Prostate Cancer

Prostate Cancer Statistics

• Other than skin cancer, prostate cancer is the most common cancer in American men.
• The American Cancer Society’s estimates for prostate cancer in the United States for 2020 are:
  • About 191,930 new cases of prostate cancer
  • About 33,330 deaths from prostate cancer
  • About 1 man in 9 will be diagnosed with prostate cancer during his lifetime.
• Prostate cancer is more likely to develop in older men and in African-American men. About 6 cases in 10 are diagnosed in men who are 65 or older, and it is rare in men under 40. The average age at diagnosis is about 66.

American Urological Association Guideline Statements Summarized

• The Panel recommends against PSA screening in men under age 40 years.
  • In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups.
• The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. (Recommendation; Evidence Strength Grade C)
  • For men younger than age 55 years at higher risk, decisions regarding prostate cancer screening should be individualized. Those at higher risk may include men of African American race; and those with a family history of metastatic or lethal adenocarcinomas (e.g., prostate, male and female breast cancer, ovarian, pancreatic) spanning multiple generations, affecting multiple first-degree relatives, and that developed at younger ages.
• The greatest benefit of screening appears to be in men ages 55 to 69 years.
  • Multiple approaches subsequent to a PSA test (e.g., urinary and serum biomarkers, imaging, risk calculators) are available for identifying men more likely to harbor a prostate cancer and/or one with an aggressive phenotype. The use of such tools can be considered in men with a suspicious PSA level to inform prostate biopsy decisions.
• To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. (Option; Evidence Strength Grade C)
  • Additionally, intervals for rescreening can be individualized by a baseline PSA level.
• The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy.
  • Some men age 70+ years who are in excellent health may benefit from prostate cancer screening.

Abrazo Urologic Institute Philosophy on Prostate Cancer Screening

• We believe in personalized medicine. Using generalized population based statistics can be problematic. Guidelines are very helpful, but ultimately, the decision to be screened is a shared decision between a patient and the health care provider.
• Using an individualized life expectancy calculation based on medical history and age, we can help set up a screening plan that makes sense for that person.
• PSA blood tests and prostate examination have been the standard of care for prostate cancer screening. However, numerous studies have indicated the potential to miss significant cancers and to diagnose cancers that are not clinically significant which could lead to overtreatment.
• New urine and blood biomarkers are commercially available to help determine one’s risk of having clinically significant disease and whether further evaluation is necessary.
• Advanced imaging of the prostate with multiparametric MRI can help us determine areas of concern along with their level of risk of being significant cancer. These images can be used for guided/targeted biopsy.

MRI fusion biopsy

• At the Abrazo Urologic Institute, we utilize the most advanced systems of MRI fusion prostate biopsy to make a diagnosis in patients at risk for clinically significant prostate cancer.
• Standard biopsy involves a transrectal ultrasound guided needle sample of the prostate. The Urologist does not know what areas are involved and the sample is templated and random in the hopes of sampling an affected area. Chances of making a diagnosis with a first time standard biopsy can range from 25-40%. Many of these cancers may not be clinically significant. Knowledge of this cancer may cause anxiety and lead to potentially unnecessary treatment and side effects.
• Dr. Ramakumar has reviewed his series of MRI guided fusion prostate biopsies
  • Timeframe: 10/11/2017- 12/4/2019
  • Total number of patients: 184
  • Age range: 43-87
  • PSA range: 3.1-61.7 Median 7.47
  • PI-RADS range (MRI scoring system to determine level of risk for prostate cancer)
    • PI-RADS 3: 57 (31%)
    • PI-RADS 4: 77 (42%)
    • PI-RADS 5: 50 (27%)
• Chance of finding clinically significant prostate cancer on MRI guided fusion biopsy (Gleason 3+4=7/Grade group 2 or higher)
  • PI-RADS 3: 34 (60%)
  • PI-RADS 4: 66 (86%)
  • PI-RADS 5: 48 (96%)

What to consider when you have a diagnosis of prostate cancer

• Prostate cancer treatment is never one size fits all. Each man must look at the severity of his disease, his own life expectancy, and the risks and side effects of each option.
• Many cases of low grade prostate cancer can be monitored closely and treatment is not needed.
• Significant cancer may require more than one treatment for long term cure.
• It is important to gather as much information as you can in order to make an informed decision. Each specialist will have their own opinion. Ultimately it is the patient who has to live with the outcome.
• Key factors in considering your cancer risk and treatment options:
  • Your PSA prior to diagnosis
  • The Gleason Score or tumor grade (aggressiveness of the cancer)
  • Your clinical stage (how far along is the cancer)
    • can the Urologist feel the cancer on an exam
    • What do your staging studies show (MRI, CT scan, bone scan)
  • Your overall health, life expectancy and quality of life values
• Consider both Urology and Radiation Oncology consultations to get the most comprehensive treatment options explained to you.

