Keyhole surgery:

New hope for prostate cancer patients

By Carol Aloysius

Cancer of the prostate is on the rise. The hidden killer disease, now a global phenomenon due to the rise in ageing populations worldwide, is also seeing an upward trend among the Lankan grey male population, with many patients being diagnosed at an advanced stage by which time the disease is incurable. Health authorities stress that the lives of many prostrate cancer patients could be saved through early detection, followed by early treatment using new improved surgical treatments that include keyhole (Laproscopy) and Robotics. The good news is that these new surgical techniques which were once available in other countries are now available in Sri Lanka as well.

A team of doctors Sohan Perera, Chathura Hingalagoda, Munipriya Willaarchchi, Jeevani Rajasinghe (Consultant Anaesthetist) led by Consultant Urologist & Kidney Transplant surgeon Dr Niroshan Seneviratne supported by a specialised nursing team successfully carried out laparoscopic surgery for Cancer of the Prostate on a 61-year-old patient for the first time at Sri Jayewardenepura General Hospital in February 2014.

Since then laparoscopic removal of the prostate is offered for patients with early prostate cancer at Sri Jayewardenepura General Hospital.

DR NIROSHAN SENEVIRATNE in this interview with the Sunday Observer discusses the adverse impacts of the hidden killer and how the path breaking surgery he and his specialised team performed recently, can benefit prostrate cancer patients in Sri Lanka, in the future.

Excerpts…

Q. Prostate cancer is now on the rise globally. What is this disease?

A. Prostate is an arecanut (puvak) sized gland located at the base of the urinary bladder, in front of the rectum. It surrounds the beginning of the urethra, the tube that passes from the bladder to the penis that carries urine and semen. Prostate cancer is a disease in which some of the prostate cells become cancerous. In this disease, abnormal cells formed in the prostate gland grow uncontrollably, which can spread to other parts of the body. This disease is the commonest male cancer worldwide. Generally it affects nearly one in 1,000 men in the western world. Due to the ageing population the incidence of prostate cancer is on the rise. Over 90 percent of prostate cancer cases are curable if they are detected and treated in the early stages.

Q. Who are the highest risk groups? Young men? Middle aged men? Elderly men? Why?

A. Nearly 30 percent of 50-years-olds have the disease, increasing up to 80 percent at 80 years. However only a small proportion of patients develop clinically significant cancer. So increasing age is a risk factor.

Q. Is it hereditary?

A. Yes. Nine percent of patients who get prostate cancer have a familial disease. The gene named BRCA1 responsible for this has been found. So presence of prostate cancer among first degree relative is a high risk factor for the other family members.

Q. What is the percentage of Sri Lanka’s population affected by this disease?

A. The exact percentage is unknown. One study has roughly estimated nearly 300 cases reported within a year 2005. I think this is truly an underestimation of the figure in our country.

Q. What is the global percentage?

A. Three percent of men worldwide die of prostate cancer. It is the most common cancer in males accounting for nearly 25 percent of all male cancers.

Q. What are the factors that cause the disease?

A. It is multifactorial. Male hormone testosterone has a promotional effect on prostate cancer. Increasing age, Africans, Americans and family history are other risk factors for the disease. Also obese people have a higher risk of acquiring the disease. Sexual activity, vasectomy and prostate infections have no bearing for the cancer.

Q. Does environment play a role?

A. Epidemiological studies have shown less exposure to sunlight may have a role. This may be a reason for the disease to be more prevalent in Scandinavian countries.

Q. What about diet?

A. There is no direct relationship between diet and prostate cancer.

However populations with high fat diets, particularly those who consume meat products are at higher risk of the disease. Soy products, cooked tomatoes, pomegranate juice, Vitamin A, D, and E have shown some beneficial effect in preventing the cancer.

Q. Can it be prevented? How?

A. Yes. Two recent studies have shown that use of drugs called finesteride and dutasteride in long-term, reduce the chance of prostate cancer.

