The prostate gland is a small gland that sits at the outlet of the bladder and surrounds the urethra (pipe) as it leaves the bladder. The main function of the gland is to contribute volume to the semen, and its secretions help to make sperm more active. The gland is thought to be the size of a walnut when one is in their 40s.
Benign Prostatic Hyperplasia (BPH) and Bladder Outflow Obstruction
As men get older, their prostate gland increases in size – this is a normal age-related change. However, in some men, as the prostate increases in size, it also starts to cause some narrowing of the urethra/pipe that passes through it resulting in bladder outflow obstruction. This often causes difficulty in passing urine, particularly with increasing age – reduced flow, hesitancy, frequency, urgency, need to pass urine several times in the night. Whilst these symptoms can have a drastic effect on a person’s quality of life, they are common and easily treatable. It is also important to remember that such symptoms in a man also often affect the quality of life of the partner. Many men worry that such symptoms may signify the presence of prostate cancer – however this is a common misconception and rarely the case as most prostate cancers do not necessarily cause urinary symptoms unless one has advanced disease.
A small proportion of younger men also suffer from the symptoms of bladder outflow obstruction – this can often be due to a somewhat tight or hypersensitive muscle at the bladder outlet. Such men often complain of some urinary symptoms dating back to their teens. This can also be an under-diagnosed problem, but one that can be easily treated.
Some men (and women) can suffer from urinary symptoms in the absence of any obstruction at the outlet – this can be due to a variety of causes including dysfunction/over-activity of the bladder, neurological problems and lifestyle factors.
All the above problems can be diagnosed fairly easily through a detailed history from the patient along with a clinical examination and some easy and non-invasive tests. A significant proportion of patients with the above symptoms can be easily treated with lifestyle changes with or without medication alone. Surgery is usually reserved for those patients who fail to respond to treatment with medication or when the symptoms are very severe.
Prostate Cancer is now the commonest cancer amongst men in the UK and the developed world. The incidence is increasing due to various factors including the ageing population, greater awareness and increased testing for the disease. Whilst the precise cause of the disease is not known, what we do know is that certain factors increase the risk of developing the disease. These include age, a family history of prostate cancer affecting a first degree relative, race (higher risk amongst men of African or African Caribbean and African descent) as well as certain dietary factors. There is still no mass prostate cancer screening programme in the UK and several other European countries – this is because the jury is still out as to the advantages and disadvantages of such an exercise. This may sound ridiculous to a lay person – surely diagnosing a disease early makes more sense and should prevent problems in the future? While this is often true, the issue is that it is quite difficult to distinguish those patients in whom the disease poses a real threat from those in whom the disease does not pose a significant threat. There is therefore the potential danger that some men may get over-treated for something that may never have been a threat to them in the first place. Screening for prostate cancer is currently the subject of several international research studies. This is also partly due to the lack of a highly sensitive, specific and reliable test for the disease. Prostate cancer still tends to be a relatively poorly understood cancer and its management can still be somewhat of an art. As a result of all the above uncertainty, the urological community in the UK still remains undecided as to whether prostate cancer screening should become normal practice.
What is however clear, is that if a person is concerned about the possibility of prostate cancer, then the right thing to do would be to discuss this with your doctor and, if necessary, seek a specialist opinion. We frequently see patients who ignore their concerns and symptoms and often seek medical attention when it is too late.
Prostate cancer can be detected through a digital rectal examination of the prostate gland (gentle insertion of a finger up the back passage) and a PSA blood test. It is, however, still possible to have the disease even when the PSA test and the examination findings are normal. The PSA test should only be performed after thorough counselling, so that one understands the benefits and potential pitfalls of the test. Neither of these tests on its own is very reliable. However, when the two are used in combination by a doctor/specialist, then the tests are more reliable. If the doctor is suspicious about the possibility of prostate cancer, then the next step may be to consider some biopsies of the prostate. Depending on the level of suspicion, or if the diagnosis is indeed confirmed, some patients may require certain ‘staging’ scans – usually an MRI scan and a bone scan. It is important to remember that not all patients would require scans. Prostate cancer diagnosis and management still remains one of the few arts in surgery – one can have prostate cancer with a normal blood test and yet some patients have a high blood PSA test result in the absence of prostate cancer. The latter can be due to inflammation or infection affecting the prostate, or even due to the prostate being above average in size. Furthermore, not all patients with prostate cancer require treatment – monitoring the disease is a reasonable option in certain men with disease considered to be ‘low-risk’. The reason for this, as mentioned above, is that the diagnosis of prostate cancer does not necessarily mean that the disease will pose a significant threat to the patient. Many patients will, however, require further treatment – this can include Radical Surgery (Robotic Assisted Radical Prostatectomy) or certain forms of Radiotherapy (External Beam Radiotherapy or Brachytherapy). Other less commonly used treatments may include High Intensity Frequency Ultrasound (HIFU) or Cryotherapy, but these are currently only used as part of a national trial).
Patients diagnosed with prostate cancer should be counselled at great depth by their consultant, often with input from a Cancer Nurse specialist – this should include information on your particular disease, the treatment options available and the pros and cons of each treatment that may be considered suitable. Your surgeon and the nurse should be there to inform, guide and support you through your treatment. They should also help you to make the best decision regarding your treatment through guidance, rather than dictating your treatment.
Prostatitis is an inflammatory condition affecting the prostate and in some patients can cause horrendous symptoms ranging from a mild aching discomfort to severe pelvic pain with urinary symptoms and sometimes high temperatures. Some patients describe the sensation of ‘sitting on a tennis ball’ and the symptoms can often be debilitating and long-lasting. The diagnosis of prostatitis is usually made on the basis of a detailed history from the patient, clinical examination and some simple tests. While some men respond to simple medication such as antibiotics, there are others in whom the disease can be very resistant to treatment and can often take a long to settle and also have frequent recurrences. The urologist would also try, through the investigations, to exclude any factors that may predispose one to get the condition.
Robotic Surgery in Urology
Gloucestershire is now a recognised cancer centre for robotic surgery. One of the biggest advances in surgery in recent times has been the development of robotic surgery. Such surgery is most widely used in urological surgery and has transformed the treatment of a variety of patients. Robotic surgery is a minimally invasive (key-hole) and highly precise form of surgery where certain operations are performed using robotic instruments inside the patient’s body. The instruments are controlled by the surgeon who operates them while sitting at a console a couple of meters away from the patient. The instruments are inserted in to the body through tiny skin incisions. The surgeon has the benefit of a greatly magnified, 3-dimensional image, which allows greater precision. Robotic surgery is most widely used for the treatment of early prostate cancer. The old-fashioned operation for prostate cancer used to involve a sizeable cut in the lower abdomen and was also associated with significant risks of bleeding, erectile dysfunction and incontinence, with a prolonged recovery period. Robotic surgery has now transformed such surgery – the recovery times are much shorter and most patients go home after an overnight stay; this form of surgery also allows quicker recovery thereby allowing patients to get back to normal activities and work sooner. The side effects also appear to be significantly reduced – this does not mean that patients no longer suffer from side effects such as erectile dysfunction and incontinence, but rather that the increased precision allows the surgeon to spare the penile nerves and the muscles responsible for continence much more accurately, thereby preserving or allowing restoration of erections and continence in a greater proportion of patients and also within a shorter period of time. There are, however, some patients in whom the penile nerves are not suitable for preservation as doing so would compromise the cancer operation.
Whilst prostate cancer surgery is the commonest type of surgery now performed using the robot, over the next few years there will be an expansion with a whole variety of other urological operations being performed using this method, with benefits to patients.