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Prostate cancer

Dec 20, 2019

Prostate cancer (prostate cancer) is one of the most pressing problems of modern oncology and a real epidemic of the aging male population. All over the world, the morbidity and mortality from this pathology is steadily increasing. According to the WHO expert assessment, about 400 thousand cases of this disease occur annually in the world. With the expected increase in life expectancy in men and the incidence of prostate cancer, the economic costs of treating this group of patients also significantly increase.  According to published data: in Russia in 2018, 42 thousand new cases of prostate cancer were detected, the share in the oncological morbidity of the male population was 14.9% and in terms of the incidence of prostate cancer was second only to lung cancer. The mortality rate from prostate cancer was 8.2% in the structure of mortality from cancer in the male population of Russia.- 4th place after lung, stomach and colon cancer. Over the past 10 years, the increase in morbidity was almost 100% and 30% in mortality, despite the development of methods for detecting and treating prostate cancer. 

Why does a man need a prostate? 

The prostate gland (prostate) is often called the "second heart of a man", because of the important role it plays in the male body. The prostate is a glandular-muscular organ located in men under the bladder.  The initial part of the urethra passes through the prostate. The prostate is a hormone-dependent organ that produces a secret that is part of the sperm and ensures the vital activity of spermatozoa. The contraction of the muscle fibers of the prostate provides the sensation of orgasm.  Being such an important organ for men, the prostate requires increased attention from a certain age. 

What should I do?

Prostate cancer is rare before the age of 40, but the risk of developing it increases greatly after the age of 50.  About 6 out of 10 new cases of prostate cancer will be detected at the age of 65 and older. The hereditary factor is also important.
If a relative of the 1st degree of kinship is ill with prostate cancer, the risk increases at least 2 times. If the disease is diagnosed in 2 relatives of the first degree of kinship or more, the risk increases by 5-11 times.
The detection of prostate cancer is based on the use of a diagnostic triad: a blood test for PSA, a finger rectal examination of the prostate and a multiparametric MRI.  Prostate cancer screening is primarily based on the determination of PSA. Currently, according to the recommendations of the European Association of Urologists (EAU Guidelines 2019), the determination of PSA is indicated for men over 50 years of age (or from 45 years of age with a burdened family history of prostate cancer). A risk-adapted strategy is used with repeated PSA determination every 2 years in patients with PSA levels >1 ng / ml in patients 40 years of age, or more than 2 ng / ml at the age of 60 years. In other cases, re-determination of the PSA is advisable after 8 years.  PSA screening in patients with a life expectancy of less than 15 years is not recommended.

What is PSA?
Prostate-specific antigen (PSA)- a substance of a protein nature, which is produced by the cells of the prostate gland, the determination of which is carried out in the blood serum, used for the diagnosis and monitoring of the course of prostate cancer and prostate adenoma.  Normally, a small amount of prostate-specific antigen enters the ejaculate and prostate secretions, and a very small amount enters the bloodstream. In prostate cancer, the level of PSA in the blood can significantly increase, which makes it a valuable tumor marker. In addition, PSA can increase with prostate adenoma, inflammatory diseases (prostatitis), after prostate massage and instrumental studies of the rectum (refrain from analysis for at least 2 days).  In addition, it is recommended to refrain from ejaculation for at least 48 hours before taking the test , which will exclude a false increase in PSA levels
 PSA is found in the blood in both free and bound forms. The lower the percentage of free PSA, the more likely it is that the increase in PSA levels is caused by a cancerous tumor.  When interpreting the results, it is advisable to take into account the norm for different age groups:

  • 40-49 years — 2.5 ng / ml
  • 50-59 years — 3.5 ng / ml
  • 60-69 years — 4.5 ng / ml
  • more than 70 years — 6.5 ng / ml

Since the early 1990s, in order to increase the sensitivity of screening programs and to refrain from useless biopsies, many new variants of PSA analysis have been introduced, which can be rationally used by doctors on an individual basis, but are not intended for mass screening of MS.   The most common and important is the determination of the free / total PSA ratio – which decreases below 15% in a patient with prostate cancer. The clinical significance of the determination of free PSA is only in the gray area of 4-10 ng / ml.  New tests are being continuously developed to improve the effectiveness of screening and limit the performance of" unnecessary " prostate biopsies. In 2012, the measurement of the prostate health index (PHI) was introduced into clinical practice: a combination of free and total PSA, [-2] pro-PSA isoforms [p2PSA]. The National General Cancer Network of the United States recommends the use of PHI in men with a level of total PSA in the "gray zone" with a negative first biopsy to make a decision about the need for a second biopsy, as well as to determine PHI after 6-12 months if the primary biopsy was not performed. PHI values above 35 are highly likely to indicate the presence of prostate cancer.
 
