THE SURGICAL RADICAL APPROACH TO REMOVE THE PROSTATIC CANCER IN LOW, INTERMEDIATE, AND HIGH RISK STAGES
Semir A. S. Al Samarrai
Penile Curvature can be congenital or acquired.Acquired curvature is secondary due to La Peyronie’s disease.
Prostate cancer mortality trends range from country to country in the industrial world (1). Mortality due to PCA has decreased in most western country but the magnitude of the reduction varies between countries. The reduced mortality seen recently in the USA is considered to be partly due to a widely adopted aggressive PCA screening policy (2). However, there is still no level evidence that Prostate-Specific Antigen (PSA) screening reduces mortality due to PCA (3).
Early detection or opportunistic screening consists of individual case findings, which are initiated by the person being screened (patient) and/or his physician.
The co-primary endpoints of the screening are:
• Reduction of mortality due to PCA
• Maintained Quality of Life (QOL) as expressed by QOL adjusted gain in life years
Men has elevated risk of having PCA are those > 50 years, or with family history of PCA and age > 45 years, or African-Americans (4).In addition, man with PSA > 1. ng/ml at 40 years and> 2. ng/ml at 60 years (5, 6) are also at increased risk of PCA metastasis or death several decades later. Informed men requesting an early diagnosis should be given a PSA test and undergo Digital Rectal Prostate Examination (DRE), (7). From a public health point of view, mass screening of PCA is not indicated. However, early diagnosis on an individual basis is possible based on DRE and PSA testing.
Guidelines for screening and early detection (European Association of Urology Guidelines 2015 edition) is as follow:
• An individualized risk-adapted strategy for early detection might be offered to a well-informed man with a good performance status and at least 10-15 years of life expectancy.
• Early PSA testing should be offered to man at elevated risk for PCA groups are:
- Men over 50 years of age
- Men over 45 years of age and family with history of PCA
- Men with a PSA level of > 1. ng/ml at 40 years of age
- Men with a PSA level of > 2. ng/ml at 60 years of age
1. Prostate cancer is usually suspected on the basis of Digital Rectal Prostate Examination (DRE) and/or Prostate-Specific Antigen (PSA) levels. Definitive diagnosis depends on histopathological verification of Adenocarcinoma in the prostate biopsy cores or specimens from transurethral resection of the prostate or surgical removal of the prostate for benign prostatic enlargement. Prostate-Specific Antigen is continuous parameter, with high levels indicating greater likelihood of PCA. Many men harbor PCA despite having low serum PSA (8).
2. Prostate-Specific non-coding mRNA Biomarker (PCA3) is detectable in urine sediments obtained after three strokes of Prostatic massage during DRE. This test (PCA3) is superior to total and percent-free PSA for detection of PCA in men with elevated PSA as it shows significant increases in the area under receiver-operator characteristic curve for positive biopsies (9-12). The main implication for the PCA3-Test is to determine whether repeat biopsy is needed after an initially negative biopsy.
3. Prostate Biopsy, The need for prostate biopsy is based on PSA level and/or suspicious DRE. Age, potential comorbidity, and therapeutic consequences should also be considered and discussed beforehand (13). Limited PSA elevation alone should not prompt immediate biopsy. PSA level should be verified after a few weeks using the same assay under standardized conditions (i.e. no ejaculation, manipulations, and Urinary Tract Infections) in the same laboratory (14, 15). Empiric use of antibiotics in an asymptomatic patient in order to lower the PSA should not be undertaken (16).
Ultrasound-guided biopsy is now the standard of care. A transrectal approach is used for most prostate biopsies, although some urologists prefer a perineal approach.
Cancer detection rates are comparable with both approaches (17, 18). Saturation biopsy has 30-43% incidence to detect PCA by saturation repeat biopsy (> 20 cores), (19). This tool of biopsy may be performed with transperineal technique, which detects an additional 38% of PCA.
Ultrasound-guided periprostatic block is state-of-the-art (20), as local anesthesia prior to prostate biopsy.
4. TRUS, The Transrectal Ultrasound Investigation of the prostate has currently not enough evidence for their routine use, because classic hypoechogenicity in the peripheral prostate is not always seen.
5. Multiparametric MRI (mpMRI), This modern tool has excellent sensitivity for score > 7 cancers (21 - 24); and mpMRI may detect and/or cancer of the prostate gland missed by systematic biopsy (25, 26). The indication for MRI-targeted biopsy is only given when clinical suspicional PCA persists in spite of negative repeat systematic with saturation prostate-biopsy.
The surgical treatment of PCA consist of radical prostatectomy, this involves removal of the entire prostate gland between the urethra and bladder resection of both seminal vesicles, along with sufficient surrounding tissue to obtain a negative margin. Often, this procedure is accompanied by bilateral pelvic lymph node dissection. The goal of the radical removal of PCA by any approach must be eradication of disease, with preserving continence and whenever possible sexual potency, (28). There is no age threshold for this radical procedure and a patient should not be denied this on grounds of age alone (27). However, patients with life expectancy of > 10 years are more likely to benefit from this procedure. Currently, the radical removal of the cancerous prostate is the only treatment for localized PCA to show a benefit for overall survival and cancer-specific survival, compared with conservative therapeutic management as shows in one prospective randomised trial (29). During 23.2 years of follow up, the SPCG-4 trial showed that radical prostatectomy was associated with a reduction of all-cause mortality. The relative risk of death at 18 years was 0, 71.
The number needed to treat (NNT) to prevent one death at 18 years of follow-up was 8, the NNT decreased to 4 for men younger than 65 years of age. The benefit of surgery with respect of death from PCA was largest in men younger than 65 years and in those with intermediate-risk PCA. However, radical prostatectomy was associated with a reduced risk of metastases among old men. The gold standard surgery of the radical prostatectomy are performed through open incision for clinically localized PCA.
A recent cohort study demonstrated that Robot-Assisted Laparscopic Prostatectomy (RALP) and Radical Retropubic Prostatectomy (open surgery) had comparable rates of complications and additional cancer therapies. Surgical expertise has decreased the complication rates of RP and improved cancer cure (30 - 33). Low rates of positive surgical margins for high-volume surgeons suggest that experience and careful attention to surgical details, adjusted for the characteristic of the cancer being treated, can decrease positive surgical margin and improve cancer control with this surgical approach (34, 35).
The indication for the radical prostatectomy is given by:
• Low-risk prostate cancer. Pelvic lymph node dissection (eLND) is not necessary by this) stage of PCA because the risk for positive lymph nodes does not exceed 5% (36).
• Intermediate-risk localized prostate cancer. The RP significantly reduced all-cause-mortality by this stage of PCA, but not death from PCA. "Intermediate-risk PCA is associated with 10-year and 15-year prostate-cancer-specific mortality rates of 13 and 19.6% (37)." The risk of having positive LNs in intermediate risk PCA is between 3.7-20.1% (36). An eLND should be performed if risk with lymph node metastases exceed 5% (36). In all other cases, eLND can be omitted, which means accepting a low-risk of missing lymph nodes metastases.
• High-risk and locally advanced prostate cancers. Patients classified with high-risk PCA are at an increased risk of PSA failure need for secondary therapy, metastatic progression and death from PCA. Nevertheless not all high-risk PCA patients have uniformly poor prognosis after radical prostatectomy (38). The radical prostatectomy is reasonable first step in selected patients with low tumor volume, and not fixed to the pelvic wall, or that there is no invasion of the urethral sphincter. Extended LND should be performed in all high-risk. PCA cases, because the estimated risk for the lymph nodes metastasis is 15-40% (36).
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Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576