Prostate Cancer

Prostate cancer, according to data from the American Cancer Society, is the most frequently observed cancer in men in Western countries, constituting approximately a quarter of all cancer cases. In our country, it is one of the most common types of cancer in men, along with lung cancer. Recent studies report that while a man’s lifetime risk of developing prostate cancer is between 15-20%, the risk of death due to the disease is about 3%. This is related to the fact that although prostate cancer is a very common cancer, its chance of recovery is very high, especially when diagnosed in the early stages and when a correct treatment regimen is applied.

What are the Symptoms of Prostate Cancer?

Prostate cancer typically has no early symptoms and only becomes apparent with complaints that arise in the advanced stage. At this stage, the person’s chance of recovering from the disease may be impossible. Therefore, it is highly important to detect the disease in its early stage, while it is still confined within the prostate, meaning when it shows no clinical findings. Ensuring that men visit a urology specialist for a prostate examination once a year after the age of 50, even if they have no complaints, can only be achieved by raising awareness about this disease.

Cause and Risk Factors of Prostate Cancer

It is not precisely known what causes cancer formation in the prostate tissue. However, some risk factors have been identified as being linked to cancer.

• Age: Cancer is rarely seen in men under the age of 40. A man’s likelihood of developing cancer increases when he reaches 50. Two out of 3 patients diagnosed with cancer are men over 65. Prostate cancer seen in men younger than 60 generally shows a more aggressive course.
• Race: The disease is more common in African-American (black) men compared to men of other races. It is less common in Asian and Latin men. The reasons for these racial and ethnic differences are not clear.
• Geography: Prostate cancer is more frequent in North America and Northwest Europe. Its incidence is lower in Asia, Africa, Central, and South America. The reason for this is not clear.
• Family History: It has been determined that the disease is continuously seen in some families. Men who have close family members (grandfather, uncle, father, or brother) diagnosed with cancer (especially if their relatives were diagnosed with the disease at <55 years of age) have a higher likelihood of developing cancer themselves.
  • If one individual in the family has cancer, the risk of cancer in other individuals doubles; if two or more individuals have cancer, this risk increases 6-11 times.
• Genetic Characteristics: In 1/5 of men with prostate cancer who do not have a family history of cancer, the presence of certain gene defects has been found. The defect in the BRCA-2 gene, which has been shown to be related to breast cancer, has also been proven to be related to prostate cancer. Men with a defect in the BRCA-2 gene have a high likelihood of developing cancer.
• Nutrition: The exact role of nutrition in this type of cancer is not clear. Prostate cancer is seen more frequently in men who follow a protein-rich diet.
  • A diet rich in red meat and a diet rich in fat have not been shown to be related to prostate cancer (2020 publications). It is seen less frequently in men whose diets are rich in phytoestrogens (soybeans, soy milk, flaxseed, whole wheat grain, spinach, cabbage, strawberries, apples, raisins).
  • Deaths related to cancer formation in the prostate are more frequent in people who consume a lot of alcohol.
  • Prostate cancer is more frequent in men with low Vitamin D. No link has been shown between Vitamin E use and prostate cancer. If prostate cancer develops in men with selenium deficiency, the disease shows a more aggressive course.
• Male Pattern Baldness: Bald men are at a higher risk of dying from prostate cancer.
• Gonorrhea Infection (Gonorrhoea): Men who have had a gonorrhea infection have a higher likelihood of developing cancer.
• Smokers: Men who consume a lot of cigarettes are at a higher risk of dying from cancer.
• Men Working with Cadmium: Cancer is more frequently observed in men working in the electric, ceramic, battery, and accumulator industries.
• Men with Infrequent Ejaculation: Prostate cancer is 25% more frequent in men who ejaculate 2 or fewer times a week compared to men who ejaculate 4 times a week.

How is Prostate Cancer Determined?

Currently, there is no early diagnostic method that can predict that a healthy man will develop prostate cancer.

