The prostate gland is located inside the urogenital system. It is a muscular-glandular organ, similar to a walnut in size. It is under the bladder (to the anus and at the base of the penis) and like a bracelet encircles the urethra in the initial area ‒ the prostatic urethra, through which an exit for urine and semen is provided.
The prostate is responsible for the production of seminal fluid and the maintenance of its vital functions. The reproductive function depends on ejaculation, in which the prostate gland directly participates. The prostate secretes a substance that is part of the sperm, to maintain the activity of spermatozoa.
The internal pathological process in prostate cancer in the early stages progresses unnoticed. Therefore, patient complaints appear when the malignant tumour of the prostate gland has grown to large sizes and becomes metastazing.
Patients cannot recognize the initial symptoms from the fact that the malignant tumour of the prostate is growing in its capsule, and it is distant from the urethra.
Besides, adenocarcinoma of the prostate gland can be concealed by the manifestations of benign hyperplasia ‒ an enlarged prostate gland that is adjacent to the urethra. Like cancer, hyperplasia also affects urination, blocking the urine flow, making it weak and causing frequent urges.
The cancer extends beyond the capsule of the prostate and along the fibres of the nerves reaches the lymphatic bed, affecting the bones and metastasizing into the lymph nodes and distant organs.
As well as tumours of the mammary glands, ovaries and uterus in women, prostate carcinoma is the most common malignant neoplasm in men. At the same time, there is a special correlation between races ‒ the Negroids are about one and a half times more likely to have it than the Caucasian race, and the representatives of the Mongoloid race, in particular, the Japanese, have it twice as rare.
It has been established that age is a determinative risk factor for prostate cancer, since after 35 years of age it is found in only one out of 10 thousand men, while after 60 ‒ already in every hundredth man, and among those who have reached 75, every eighth man suffers from carcinoma. In connection with this situation, WHO experts recommend that all men who have reached the age of 50 years old should do all the necessary tests in order to prevent the disease from worsening.
Causes of Prostate Cancer
Modern research has linked the causes of prostate cancer to chronic diseases and inflammatory processes that affect the prostate and provoke pathological changes in its tissues.
Common causes of prostate cancer include:
- Hormonal imbalance ‒ since the prostate gland tumour is hormone-dependent, its emergence and growth can be triggered by an increase in the level of dihydrotestosterone and androstenedione (male sex hormones).
- Prostatitis ‒ inflammation of the prostate gland, as a result of which blood circulation and oxygen metabolism in its tissues are disturbed.
- Prostate adenoma ‒ benign tumours contribute to the emergence of cells that normally do not appear in the prostate gland, they are more prone to mutation and malignancy, which provokes the onset of the oncological process.
- Bacterial lesions of the prostate cells and autoimmune processes damage the genetic apparatus of the cells, contributing to their uncontrolled division and the formation of a tumour.
Precancerous conditions which include atypical adenosis and prostatic hyperplasia, lead to the formation of a cancerous tumour. In the case of atypical adenosis, nodule formations appear in the center of the gland, the cells of which quickly divide, and under the influence of mutagenic factors can turn into malignant ones. Hyperplasia is an active focal cell division with subsequent degeneration or malignancy; the risk of a cancerous tumour considerably increases.
Risk factors for prostate cancer are associated with a hereditary predisposition and lifestyle. Thus, the increased content of animal fats in the diet, the entry of carcinogenic substances into the body with tobacco smoke and alcoholic beverages, hazardous working conditions in the textile and chemical industries, welding shops and printing works can contribute to oncogenic formation development. Stagnation of prostatic fluid because of a sedentary lifestyle and irregular sexual activity can be a predisposing factor for the development of the pathology.
Other risk factors include sexually transmitted diseases, advanced age, retrovirus, cytomegalovirus, and a weakened immune system.
Symptoms of Prostate Cancer
Very often the first stage of prostate cancer is asymptomatic. You should be very mindful to what happens in your body to find out some early signs of starting disease. It is widely known that men diagnosed with prostate disorder, both malignant and benign, have difficulties when urinating. It is logically as prostate is close to the urogenital system but not true in all cases. Sometimes tumor is located rather far from urethra to create a pressure on it and a man could live without knowing before it has grown bigger.
Together with above mentioned one, the signs of starting prostate cancer are:
- Pain and difficulties with urination
- Loss of bladder control
- Urinating more frequently but by small portions
- Blood in urine
- Pain when ejaculating
- Sexual dysfunction
When prostate tumor has enlarged, together with increasing of the above symptoms the other physical signs of disease can appear.