Q. What are symptoms of prostate cancer?

A. Prostate cancer does not usually cause any symptoms in its early stage which is called the Asymptomatic stage. Your doctor may have spotted a sign during a routine check-up or looking at a blood test called PSA.

If the cancer grows to compress the urethra, it will cause the following changes in your bladder habits.

This is the Symptomatic stage.

They include: difficulty in passing urine, increase urinary frequency, poor stream, hesitancy to pass urine, straining etc.

These symptoms commonly are caused by non-cancerous prostate conditions called benign prostate enlargement frequently seen among elderly men.

As the prostate cancer spreads to the bone and lymph glands the following Advance stage symptoms are noticeable:

Pain in the back, hips, thigh. Swelling of the scrotum, penis, legs and feet. Weight loss. Fatigue. Loss of appetite.

Q. How does early detection help?

A. Fortunately prostate cancers grow slowly. If detected early before the prostate cancer spreads, it can be cured in 90 percent of patients. In the rest the disease can be controlled to reduce morbidity specially bone pain and fractures and early deaths.

Q. What are the methods used for early detection? X-rays? Blood specimens?

A. A simple blood test named PSA (prostate specific antigen) can be done.

Also, during a rectal examination where by placing a gloved finger into the rectum over the prostate, a doctor can feel the shape and the consistency of the prostate. These two tests in combination have a 50 percent to 70 percent sensitivity of detecting a prostate cancer.

Q. How is prostate cancer diagnosed?

A. TRUS biopsy is the ultimate test to diagnose a cancer. TRUS stands for Trans Rectal Ultra Sound. This is a specialised scan where a probe is placed in the rectum to get some pictures of the prostate. At the same time a special needle is passed to the prostate to obtain a sample of tissues (biopsy) for the diagnosis.

Q. What are the methods used in Sri Lanka?

A. Both PSA blood test and TRUS biopsy are available in Sri Lanka.

Q. How do you treat prostate cancer?

A. Treatment options are quite a complex process. From the biopsy report the cancer is graded into low risk, intermediate risk and high risk disease. Supported by further scans such as CT scan, MRI scan and Bone scans, the cancer is also stage in to the same.

‘Stage’ means to what extent the cancer has spread beyond the prostate. Patients can be treated by surgery, ray treatment or by drug therapy depending on the grade and stage.

Q. What are the methods that are traditionally used to treat the disease in most hospitals?

A. If a prostate cancer is diagnosed at early stage, removal of the entire prostate gland is done. This is done by open surgery by making an incision in the lower abdomen. This method of surgery is available in many hospitals. In case the patient presents in the late stage, a scrotal surgery is done to reduce the testosterone (male hormone) production which is important to control the advance disease.

New techniques

Q. I understand you are a pioneer in a new technique used for treating prostrate cancer patients. Tell us more about it. Is it invasive or non invasive? How is it done?

A. Laparoscopic Radical Prostatectomy is a keyhole method where the entire prostate is removed without making a big cut in the belly.

Here under General anaesthesia small stab incisions; in the size of half centimetre to one centimetre are made in the belly of these patients. These are called port site incisions. Generally five ports are used to introduce small tubes. Through the centre tube a special camera (laparoscope) is inserted to the belly where a magnified view of the internal organs is seen using special TV monitor. The camera is held by the assistant surgeon. Using different working instruments through rest of four tubes/ports the entire cancerous gland is removed by the operating surgeon. Finally the continuity of the urine tract is made by stitching the bladder to the urethra.

Q. Usually, patients undergo prostate surgery by means of key hole surgery called TURP. Is this a similar or different to this surgical method?

A. TURP means transurethral resection of prostate. This is is a key hole method where the prostate gland is cored from inside the urethra by passing a special instrument along the urethra. Here the prostate coverings (capsule) are left in the patient. This is a surgery done for prostate enlargements due to non-cancerous causes.

Q. What are the advantages of this new method as against the conventional methods? How does it enhance the quality of life of the patient?

