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Active surveillance is a way of monitoring prostate cancer which aims to avoid unnecessary treatment in men with less aggressive cancer. 

Active surveillance is suitable for men with low risk, early stage prostate cancer. To decide if you are suitable for active surveillance, your urologist will consider:

  • your PSA level
  • your biopsy findings
  • what your prostate feels like during digital rectal examination (DRE)

 

Active surveillance vs Watchful waiting

Active surveillance and watchful waiting are two ways of monitoring prostate cancer and avoiding immediate treatment.

Watchful waiting involves yearly PSA blood tests with the aim to control the cancer, rather than getting rid of it completely. It is suitable for older men and men who have other health problems where prostate cancer is unlikely to affect their life expectancy.

Active surveillance involves regular tests with the aim to treat to cure the cancer promptly if it shows signs of changing.

 

Active surveillance tests

  • Prostate specific antigen (PSA) blood test to measure the amount of PSA in your blood.  PSA is a protein produced by your prostate.
  • Digital rectal examination (DRE) where the urologist will feel your prostate gland for changes through the wall of your back passage (rectum).
  • Prostate biopsies involves taking small pieces of prostate tissue.  This is sent to the laboratory to look for signs of prostate cancer.  It will be like the biopsy you had when your cancer was first found.  This may be called a transrectal ultrasound prostate (TRUS) biopsy
  • Saturation grid biopsies are sometimes required if the urologist decides a larger sample of prostate tissue is needed to assist the diagnosis.  This procedure is done under a general anaesthetic.
  • Magnetic resonance imaging (MRI) scans may be undertaken to look for any abnormal areas in the prostate.  This will assist the urologist with their diagnosis. This is only required for a small number of men, particularly if the cancer has been hard to find.

If tests show signs that the cancer is changing, your urologist will discuss with you whether you should have treatment and what your options are.

 

Active surveillance protocol

Your urologist will follow a strict protocol which is internationally recognised for the safe follow-up of prostate cancer.

PSA: this will be tested 3 monthly for the first year, then 6 monthly for the next 18 months, then yearly thereafter. Your PSA usually fluctuates each time it is tested, but the general trend is more important than each individual value. This is why it is tested regularly to begin with.

TRUS biopsy: repeat biopsies will be recommended after 6 months, again after a further 2 years, again after a further 3 years, then every 5 years thereafter. The reason to repeat the biopsy is to make sure the cancer is not changing.

DRE: your urologist will feel your prostate gland each time you need a repeat biopsy. This is to ensure that there is no obvious sign of growth of the cancer.

Posted
AuthorUrology Associates
X-ray showing the placement of radioactive seeds within the prostate

X-ray showing the placement of radioactive seeds within the prostate

Brachytherapy (properly known as low-dose rate brachytherapy or LDR brachytherapy) is a day surgery procedure where the surgeon implants small radioactive seeds (smaller than a grain of rice) into the prostate under a general anaesthetic. These deliver radiation to the cancer from inside the prostate. The implanted seeds are small enough that they will not be felt by the patient. Brachytherapy is also referred to as 'interstitial radiation therapy' or 'seed implant therapy'.

Before the seeds are implanted, the patient will have a special ultrasound test of the prostate to plan the appropriate treatment. This is usually a few weeks before the day when the seeds are implanted and is called a "planning study." Needles containing the seeds are then inserted through the skin of the perineum (the area between the scrotum and anus) using transrectal ultrasound guidance. The seeds remain in the prostate and the radioactive material gives off localised radiation for a number of months to destroy the prostate cancer. This procedure allows high doses of radiation in the prostate with minimal contamination of the surrounding organs (bladder/rectum). Most men can resume work and normal activities a few days after the treatment.

Brachytherapy is a very effective and safe way to treat selected prostate cancers. Your urologist will recommend if this is right for you. Long-term results are similar to open surgery when brachytherapy is chosen to treat the correct sort of cancers, typically the slower growing, less aggressive forms of prostate cancer.

Click on the image above to download our Brachytherapy information sheet for more detailed information about the treatment.

Click on the image above to download our Brachytherapy information sheet for more detailed information about the treatment.

Posted
AuthorUrology Associates

da Vinci Robot (centre) with the surgeon's console on the right

Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical removal of the prostate to treat prostate cancer.  The robot is a state-of-the-art surgical interface system. It includes fine instruments that a urologist uses to remove the prostate gland through several small incisions (keyhole surgery).