Bone pain. In advanced stage prostate cancer spread metastases to the bones and a patient experience severe pain throughout the body especially in the pelvic area and backbone. The bones become to be easily fractured.
Anemia. When metastatic cancel affects the spinal cord, it can cause anemia as result of bone marrow lesion. The patient has weakness and easily grows tied.
Lymph nodes swelling. This condition have the same reason as previous: affected bone marrow causes disorder of the blood and lymphatic system.
Weight loss. In advanced stages the patients loose appetite and fill themselves unable to eat. That is a result of body intoxication.
Some of those symptoms and signs can be related with other diseases, so you need highly qualified medical help to determine the reason of your problems. Diagnostic and rehabilitation centers in Germany offer various kinds if diagnostics means for precise diagnosing.
Grades and Stages of Prostate Cancer
The grade or stage of prostate cancer is determined based on the size of the tumour and the extent to which it has spread. Another important factor is the presence of metastases. This is the name for secondary tumours which emerge because the blood and lymph carry malignant cells to distant organs.
In order to establish the stage of prostate cancer a patient needs to be examined. To do it, different diagnostic methods are used:
- Determination of the level of prostate specific antigen (PSA) in the blood.
- Digital investigation ‒ the doctor examines the gland through the anus. In this way you can estimate the increase in its size, elasticity, the emergence of indurations.
- Ultrasound examination of the prostate with a rectal probe that is inserted into the rectum. By using it the doctor can detect indurations, nodes and tumours, their size and location.
- A prostate biopsy is needed when there are tumours and an elevated prostate antigen. In this case, the doctor determines whether the tumour is benign or cancerous. The examination is carried out under the control of ultrasound. Using a special needle, the doctor takes a few pieces of the tissue from different parts of the organ. In the laboratory, the samples are imbued and the characteristics of the cells are examined under a microscope.
- Computed tomography and magnetic resonance imaging are needed when a biopsy has confirmed the presence of cancer. These studies help find out the size of the tumour and detect metastases.
After the examination, the doctor diagnoses and determines the stage of prostate cancer.
Stage I ‒ the tumour is microscopic in size. It is impossible to palpate or see it with ultrasound. Only elevated levels of specific prostatic antigen (PSA) indicate it. In this stage, the patient does not notice any signs of the disease.
Stage II ‒ the tumour grows, but does not spread beyond the boundaries of the organ. It is limited to the prostate capsule. Cancer of grade two can be palpated during a digital examination. It is in the form of dense nodes and is detected by ultrasound. In the case of prostate cancer of Stage II, urinary disorders may occur, which are associated with the fact that the prostate squeezes the urethra. The urine stream becomes weak, there is colic and pain in the perineum. The need to go to the toilet makes the man wake up 3-4 times at night.
Stage III ‒ the cancerous tumour spreads beyond the prostate and invades nearby organs. The seminal vesicles, the bladder and the rectum are affected first. The metastases of the tumour do not invade distant organs. Stage III prostate cancer is manifested by disorders of potency, pain in the pubic and in the small of the back. There is blood in the urine and a strong burning pain when emptying the bladder.
Stage IV ‒ the malignant tumour increases in size. Metastases are formed in distant organs ‒ bones, liver, lungs and lymph nodes. Stage IV cancer is characterized by a severe intoxication, weakness, fatigue. When emptying the bladder and intestines, the patient experiences difficulties and severe pain. The man often cannot urinate on his own, and it is necessary to use a catheter.
Prostate Cancer Diagnostic Methods
Novadays the diagnosis of prostate cancer stands on the three important pillars:
- Analyzing of Prostate-Specific Antigen (PSA) in the blood
- The digital rectal exam of the prostate (DRE)
- The transrectal ultrasound-guided prostate biopsy (TRUS)
The diagnostically reliable evidence of a malignant neoplasm in the organ-limited early stage on the one hand, and on the other hand, the assessment of its aggressiveness, the tumor biology, is still associated with many open questions. It is about a certain assertion to distinguish between clinically significant findings requiring treatment and clinically insignificant tumors, which do not need immediate therapy, but can be treated later. To clarify this issue it is of particular importance to determine whether a tumour with a low tendency to rapid spreading ("low risk" tumors) is subjected to an aggressive therapy concept, or conversely, insufficient and delayed treatment in the case of very fast, aggressive growing tumors ("high risk" tumors).
