THE JOURNEY OF A PATIENT WITH PROSTATE CANCER

• Primary prevention
  There are no primary prevention programs that are actually effective. There is no confirmed link between prostate cancer and certain behavior or eating habits although some lifestyle appears to be more protective.
• Early diagnosis
  In the absence of primary prevention programs, which make it possible to decrease the chance of getting cancer, like there are for breast cancer, early diagnosis is the most important thing.
• How is early diagnosis made?
  After the age of 50, it is advisable to visit a urologist; the urologist will perform a digital rectal examination and evaluate the PSA. More recently, there has been the introduction of a new marker, PCA3, the usefulness of which is still being studied;
• Prostate biopsy and the diagnosis of prostate cancer
  If the PSA is elevated and / or there are doubts arising from the rectal examination, the urologist may ask for a prostate biopsy.
  A prostate biopsy consists in taking some samples of prostate tissue to analyze under the microscope and assess whether there are any cancer cells.
  If the biopsy confirms the presence of cancer cells in the prostate (diagnosis) the next step is to determine how widespread the cancer is in order to decide the most appropriate type of treatment (staging).
• Staging
  Through the analysis of the PSA, the rectal examination, and the Gleason score (which is shown on the biopsy report) it is possible to estimate the extent of the disease. Sometimes a CT scan and bone scintigraphy are carried out to gain a more complete picture. Once the staging has been completed, the urologist can evaluate the different therapeutic options including robotic surgery

ROBOTIC SURGERY

Robotic surgery is now the most widely used form of surgery for the treatment of prostate cancer; in the USA more than 85 percent of all radical prostatectomies are performed with a robotic technique and also in Italy the trend is clearly in favor of this approach.

Robot-assisted laparoscopic prostatectomy (RALP) is, by virtue of its results, replacing the radical retropubic prostatectomy (RRP) approach as a “gold standard” in the treatment of localized prostate cancer.

It is necessary to emphasize that the functional and oncological results do not only depend on the machine, and that the experience and skill of the doctor are the key factor.

In detail:

COMPLICATIONS

• Intra and perioperative blood loss and transfusion rates were significantly lower in the RALP compared to both laparoscopic and retropubic prostatectomies
• Lymphocele, perianastomotic urine leakage and reoperation represent the most common complications of RALP and are directly proportional to the experience of the surgeon and patient characteristics (BMI, large prostates with third lobe, previous abdominal or prostate surgery, PSA, and GS). The overall complication rate is still comparable to the complications of radical retropubic prostatectomy.

ONCOLOGY RESULTS

• The rate of positive surgical margins (PSMs) and biochemical recurrence (BCR) after robotic prostatectomy is comparable to the results of open prostatectomy
• With the robotic procedure extended lymphadenectomy is also feasible without significantly increasing the rate of complications; the RALP can therefore also be used in patients with carcinomas of the prostate at high risk

FUNCTIONAL RESULTS

• There is a significant advantage of the robotic approach compared to laparotomy and laparoscopy in terms of recovery of continence at 12 months after surgery.

Advanced age, BMI, large volume of prostate, co-morbidities, the presence of symptoms in the lower urinary tract and the surgeon’s experience are the main factors that impact the incidence of urinary incontinence after RALP.

• If applied, the posterior reconstruction techniques of the sphincter (with or without anterior reconstruction) provide a slight advantage also in terms of the rapidity of recovery of continence (1 month post-surgery).
• Also in terms of recovery of sexual potency, the RALP offers a significant advantage over traditional surgery at 1 year after surgery.

Age at surgery, pre-op sexual activity, and the characteristics of the nerve-sparing surgery are the main risk factors for the development of erectile dysfunction.

AFTER DISCHARGE

The discharge letter contains all the advice and the prescriptions to do with each case.

