Prostate cancer: from symptoms to robotic-assisted prostate surgery

Around one in eight men in the UK will be diagnosed with prostate cancer, making it currently the most common cancer diagnosis in the UK. In most cases, prostate cancer is a slow-growing cancer and can be effectively treated with surgery. Advancements in technology, including innovations such as da Vinci® robotic-assisted prostate surgery, mean that functional and cancer outcomes for prostate cancer surgery have significantly improved over the last decade. 

Here, we will take a closer look at prostate cancer, its treatment and outcomes.

Types of prostate cancer

Prostate cancer affects the prostate gland, a walnut-sized gland that sits just below the bladder and produces seminal fluid that nourishes and transports sperm. 

There are several types of prostate cancer, which are grouped according to the cells they originate from — the most common type is adenocarcinoma. 

Prostate cancer can be further categorised by how aggressive it is using the Gleason grading system. This ranges from six, which indicates a slow-growing cancer to 10, which indicates the most aggressive form of cancer. 

Prostate cancer can also be categorised according to how far it may have spread. This is broadly divided into localised, where it is restricted to the prostate gland; local advanced, where it has spread beyond the outer layer of the prostate and into the nerves that supply the penis and the sacs that hold seminal fluid (seminal vesicles); and advanced, where it has spread to other areas, such as the bladder, rectum, lymph nodes and bones. 

Risk factors for prostate cancer

The biggest risk factor for prostate cancer is age, with the risk significantly increasing after age 50 and most men being diagnosed after age 65. 

Your genetics also play a role. Your risk is two and a half times higher if you have a father or brother who has had prostate cancer. Similarly, if you are of African descent, you are three to four times more likely to develop prostate cancer than if you are Caucasian. If you are of Asian descent, your risk is lower than that of Caucasian men. 

Errors in certain genes, namely BRCA1 and BRCA2, also slightly increase your risk. These genetic errors can often cluster in families with a history of breast and prostate cancer. 

Symptoms of prostate cancer

Prostate cancer, particularly in the early stages, often does not cause any symptoms. When symptoms do develop, they can include difficulty starting to urinate, weak urine flow, urine dribbling, feeling that your bladder isn’t empty even after you urinate, sudden urges to urinate and urinating more often, especially at night. 

The symptoms above also occur in other prostate conditions, such as an enlarged prostate (benign prostatic hyperplasia), inflammation of the prostate gland (prostatitis) or a urinary tract infection (UTI), which can include an infection of your urethra, testicles, bladder or kidneys. 

Other symptoms that occur as prostate cancer progresses include pain in your bones and blood in your urine and/or semen. While blood in your urine can be a symptom of prostate cancer, it can also be a symptom of kidney stones, bladder cancer, kidney cancer or testicular cancer. 

It is important to be aware of the symptoms of prostate cancer as the earlier it is detected, the greater the chances of successful treatment. 

Diagnosing prostate cancer

Prostate cancer is usually picked up by chance when investigating another health condition as it often produces no symptoms in the early stages and there is no national screening programme for prostate cancer. 

While there is a blood test to detect levels of the protein ‘prostate-specific antigen’ (PSA), which are raised in prostate cancer, this is not used as part of a screening programme. This is because PSA levels can be raised due to many other reasons, including other health conditions such as an enlarged prostate, prostatitis or UTI, as well as certain activities, such as ejaculation, anal sex, physical stimulation of your prostate, vigorous exercise and long-distance cycling in the 48 hours preceding your PSA blood test. 

When to seek help and what happens next

If you’re concerned about your prostate health, either because you have a higher risk of prostate cancer due to your ethnicity, age and/or family history, or because you have noticed unusual symptoms, see your GP. 

They will ask about any symptoms you’re experiencing, as well as your personal and family medical history. They may then recommend a PSA blood test. PSA levels naturally increase with age, so your PSA levels will be compared to what is considered normal for your age group.   