What are the benefits of surgery over other treatment options?

• Excellent long-term cure rate
• Allows for the option to have radiation after surgery in high-risk cancers. If you have radiation first, then surgery is not an option afterwards.
• Allows for a full pathology evaluation of the prostate and lymph nodes after they are removed, which provides accurate staging and prognosis
• Easy monitoring after surgery. PSA must be undetectable.

What are the benefits of Robotic Prostatectomy over Open Surgery?

• Less pain
• Less bleeding
• Shorter hospital stay
• Less catheter time
• Fewer long-term complications (such as bladder neck contracture. There is a 0.1% bladder neck contracture in robotic surgery vs. 10% in open surgery)
• Smaller incisions
• Better visualization for the surgeon
• Quicker recovery

A Comparison of Open Surgery vs. Laparoscopic Surgery vs. Robotic Surgery for Prostatectomy

Coelho et. Al. Journal of Endourology, 2010

Dr. Ramakumar’s Results: Robotic Prostatectomy

• Almost 15 years of Robotic Prostatectomy experience.
  • Dr. Ramakumar performed the first Robotic Prostatectomy in Southern Arizona in April 2005
  • Over 1200 Robotic Prostatectomies performed (as of December 2019)
  • 0.4% of patients requires transfusions (5 patients)
  • No conversions from robotic to open surgery
  • No deaths in the post-surgical period (90 days)
  • Complications
    • Hernia (2-3%)
    • Retention (<0.5%)
    • Pulmonary embolus (<0.1%)
• Since 2014 Dr. Ramakumar has utilized nerve identification and preservation techniques during surgery. This can improve continence and potency.

Overall Data

• Years reviewed: 2016-2017
• Total number of patients: 158
• Age range : 47-79, median 66.5
• PSA range: -1.4-68.7, average 10.589
• Preop Gleason score grade group percentages
  • Group 1: 5%
  • Group 2: 24%
  • Group 3: 30%
  • Group 4: 30%
  • Group 5: 11%
• Path staging percentages
  • pT0: 1%
  • All pT2: 47%
  • pT3a: 36%
  • pT3b: 16%
  • Any N1: 8%
• Overall positive margin rate: 25/158: 25%

Continence

• Scale o No pads o Safety pad (rare or no leakage but small pad used for security) o 1 pad in 24 hours (occasional leakage) o >2 pads in 24 hours
• Timepoints
  • 3 months
    • No pads: 55%
    • Safety pad: 18%
    • 1 pad: 16%
    • >2 pads: 12%
  • 6 months
    • No pads: 71%
    • Safety pad: 17%
    • 1 pad: 8%
    • >2 pads: 4%
  • 9 months
    • No pads: 72%
    • Safety pad: 19%
    • 1 pad: 6%
    • >2 pads: 3%
  • One year
    • No pads: 79%
    • Safety pad: 13%
    • 1 pad: 6%
    • >2 pads: 2%

Potency at one Year

• Scale (results are a percentage of those with data available)
  • No data=X
  • No function or not interested in treatment=1
  • Functional using VED or injections=2
  • Functional using oral agent=3
  • Functional without assistance=4
• Patients with normal sexual function before surgery (Preop SHIM score >=21)
  • Full nerve sparing surgery (no radiation or hormone therapy)
    • X: 35%
    • 1: 18%
    • 2: 27%
    • 3: 36%
    • 4: 18%
  • Unilateral or partial nerve sparing (no radiation or hormone therapy)
    • X: 41%
    • 1: 0%
    • 2: 10%
    • 3: 60%
    • 4: 30%
• Patients with compromised sexual function before surgery (Preop SHIM score <21)
  • Full nerve sparing surgery (no radiation or hormone therapy)
    • X: 55%
    • 1: 20%
    • 2: 20%
    • 3: 40%
    • 4: 20%
  • Unilateral or partial nerve sparing (no radiation or hormone therapy)
    • X: 63%
    • 1: 21%
    • 2: 23%
    • 3: 38%
    • 4: 8%

