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Prostate Cancer

Prostate Cancer

Prostate cancer is the second most common type of cancer in men, and the third leading cause of cancer death. The cancers develop when a group of abnormal cells within the gland are able to grow without constraint, forming a malignant tumour that can then escape and invade either into surrounding structures, the lymph nodes, or more distant organs such as skeletal bones.

By the age of 85, 1 in 7 men will be diagnosed. Fortunately, many of these tumours will be slow growing and can either be safely watched, or will be caught in time for safe & effective treatment. Dr Symons strongly advocates for a conservative path of management where possible, whilst at the same time recognizing that for some men upfront treatment is best, so as to utilise the ‘window of opportunity’ for a succesful cure.

Following your biopsy, Dr Symons will review your particular scenario, and arrange additional staging scans as might be required. This helps to confirm that the tumour is located within the prostate, and helps to guide the treatments that might be required to offer you the best balance between cancer cure,  preservation of quality of life, and treatment intensity.

Dr Symons practices ‘best practice’ cancer care and is actively involved in several Multidisciplanary Cancer Meetings. These team meetings, held routinely at no cost to the patient, involve a group of cancer experts (pathologists, imaging experts, medical & radiation oncologists, and fellow cancer surgeons), and offer re-review of the biopsy material, any scans done to date, and allow for multiple “second-opinions”. This ensures that the treatment plan a patient has is not just based on the years of experience & knowledge of one individual, but a whole room full!

The diagnosis of prostate cancer is understandably a trying time for most men. It is usual for people to face a multitude of emotions, and have a multitude of questions.

Dr Symons and the Sydney Uro team are here to support you on this journey, and will be only too happy to provide a sympathetic ear or provide any extra attention that you might require. We understand that after receiving an unwanted diagnosis, navigating the healthcare system can become even more challenging.

Dr Symons and the team want to minimise any stress that you or your family might feel, and will work with you to help streamline any additional appointments or investigations that might be required.

What is PSA?

The prostate specific antigen, or PSA, is a protein made only in the prostate gland. It has a role in healthy male function, specifically as a mucolytic enzyme. It is NOT specific to prostate cancer, but rather acts as an essential part of human reproduction. When a man ejaculates, the PSA travels with the rest of the semen until it hits the female cervix, where it dissolves the mucous plug to allow sperm to swim through and reach an egg.

Prostate Cancer Diagnosis

The Cancer Diagnosis (Moving from Uncertainty to Clarity)

(The Process of Design Squiggle by Damien Newman, thedesignsquiggle.com)

Following a prostate biopsy, in your consultations with Dr Symons there are a series of key pieces of information that Dr Symons will gather for you to assist in the management of your cancer.

Grade – how aggressive is the cancer?

Stage – how far has the cancer spread?

Once this information is gathered, Dr Symons will be able to further outline the treatment options, particularly as they relate to your unique cancer situation, and arrange the treatment plan that best suits YOU.

Transperineal Prostate Biopsy (TPB)

A safe and accurate biopsy technique is essential for the management of prostate cancer.

Patients are selected for biopsy based on a complex algorithm of their PSA and kinetics, examination findings, age and comorbidities, and individual risk factors for cancer. These include family history, patient concern of cancer, MRI findings, or a prior diagnosis of prostate cancer for which the patient is on an active surveillance program.

Dr Symons has been at the forefront of prostate cancer diagnosis and management for almost a decade. In 2013, Dr Symons authored the world’s largest series of the then new and safer Transperineal Prostate Biopsy. At the time, TPB accounted for < 0.5% of all biopsies done in Australia, with the remainder done through the more traditional transrectal route. This older style of biopsy, risking faecal contamination with each needle passage, can unfortunately miss 20-30% of tumours.

In 2016, Dr Symons was honoured to be invited to write the inaugural textbook on Transperineal Prostate Biopsy, a technique which has since continued to grow in popularity around the world.

As one of the world’s pioneers in this technique, Dr Symons uniformly performs Transperineal Prostate Biopsy. The advantages include:

  • Increased biopsy accuracy
  • Increased prostate sampling
  • Extremely low risk of infective complication
  • Ability for Dr Symons to fuse your MRI or PSMA PET scan with real-time ultrasound at the time of the procedure to further increase biopsy accuracy
Procedure Information

Transperineal Biopsy is routinely performed in a day surgery under anaesthetic.

You will not feel much discomfort following the procedure, though it is common to see some blood in the urine and ejaculate for a short time afterwards.

Some men may find that the prostate gland swells, giving a transient restriction to the urinary flow.

Resources

Outcomes of transperineal template-guided prostate biopsy in 409 patients – Article

Over the past 10 years Dr Symons has studied the evolving surgical techniques, with the majority of his cancer operations now performed using the Da Vinci robotic device. This allows for a more minimally-invasive procedure to completely remove the prostate (radical prostatectomy). Compared to open surgery, it conveys all the benefits of laparoscopy such as decreased pain, earlier mobilisation and return to work, lower blood loss, and a reduced hospital stay. As per open surgery, it confers excellent local cancer control, and for many men can give an earlier return to continence.

Prostate Cancer Treatments

Prostate cancer can be cured when it is localised to the prostate. Depending upon patient and tumour factors, it can be cured with either radiotherapy, surgery or a combined (multimodality) approach.

