present, is lower than for other forms of prostate cancer treatments. (top)