12. Organ confined prostate cancer; benign prostate hyperplasia diagnosis

Question 1

Organ confined prostate cancer treatment

Answer 1

• Radical prostatectomy: Removal of prostate, seminal vesicles, regional lymph nodes, and the urethra is anastomized to the bladder neck.

There are 4 main
approaches:
o Retropubic: Surgeon makes a cut starting just below the umbilicus reaching the pubic bone.

o Perineal: The cut is smaller and the operation time is shorter, but it is harder to preserve nerves around the prostate and to remove nearby lymph nodes

o Laparascopic. However, open surgery is still preferred

o Robotic

External beam radiotherapy is an option. Typically delivers 65-75Gy to the prostate for
6-7weeks.
NB: A lot of prostate cancers are slow-growing and present at a late stage of life, an
several factors has to be taken into consideration before choosing surgery:
• If patient is older than 75 years and has a low stage, low grade cancer, the
likelihood of him dying from the disease is small
• Active surveillance may be optimal in these cases
• If the cancer seems to be aggressive, surgery is the solution

Note that TURP is NOT used for prostatic cancer, only for symptomatic BPH.

Question 2

Complications after prostate resection.

Answer 2

Complications:
o Incontinence

o Impotence due to damage of the prostatic nervous plexus and pudendal nerve

o Improvement of complications are expected after 1 year

Question 3

Benign prostatic hyperplasia, diagnosis

Answer 3

Patient history, checking for other possible causes of the urinary symptoms.

• Past urological disease or operation
• Past non-urological operation
• Neurologic or psychiatric diseases
• DM

Symptoms can be assessed using the international prostate symptoms score and the BPH impact index:

• International prostate symptoms score: 7 questions for the patient to quantify his symptoms
• BPH impact index: Quantify how bothersome the symptoms are on a scale of 0-6, from happy to terrible.

Digital rectal examination:
• A bit harder than compared to a young man, but softer than cancer
• In case of inflammation it is tender
• Cancer is not painful and is rock hard

Measure prostate volume by US. Normal = 20ml. BPH > 30ml.
Measure urine flow by US.

Differential diagnosis: Bladder cancer, bladder stone, urethral stricture and medication.

Question 4

• International prostate symptoms score: 7 questions for the patient to quantify his symptoms

Answer 4

Incomplete emptying
Frequency
Intermittency of stream
Urgency
Weak stream
Straining
Nocturia