The rapid development of imaging techniques (computer tomography (CT), magnetic resonance imaging (MRI), sonography, nuclear medicine) in the recent years persists to this day and provides more and more detailed imaging that gives new diagnostic information helping to conduct more effective therapy.
So after the introduction of the multi-parameter MRI (mpMRI) a few years ago it became possible to find with good sensitivity and specificity more clinically significant cancers that used to have negative prostate biopsy while cancer suspicion was still present, but also less significant prostate tumors in a repeated prostate biopsy.
Therefore the updated interdisciplinary S3 guideline used for diagnosis and therapy of prostate cancer (version 2018) recommends that mpMRT shall be used in a secondary biopsy for carcinoma suspicious lesions, as well as in preparation for a primary biopsy.
The recently published results of a high-level international scientific study on the current role of multiparametric MRI in the diagnosis of prostate cancer (PRECISION Study) show that in 38% of cases in patients who got a biopsy after suspicious multiparametric MRI results, a significant prostate cancer was found (compared with standard biopsy, 26%).
Currently, in Germany, in individual cases the costs for conducting of an mpMRT with a possible fusion biopsy after a written request are covered by the statutory health insurance if a negative ultrasound-controlled first biopsy has already been performed and there is a persistent suspicion of carcinoma.
After the implementation of the multiparametric MRI ultrasound guided prostate biopsy using the multiparametric MRI-findings (so-called fusion biopsy) should be performed in case of a secondary biopsy. The fusion is the result of the two imaging methods: sonography and magnetic resonance imaging.
The computation of the multiparametric MRI-findings is based on the anatomical description (T2-image), the assessment of the biological behaviour of the tissue (classification of the diffusion behavior of the prostate) and the blood flow in the tissue after administration of contrast agent (dynamic contrast medium intensified MR). A so-called Score for characterization of the prostate tissue which includes the probability of the existence of a prostate cancer is formed from these three components:
The Score scale (PI-RADS Score) describes the suspicion of a malignant prostate tumor as "highly unlikely" (1), "unlikely" (2), "questionable" (3), "probably malignant" (4), and "malignant" (5).
Based on the PI-RADS Score, the recommendation for US/MR-controlled fusion biopsy of the prostate is made. The multiparametric MRI is a modern sophisticated imaging method, both in technical execution and in the interpretation of the differentiated results for the diagnosis. For example, multifocal prostate cancer (multiple carcinomas), as well as a pronounced benign change in the prostate (benign prostatic hyperplasia), prostate inflammation (prostatitis) or irritation in the prostate tissue shortly after the previous primary biopsy represent a diagnostical challenge, which must be considered by a physician with appropriate professional expertise. The radiologists point out that at present the experience in this particular field of MRI is very different and did not reach the desired level throughout the country. Last but not least, a radiologist needs to have a radiological certification for the multiparametric MRI-examinations for prostate cancer diagnosis similar to the mammography certification. An internationally standardized structured evaluation of the multiparametric MRI is still pending and it is currently available only in specialized centers ("centers of excellence"). Only the sole combination of a controlled pathologically elevated PSA value combined with "suspicious" multiparametric MRI findings (PI-RADS ≥ 3) without a prostate biopsy does not mean that a clinically significant, in other words treatment requiring prostate cancer is present.
Ultrasound diagnostics is also associated with a rapid technological progress that, according to experts, has a high development potential and is going to evolve. The conventional transrectal ultrasound for prostate cancer diagnosis combined with the ultrasound-controlled prostate biopsy thanks to the use of higher sound frequencies give a more accurate and higher image resolution compared to abdominal sonography and thus more detailed information on changes of the prostate tissues.
Technical developments in medical sonography allows to get more additional information on tissue composition. In the recent past, the combination with computer systems for image evaluation led to significant advances in sonography for prostate cancer detection. This so-called ANNA/C-TRUS method makes it possible to achieve a higher prostate cancer detection rate with lower number of biopsy sessions compared to conventional transrectal sound or US/MR fusion biopsy.
By analogy with the multiparameter MRI (mpMR) the variety of new special methods of transrectal sonography through the application of color-coded Duplex sonography, elastography and the use of ultrasonic contrast agents is called Multiparameter ultrasound (mpUS). These new and sophisticated procedures can be performed using a single ultrasound diagnostic unit (high-end equipment) virtually simultaneously, but require extensive experience and special knowledge from the examiner. Therefore, these techniques should only be used in designated centres of excellence.