Multiparametric MRI.
In the framework of numerous clinical studies, it has been proved that transrectal ultrasound and other methods of ultrasound examination of TRUZI in the seroscale mode do not allow to determine the prostate cancer with sufficient reliability. Currently, the main imaging method for prostate cancer is multiparametric MRI, which includes the T2-gain mode in combination with at least one functional mode, including diffusion-weighted image, dynamic contrast, and/or H1-spectroscopy. The use of MRI allows 27% of men to avoid prostate biopsies, diagnose clinically significant prostate cancer 18% more often, and clinically insignificant 5% less.

Prostate biopsy. 
In the case of an increase in PSA, positive data obtained by performing a finger rectal examination and multiparametric MRI, the next mandatory stage of the examination is morphological confirmation of the intended diagnosis. A prostate biopsy can be performed by transrectal or perineal access.
There are systemic and targeted (targeted) prostate biopsies.  At the moment, a standard systemic prostate biopsy is usually performed transrectally under ultrasound control, with an automatic biopsy needle of 10-12 points from different areas of the prostate. Local anesthesia is performed by periprostatic infiltration.  If indicated, it is possible to perform a saturation biopsy of the prostate from more than 20 points. Targeted biopsy involves preliminary detection of pathological foci in the prostate, and then performing a biopsy directly from them.  In the urology department of the MCSC named after A. S. Loginov, a targeted prostate biopsy is performed under navigation assistance using histoscanning technology. HistoScanning® - computer analysis of reflected native ultrasound signals with the construction of a 3-dimensional image of the gland. The method provides on-screen visualization of suspicious areas and quantitative representation simultaneously in sagittal, axial, frontal and 3D projections, and provides navigation when performing a prostate biopsy. 
 In the future, a pathomorphological study of the obtained prostate tissue is performed for the early diagnosis of prostate cancer. Based on the data obtained, further treatment is planned.
Early diagnosis of prostate cancer is a priority area of work of the urology department of the MCSC named after A. S. Loginov, the doctors of the department have extensive experience in the primary detection of this disease and are always ready to help you. 

 

Treatment of prostate cancer. We will help you!

The main method of treatment of localized prostate cancer is radical prostatectomy, recommended by the European Association Urologists as the "gold standard" for patients with an estimated life expectancy of at least 10 years.  At the moment, the operation exists in 3 main variants: open, laparoscopic and robot-assisted (RARP).    Thanks to the research in the field of prostate anatomy, the accumulated experience of surgical intervention in this area, the improvement of anesthesiological techniques and postoperative management methods, the level of prostatectomy complications has significantly decreased over the past decades.  The situation changed with the advent of the Da Vinci robot complex. The first RARP was made in the USA in 2000. Since its appearance, RARP has become geometrically widespread. Despite the high cost, in 2013, more than 80% of radical prostatectomies in the United States were performed using the Da Vinci complex. An important stage associated with the introduction of RARP was the re-evaluation of the surgical technique of open prostatectomy, in order to minimize complications, improve oncological results of the operation and review approaches to the quality of life. Multiple magnification, 3D visualization, and a unique range of manipulator movements that allows you to operate in a limited space of the small pelvis provide an opportunity to successfully solve many problems that arise when performing radical prostatectomy. In addition to the oncological results of the operation, the assessment of postoperative urinary retention is of great importance for the quality of life. After all, it is the fear of constant urinary incontinence, it should be recognized, that can cause the patient to refuse the operation and choose another method of treatment. And it is difficult to imagine any other complication of prostatectomy that can further reduce the quality of life and patient satisfaction from the operation.  An important contribution of RARP was the "raising of the bar", which allowed us to define the retention of urine as the complete absence of the need for the use of pads. According to various studies that evaluated the functional results of robotic radical prostatectomy, approximately 89-100% of patients regain the ability to retain urine within 1 year after surgery, without the need for regular use of pads and without urinary incontinence after moderate exercise. Severe or permanent urinary incontinence - a condition in which normal exercise leads to loss of urine or the patient uses at least 3 pads a day, is observed in 1-6 % of patients. The use of nerve-sparing prostatectomy techniques allows to preserve erectile function in 75% of patients.                                   

The Urology department of the MCSC named after A. S. Loginov currently has experience in performing more than 600 radical robot-assisted prostatectomies.  

The operation demonstrates an excellent safety profile and a low level of postoperative complications.  

The oncological and functional results of our operations correspond to the data of international clinical reviews.  The period of stay in the department after surgery is 5-7 days. 

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