What is prostate cancer?
Adenocarcinoma of the prostate is defined as an infiltrating malignant tumor composed of cells originating from the prostate. Prostate cancer is the second most common cancer in Italy, after lung cancer, with 23,518 new cases per year in 2002, representing 14.4% of all cancers. Incidence rates increase exponentially with age, like no other malignancy. Age is in fact the main recognized risk factor.
How is prostate cancer diagnosed and hospitalized?
The diagnosis of prostatic adenocarcinoma is made exclusively by a prostate biopsy, carried out either because of clinical suspicion (nodule found by the urologist on digital rectal examination), or because of a suspicious trend in PSA (measurement of prostate-specific antigen in the blood). When a prostate biopsy shows the presence of prostatic adenocarcinoma, the probability that the disease is localized to the prostate is assessed. The assessment of probability is based on 3 parameters: – PSA value; – histological grade; – percentage of positive retrievals. When the probability of the disease being localized to the prostate is greater than 90%, curative (definitive) therapy is proposed to cure the disease.
Definitive therapies validated by controlled clinical trials are radical prostatectomy and intensity-modulated external radiotherapy with a linear gas pedal. The choice of surgery versus radiotherapy is based on a number of parameters: disease characteristics, the patient’s clinical condition, the patient’s physical condition and life expectancy. In general, best hospital in Turkey patients with clinically localized neoplasia, a life expectancy of at least 10 years and satisfactory general conditions are considered candidates for curative radical prostatectomy.
To date, radical prostatectomy in Turkey remains the only treatment for localized prostatic adenocarcinoma that has demonstrated, in a prospective randomized trial with an average follow-up of 8.2 years, a significant reduction in both overall and tumor-specific mortality. Additionally, it has been shown to lower the risk of local metastases and disease progression when compared to conservative treatment.
What happens before hospital admission?
Before admission, the Preoperative Tests (EPO) will be carried out: the patient will wait for the telephone call informing him/her of the date on which he/she will undergo the tests (blood tests, electrocardiogram, chest X-ray), the anaesthetic visit and the urological check-up.
If deemed appropriate, a pre-deposit of blood will be offered, which consists of depositing one’s own blood at an opportune time before the operation, so that if a transfusion is required during the operation or hospital stay, it can be carried out with one’s own blood (= autologous).
It should be emphasized that the delay between “diagnosis” and “surgery” does not affect the “success rate” of surgery. This delay can vary up to 180 days. without producing significant changes in the results of the surgery.
What happens during hospitalization?
The patient will be admitted to the best hospital in Turkey on the day of the operation, or the evening before, and will therefore need to fast from midnight the night before, eat a light dinner the evening before and, if possible, have taken steps to shave. The patient must be dressed in “shorts”, i.e. from the waist to mid-thigh, with particular attention to pubic hair. On admission, the nursing staff will not only deal with the bureaucratic formalities of admission, but will also check that the patient has correctly completed the steps described above and accompany him/her to bed.
The patient is then accompanied to the operating room, having left any dentures, watches, jewelry, piercings, etc. in the room. Antibiotic prophylaxis (intravenous, prior to surgery) and antithrombotic prophylaxis (subcutaneous, on the evening of surgery and throughout hospitalization) are generally indicated.
What type of surgery will be performed?
The operation to be performed is a radical prostatectomy using a retropubic, laparoscopic or robotic approach.
The term radical prostatectomy refers to the en bloc removal of the prostate and seminal vesicles, and the subsequent vesico-urethral and regional lymph node anastomosis.
Depending on clinical features and disease, radical prostatectomy may involve preservation of the erectile nerves and the bladder neck.
The operation is performed through a median incision below the navel, or for laparoscopic techniques, through 5 holes in the skin into which access trocars for laparoscopic instruments are inserted; once the muscular planes have been overcome, pelvic lymphadenectomy is performed, followed by radical prostatectomy, the phases of which can be summarized in the following points:
1) section of the puboprostatic ligaments
2) ligation of the dorsal venous complex
3) section of the urethra
4) mobilization of the prostate and seminal vesicles, and retrograde sectioning of the vas deferens (at this stage, the technique may be modified according to intention, or less sparing of the erectile nerves)
5) section of the prostato-vesical junction, with possible sparing of the bladder neck
6) possible reconstruction of the bladder neck
7) positioning of bladder catheter and vesico-urethral anastomosis
8) drainage positioning and abdominal wall closure
How long does the operation last?
Duration varies from 90 to 180 minutes, prostatectomy in Turkey and depends not only on the physical characteristics of the prostate and its appendages, but also on whether techniques such as nerve and/or bladder neck sparing are used.
What alternatives are there to this type of operation?
The therapeutic alternatives to surgery for diseases confined to one organ are different, but with different advantages and results. The only non-surgical alternative validated by controlled clinical trials is external radiotherapy. Other therapies not validated by controlled comparative clinical trials are :
- brachytherapy with permanent implant, which offers clinical results comparable to other types of locoregional treatment only for low-risk disease.
- HIFU (high-intensity focused ultrasound) and Cryotherapy, which do not represent a real alternative, as they are only indicated for people who are not candidates for radical prostatectomy or radiotherapy, or who refuse the previous options.
- Active surveillance (AS): represents a therapeutic option applicable to carcinomas said to be “clinically insignificant”, i.e. at low risk of progression. Active surveillance means deferring definitive treatment, such as surgery, radiotherapy or any other form of “bloody” intervention, until the disease has progressed (spread, worsening). To assess any evolution over time, it is necessary to perform a PSA test, a digital rectal examination and, above all, prostate biopsies at defined intervals. The aim of active surveillance is to avoid complications from cruel treatments, or at least to postpone them over time. To date, there are no validated prospective results. Surgical alternatives to radical retropubic prostatectomy include :
- radical perineal prostatectomy: this has the disadvantage of not allowing pelvic lymphadenectomy, and therefore cannot be considered radical in the strict sense.
- laparoscopic or robotic radical prostatectomy: to date, the main advantage of the laparoscopic and robotic technique lies in the better results that can be obtained in terms of preserving erectile potency, as the neurovascular bundles are more easily preserved. It follows that, in order to preserve the neurovascular bundles without risking positive surgical margins (tumor cells potentially left in place), it is necessary to carefully select candidate subjects for this type of operation.