Still all these imaging methods for diagnosis of prostate cancer currently cannot replace the prostate biopsy to confirm the diagnosis. Only the exact histological result of the biopsy makes it possible to produce a reliable assessment to estimate the progression risk of a proven prostate cancer, not least in view of the specific individual therapy concept for the respective patient.
For the early detection of a renewed progression of the disease after the therapy, modern techniques of nuclear medicine based on the prostate-specific membrane antigen, the so-called 68Ga-PSMA-PET/CT, are used. This molecular imaging process is not yet part of routine diagnostic process and is currently used only in scientifically proven designated studies, but includes an extensive amount of new essential detailed information.
In summary, a creative interdisciplinary collaboration between urologists, radiologists, and pathologists is required for a modern prostate cancer diagnosis, in which the appropriate method from the variety of currently available imaging systems can be applied for the particular case with the highest informative value.
Prostate Cancer Treatment Methods
The doctor selects the treatment for prostate cancer individually for each man. The urologic oncologist must take into account the age, the stage of the tumour, concomitant diseases and the patient’s wishes.
Expectant Management
The man’s advanced age (over 70), severe chronic diseases of the heart, blood vessels and lungs can be contraindications to treatment for prostate cancer. It can be more dangerous for life than the disease itself. If the tumour is small, does not spread beyond the boundaries of the gland and has stopped its growth, the doctor will suggest postponing treatment. In this case, it will be necessary to perform a prostate ultrasound every 6-12 months and to have a PSA test.
Surgery
Surgical removal of the prostate gland (radical prostatectomy) is one of the main methods of treating the tumour. This is the most common method of fighting cancer in men younger than 65 years old.
The surgeon makes a small incision in the lower abdomen or in the perineum. Through it, the gland is completely removed. The doctor also excises the surrounding tissue and, if necessary, the lymph nodes. The operation lasts 2-4 hours. All this time the man is under general anesthesia. Regional anesthesia (epidural anesthesia) is sometimes used when there is no sensitivity below the waist.
If the tumour has not spread beyond the connecting capsule, it is possible to defeat the disease in 100% of cases. But if the tumour has invaded nearby organs, it can also be removed, but the prognosis for recovery is worse. Chemotherapy or radiotherapy may additionally be required.
Modern clinics offer treatment with the help of a special robotic system ‒ the da Vinci surgical system. The doctor controls all the actions of the robotic system which with high accuracy saves the body from the tumour. The surgery is performed through small punctures which then close up quickly. The new technologies can minimize the risk of complications. It is possible to avoid such side effects as urinary incontinence and impotence.
Another measure to fight prostate cancer is orchiectomy ‒ the removal of either one or two testicles.
This surgical intervention leads to a cessation in the production of testosterone of the endogenous type and a decrease in the growth rates and further development of the malignant formation. The intervention is preferably performed solely on the basis of a diagnosis after a gland biopsy has been performed.
The intervention can be performed not only on an outpatient basis, under local anesthesia, but also under general anesthesia. During the operation the doctor uses the techniques due to which changes of a visual character remain unnoticed (spermatic cord reservation, implantation of artificial testicles).
Orchiectomy makes sense in the following cases:
- The process of treatment with the help of hormonal drugs is impossible as a result of satellite diseases that are not in any way associated with the malignant tumour;
- in the absence of the possibility of taking the prescribed hormonal drugs or injections daily.
Chemotherapy
Chemotherapy for prostate cancer is the destruction of tumour cells with drugs that contain special toxins. These substances destroy the cells that divide rapidly. It is this feature that distinguishes cancer cells from the rest. Chemotherapy drugs destroy the nucleus and cell walls of the tumour, causing their death.
Chemotherapy is used instead of surgery for Stage III and Stage IV, when the tumour has spread out and metastases have appeared. Toxins are carried by the blood throughout the body, find cancer cells and destroy them. The drugs are inroduced intravenously in courses (Paclitaxel), sometimes they are taken as tablets. In total, the treatment lasts six months.
Prostate cancer is sensitive to chemotherapy, but in the early stages it is rarely prescribed. The reason is that chemotherapy drugs also influence healthy cells and cause many side effects (baldness, weakness, nausea).