Potential management options include:

Active Surveillance

Robotic-assisted Radical Prostatectomy

Nerve-sparing Robotic Prostatectomy

Open Radical Retropubic Prostatectomy

Radiotherapy Planning
(SpaceOAR & Fiducial Seeds)

Salvage Prostatectomy
(following radiotherapy failure)

Watchful Waiting

Our dedicated & caring team of professionals are here to help.

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Da Vinci Robotic-Assisted Radical Prostatectomy

What condition(s) is a Robotic Prostatectomy used to treat?

Radical prostatectomy is an operation to completely remove the prostate and the seminal vesicles, and sometimes the lymph glands, for men with prostate cancer. 

 

Historically this was done through an open abdominal incision, though in recent years more and more patients have preferred to this surgery with robotic assistance. The pain is minimized, the hospital stay is minimized, and the time for return to normal activity is shortened. 

 

Dr Symons has trained extensively in the art of robotic prostatectomy, with fellowships both in Australia and abroad. Whilst open procedures are still performed, nowadays this is reserved for rarer cases who will not be suitable for a minimally-invasive approach.

 

Procedure Information

Da Vinci surgery is a minimally-invasive technique that allows the prostate operation to be done via small keyhole incisions, one of which allows the prostate to be removed through it. This main incision is above the umbilicus and is usually only around 2cm. 

The immediate advantage of robotic prostatectomy is more rapid recovery time, less post-operative pain and less scarring than with standard surgery. This surgery itself can be almost bloodless, which minimizes the likelihood of a blood transfusion (which was commonly needed with standard open surgery). Patients who require ongoing aspirin cover, or where we must avoid a blood transfusion (Jehovah’s Witness, for instance) are well suited to a robotic approach. 

The combination of bloodless surgery and the highly magnified, 3D view allows for a very accurate and gentle dissection. This helps with Dr Symons dissection deep in the pelvis, where views during open surgery can otherwise be restricted. Dissection around the apex / urethra is enhanced, and there is also excellent vision of the nerves supplying erections. 

The Robot is not autonomous – it does not do the surgery itself! Instead, it enhances an experienced surgeon with an extremely effective tool to give better vision and access to the prostate and surrounding areas, allowing the best possible results from the surgery. 

 

Procedure Preparation:

Dr Symons has a trusted team of regular anaesthetists who will review you prior to the surgery to check your general health and explain the anaesthetic.  

 

In order to assist with your continence, it is routine for Dr Symons to link you in with a team of dedicate pelvic floor physiotherapists. Initial consultations are done with the physio, and exercises can then be practiced from the comfort of your home. 

 

Procedure:

Whilst the surgery routinely takes several hours, you will go down to the Operating Theatre well before and spend time in Recovery afterwards – you should expect to be away from the ward for at least half the day. In general, the anaesthetist will call a nominated family towards the end of the procedure, and Dr Symons will call at the end of the procedure. 

In general, pain is not a major problem following robotic surgery, and need for a blood transfusion is extremely rare. 

Recovery & After Care

Urine Control:

Whilst many people will have almost perfect urine control as soon as the catheter is removed, for some men it may take up to three months for their urine control to return. In a very small number, it may take between 3-12 months to reach maximum improvement.  

 

In the longer term, only 1%-2% of people will have significant difficulties with their urine control (incontinence), and if problematic this can be repaired. 

 

Return to Work:

Dr Symons appreciates that many of his patients live extremely busy lives, and as such are keen to return to their normal activities as soon as possible. Whilst some patients will be back to work less than a week post-operatively, this is not encouraged.  

 

A cancer diagnosis, and treatment, is a significant life event for all men, and you are encouraged where possible to take some time off to fully convalesce, and where possible use it as time to spend quality time with family and other loved ones. 

 

Depending upon the nature of your work, a return to between 2-4 weeks would be routine. 

Playing sport, such as golf / going to the gym, or doing heavy work around the house, such as mowing the lawn, can be commenced after about six weeks. Dr Symons will review you in the rooms before this to give you clearance. 

 

Sexual Activity:

Depending on your age, pre-operative potency, and tumour factors that impact upon the ability to preserve the nerves supplying erections, it is hoped that the erections will return over a 3 – 12 month period. Some men will have their sexual function return much faster than this. The erections may not fully recover in some men, particularly if older in age, or in those with impaired erections at baseline, or pre-existing conditions such as diabetes or cardiovascular disease. 

To assist with sexual preservation, in eligible men Dr Symons employs both penile pre-habilitation and post-operative rehabilitation programs. 

 

Resources

Da Vinci Robotic Radical Prostatectomy – Video

Open Radical Prostatectomy

Whilst now seldom done, Dr Symons has a decade of experience with the traditional operation, and will perform it for select men where a minimally-invasive approach is not deemed appropriate.

Salvage Prostatectomy

For men who initially chose radiotherapy and then found the primary treatment failed, restaging PSMA PET scans may show that the cancer recurrence is limited to the prostate. If this is the case, then surgical removal of the gland can be performed. However, the risks of surgery on the irradiated prostate are immeasurably higher than for the non-irradiated gland, and include, but are not limited to, permanent urinary incontinence and potential need for a colostomy (bowel bag).

Watchful Waiting

This pathway is suitable for many older men with a likely slow growing (“indolent”) tumour. The oft-quote phrase “more men will die with prostate cancer than from prostate cancer” applies to men in this group of patients.

In conjunction with the patient’s General Practioner, Dr Symons provides routine follow up and directs care targeted to the to the symptomatic relief from the cancer’s advances, rather than actively trying to slow the disease down or cure it altogether.