• How reliable is the PSA test?
• If cancer is diagnosed, should I have radiotherapy, brachytherapy, surgery or Active surveillance?
• What is Active Surveillance?
• Why are certain patients ineligible for brachytherapy?
• What are the commonest side-effects of radiotherapy?
• Consultants ordinarily recommend a biopsy, or even more than one, to see what degree of cancer may be present if the PSA level is raised above the norm (greater than 4 ng/mL). I am told this can be very painful and unpleasant. Is this true, and why is it necessary?
• And again, consultants sometimes want you to have a bone scan, CT scan or MRI before they will deliberate on the best course of treatment. Why is this?
• So, if I go for surgery, is the operation painful?
• Is there much loss of blood?
• Do I need to have some of my own blood taken beforehand?
• While on the subject of blood, I have heard that you see traces of blood in the urine after the operation. Is this true and why is it?
• Is there any risk that I will die during or shortly after the operation?
• What about unsightly scars as a result of the operation?
• How long will I be in hospital?
• When will I know if the surgeon has successfully excised the cancer?
• Will the PSA have dropped out of sight after the operation?
• How many years do I have to have these tests?
• Are there any special things I need to remember when I am in hospital?
• Is it true that my penis will be shorter after the operation?
• I have heard that after the operation my scrotum and possibly my penis will be very badly swollen and look severely bruised. What will they have done to them and why is this?
• Do I need any special nursing care when I first go home?
• Is it painful to have the catheter removed?
• Will I feel tired and washed out after the operation?
• How long should I be off work?
• Can I exercise after the operation?
• Will I lose my continence control?
• Is sexual dysfunction a problem?
• Are there things I can do to help me get back my erections?
• How will my partner be affected?
• Should I tell my family and friends I have, or have had, a cancer?
• Will the cancer come back?
• Was there anything I could have done to prevent the cancer in the first place?
• And what about the future in terms of treatments?

If cancer is diagnosed, should I have radiotherapy, brachytherapy, surgery, or active surveillance?

There is no right and wrong answer in the treatment of early prostate cancer and treatment approaches can vary with many different factors. The options can be between active surveillance, radical radiotherapy with either external beam treatment or brachytherapy or radical prostatectomy. The treatment choices that you are offered will depend on some factors related to the tumour itself. These include the stage of the prostate cancer (how much cancer can be seen and felt in the prostate), the grade (the level of aggressiveness of the biopsies) and the level of presenting PSA. Some men have other medical conditions that may make certain treatments more difficult or more likely to cause certain side effects and this will also need to be considered. When there is a choice between several treatment options, it is important that you are able to discuss these therapies with all the relevant doctors and nurses and make a decision as to which treatment best suits your individual needs and circumstances. The choice can sometimes be influenced by where you live and the how the different side effects of treatment may affect you individually.

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Why are certain patients ineligible for brachytherapy?

Low dose rate (LDR) permanent seed brachytherapy can also be an effective alternative in some men with early prostate cancer. It involves ‘radioactive seeds’ being implanted in the prostate under anaesthetic. The seeds are left in the prostate permanently where they slowly lose their radioactivity and treat the prostate cancer over several months. This type of brachytherapy is most suitable for men with early localised prostate cancers that are growing slowly (Gleason grade 6) It is not usually suitable for men with high grade or more extensive tumours. There needs to be a careful assessment of prostate size before treatment as men with large prostates can have an increased risk of urinary side effects with this treatment and this can be another reason why some men are not suitable for seed brachytherapy. If TURP has been performed previously, the radioactive seeds cannot be sited correctly in the gland.  Pre-treatment with prostate-shrinking drugs such as LHRH analogues can sometimes make brachytherapy suitable for men with large glands.

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What are the commonest side-effects of radiotherapy?

Most men experience some side-effects during radiotherapy but the severity varies from person to person. Side effects can occur during treatment (acute) and are usually temporary or later after the treatment has finished and these can be permanent. You should however be able to continue normal activities during the radiotherapy
Acute or Short Term side effects are temporary and usually occur in the last three or four weeks of treatment and start to get better a few weeks after the treatment is over. You will be given advice about diet and skin care before the treatment starts. Your doctor will prescribe creams and medicines if you need help with any of these problems. The common temporary side effects are tiredness, frequency and stinging when passing urine, diarrhoea and soreness in the rectum. There can be occasionally be some bleeding or mucous (slime) form the rectum. There may be some darkening and soreness of the skin in the area being treated especially between the legs and around the anus. Other side-effects can occur many months after the radiotherapy has finished and these can be permanent. These include loss of erections, long term change in bowel habit with diarrhoea or urgency to have the bowels open and occasionally some bleeding from the rectum.