Items to Bring to your Consultation

• Pathology Report from Prostate Biopsy
• PSA Values (especially the ones just prior to your biopsy)
• Results of any imaging tests that have been done

Robotic Assisted Laparoscopic (da Vinci®) Prostatectomy

How to prepare for surgery

• Practice deep breaths and coughing before your surgery. Use Spirometer.
• Walk a mile each day.
• Kegel exercises – 10 times (hold for 10 seconds), 3 times per day. Practice while walking, laughing, coughing
• No Advil/Ibuprofen 48 hours before.
• No Aspirin 7 days before.
• Avoid garlic and other herbal remedies a week before.

Purchase

• Hibiclens
• Fleet saline enema
• MiraLAX
• Sweat pants
• Extra large underwear – 1 to 2 sizes larger.
• White Vinegar
• “Depends” and small guards

Day before

• Will receive call the day before after 2pm. If you don’t receive a call by 7pm, call.
• Eat light diet, small sandwich, eggs, toast, soup. Limit dairy. Avoid fried foods and lot of seasoning
• After dinner, use a Fleets saline enema.
• Shower with Hibiclens – use ½ bottle. Rub it on mid-section area. Then rinse off. Use a clean towel.
• No eating after midnight. Can drink up to 12 ounces of water up to 2 hours before.

Day of Surgery

• Shower with ½ bottle of Hibiclens. Take your medications.
• Bring lace-up sneakers.
• Bring Health Care Proxy Form.
• Bring cell phone and charger.
• Bring a case for personal items – eyeglasses, hearing aids,
• You will get an IV. Then meet with Anesthesiologist. Compression boots will be placed. You will get a breathing tube inserted, and a urinary catheter.

Surgery Stats

• Operating time: 2-2.5 hours
• Hospital stay: 1 night
• Catheter time: 1 week

• You will be taught how to care for the catheter by the nursing staff

Recovering after Surgery

When you wake up you will:

• Be receiving oxygen thru a thin tube below your nose.
• Have a catheter. You may see blood, stringy tissue, blood clots in urine.
• Have a drain to draw out excess fluids. (You may possibly go home with this, depending on how much fluid).
• Have compression boots.
• Be encouraged to walk every 2 hours with help of a nurse. Use your Spirometer – 10 times in a row every hour.
• Do not do Kegel exercises while you have a catheter inserted.
• Have pain in your abdomen from incisions.
• Gas pains, and pains in back and maybe shoulders. Perhaps pressure in your rectum. Perhaps bladder spasms.
• Maybe have bruising on abdomen, penis, or scrotum.
• Maybe have bloating in abdomen for several days. Walking can help. Avoid carbonated drinks.
• Need to maybe take Tylenol or Advil.
• Your scrotum may swell up to be the size of a grapefruit. This will subside when catheter is removed.
• You can help reduce size of scrotum swelling by raising it on a rolled towel while sitting or lying down.
• No antibiotic prescription is indicated.

After Discharge

Bowels:

• For first few days after, eat soft/light foods (smoothies, yogurt, soup, liquids) until you have first bowel movement.
• Avoid brans, broccoli, onions, cabbage, cauliflower until you have had your first bowel movement.
• You may not have a bowel movement for up to 5 days. This is normal.
• If you haven’t had a BM by the second evening (Monday night), take MiraLAX. You can take it every 6 hrs.
• If you haven’t had a BM in 5 days, call your doctor or nurse. If you haven’t passed gas in 2 days, call your doctor.
• To prevent constipation, take 1 capsule of Colace 3 times a day (stool softener). You may add to any over-the-counter stool softener such as prune juice, Milk of Magnesia, MiraLAX; Just No enema or suppository for 6 weeks.
• Walking helps BMs.
• Drink 8 glasses of liquids daily (maybe 1 every hour). Water, juices, soups; Caffeine is not good.
• Do not strain to have a bowel movement.
• You may have blood or urine leaking from tip of your penis around the catheter while walking or having a bowel movement.
• Consider using an elevated toilet seat with arm rests to help with the pelvic/penile pressure and discomfort with bowel movements. As long as you see urine draining into the draining bag, this is okay.