 

Antibiotic therapy

It is not usually necessary. In some cases however it is prescribed depending on clinical needs

 

Antithrombotic therapy:

– No strenuous physical activity can be carried out immediately after the operation which may lead to stagnation of blood in the veins especially in the legs (a little like on airplanes). To prevent the formation of clots it is good to adhere to the following rules:

– Do not stay in bed too long. Walk for 15 minutes every hour.

– Wear compression stockings for 15 days. Compressing the legs helps to prevent dilation of veins and the formation of blood clots.

– Doing injections of Clexane in the shoulder every day for 15 days. (in case an administration is forgotten it is best not to skip a dose but to perform the injection the next morning).

 

Diet:
The patient can eat any type of food, but it is preferable to eat foods that do not cause constipation.

Suggested foods:

• Whole grain bread and crackers
• Whole grain rice and pasta, vegetable puree, vegetable soups
• No restriction on meat, fish and eggs
• Cooked vegetables; carrots, green beans, zucchini, artichokes, spinach, cabbage, turnips. Fresh vegetables in general
• Vegetable fats, fresh butter
• Saturated fat
• Fresh fruits; pears, grapes, peaches, cherries, plums, figs. Cooked fruit
• Yogurt, jam, honey

 

The management of the urinary catheter:

A urinary catheter is a latex rubber tube whose tip is positioned in the bladder. The catheter remains secured to the bladder thanks to a balloon that is inflated with water (or air) that prevents it from sliding out.

The catheter, which is usually yellow or transparent, is yellow at one end and red (or orange) at the other.

The yellow end is for urine, which is usually connected to a collection bag.

The red end is connected to a balloon. It consists of a valve which enables the balloon to be inflated or deflated when the catheter needs to be removed from the bladder.

Unless doctors or nurses give specific instructions to do so the red end should not be manipulated.

Surgical wounds:

Small surgical wounds can be medicated by passing a sterile swab soaked in iodine solution or equivalent, and then can be covered with a new dressing. There are no stitches to remove.

After the removal of the urinary catheter:

• Urinary Continence
  On removing the urinary catheter, it is normal to observe some involuntary leakage of urine. A bit like a faucet that is difficult to turn off.

  It is temporary in 97% of cases.

  At first it is better to wear adult diapers that avoid leakage to clothing.

  After 3 months, approximately 60% of patients are continent and after 6 months approximately 90% of patients are continent.

  The technique known as the Rocco stitch has helped to reduce the time to recovery of urinary continence.

  The recovery of continence can be accelerated with targeted physiotherapy exercises.

  In the event of definitive incontinence (3% of cases), small corrective operations, which have high success rates, may be performed.

• Sexual activity
  The resumption of sexual activity is linked to many factors. In patients in whom the nerves fibers for erection are spared the probability of recovery may be more than 70% in patients who are under 65 with normal preoperative erectile function.

  It is useful to define some of the components that are involved in sexual activity in order to understand how the operation might influence them.

  The libido: sexual desire. The patient who undergoes robotic prostatectomy surgery retains his libido. It is possible that temporary postoperative incontinence and discomfort related to the surgery may cause a temporary attenuation of the libido which is, in general, maintained.

  The erection: the ability to achieve and maintain the hardening of the penis in order to obtain penetration. Robotic prostatectomy surgery may cause lesions of the nerves that are responsible for erections. Therefore, despite sexual arousal the penis may remain partially of completely flaccid.
  The robotic approach may damage the erection to a lesser extent than the traditional approach as the nerves that are responsible for erection can be delicately moved aside from the prostate and therefore not damaged.

  The time needed to regain erectile function varies widely and is related to many factors. The possibility of regaining erectile function usually occurs within 18 months after surgery.

  The orgasm: the feeling of pleasure resulting from sexual stimulation: in spite of the possible lack of erection an organism can still be achieved as a result of sexual stimulation

  The ejaculation: ejaculation, i.e. the ejection of seminal fluid during orgasm no longer occurs. This is because the production of part of this fluid is made by the prostate that has been removed and because the seminal ducts are transected during the surgery.