WHAT IS PROSTATE CANCER?
Prostate cancer is the cancer of the prostate gland. The prostate is a walnut-sized gland in between the bladder and the urethra that nourishes and transports sperm. Prostate cancer is the second most common cancer among men in Singapore.
SYMPTOMS OF PROSTATE CANCER
Early stage prostate cancer has few or no symptoms as the cancer develops slowly. If symptoms appear, they may include difficulty in passing urine, burning sensation while urinating, blood in urine, loss of appetite and/or weight, and lower back pain.
DIAGNOSING PROSTATE CANCER
Men with either abnormal Prostate Specific Antigen (PSA) blood test and/ or abnormal digital rectal examination of the prostate are considered at higher risk of having prostate cancer. However, prostate cancer can only be diagnosed through a biopsy. A Magnetic Resonance Imaging (MRI) scan of the prostate is usually performed before the biopsy to visualize areas within the prostate that are suspicious for harbouring prostate cancer. At Urohealth Medical Clinic, we offer MRI Targeted Biopsy of the prostate. Dr Tan Yung Khan, Medical Director and Senior Consultant Urologist of Urohealth Medical Clinic, established the MRI Targeted Fusion Biopsies of the Prostate using the UroNav Platform in Asia. Using MRI and fusion with ultrasound, targeted biopsies of suspicious areas within the prostate seen on MRI scan are performed. This improves the accuracy of the biopsies and reduces the need for repeat biopsies.
MAGNETIC RESONANCE IMAGING (MRI) TARGETED BIOPSY OF THE PROSTATE
Elevated levels of PSA can be associated with a number of reasons. These include infection, prostatic enlargement but most concerning of them all, prostate cancer.
In the past, to exclude prostate cancer in patients with raised PSA, the patient would be subjected to a systematic or random biopsy of the prostate. This involves 12 biopsies taken from the prostate in a random manner. As such, it is possible to miss a cancer, and in the event that the biopsy was negative for cancer, the patient would have to undergo another random biopsy if the PSA was still elevated.
In recent years, we have discovered that MRI of the prostate can offer valuable insights as to whether an elevated PSA is due to cancer. As such, using MRI and fusion with ultrasound, we can now do targeted biopsies of the prostate. This allows for a quantum leap in accuracy of the biopsies and reduces the need to repeat them. This also lowers the risk of infection with repeated biopsies. Targeted biopsy of the prostate can be carried out under sedation or local anaesthesia and patients usually can be discharged on the same day.
TRANSPERINEAL OR TRANSRECTAL BIOPSY OF THE PROSTATE
As the prostate lies just in front of the rectum, traditionally, prostate biopsies have been performed by passing the biopsy needles through the rectum into the prostate. This is known as a Transrectal Prostate Biopsy. Unfortunately, the rectum is full of bacteria and studies have reported that the risk of severe infection (sepsis) after prostate biopsies can range between 2 to 10%! To mitigate the risks of infection, doctors have tried various measures including giving stronger or multiple antibiotics, or tailoring the antibiotics based on the bacteria grown from a swab of the rectum. However, all these techniques have not managed to eliminate the risk of sepsis, and antibiotics themselves can lead to complications including diarrhoea and other digestive issues, allergic reactions and promoting antibiotic resistance.
An alternative approach is the Transperineal Biopsy. In this biopsy technique, the biopsy needle is passed through the skin behind the testicles (known as the perineum), and do not pass through the rectum. As skin can be easily cleansed compared to the rectum, the risk of sepsis after a Transperineal Prostate Biopsy is near zero, with data showing a risk of sepsis of less than 0.1%. In fact, in Europe, it is the recommended technique for prostate biopsy (as per the European Association of Urology practice guidelines) ahead of the traditional biopsy through the rectum. Dr Tan Teck Wei, consultant urologist at Urohealth Medical Clinic, introduced Transperineal Biopsy under local anaesthesia in the region. With good local anaesthesia nerve blocks (and sometimes with light sedation), the entire biopsy can be done in the clinic, usually through two tiny punctures in the skin of the perineum.