If your PSA levels are raised, you will be referred to a doctor who specialises in treating the genitourinary system (a urologist), specifically one who specialises in prostate cancer. You will then be advised to have a prostate MRI scan, which will produce detailed images of the inside of your prostate to help detect cancer and other prostate conditions. 

Depending on the results of your MRI scan, you may need further investigations, namely a transperineal biopsy. This is a minimally invasive procedure to collect a tissue sample from your prostate by passing a small needle, guided by an ultrasound scan, through a patch of skin between your testicles and anus called the perineum.

The tissue sample will be sent to a lab for analysis; the results can confirm whether or not you have prostate cancer. It can also detect non-cancerous prostate conditions such as prostatitis and pre-cancer. 

How prostate cancer is treated

If your prostate cancer is localised, that is, limited to the prostate gland, you will primarily be under the care of a urologist (surgeon). If it has spread, you will primarily be under the care of a doctor who specialises in treating cancer (an oncologist). 

As prostate cancer can be very slow-growing, in some cases, treatment may not be needed and instead, you will be under active surveillance where your prostate cancer will be closely monitored until treatment is needed. 

If treatment is needed and you have localised prostate cancer with only one isolated site, you may be able to receive focal therapy. This involves targeting the tumour with high-intensity ultrasound energy (high-intensity focused ultrasound treatment) or cryotherapy. 

Focal therapy has the benefit of reducing some of the functional side effects associated with whole gland treatment; however, it has a higher risk of the cancer returning or needing further treatment at a later stage. 

Alternatively, you may receive whole gland treatment with prostate surgery called robot-assisted laparoscopic prostatectomy, or hormone treatment to block testosterone and radiotherapy to treat the cancer. Radiotherapy can be applied externally or internally, with the latter called brachytherapy. Both treatments are considered to be equivalent in the management of prostate cancer.

How to prepare for prostate cancer surgery 

To reduce the risk of complications during and after your prostate cancer surgery and to speed up your recovery, certain lifestyle changes can help. This includes quitting smoking and reducing or stopping drinking alcohol. Together, this will reduce your risk of blood clots, excessive bleeding and complications from the anaesthesia.

Following a healthy, balanced diet, exercising regularly and losing any excess weight will also reduce your risk of complications and improve your fitness so that you are better able to cope with surgery and speed up your recovery. 

As urinary incontinence can be a risk after surgery, strengthening exercises that focus on your pelvic floor muscles (kegel exercises) before surgery can help reduce this risk and restore your continence more quickly.

Prostate cancer surgery brings mental as well as physical challenges. This is why it is important to speak with your care team so you have a complete understanding of the disease and treatments and are able to set realistic expectations from surgery, and the temporary and permanent changes you may face after surgery. 

It is also helpful to have a support network of friends, family and/or patient groups to help you cope with any anxiety you may have about surgery and life after surgery.

Recovering from prostate cancer surgery 

If you have a robot-assisted laparoscopic prostatectomy, you will likely remain in hospital for one night and will be discharged home with a catheter ie a thin tube inserted into your bladder via your penis, through which urine will be drained out of your body. You will need to use a catheter to pass urine for seven to 10 days after surgery. 

Complete recovery from a robot-assisted laparoscopic prostatectomy usually takes around four weeks, although many patients find that this can be as quick as two weeks. 

Following a robot-assisted laparoscopic prostatectomy, it is important to get moving as soon as possible after surgery to reduce your risk of blood clots and help your bowel return to normal as it can be sluggish after surgery. Make sure you walk around the house and do not spend all day in bed or seated. 

However, you should avoid heavy lifting and vigorous exercise (eg running, sports, etc) for the duration of your recovery. You should only return to driving once you can comfortably make an emergency stop. Typically, therefore, you will need at least four weeks of recovery before you can return to these activities. 

If you have an open prostatectomy, where a cut is made into your lower abdomen, you will remain in hospital for up to a week after your surgery. Recovery takes longer and can take up to three months to recover fully. Open prostatectomy is now hardly ever performed in England. 