Activity:

• You can shower 24 hours after surgery. Gently wash the incision area. And pat the area with a towel after. Leave incision uncovered, unless there is drainage. Skin around the incision may feel numb – normal.
• Leave you drain site bandage on for two days. You may change it with more gauze and tap if it is soaked and uncomfortable.
• No driving with the catheter. No bicycling for 3 months.
• Don’t lift more than 10 pounds for 4 weeks.
• If you received an abdominal binder, wear it continuously for 6 weeks to prevent the risk of incision hernias. It should be tight but you should still be able to breath.
• To decrease discomfort, you may bending over by using an over-the counter grasper pole to reach for things that fall on the floor.
• At your 1 week post-operative appointment, you will discuss/receive your Pathology results.

Catheter Care:

• Your catheter will be removed only after your cystogram shows no significant leak, typically at your 1 week appointment.
• You can shower 2 days after the drain was removed in the hospital with the catheter night bag. It is more waterproof. You can clean the catheter while you are in the shower. With mild soap (Dove), Water, and elastic strap. Consider placing the bag a small plastic garbage pail which can be kicked to move if needed.
• Clean your urethra, which is where the catheter enters your body. Clean it from where it enters your body and then down, away from your body. Hold the catheter at the point it enters your body so that you don’t put tension on it. Rinse well and dry gently.
• Keep tip of penis clean and dry. You will receive a paper script for Bacitracin to apply four times per day while the catheter is in place. You may also apply MedChoice lubricating gel (over the counter) around tip of penis to prevent irritation.
• Change the draining bag twice a day. Make sure the connection is secure so it does not leak. In the morning after you shower, change night bag to the leg bag. And then at night, before you go to bed, change the leg bag to the night bag.

How to change the bags:

Wash hands with soap and warm water. Empty urine from drainage bag into toilet. Don’t let spout of bag touch anything. Place clean cloth or gauze under connector to catch leakage. Pinch off catheter with fingers and disconnect used bag. Wipe the end of catheter with alcohol pad. Wipe connector on new bag with 2nd alcohol pad. Connect clean bag to catheter and release your finger pinch. Check all connections. Straighten any kinks or twists. Use “Shout” to clean the large underwear before washing as staining is frequent.

Leg Bag: Wear the leg bag below the knee. Keep it secure with Velcro strips. Don’t make the straps too tight. Empty the leg bag into toilet every 2 to 4 hours. Don’t let the bag get completely full. Don’t lie down for longer than 2 hours while using the leg bag.

Night Bag: Keep the night bag below the level of your bladder. To hang the night bag while you sleep, place a clean plastic bag inside of a wastebasket. Hang the night bag on inside of wastebasket.

Cleaning Draining Bags: You’ll need White Vinegar and Cool Water. Wash hands, and rinse bag with cool water. To decrease odor, use a funnel to fill bag halfway with mixture of 1 part white vinegar and 3 parts water. Shake bag and let it sit for 15 minutes. The Rinse bag with cool water and hang to dry.

Catheter Removal: Obtain your cystogram x-ray prior to your post-operative appointment. If there is not leak, then you will receive a fill and pull voiding trial. If a leak is present, expect to continue the catheter and repeat the cystogram in 1 week.

After catheter is removed, bladder and urethra will be weak. Don’t push to urinate. Let urine pass on its own. Don’t strain to have a BM. You may now decrease drinking to 4-6 glasses each day. Limit amount of liquids after 7pm. After catheter is removed, call doctor or nurse if you aren’t able to urinate or have severe pain in lower abdomen when urinating. You may begin to do the Kegel exercises 2 days after the catheter is removed – 10 times, 3 times a day.

It may take several months to regain full control of your bladder. You will be referred to physicial therapy for additional training.

Call doctor if:

• Catheter falls out.
• You have 101 fever.
• You are making less urine than usual.
• You have foul smelling urine.
• You have bright red blood or large blood clots in urine.
• You have abdominal (belly) pain and no urine in catheter bag.

Links for More Information

For more information on prostate cancer:
http://www.urologyhealth.org/urology/index.cfm?article=146

For more information on robotic prostatectomy:
https://www.davincisurgery.com/procedures/urology-surgery/prostatectomy

For more information on Dr. Sanjay Ramakumar and the Abrazo Urologic Institute:
AbrazoMedicalGroup.com

For more information on the Transperineal Biopsy:
https://perineologic.com/precisionpoint