Radiotherapy
Radiotherapy is the treatment for prostate cancer with x-rays, neuronic, gamma, beta or other radiation. Exposure to rays breaks the DNA of tumour cells. This leads to the fact that they cannot divide, grow old and die.
During treatment for prostate cancer, irradiation is performed by using special equipment ‒ a linear accelerator. This method is called remote radiation therapy.
The doctor will recommend remote radiation therapy if the tumour is large, and there are metastases in other organs. In this case, it is necessary to irradiate not only the tumour itself, but also the lymph nodes. The course of treatment lasts about 2 months, 5 days a week. Exposure to rays lasts 15 minutes, and it is absolutely painless. After the procedure, you need 1-2 hours to rest and on the same day you can return home.
But it will be more effective to introduce particles of the radioactive substance directly into the prostate. The method is called brachytherapy. For this purpose, iridium or radioactive iodine is used. As a result of such exposure, the cancer tumour dies out, and healthy tissues are minimally irradiated. It helps to avoid serious side effects.
The procedure is performed under anesthesia. There are techniques when radioactive seeds remain in the gland. There are also techniques when the needles with the irradiating material are introduced for a while and removed on the same day.
Radiotherapy is also used to treat cancer in the early stages and in neglected cases, when the operation cannot be performed.
Fewer complications occur when prostate cancer is cauterized with a thin beam of high frequency ultrasound (HIFU therapy). Under its influence the protein in cancer cells is destroyed, and they die out. HIFU therapy is widely used in foreign clinics.
Medication Treatment (Hormone Therapy)
Prostate cancer is a hormone-dependent tumour. The more male sex hormones the man has, the faster it grows. Drug treatment is aimed at reducing the concentration of hormones, androgens, and reducing the sensitivity of the tumour to their effects. As a result, it is possible to stop the development of cancer. The earlier you start taking the medicine, the better the result will be. But even in the final stages of prostate cancer, treatment can considerably alleviate the condition and prolong the patient’s life.
For elderly men who cannot be operated on for health reasons and for patients with cancer of Stage IV, hormone therapy is the only available treatment.
To treat prostate cancer without surgery the following medications are use:
- Antagonists of gonadotropin-releasing hormone. These drugs reduce testosterone levels. They inhibit tumour growth, help its cells become more differentiated (similar to other prostate cells).
- Analogues of the pituitary hormone. Injections of these hormones provide “medical castration”. Within 2-3 weeks the level of male hormones drops as much as if the testicles have been removed. But this phenomenon is temporary, and gradually the concentration of testosterone in the blood rises again.
- Antiandrogens. These drugs prevent tumour cells from interacting with hormones that are secreted in the adrenal glands. They are used together with analogues of the pituitary hormone. This combination is called “maximum androgen blockade” and helps to achieve the best result in cancer treatment.
In some cases the doctor prescribes only one drug from the group of antiandrogens ‒ Casodex. If this treatment is suitable for the man, it is possible not only to stop the growth of the tumour, but also to preserve sexual desire and erection.
In men younger than 60 years old, hormone therapy is combined with cryotherapy ‒ freezing the tumour at low temperatures. Ice crystals that form in cancer cells destroy their walls. Combined use of hormones and radiation therapy has a good effect.
If treatment with hormones has not worked, the doctor recommends the patient surgery to remove the testicles. After it the level of testosterone falls, and the tumour stops growing. But psychologically it is difficult for men to endure surgical castration.
Among the new methods of treatment the most promising one is considered to be virotherapy. Specially developed viruses find and dissolve (lyse) cancer cells. ECHO 7 Rigvir has proven itself best of all. The drug reduces the tumour and stimulates the immune system so that it independently fights mutant cells. It is prescribed in the early stages of the disease before and after the operation.
If cancer is detected in Stage IV, the doctor prescribes a treatment that is aimed at relieving pain and improving the condition. In this case, the tumour is not removed, but the doctor tries to stop the spread of metastases.
The surgery or a properly chosen treatment helps a man to live for 15 years and even more. Constant research is being conducted in this area and new drugs are being tested. This gives hope that in a few years, doctors will be able to cope with the disease in the later stages.
Prostate Cancer and TOOKAD Vascular Photodynamic Therapy
Vascular targeted photodynamic therapy with TOOKAD has proven its absolute efficacy in the treatment of early-stage prostate cancer and is a good substitute for radiotherapy or radical prostatectomy in the absence of concurrent reactions and complications.