A. Due to a six times magnified view during the laparoscopic surgery the surgery can be done very precisely with minimal damage to blood vessels and nerves. Hence the operative blood loss is less. Furthermore the key hole method has less post-surgical pain and the patient recovers faster with minimal requirement of pain relief medications. Patients can also be mobilised early with shorter hospital stay and early return to normal activity.

Q. How long does it take for him to return to his usual activities?

A. About two weeks.

Q. Is this new treatment available in most state hospitals? Do you see it replacing open surgery in the near future?

A. This new method was initially introduced to Sri Lanka at the National Hospital by a team of four Urologists led by Prof. Neville Perera nearly eight months back.

At present laparoscopic prostate service is available at National Hospital and at the Sri Jayawardenepura General Hospital. However with the return of more newly trained urologists to the country, we expect many hospitals will transform from open surgery to laparoscopic surgery in the future.

Q. Has the world moved beyond laparoscopic surgery for prostate?

A. Yes. Now this surgery is commonly done with the use of a Robot; Robotic Radical Prostatectomy. It will be available in Sri Lanka for our patients in the near future.

Q. Do you foresee an increase in prostate cancer patients in the future? Why?

A. Considering that populations are ageing fast both in Sri Lanka and globally, many more patients are likely to be detected with prostate cancer in the future.

Q. Are there any other methods of treatment for this disease?

A. Apart from surgery ray treatment, use of Ultrasonic waves (HIFU) or rapid cooling and thawing the prostate (cryotherapy) can be done to treat early prostate cancer. However the latter two is done only in limited settings.

Q. Are there any other surgical treatments for patients who have reached the advanced stage?

A. When prostate cancer has spread to the bones removing the cancerous gland is not possible. Prostate cancer growth is dependent on male hormone name testosterone produced by the testicles.

At advance stage it is possible delay the progression of the disease by controlling the cancer growth by cutting down the testosterone hormone supply. This is achieved by a surgery of testicles or by drugs inhibiting the testosterone action.

Q. Your message to the public?

A. Prostrate cancer is a curable disease if detected early. If you are in a high risk group, get a PSA blood test done.

If you develop any urinary symptoms mentioned above seek medical advice.

Suspended animation trials begin: sci-fi technology could save lives

Doctors are set to recreate a sci-fi technique as they begin suspended animation by freezing trauma victims in the hope of keeping them alive.

The technique will be used on ten patients who would otherwise be expected to die from their wounds, which will likely come from stabbings or shootings. The doctors on the project will be paged when a patient is likely to fit the procedure. There is around one such case every month, and they have a survival rate of less than seven percent.

Doctors will begin by removing patients’ blood. Their body temperature will then be lowered to around 10 degrees Centigrade by pumping a large volume of cold fluid through a tube placed in the aorta, the largest artery in the body. After the process is complete patients will be clinically dead. To resuscitate them, doctors will use a heart-lung bypass machine to restore blood circulation.

“We are suspending life, but we don't like to call it suspended animation because it sounds like science fiction,” Samuel Tisherman, the surgeon who is leading the trial, told the New Scientist.

“So we call it emergency preservation and resuscitation.” Because the patients will be unable to give consent to the procedure, researchers will instead run a publicity campaign to allow potential patients to opt out. Locals will be able to order bracelets to indicate that they don’t consent.

The outcome of the ten initial patients will be compared with ten other patients that could not receive the procedure. Doctors then hope to refine the technique.Patients will only be cooled down for a few hours, but doctors hope that will be enough to save the patients from losing too much blood. Doctors already use cool down parts of patients’ bodies to stop blood flow and perform surgery.

The technique has been successfully used on pigs. In experiments, scientists simulated gunshot wounds by inducing fatal wounds in the animals and simulating medical procedure.

While all the pigs that weren’t cooled died from the wounds, 90% of pigs that were cooled at a medium rate survived.

The surviving pigs had no long-term physical or cognitive problems.

At lower temperatures, cells need less oxygen because chemical reactions slow down.

Similar effects to the techniques have been seen in some accidents, where climbers and skiers have fallen into cold water and entered the state by accident.

- The Independent