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Consultants ordinarily recommend a biopsy, or even more than one, to see what degree of cancer may be present if the PSA level is raised above the norm (greater than 4 ng/ml).  I am told this can be very painful and unpleasant.  Is this true, and why is it necessary?

Biopsies are not exactly thrilling or agreeable to experience; they can be very uncomfortable or, at worst, rather painful. They can also cause rectal bleeding and blood in the ejaculate, but this has been likened to having a nosebleed, and it will stop.  Nowadays, doctors taking biopsies from the prostate, via the rectum, will often use a local anaesthetic. You will also be treated with antibiotics to help prevent any associated infections

The biopsy results give very important information about the extent of the cancer within the prostate and also the level of aggressiveness. The pathologist will give any cancer cells a grade called the Gleason Grade. Prostate cancers range from slow growing tumours which are unlikely to spread and cause any problems to fast growing tumours which can spread quickly. The Gleason Grade is a scoring system between 6 and 10. The higher the score, the more aggressive the cancer is thought to be, These results in combination with the stage of the cancer and the original PSA will be important in deciding the best treatment option.

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And again, consultants sometimes want you to have a bone scan, CT scan or MRI scan before they will deliberate on the best course of treatment.  Why is this?

These tests will show if the cancer has spread outside the prostate and again are very important in deciding the best treatment options. It is common to have a CT or MRI scan which will give information about whether the cancer has spread outside the prostate to the immediate surrounding areas or to the local lymph nodes. A bone scan may also be arranged to see if any cancer cells have escaped and spread to the bones. These scans along with the information from feeling the prostate at DRE will enable the doctors to stage the cancer. There are basically three different stages with different treatment options.

Localised or early prostate cancer is when the tumour is contained within the prostate gland and has not spread to any other parts of the body. These early tumours can usually be treated with surgery, radiotherapy or sometimes active surveillance (see above). The stage of the tumour will be considered in combination with the Gleason Grade (above) determined from the biopsies and the PSA results. Some men have normal scans but a high Gleason Grade or PSA and this can be an indicator that there could be a risk of tiny microscopic prostate cells that have spread to other places in the body that are too small to be seen on a scan. In this situation it is common to offer both local treatment, (usually with radiotherapy) and also hormone therapy which has been shown to help prevent or delay the cancer developing in other places in the body

Locally Advance prostate cancer is when the cancer is seen or felt to have spread just outside the capsule of the prostate into the immediate surrounding tissues or local lymph nodes within the pelvis.
Men with locally advanced prostate cancer have a higher risk that microscopic cancer cells may have already spread (as above). In this situation treatment is usually with radiotherapy to include the surrounding structures (as well as the prostate) in combination with hormone therapy as this can delay or prevent the cancer coming back in other places and is given by tablets or injections. Some men with locally advanced prostate cancer are treated with hormone therapy alone. The choice depends on factors that you will discuss with your doctor.

Advanced or Metastatic prostate cancer is diagnosed when the scans show that the cancer has spread to distant sites usually the bones. This is usually treated with hormone injections initially but there are many other therapies that can be added later if necessary to keep the cancer under control.

So staging scans as well as biopsies are vitally important for making treatment decisions

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So, if I go for surgery, is the operation painful?

Not really, because any pain is expertly controlled.  This can be achieved, for example, through the use of epidural anaesthetics and of drugs given to you post operatively. The side effects of the surgery and what to expect afterwards will be discussed with you before the operation .

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Is there much loss of blood?

No, not normally.  Only a small proportion (about 10%) of patients undergoing radical prostatectomy nowadays require a blood transfusion, possibly about two pints — not a particularly significant quantity.

The new approaches of removing the prostate with either keyhole (laparoscopic) surgery or robotic assisted keyhole surgery have been shown to reduce blood loss even further

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Do I need to have some of my own blood taken beforehand?

No, unless it will buy you peace of mind, but if there are no exceptional circumstances there is no need.  Use of your own (autologous) blood is more common in the USA, where there is possibly a higher risk of infection from regular blood transfusion.  It is not advised in the UK.

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While on the subject of blood, I have heard that you see traces of blood in the urine after the operation.  Is this true and why is it?

It is true, but normally it is only a trace, and just while the catheter is draining urine immediately after the operation, or perhaps for a while longer while the re-routed ‘plumbing’ inside is healing.  It normally clears after a week or two at most.  Drinking extra fluids is helpful, as is taking laxatives, whole wheat cereal, prune juice and fruit to keep the bowels regular.

