SURGICAL PROCEDURES

PROSTATE FOCAL THERAPY

For many men with newly diagnosed prostate cancer focal therapy is now an option. Focal therapy is suitable for men with disease confined to one area of the prostate rather than larger more widespread tumours.  Focal therapy has become possible due to improved imaging and localisation of disease with target and mapping prostate biopsies.

 

WHAT IS THE AIM OF FOCAL THERAPY?

The aim of focal therapy is to destroy areas of cancer and preserve normal areas to reduce side effects. Typically focal therapies are given as day case procedures, require brief periods of post operative urethral catheterisation and cause sexual and urinary side effects less frequently and less severely than conventional whole gland therapies. Mr Dudderidge is one of the UK’s leaders in focal therapy. He is a member of the UK Focal Users Group and recruits to the INDEX Lite study and FORECAST study evaluating focal therapies.

For more information, visit the Focal Therapy User Group.

 

WHAT IS FOCAL HIFU?

High-intensity focused ultrasound (HIFU) uses the energy of focused sound waves to generate heat within tissues and kill cancer cells within treated tissues. HIFU is planned based upon multi-parametric MRI scans and biopsy results. Typically half the prostate is treated.  Patients are usually treated as day cases and they keep a catheter in for 1 week. Sexual and urinary side effects are usually mild and serious risk are very low.

 

 WHAT ARE THE RESULTS OF HIFU?

Results of focal HIFU have only 5 year outcomes reported which is too short term to give representative figures. Furthermore its difficult to compare the results in this study to the results of surgery or radiotherapy as the case is is likely to be different and follow up much longer. The early report from the UK Focal Users group presented 5 year outcomes on 625 cases, 81% of which were intermediate risk disease. After treatment 98% were pad free meaning very little incontinence. 86% maintained their erections. 2 patients experienced a fistula (damage to the rectum causing a leak of urine into the rectum) one of which healed spontaneously with a catheter, the other required surgery to repair the damage. 20% of men required pretreatment with HIFU. 7% required surgery or radiotherapy and 1% required hormones for metastases. There were no cancer related deaths.

In summary the study shows that in suitable patients, HIFU is a safe, low risk treatment which is repeatable and keeps the door open for further therapy if its needed.

WHAT IS FOCAL CRYOABLATION?

Focal cryoablation uses fine cryotherapy needles which allow the passage of compressed gasses to generate cold (argon) or heat (helium). The temperatures within the ice ball get down to at least -40 degrees C and the repeated freeze-thaw cycle kills cancer cells in the frozen areas. This technique is particularly good for anterior prostate cancers or in prostates where HIFU is unsuitable e.g. large glands or those with excessive calcifications. It can be used as a primary therapy or in men previously treated with radiotherapy. Focal cryoablation causes fewer side effects than whole gland therapy.

 

WHAT ARE THE RESULTS OF CRYOABLATION?

Results from focal cryotherapy have been assessed in a systematic review of published studies. In total 9 studies of primary focal cryotherapy were identified and these showed that between 71 and 93% of patients were free of cancer based upon their PSA at follow-ups ranging from 9 to 70 months. This suggests equivalent success rates to whole gland treatments in the short to medium term.  The results from the primary focal cryotherapy studies also show relatively low rates of side-effects. Incontinence ranged from 0 to 3.6%, while ED occurred in 0–42%. Other side-effects such as haematuria, strictures and rectal fistulae were very uncommon.

ROBOTIC PROSTATECTOMY

This procedure involves the removal of the prostate and seminal vesicles and is directed at curing prostate cancer. In men at higher risk a pelvic lymph node removal is also carried out. Once the prostate is removed the bladder neck and urethra are joined together with stitches and a catheter is placed to help drain the bladder while the joined up “anastomosis” heals up.  The catheter is usually left in place for 7 days, but this may vary slightly.

WHAT ARE THE RISKS?

The main risks specific to this operation are incontinence and erectile dysfunction. These occur due to the proximity of surgery to the urethral sphincter and the nerves and blood vessels that run next to the prostate that support erections. Where possible we help preserve these structures (i.e. nerve sparing, bladder neck and fascial reconstruction) and this allows early functional recovery.

CYSTOSCOPY

A cystoscopy is a telescopic camera  inspection of the bladder. Most patients will have a flexible cystoscopy as an outpatient test.  A small fibre-optic telescope is passed up the urethra (water pipe) following the instillation of a local anaesthetic gel. The instrument allows us to inspect the urethra and lining of the bladder and prostate (in men). This can all be viewed by both the patient and your surgeon on a television screen.

 

HOW DOES THE PROCEDURE WORK?

This procedure can also be done under a general anaesthetic although this requires you to fast beforehand, you would need somebody to take you home once fully awake several hours later and be unable to drive for at least 24 hours. This approach is usually taken when an additional procedure e.g. biopsy is required.

 

CRYOTHERAPY

Prostate cryotherapy is a form of prostate ablation which is used for both newly presenting cancers and those recurring after prior treatment e.g. radiotherapy. The procedure can be used to abate some or all of the prostate. The procedure is carried out under general anaesthesia and it is usually a day case operation.

 

HOW DOES THE PROCEDURE WORK?

Patients have needles passed into the prostate which create ice balls of tissue when gas is passed through fine channels intake needles. Ultrasound or sometime MRI is used to monitor the treatment and temperature probes also help to ensure safety and adequacy of the treatment.

If you would like to learn more about prostate cryotherapy, please visit:  https://www.europeanurology.com/article/S0302-2838(18)31036-4/fulltext

CIRCUMCISION

Male circumcision is the surgical removal of the foreskin, the retractable fold of skin covering the end of the penis. In adults, the procedure is usually performed because of phimosis, a narrowing of the foreskin which prevents it being retracted easily. This can affect urination and sexual function.

 

HOW DOES THE PROCEDURE WORK?

The procedure is fairly straightforward; cuts are made to the outside and inside of the foreskin and the scar tissue between the cuts is removed. The skin is then joined using dissolvable stitches.

Circumcision is usually only recommended when other less invasive treatments have been tried and haven’t worked.

 

ARE THERE ALTERNATIVE OPTIONS?

Where possible, Tim is always keen to promote non-surgical solutions for phimosis, such as the use of steroid creams or foreskin stretching.

Please feel free to ask about alternatives to circumcision, which may include less invasive procedures such as preputioplasty or frenuloplasty.