WHY DO IT WITH US?
Dr Tan Yung Khan established the MRI Targeted Fusion Biopsies of the Prostate using the UroNav platform in Asia. In his published series, he has shown that in his hands, there has been a significant improvement in the detection of clinically significant prostate cancer. Dr Tan Yung Khan has also gone on to set up the Asia Pacific Centre of Excellence for UroNav guided targeted biopsies and has given talks and run masterclasses for urologists in the region on the use of this system.
Dr Tan Teck Wei established the Transperineal Prostate Biopsy technique in Southeast Asia and published a paper on Transperineal Prostate Biopsy under local anaesthesia in a clinic setting. In his series, there have been no cases of urinary infection or sepsis after this biopsy. The technique is safe, effective, and well tolerated.
TREATMENTS FOR PROSTATE CANCER
Treatment will depend on the aggressiveness and stage of cancer.
In low grade early prostate cancer, active surveillance is usually an option due to the low risk of cancer growth and spread. However, patients are required to visit their urologists regularly for blood tests, rectal examinations and periodic repeat MRI scans and prostate biopsies. All these measures allow their urologist to detect changes in the cancer and recommend treatment if and when appropriate. For patients unwilling to undergo active surveillance, alternatives include surgery or radiation therapy.
For higher grade cancers localized within the prostate, the standard treatments are surgery or radiation therapy (which uses high-dose x-rays or other particles to kill cancer cells).
Surgery involves removing the prostate and the surrounding tissues completely. The gold standard surgical option nowadays is:
- ROBOTIC RADICAL PROSTATECTOMY
- The world renowned Da Vinci Surgical System is the robotic system that surgeons use to robotically remove the prostate. It is less traumatic and minimally invasive. The Da Vinci Robotic Prostatectomy improves the surgeon’s visualization, dexterity and precision compared with open or laparoscopic surgery while enabling the entire operation to be done through six small incisions around 1cm in size.
- Two of the main long-term side effects of surgery are erectile dysfunction (inability to achieve or sustain erections for sexual intercourse) and urinary incontinence (involuntary leakage of urine, requiring patients to wear pads or diapers).
- Nerve-Sparing Robotic Radical Prostatectomy: The nerves that help control erections lie closely on each side of the prostate. Patients who are sexually active, and who do not have extensive or aggressive prostate cancer, are suitable for Nerve-Sparing Robotic Radical Prostatectomy. With the improved visualization and precision of the robot, these nerves can be meticulously freed away from the prostate during the surgery. With nerve-sparing prostatectomy, up to 50-75% of patients may be able to achieve erections sufficient for sexual intercourse after surgery.
- Retzius-Sparing Robotic Radical Prostatectomy: This is a technically challenging modification of the conventional Robotic Radical Prostatectomy, but has been proven to improve early return of urinary continence after surgery. The space of Retzius is an area behind the pubic bone and in front of the bladder and prostate. This area contains the strong ligaments and structures that anchor and support the prostate and bladder, which are crucial in the maintenance of continence in men. In conventional Robotic Radical Prostatectomy, the space of Retzius is opened up and these ligaments and structures are cut in order to gain access to remove the prostate. In Retzius-Sparing Robotic Radical Prostatectomy, the prostate is approached from behind through a small incision in the peritoneal lining between the bladder and colon. The space of Retzius is undisturbed during the surgery. Dr Tan Teck Wei is one of a handful of surgeons in Asia who can offer this surgical technique to appropriate patients.
- FOCAL THERAPY
Focal therapy for prostate cancer involves treating a specific part of the prostate with cancer while preserving the rest of it. It is for small prostate cancer tumors that are localized, which means in one area of the prostate only. This is an option for patients with lower risk and localized prostate cancer. Focal therapy allows patients to mitigate side effects of more radical treatments.