Prostate

What is the prostate?

The prostate is a walnut sized gland found beneath the bladder, in front of the rectum in men. The urethra passes through the centre of the prostate gland. Ducts coming from the sexual organs (testicles) also enter the prostate gland and join the urethra.

What does the prostate do?

Many of the functions of the prostate are unknown. It is known that the prostate produces part of the semen fluid that keeps the sperm healthy and supported prior to ejaculation.

What is prostate cancer?

Cancer develops when the cells of the body divide and reproduce in an uncontrolled manner to form a mass of tissue that can invade the surrounding organs and also spread to distant parts of the body (metastases).

Prostate cancer usually develops in the outer part of the gland and can spread locally to the bladder and also to other organs such as liver and commonly to bones. It is not known exactly why prostate cancer occurs, however, it appears to occur as a result of faults in the genes controlling growth and division of the prostate gland cells.

Am I at risk of getting prostate cancer?

Some known risk factors are as follows:

• Age: Prostate cancer is unusual under the age of 40. Between the ages of 40-60 your risk is about 1 in 100. Between 60-80 years of age, 1 in 8 men may present with prostate cancer. Your lifetime risk is 1 in 6.
• A family history of prostate cancer: If a close relative (brother, father, grandfather or uncle) has had prostate cancer, especially at a young age, your risk is increased compared to the general population.
• Race: Afro-Caribbean men are at higher risk of developing prostate cancer. Japanese men have the lowest risk of developing this type of cancer.
• Diet: If all other risk factors are equal, a high intake of animal and dairy fat can increase your risk of developing prostate cancer. This is based on population studies and is therefore difficult to apply at an individual level.

What are the symptoms of prostate cancer?

Initially, prostate cancer may have no symptoms at all. Most men see their GP because of urinary symptoms such as hesitancy, urgency, frequency, nocturia, dribbling, weak stream and incomplete emptying. You will be assessed and investigated if prostate cancer is suspected.

Which other patients are assessed for prostate cancer?

• You may have a close relative that has had prostate cancer and you wish to have a medical check up to exclude the disease.
• Increased awareness of men’s health issues in the media may lead you to seek specialist advice concerning this disease.

What is the PSA test?

The PSA, Prostate Specific Antigen, is a protein substance produced by the prostate under normal circumstances.

If your PSA is elevated on the blood test, it may indicate that there is a cancer within your prostate. It is important to note that an elevated PSA does NOT diagnose cancer of the prostate.

It merely enables your specialist to decide whether further investigation of the prostate is necessary to look for cancer (for instance, TRUS biopsy).

The normal range for PSA is 0-4.0ng/ml, but this varies according to your age and the reference range used by the pathology laboratory.

What is a TRUS biopsy?

Trans Rectal UltraSound of the prostate and biopsy is used to obtain very small samples of prostate tissue so that they can be looked at under the microscope to see if cancer cells are present.

Are there any other investigations?

If prostate cancer is found, you will probably be asked to have the following further tests:

• An MRI scan of the pelvis: This is a special scan using very strong electromagnets to image the organs within the pelvis including the prostate. This will enable your urologist to check if the cancer has spread out of the prostate.
• A bone scan: This test is to see if the prostate cancer has spread to the bones (metastases). A very small amount of radioactive liquid is injected into your arm and some hours later a picture is taken that can detect radioactive “hotspots” in bones that may be affected by prostate cancer.

What are the treatments for localised prostate cancer?

If the cancer is localised to the prostate, the following options are available:

• Active Surveillance: This refers to regular monitoring of the PSA and often a further biopsy of the prostate. It is appropriate in men whose prostate cancer has been diagnosed with a relatively low PSA and when the biopsies have demonstrated only a small amount of cancer. In addition the Gleason Score (a measurement of the aggressiveness of the cancer after examination under a microscope) is usually 6.
• Radical Prostatectomy: This is a surgical procedure whereby the prostate gland is removed whole. After removal of the prostate, the urethra and bladder are then rejoined so that you should be able to pass urine normally.
• External Beam Radiotherapy: This involves shining X-rays on the prostate gland to destroy the cancer cells within the prostate.
• HIFU (High Intensity Frequency Ultrasound) a new treatment option that can be used to treat localized prostate cancer.
• Brachytherapy: This is a newer procedure made popular in the USA, whereby small radioactive needles are implanted into the prostate. This allows a local, high dose of radiation to penetrate the prostate and kill off the cancer cells.