Due to magnified 3D-visualisation of the anatomy, very precise surgery is possible. This results in less blood loss and faster recovery after surgery compared to conventional open surgery. Some studies show that there is a better outcome with regards to post-operative continence and sexual function.

The robot is completely controlled by the surgeon at all times and cannot operate independently. 

 

Before your operation

The operation and outcomes will be explained to you by your surgeon. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form.

  • This consent form should be signed by both yourself and your surgeon and forwarded to the hospital a few days prior to your admission.
  • A blood test will need to be performed and a urine sample may need to be taken 4-5 days prior to surgery. Your surgeon will give you a form to take to the laboratory to have these tests done.
  • If you are over 60 or have other medical conditions you may have an electrocardiogram (ECG) to check the health of your heart prior to surgery.
  • It is important to avoid constipation. Try to establish and maintain a regular, soft bowel habit leading up to your operation. Identify the foods that can help you maintain a regular bowel habit for your post-op period.

 

Operation day

RALP is an operation performed by making several small cuts in the abdomen between your navel and pubic bone.

Laparoscopic ports are placed into these cuts and the robotic camera and instruments are introduced into the abdomen via these ports. The prostate will be removed. The cut at the navel will be enlarged slightly to remove the prostate. The bladder is joined back into the urethra (outflow pipe) and a catheter is placed to drain the urine.

The procedure takes about 2 hours.

 

Recovery

You will probably be in hospital 1 or 2 nights following this type of surgery.

When the operation is completed, you will go to the recovery room for a short while where you will be cared for until you are ready to be transferred to your room. When you wake up it is common to feel an urgent desire to pass urine. This is due to the catheter in your bladder.

 

Pain control

Pain control is managed in conjunction with your anaesthetist. For pain relief it is likely you will have a PCA (Patient Controlled Analgesic) pump attached to your intravenous line. You will be able to control the amount of pain relief by pressing a button connected to the pump. 

Our aim is to keep you as comfortable as possible: it is important to let your nurse know when the pain or discomfort starts. At all times your nurse is there to help you. Please ring your bell if you need assistance and your nurse is not nearby.

 

Catheter

Your nurse will monitor your catheter drainage which is likely to be blood stained for the first 24 hours. Your catheter usually is left in place for 1-2 weeks after surgery. You will therefore go home with a catheter in.

Our continence advisor will contact you to organise a date to have your catheter removed at Urology Associates. The catheter is removed by deflating the balloon holding it in place. Once the balloon is deflated, the catheter slides out easily causing little discomfort.

Once the catheter comes out you may at first have a burning sensation when passing urine. If the burning sensation lasts for longer than 3 days, or there is sign of infection or obstruction, it is important to contact your surgeon or GP.

 

Bladder control

Initially, you will probably have to wear pads to control varying amounts of urinary leakage. At the appointment for catheter removal, pelvic floor exercises will be taught to help you regain control of your bladder. You will probably not require pads after 3-6 months.

 

Wound and drain tube

You will have six small wounds on your abdomen. The sutures are dissolvable and do not need to be removed. 

You may have a drain tube coming from your abdomen. This will be removed after 1-2 days.

 

Expected symptoms

After surgery, you may or may not experience some of the following symptoms:

  • A stinging or burning sensation at the tip of the penis where the catheter enters. This is generally due to irritation and may be relieved by increasing fluid intake or ensuring the catheter is well supported.
  • A feeling of having a full bladder and low to nil drainage of urine through the catheter. This can be caused by blockage of the catheter tube either by a blood clot or by accidental kinking of the tube. Catheter blockages are easily cleared by the nurse.
  • Bladder spasms (short, sharp, grabbing pains) due to the bladder trying to expel the catheter because of irritation. These are easily treated with medication.

After discharge

You will receive two follow up appointments after your surgery. The first is for the removal of your catheter with the continence nurse and the second with your surgeon six weeks after the operation.

You can do most activities after your operation except heavy lifting, straining, intercourse or strenuous activity which should be avoided for 2-3 weeks after surgery. You will be able to continue with your normal daily routines as you feel able.

Generally when you feel that you could perform an emergency stop without being concerned about abdominal pain (at about 3 weeks), then you can resume driving. 

You will be asked to drink extra fluids after your surgery and for the next few weeks after your discharge. This helps to keep the catheter draining. 

It is normal to have some leakage or discharge at the end of your penis/catheter. The discharge may be urine, blood or brown coloured. You should wash the area with soap and water to remove this discharge and reduce any irritation. It is also normal to see blood occasionally in the catheter bag. 