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Is there any risk that I will die during or shortly after the operation?

There is always such a risk with any operation (around 1 in 1000), but we do not often hear of it happening.  Do not be afraid to ask your surgeon what his own mortality rate is.

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What about unsightly scars as a result of the operation?

This need be the least of your concerns.  To gain access to the prostate, many surgeons perform an 8—10 cm lateral or vertical incision above the pubic bone, with a small drain hole beside it.  Clips are more commonly used than stitches these days, and the healing process is quick.  Indeed after a few months the scar is almost, but not quite, invisible.  New recent developments include Laparoscopic (keyhole)  and Robotic (robot assisted keyhole) radical prostatectomy.
These techniques involve making 4 to 6 very small cuts and the surgeon removes the prostate using tiny instruments within small telescopes.
The surgeon views the operation on a television screen. This has the advantage of reducing blood loss and shortening the recovery time after the operation. The very latest development is the use of a robot to assist keyhole surgery. This involves the surgeon conducting the surgery via a robot. The surgeon sits at a console and his/her movements are replicated by the robot with extreme precision beyond the capabilities of the human hand. This again allows reduced blood loss and better preservation of the tiny nerve bundles that are important for achieving erections. This new technique looks set to increase in the future.

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How long will I be in hospital?

Between 4 and 7 days, often including a 12—24-hour period in a progressive care ward where you will be monitored for bleeding, signs of respiratory infection, or any heart rate instability.  About a fortnight after the operation, your catheter will be removed and you will be watched closely for 24 hours to make sure the new ‘plumbing’ is in order (for example, your fluid intake will be checked against your urine output). The newer keyhole operations have the advantage of a shorter recovery time and a reduced stay in hospital.

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When will I know if the surgeon has successfully excised the cancer?

He will tell you what he thinks within 24 hours, but he has to wait for a few days for the laboratory report on the removed prostate to be sure what has been achieved.  If the report is such that some cells are thought to have escaped from the prostate into the surrounding tissue, then the surgeon may recommend some ‘mop-up’ radiation, which is usually very successful.  The radiation therapy does not have that much to do compared with clearing the whole prostate of cancer (as is necessary if surgery is not performed).  Side-effects are not usually too troublesome, although some rectal irritation and minor bleeding may occur.

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Will the PSA have dropped out of sight after the operation?

Yes, it should have dropped to about 0.6 ng/ml or thereabouts immediately after the operation, and then gradually reduce further to an ideal of below 0.1 ng/ml where, in successful cases, it will remain for the rest of your life.  But remember to have it checked every 3 months for at least a year, and at the same laboratory too, otherwise you may get a variation in results that could alarm you.  In other words, one laboratory may have machines that only read as low as 0.5 whereas another might read down to 0.1, or even 0.01.  In essence the result, as far as you are concerned, is the same. If the PSA begins to increase months or years after the surgery you may need some mop up radiotherapy at that stage and your surgeon and oncologist will advise you about this.

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How many years do I have to have these tests?

You will need to have PSA tests for many years but these will be less and less as time goes on. It is important to note that after surgery we aim for the PSA to be less than 0.1ng/ml to 0.2ng/ml  but after radiotherapy the PSA levels will be higher due to the fact that the normal prostate tissue can secrete small amounts of PSA. The current definition of good response to radiotherapy is a PSA that remains below 2 to 3. Also if hormone treatments are given in combination with the radiotherapy, the PSA will increase a little after the hormones are stopped as the normal prostate tissue recovers from the therapy.

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Are there any special things I need to remember when I am in hospital?

Yes.  Don’t encourage too many visitors; don’t worry about breaking wind (nurses love wind because it shows things are beginning to sort themselves out in the bowel, which will have been a bit disturbed during the operation): don’t eat too heavy a diet because you don’t want to get constipated through lack of exercise and too many heavy meals: drink as much as you can — at least 8 pints of water or soft drinks, like cranberry juice, every day for a couple of weeks if you can stand that (it helps to flush the system through after your internal plumbing has been re-routed); and, most importantly, just look forward to the new future that the surgeon will have given you.

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Is it true that my penis will be shorter after the operation?

Well, yes, some men have noticed a detectable change in length, but not circumference, when the penis is at rest once everything has settled down.  But it’s somewhat relative.  It rather depends upon how well endowed (as the expression goes) you were to begin with.  If there is a noticeable difference, it is very slight.  It is because the newly organized and re-routed urethra has been necessarily shortened and therefore had the effect of ‘pulling back’ the penis into the body just a little.  After a few months, the urethra will stretch to accommodate most of the change.  On erection, the difference is usually of little or no consequence.