Risks of prostate cancer surgery

Every surgery comes with risks, including infection, bleeding, blood clots and damage to surrounding tissues, such as the bowel and blood vessels. For any cancer surgery, there is always the risk that not all of the cancer is removed — a margin of tissue around a tumour is removed to help ensure that no cancer cells remain but this is not a guarantee. Cancer may return in future and you may need further treatment as a result of this. 

For prostate cancer surgery, there are three specific functional risks: infertility, erectile dysfunction and incontinence. 

If your whole prostate and seminal vesicles are removed, you will no longer produce seminal fluid. This means that your sperm will have no fluid to nourish and transport them during ejaculation. Consequently, your sperm will be reabsorbed by your body and you will have dry ejaculate. As a result, you will not be able to conceive children naturally, though you should still be able to achieve orgasm. 

Prostate cancer surgery also carries the risk of damaging the nerves around your prostate that control your ability to have an erection. With robotic technology, we are able to perform nerve-sparing surgery in select cases, and this technique improves your chances of potency after surgery markedly, that is, the ability to maintain erections that are hard enough for sexual intercourse. 

All patients who undergo robotic surgery for prostate cancer should have access to penile rehabilitation to help regain or achieve erections post-surgery. This may include erectile dysfunction treatments such as medications and vacuum-assisted erection devices.

Prostate cancer surgery can additionally damage the nerves and muscles around your bladder, leading to urinary incontinence. However, robot-assisted laparoscopic prostatectomy reduces this risk significantly, as it allows visualisation and protection of the sphincter muscle, which keeps you dry.

Incontinence after robot-assisted prostate surgery typically is due to weakening of the pelvic floor muscles and urinary sphincter. However, these muscles can be strengthened with kegel exercises to restore your continence over several months. This process of regaining continence can take up to a year in some patients. 

Robot-assisted laparoscopic prostatectomy

Laparoscopic surgery is also known as keyhole surgery as it uses special small instruments alongside a fibre-optic camera, which together allow the surgery to be completed through cuts in the body that are much smaller than those used in traditional open surgery. Robot-assisted laparoscopic surgery extends this technique. 

In a standard laparoscopic surgery, the instruments are held by the surgeon, but in a robot-assisted laparoscopic surgery the instruments are attached to robotic arms on a patient-side cart. These robotic arms are controlled by the surgeon, who is also in the operating theatre, using a console. 

The surgeon receives a high-definition, magnified, 3D view of the area being operated on from the fibre-optic camera that sends this visual information to a monitor. The hand and wrist movements that the surgeon makes via the console are then mimicked by the robotic arms acting on the patient. 

A robot-assisted laparoscopic prostatectomy, such as the da Vinci system, uses this approach to remove part or all of the prostate gland. This technology allows for more precise, accurate and steadier movements than surgery performed without robotic assistance. Consequently, the functional outcomes after surgery are better. 

Robotic-assisted laparoscopic surgery has been used in the field of urology for around 20 years and is now commonplace. The da Vinci system is the latest iteration of this advancing technology. It has revolutionised the field by delivering better functional outcomes for patients, namely reduced risks of incontinence and erectile dysfunction, and faster recovery times due to less bleeding and pain. Robotic-assisted laparoscopic prostatectomy also results in less visible scars. 

The outlook for prostate cancer

The general outlook for prostate cancer in the UK is good. When considering all stages of the disease, over 95% of individuals survive for at least a year, around 90% survive for at least five years and around 80% survive for at least 10 years. 

These survival rates improve even more the earlier prostate cancer is detected, with almost all individuals surviving for at least five years when the cancer is localised ie limited to the prostate gland. If your prostate cancer has just started to spread — ie it has passed through the covering of the prostate gland and into the seminal vesicles — with treatment, 95% of individuals still survive for at least five years. 

This is in large part due to advances in prostate cancer surgery and a range of options available in the treatment of the disease. With robot-assisted laparoscopic prostatectomy, such as that delivered by the da Vinci system, you can benefit from a more predictable recovery and a better quality of life after surgery.