These treatment options have many advantages and disadvantages, which should be discussed with you on an individual basis with your urologist at the time of consultation.

What if the cancer has spread beyond the prostate?

If the cancer has spread, some of the following options are available:

• Watchful Waiting: In this instance, no specific intervention is offered. It involves monitoring you on a regular basis and intervening if symptoms develop. Some people see this as “no treatment at all”, however, it is based on the fact that your quality of life remains the same as it was before your diagnosis.

It is usually offered to older patients with the understanding that some of the other interventions (such as those listed below) may have more risks and complications compared to the benefit that may be received at the end of such treatment.
• Hormonal Therapy: Prostate cancer is “driven” by the hormone testosterone. By manipulating your hormone levels, the amount of testosterone within the body can be reduced thereby reducing the tumour size and the overall progression of the tumour may be delayed. The anti-testosterone treatments can be in a tablet form or injections that are given monthly or every three months.
• Orchidectomy: This is a surgical option whereby the testicles are removed in order to remove a large source of testosterone from the body. Although it sounds drastic, it is simple to perform and is effective in 70-80% of men.

How is the success of treatment monitored?

Clinical examination and testing of your PSA levels will be carried out at regular intervals. For example, after radical prostatectomy, your PSA should drop to almost un-recordable levels, ideally to below <0.1. Be aware that different laboratories have different reference ranges and therefore the actually PSA number may be slightly higher than the above.

If after treatment of a localised prostate cancer, your PSA remains at this low level for three years, you can usually assume that the cancer will not come back and that you are cured

The future?

Much research continues into the causes and treatments of prostate cancer. Attempts have been made to identify the possible genes responsible for prostate cancer development and therapies directed at altering the function of these genes may give rise to effective treatments in the future.

Prostate Benign Rostatic Hypertrophy (BPH)

What is benign prostatic hypertrophy (BPH)?

This is part of the normal ageing process in men where the prostate gland increases in size. The prostate grows to its normal size around the time of puberty, however, it then starts to slowly increase in size in the third decade and onwards.

As the prostate gland is somewhat contained by its outer layers, an enlargement of the prostate tends to impinge upon the urethra, narrowing the channel for urine in the process.

This can lead to some of the symptoms of BPH. Around 10% of men in their 40’s have BPH and this figure rises to 50% of men in their 50’s and 90% of men over the age of eighty.

What controls the growth of the prostate in BPH?

• The male hormone, testosterone, appears to be one main factor that influences prostate enlargement.
• There are a number of specific growth factors within the body that can influence the development of BPH.
• A strong family history of BPH is also relevant.

What are the symptoms of BPH?

The symptoms of BPH are caused as a result of the narrowing of the urethral channel, which obstructs the flow of urine from the bladder outwards. Symptoms can be:

• Irritative: urgency, frequency of urination and nocturia.
• Obstructive: a hesitant weak stream of urine, dribbling at the end of urination and the feeling of incomplete emptying.

Strangely, some men with a large prostate have no symptoms at all, whereas small prostates can cause severe symptoms.

If the urethra is blocked completely, the patient may not be able to pass urine at all and this results in acute urinary retention, requiring immediate medical attention.

How is BPH diagnosed?

Patients usually see their GP’s complaining of urinary symptoms. These include having a weak stream, having to wait to get started to pass urine, a feeling that the bladder isn’t emptying, frequent and urgent desire to pass urine along with having to get up during the night to do so.

Examination of the prostate demonstrates whether it is enlarged or not. Your doctor may request a blood test to check your PSA. This can be used as a possible indicator for prostate cancer in some circumstances.

If a diagnosis of BPH is made, the GP will then refer you to a urologist. Your urologist will confirm your symptoms history and repeat the prostate examination to confirm your GP’s findings. Your urologist then may order the following tests:

• Urine flow rate: this will involve you passing urine into a machine that can measure how strong your urine flow is.
• Urine test: this is to check for blood in the urine, infection and also the presence of glucose that may indicate a problem with your sugar control.
• Ultrasound scan: this is to look at your kidneys and also check if you are retaining urine after you have passed urine. Incomplete emptying of the bladder may confirm the findings of bladder outflow obstruction.
• Flexible cystoscopy: this test uses a small telescope to examine the urethra, prostate and bladder to ensure that there are no other causes for your symptoms.

What is the treatment for BPH?