Prostate cancer screening is first recommended as annual check-ups at age 50 and after for men with no family history of prostate cancer, while it is recommended at earlier ages for those with a family history.

The basic methods used for screening are digital rectal examination (for the prostate) and PSA (prostate-specific antigen) measurement via blood test.

PSA Test:

The PSA test, which is checked in a blood analysis, can help diagnose prostate cancer early. Early diagnosis of prostate cancer is very important for increasing treatment options.

PSA is a hormone secreted by the prostate gland. For this reason, it can also be high after conditions other than cancer, such as BPH (benign prostatic hyperplasia), prostatitis (prostate inflammation), sexual intercourse, rectal prostate examination, urinary tract infection, or urinary tract procedures (catheter insertion).

That is, while a high PSA level does not always mean cancer, a low level may also be insufficient to rule out cancer. Therefore, the PSA test is supported by additional tests such as a prostate examination and prostate MRI in the screening and diagnosis of prostate cancer.

Genetic-Based Tests from Urine:

• Prostate Cancer Gene 3 (PCA3): A test based on checking for PCA3 microRNA in urine collected after a prostate massage. If the PCA3 test is negative in a person with high PSA, there is a 91% chance that person does not have cancer.
• Select Mdx: A test based on checking for HOXC6 and DLX1 microRNA in urine collected after a prostate massage.
• Mi Prostate Score: The TMPRSS2-ERG gene fusion is found in 50% of patients with prostate cancer. If the TMPRSS2-ERG gene fusion is present in the urine collected after a prostate massage, a special calculation is made using the PCA3 and the PSA value from the blood. This result is called the Mi Prostate Score.
• EkoDx: A test that examines exosomes shed from prostate cancer cells in the urine. Patients with a positive EkoDx test result are more likely to have aggressive cancer.

Multiparametric Prostate MRI

It is a valuable imaging method that can support the diagnosis in patients with suspected prostate cancer. Cancerous tissue parts inside the prostate have a different image from normal prostate tissues because they are more densely supplied with blood than healthy tissues, resulting in different cell densities.

In addition to diagnosing prostate cancer, Multiparametric MRI can detect whether the tumor has breached the prostate capsule and potential lymph node metastases. Thus, it provides important information to the clinician for staging the disease.

Patients who are found to have suspicious areas for cancer in the prostate tissue as a result of the MRI should definitely be referred for a prostate biopsy. MRI images can also be used as a guide when performing a prostate biopsy on the patient.

Prostate Biopsy

The process of taking a piece of tissue or cells from any part of the body for examination under a microscope and performing various tests is called a “biopsy.” Definitive diagnosis of cancer is only possible through a biopsy.

In a prostate biopsy, random samples are taken from different regions of the prostate. In a standard prostate biopsy, random pieces are taken from the prostate with the help of a special device placed in the rectum under local anesthesia. Afterward, pathological examinations check whether there are cancerous cells in these tissues.

With the advancement of technology, new biopsy methods have been developed, thereby increasing the diagnostic accuracy rates.

• Standard Prostate Biopsy: Prostate biopsy is the process of taking pieces from the prostate with a biopsy needle through the rectal path, guided by a special ultrasound. In standard (older) biopsies, random pieces are taken from different regions of the prostate. Biopsy procedures performed this way are generally done under local anesthesia, but general anesthesia (sedation) may also be preferred depending on patient factors.
• Robotic MR-Ultrasound Fusion Biopsy: In this method, the patient’s previously taken MRI images are transferred to the ultrasound device used for prostate biopsy (fusion), allowing the exact location of the area suspicious for a tumor to be determined.
  • Thus, instead of taking “random” pieces as in classical biopsies, a biopsy is performed directly from the suspicious focus by “targeting.” Since the exact location of the tumor or suspicious focus can be found, taking fewer samples may be sufficient instead of taking a large number of pieces.
• Next-Generation Robotic Prostate Biopsy: The latest innovation in prostate biopsy is performing the biopsy procedure with a robotic system. This system is a new-generation prostate biopsy method used in a limited number of centers in Europe. The differences and advantages of this system are:
  • MRI and USG images are combined (Fusion) to target the suspicious lesion.
  • The process of taking samples from the target is carried out by a ROBOTIC system, eliminating the margin of error of the human hand.
  • The risk of infection is minimized as the procedure is performed from the perineal (skin) region instead of through the rectum.
  • The patient’s biopsy map is recorded in the robotic system. Thus, if the sample taken turns out to be cancer, since the exact coordinates of the lesion are known, it allows for non-surgical (focal) treatments.