Some patients experience bladder spasm. Symptoms may include:

  • leakage of urine around the catheter
  • a feeling of wanting to pass urine
  • lower abdominal pain

Medication can be prescribed to relieve the spasm.

 

Complications

Bleeding

Bleeding severe enough to bring you back to the hospital is rare. This risk disappears when healing is complete, 6-8 weeks after surgery. If you notice an increase in bleeding or are unable to pass urine, contact your GP.

Incontinence

Urgency is common. Incontinence, or leakage of urine without control, may occur temporarily. Only very few patients have incontinence which lasts beyond the first few months. 

If you have any incontinence after your operation, you will be given information and instructions about exercises that you can do to strengthen the pelvic floor muscles. Your surgeon or nurse can also provide you with information about the management of leakages.

Urethral stricture

In a small number of cases tightness may develop in the urethra. This may occur either near the tip of the penis or further up the urethra, several months after the operation.

You may notice your urinary stream, which was better after the operation, slows down again. Please mention this problem to your doctor. If detected early and treated with gentle stretching under local anaesthetic most strictures resolve. An operation to cut open the tight area may be appropriate.

Sexual function

A RALP can cause impotence – the inability to have an erection. The likelihood of this occurring depends on a number of factors.  

At best only 35% of men retain normal erections which may take a year to return after surgery. This does not mean that you cannot continue to have a satisfactory sexual life. With some creativity, men can have orgasms without having an erection. There are also a number of treatments available to help bring back erections. Talk to your urologist about this if you are experiencing difficulties in this area.

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Prostate Surgery

Booklet with more information about the Robotic Assisted Laparoscopic Prostatectomy (RALP)

Posted
AuthorUrology Associates
TagsRALP

Transrectal ultrasound showing the volume of the prostate

In case of an elevated PSA blood test or a suspicious finding on digital rectal examination of the prostate, a transrectal ultrasound provides accurate imaging of the prostate. It is possible to take samples of the prostate with a biopsy needle.

To take the biopsy, a probe or a transrectal ultrasound (TRUS) is slipped into the rectum and guides a fine needle into the prostate through the rectal wall.

To reduce the risk of infection after the test, antibiotics will be given. The procedure is performed in the rooms and local anaesthesia can be used. The procedure normally takes 5-10 minutes. Most men can resume work and normal activities the next day.

 

Preparation

To reduce the risk of infection after the test, you will be given some antibiotics. Please start the antibiotics two hours before your biopsy appointment. Check you are not allergic to the antibiotics prescribed.

There is no other special preparation for this procedure, although having the bladder overfull can make the test uncomfortable. You may eat and drink before the examination. We recommend that you arrange for someone to drive you home afterwards.

 

Procedure

You will be asked to lie on a bed on your left side. After performing a rectal examination, the specialist will place the ultrasound probe into your rectum. The probe will display an ultrasound picture of the internal part of the prostate.  If biopsies of the prostate are to be taken, local anaesthetic may be injected into the prostate. Fine needles then take small samples of the prostate from different places within the gland.

Following the biopsy, your samples will be sent to the lab for analysis. It may take up to two weeks to get the results. An appointment will have been made for you to return for your results.

 

Following the procedure

  • Finish your antibiotics as prescribed.
  • After a biopsy you may see blood in the bowel motion, urine or with ejaculation.  This is normal and unless there is lots of bleeding, there is no cause for concern.
  • While there is blood in the urine, continue to have a good fluid intake. This blood may be present for over a week. Blood may be present in the ejaculate for up to 6 weeks.
  • Occasionally swelling may occur within the prostate after the biopsy.  This swelling may slow your urine flow and a catheter may be required until the swelling settles down.

If you develop high fevers, shivering and cold sweats, you may have an infection. This generally happens within the first 48 hours after the biopsy.  An infection is serious and you must contact your urologist.  There is always a specialist on call regardless of the time of day or night. You should contact them on the main phone number, 03 355 5129.

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AuthorUrology Associates
TagsTRUS

Urology Associates work with Dr Chris Wynne and Associate Professor Chris Atkinson at St George's Cancer Care Centre to provide men the option of external beam radiation therapy (EBRT) for the treatment of prostate cancer.

Dr Wynne and Associate Professor Atkinson are both radiation oncologists - doctors with specialist expertise in the use of radiation therapy to treat cancers.

The radiation oncologists run visiting clinics in our rooms at Urology Associates. Your urologist will offer you an appointment to see one of them if this is appropriate for your type of prostate cancer. If you choose to have EBRT treatment, the treatments will be given at St George's Cancer Care Centre.

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AuthorUrology Associates
TagsEBRT