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I have heard that after the operation my scrotum and possibly my penis will be very badly swollen and look severely bruised.  What will they have done to them and why is this?

This is seldom mentioned before the operation because it is of no long-term significance, but yes, there can be some rather alarming-looking swelling — more often associated with the scrotum, which can occasionally swell to the size of a small orange — but it subsides quite quickly, doesn’t hurt, and is neither damaging nor even particularly inconvenient or uncomfortable.  The penis can appear a bit bruised also, and this has to do with inevitable disturbance (during the operation) of the blood vessels and nerve endings serving the scrotum.  But it really is a very short-term problem and is soon history.

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Do I need any special nursing care when I first go home?

Not normally, though you may need some help getting up from deep armchairs, or getting into and out of bed during the first few days at home.  And it is advisable to wear loose clothes like tracksuit bottoms because your lower tummy will be a bit swollen, and getting zips done up can be a problem for a while.  Also you need a spare urine collection leg bag, which the hospital can give you, or you can buy them easily from chemists.  You need to keep yourself scrupulously clean to reduce the risks of any infection while the catheter is still in place.

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Is it painful to have the catheter removed?

Not normally, because catheters are much slimmer these days.  Usually it only takes a moment and it’s gone, but they can occasionally get a little stuck because of a tight fit — which in fact is a good thing in some respects.  If this does happen, a doctor will help with the removal, and frankly that can be somewhat eye-watering in effect unless they give you a sedative at the time.  But a modern catheter getting severely stuck is unusual, and you would have to be unlucky to experience it.

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Will I feel tired and washed out after the operation?

Yes, you will, and this is a normal protective mechanism to allow healing.  Some men feel a tremendous loss of energy, and have days when they think they will never regain their original verve, but gradually the energy level returns and the post-operative tiredness and lassitude are soon forgotten.

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How long should I be off work?

Between 6 and 8 weeks is recommended, although reading, telephone calls, and stress-free activity are all fine.  Every single patient with whom we have spoken who has returned to work a bit early has really regretted it, and his recovery has taken longer.  Remember, nobody is indispensable, and it will probably do your colleagues the world of good to shoulder some of your responsibilities while you are away!  Even if you are retired, take it easy, and handle one day at a time.  You can’t really drive comfortably for a month, anyway, so get somebody to drive you!

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Can I exercise after the operation?

Yes, but listen to your body: it will tell you how much is sensible and when to rest.  But avoid heavy lifting, such as weight training.

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Will I lose my continence control?

Not unless you are very unlucky.  Most patients now recover control almost as soon as the catheter is taken away, but it is true that for some it can take a few hours, a few days, a few weeks, and even a few months, and you might need to wear some padding for a while if leakage is a bit of a problem.  As explained earlier, many surgeons ask you to stay in hospital overnight after the removal of the catheter, measuring fluid intake and outflow to see that the plumbing is working as it should and that there are no internal leaks.  To some extent, regaining continence control depends upon individual muscle tone (and you will be taught exercises to strengthen the pelvic muscles), the skill of the surgeon who will have done all he can to spare the nerves that affect continence, and a certain amount of incalculable individual luck.  The good news is that things almost always dry up sooner rather than later, and you should have a urine stream like when you were a teenager.  If the urinary stream does deteriorate, alert your urologist.  You may be developing a bladder neck contracture, which requires gentle stretching under light anaesthetic.

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Is sexual dysfunction a problem?

Yes, for nearly everyone, whatever they claim.  However, some ability and sensation, albeit with a dry orgasm (because the seminal vesicles have been removed as part of the operation) can return after a few months, or sooner for a few lucky ones.  Normal penetrative sex is a problem because however careful the surgeon was to avoid damaging the nerves during the operation, achieving a sustainable firm erection is more difficult for most patients, although some men say they can manage reasonably satisfactorily.  Having a successful radical prostatectomy is unquestionably a trade-off because if the alternative is to die of prostate cancer, then it has to be remembered that so far as we know there is not a great deal of sex in the graveyard. (Although a local vicar, who incidentally has undergone a radical prostatectomy, told us that there is rather too much in his!) Sexual dysfunction is also quite common after radiotherapy.

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Are there things I can do to help me get back my erections?