Prostate Cancer Treatment

The choice of treatment for prostate cancer is made by considering the pathological features of the tumor (stage, grade, etc.) as well as the patient’s age and general health status.

Treatment options include Surgical Treatment (Radical Prostatectomy), Radiation Therapy (Radiotherapy), Focal Treatments (HIFU, Brachytherapy, Nanoknife), Hormone Therapy, Drug Treatment (Chemotherapy), or Active Surveillance. The most correct approach will be a decision made jointly by the patient, their family, and the doctor, considering the criteria mentioned above.

Surgical Treatment

The treatment for prostate cancer that has not spread to other organs is the surgical removal of the prostate. This surgery is called radical prostatectomy. The 10-year disease-specific survival rates for patients with low-grade tumors after radical prostatectomy operation are over 90%. This means that the vast majority of patients who are detected and operated on at this stage are considered cured of this cancer.

• Radical Prostatectomy (Open Surgery): Radical prostatectomy surgery can be performed through an incision of approximately 15 cm below the navel or an incision of 8 cm in the perineal region (between the scrotum, where the testicles are located, and the anus).
  • This surgery is generally recommended for men in good condition and without serious health problems. The prostate is anatomically in close proximity to the nerves that aid in urinary continence and erection. Since the goal of this surgery is to leave no cancerous tissue behind, these structures can be partially affected during the procedure.
  • The operation usually causes the inability to get or maintain an erection in the early period (sexual impotence). This condition generally improves over time but may require additional treatments.
  • Furthermore, this surgery can cause problems with controlling the bladder (urinary incontinence). Although techniques used during surgery can reduce the likelihood of these side effects, these effects can be encountered to certain extents, regardless of the method used.
• Robotic Radical Prostatectomy (Laparoscopic Surgery): Robotic surgery is the performance of laparoscopic (closed) operations under 3D imaging with the assistance of a robot. The surgeon controls the arms via a console.
  • The main goals of robotic surgery for the prostate are the removal of the prostate without leaving cancerous tissue behind, the preservation of the nerves that ensure the continuation of sexual functions, and the avoidance of damage to the structures that ensure urinary continence when the prostate is removed.
  • A “Bladder-Sparing Technique” has been defined in robotic prostate surgeries by identifying an anatomical plane between the bladder and the prostate. The rates of urinary incontinence in patients after surgery performed with this technique have greatly decreased.

What are the Advantages of Robotic Surgery?

The difficulties of open surgery for the patient include long hospital stays and recovery times, as well as the risk of wound infection. Due to the narrowness and depth of the surgical field, the inadequacy of hand movements and the inability to provide a good field of view lead to longer operation times. These negative aspects can be counted as difficulties of open surgery for both the surgical team and the patient.

Thanks to the slender structure of the arms used in robotic surgery, their superior range of motion, their vibration-dampening operating principle, and the advanced 3D imaging systems of the robotic system, structures in close proximity to the prostate can be more easily protected during prostate surgery. Thus, the probability of complications decreases, blood loss is reduced, and the duration of the operation is shortened.

After the operation, reduced pain, a shorter recovery period, and shorter hospital stays are among the scientifically proven advantages of robotic surgeries.