Men are often concerned that their symptoms are indicative of a risk of prostate cancer. If their GP or urologist is able to reassure them that this is not a particular concern they may feel that the symptoms aren’t sufficiently bothersome to warrant treatment.

Drug treatments are available to try and relieve your symptoms. There are two main classes of drugs that are in use:

i) Alpha-blockers. These act by relaxing the smooth muscle of the prostate and bladder neck outlet to improve your urinary flow. Drugs in this group include tamsulosin, alfuzosin, terazosin and doxozacin.

ii) Drugs that stop the production of dihydrotestosterone (DHT) produced from testosterone. The main drug in this group is finasteride. Finasteride takes longer to work and has been shown to be of most benefit in patients with larger prostates.

Your urologist will discuss the side effects of these drugs with you at your consultation.

Operative treatments for BPH include TURP,  laser prostatectomy and other minimally invasive therapies.

What is a TURP?

Trans Urethral Resection of Prostate (TURP) involves “coring out” the prostate to create a wide channel through the prostate to enable you to pass urine more freely. Over the years, TURP had assumed the position of the gold standard treatment for bladder outflow obstruction due to prostatic enlargement. In recent years laser technology has been increasingly successful in replacing traditional TURP.

Will further surgery be necessary?

After traditional TURP some 10% of men may require a second coring out of the prostate at 8 years. In some instances, the scar tissue forming around the bladder neck can give rise to the need for earlier operation, soon after TURP. This is called bladder neck stenosis and can occur in up to 15% of patients undergoing TURP.

HIFU for Prostate Cancer

What is HIFU?

HIFU is high intensity focused ultrasound. The technology has been developed as a curative treatment for localised prostate cancer.

It is indicated as a first choice therapy for localized prostate cancer in suitable patients.

Additionally, it can be used as salvage therapy of local recurrence after a radical prostatectomy operation or radiotherapy.

How does HIFU work?

A transducer probe emits a powerful ultrasound wave that can be focused and concentrated to a point a small distance away from the probe.

This is similar to the way in which a magnifying glass can be used to focus the power of the sun’s rays to a point, causing a burn.

Similarly, the concentration of the HIFU beam can create maximum pressure at a point (the focal point), creating temperatures of between 85° and 100°C at this point.

What is the effect of HIFU on the prostate?

At the point of ultrasound concentration, two main effects occur:

• A thermal effect directly related to the increased tissue temperature.
• A cavitation effect due to pulsating air bubbles within the prostate created by the ultrasound energy and increased tissue heating.

Clinically, this causes a small cigar shaped lesion within the prostate, destroying the prostate cancer cells and surrounding tissue.

Is the whole prostate treated?

Yes. The operating surgeon uses computer software to treat the prostate and the cancer within.

The HIFU beam is concentrated at different points within the prostate, in three dimensions, to ensure that destruction of the tissue is complete.

How long does the HIFU treatment take?

Depending on the size of the prostate, the average treatment takes 2-3 hours to complete.

The patient requires either a spinal anaesthetic or general anaesthetic for the duration of the procedure

Can all prostate cancers be treated with HIFU?

No.

• The cancer must be localized within the prostate with no spread to surrounding organs.
• The prostate must not be too large, as this will make complete treatment difficult to carry out.
• The rectal lining and anatomy must be normal. This will affect how the ultrasound probe is placed and how well it works during treatment

Contraindications for HIFU treatment

• Calcium deposits within the prostate. This may affect prostate visualization during the treatment leading to poor results.
• Previous treatment with brachytherapy. The presence of permanent radioactive seed implants will prevent effective HIFU treatment.
• Rectal abnormalities such as rectal fibrosis or stenosis may prevent suitable placement of the treatment probe.
• The presence of an artificial prosthesis such as an artificial urinary sphincter, penile prosthesis or intraprostatic stent. The prosthesis may be damaged during HIFU treatment and visualization of the prostate during treatment may be difficult.

Preparation before HIFU treatment

• A diagnosis of prostate cancer is confirmed on a TRUS biopsy.
• Anticoagulant therapy such as warfarin or aspirin should be stopped 10 days prior to having the treatment.
• Pre-operative assessment is carried out to ensure that the patient is fit for anaesthesia and surgery. This includes blood tests, a chest X-ray and an ECG heart tracing.
• Bowel preparation consisting of an enema 2 hours prior to the HIFU treatment.