Yes, there are silicone implants (for those who wish to afford them privately), and these work rather like a bendy toy, in the sense that you bend it up when you want that, and down when you don’t.  It has to be said, however, that some men have complained that when swimming or playing sports, they can occasionally appear to have a half erection in place, which can be understandably embarrassing.  Inflatable penile prostheses produce a more life-like result, but are considerably more expensive and also prone to malfunction.

There are penile injections of prostaglandin which are uncomfortable but not too painful, and provide an almost immediate erection which lasts well, but some men instinctively find it difficult to give themselves such injections.

Vacuum pumps can also help.  After an erection has been achieved, it is held in place by a rubber ring slipped over the base of the penis.  Although effective, some find such a device scarcely conducive to spontaneity.

Penile suppositories of prostaglandin (known as MUSE) are available, but are quite expensive.  They do work, though, and are favoured by some patients.

And now, of course, there are Viagra (sildenafil).  Some surgeons are suggesting this be tried about 3—4 months after the operation.  But it does not seem to work so well until some 6—9 months or so have passed.  And then for those with no contraindicated medical history, such as angina or a recent heart attack, sildenafil can be very effective, especially at the higher doses.  If the drug is used with common sense, many patients have reported results little short of amazing, with very few side-effects of consequence.  Perhaps a little face flushing or a headache, but after about an hour, sex is possible with a good erection, providing there is physical stimulus.  It does not work as the other methods do.  It needs sexual stimulus, and then it can often provide repeated satisfaction over a period of some 12 hours.  The tablets should not be taken more than once in a 24-hour period, and you should never mix Viagra with nitrates (used to treat angina).  Amyl nitrite, also known as ‘poppers’, is popular with the gay community, but this should never be used along with Viagra.  Such a practice could prove highly dangerous. Viagra works by relaxing the blood vessels in the penis so allowing the blood to flow there more freely.  It is a drug that can now be prescribed on the NHS for prostate cancer sufferers or diabetic men. Do not buy Viagra through the internet.

Other drugs such as Uprima (apomorphine) can be helpful.  Successors to Viagra, known as Cialis (tadalafil) and vardenafil, may act more quickly and stay effective for longer.

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How will my partner be affected?

Nobody can ‘catch’ prostate cancer from you, but your partner will certainly be affected if impotence is the result.  Frank discussion is vital before and after the operation, particularly if you go for a radical prostatectomy, and the partner must understand the implications along with you.

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Should I tell my family and friends I have, or have had, a cancer?

It’s up to you of course, but why should there be a need for secrecy and shame, and why not become an advocate for regular check-ups and possibly save a life in the process?  This is particularly true if you have sons or brothers who have yet to reach their 40s and 50s when a check-up would be wise, unless by then medical science has beaten this disease completely.

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Will the cancer come back?

Well, yes, this has been known, with any of the treatments. The doctors will determine the risks of your individual case and do everything to try and prevent any recurrence of the cancer as early as possible. This can sometimes mean that you will need a course mop up radiotherapy after surgery. This can be given as a planned procedure after the operation if the surgeon and pathologist feel there is some cancer left behind in the bed of the prostate. Sometimes a small rise in PSA months or years after the surgery can be an early warning sign that the cancer could be active again and radiotherapy can also be given successfully at this stage. If there is a risk that there could be tiny microscopic tumour cells in other parts of the body, your doctor may advise a period of preventative hormone therapy with either tablets or injections as this has been shown to prevent or significantly delay any cancer recurrence.   If the cancer does come back there are many other effective treatments including different hormone drugs that can be used in sequence. Chemotherapy has recently been shown to be effective in prostate cancer if and when some of the cancer cells stop responding to hormone therapy. There are also many new and very promising new drugs that are being developed and are currently being tried out in clinical studies.

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Was there anything I could have done to prevent the cancer in the first place?

Not really, because nobody knows for certain why anyone is affected by it.  There are plenty of theories.  Some say it is all to do with diet (ranging from eating too much red meat, to eating a lot of ice cream); others believe it is a genetic disease (and there is much research going on in that direction); yet others say it is connected with a multifarious and largely unidentifiable mix of factors, including having had a vasectomy.  Nobody has a monopoly of wisdom on the subject.  The latest research has found that men who carry a damaged version of a mutant gene are four to five times more likely to suffer from prostate cancer than those who do not have this faulty gene.  It’s a case of ‘watch this space’.

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And what about the future in terms of treatments?

There is much research going on that may one day find a solution for prostate cancer, through a vaccine, gene therapy or a more certain cure without losing the gland, but we are presently years away from this happy circumstance.  And, inevitably, more research money is needed.

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