Photodynamic therapy for prostate cancer consists of performing an intravenous infusion of TOOKAD Soluble which is straight away followed by infrared laser irradiation through. In order to do this, thin optical fibers are introduced into the tumour of the prostate gland. Everything is performed under ultrasound control. The preparation is obtained from bacteriochlorophyll, the photosynthetic pigment of some aquatic bacteria that use the energy of sunlight.
The preparation remains in the patient’s blood circulatory system from three to four hours and does not manifest any toxic effects. Low-power laser irradiation of the affected tissue activates the preparation locally, which leads to an extensive production of nitric oxide and oxygen radicals. These toxic molecules are short-lived but highly reactive. They trigger a rapid process of occlusion and destruction of the tumour blood vessels, which soon leads to necrotic death of the tumour. The tissues adjacent to it as well as their functioning do not suffer.
TOOKAD vascular targeted photodynamic therapy gives the possibility of treating even large and deeply embedded malignant prostate tumours safely in a day patient facility. The operation lasts 90 minutes on average. The patient goes home a few hours after it, and in another few days the person returns to usual activity, without any of the side effects that are usually observed after prostatectomy or radiation therapy.
The minimally invasive technique has become a good substitute to patients with prostate cancer in the early stage. The number of such patients has considerably increased over the last two decades, owing to extensive screening based on prostate specific antigen (PSA) levels. These people face a dilemma associated with the risk of complications after radical prostatectomy and an elevated risk of the tumour progression. Vascular targeted photodynamic therapy with TOOKAD offers this group of patients efficient treatment for prostate cancer that gives decent results and preserves quality of life.
The Treatment of Prostate Cancer with the Nanoknife Therapy
NanoKnife, also called irreversible electroporation or short IRE, is a new and very low-side-effect treatment of prostate cancer. The patients treated with it are generally very satisfied with their treatment. Some urologists against it refer to missing long-term studies on this therapy and advise against as long as these study results are not yet available. They especially recommend the for years used treatment methods surgical removal of the prostate or radiation.
The fields of application of the NanoKnife therapy
NanoKnife can be similar to an irradiation device not only against prostate cancer but also against tumors in the pancreas, the liver, the lungs, the kidneys, etc. In Germany, NanoKnife is used to treat liver tumors. The pancreatic cancer is being treated with NanoKnife at Klinikum Stralsund. In part, this is an open surgery, and tumor remnants are removed with NanoKnife. Here only the treatment of the prostate with NanoKnife is considered. This is mainly used as a focal therapy in prostate cancer, which have not yet exceeded the capsule. In the prostate center near Frankfurt, in Offenbach, NanoKnife is also used in more advanced tumors.
In about 40% of the treatments, the entire prostate is used NanoKnife porates, that means all cells of the prostate are destroyed. This is called complete ablation. It is thus removed as in surgery, the entire prostate, but minimally invasive with very few side effects. In advanced tumors, hormone therapy is used for about three months before surgery to reduce the tumor mass before surgery. So far, NanoKnife is only available at very few locations in Germany. Most of the operations have so far been carried out by the Prostate Center in Offenbach.
The clinic for prostate therapy in Heidelberg has also carried out a large number of treatments and, in cooperation with the manufacturer, offers training on the use of the NanoKnife device.
The CyberKnife therapy, a new treatment technique, can destroy even smaller metastases compared to NanoKnife, since the area to be treated can be even narrower here. Thus, after a NanoKnife therapy remaining metastases can still be removed.
How the NanoKnife therapy works?
With the NanoKnife therapy, several electrodes are inserted into the prostate through the dam. These electrodes generate extremely short current surges in the micro- to millisecond range with very high voltage in the region of the prostate. As a result, the membranes of the cells in the treatment area are porated or "perforated". The cell liquid flows out through these pores and the cell is no longer viable in a very short time. The porated cells are then broken down as in an internal injury from the body. This takes several months depending on the size of the treated area. If, for once, the reduction does not take place as expected, it may a scraping through the urethra (TUR-P) as done in a prostatitis. In the treatment area both cancer cells and normal cells in this way destroyed. Spared is the cell matrix of the healthy tissue. This makes it possible for the body to replace the porated cells with new, healthy cells. Unlike other therapies, a NanoKnife operation can delineate the treatment field to within a few millimeters, avoiding tissue damage beyond the edges. A repeated treatment of the same area would be technically possible.
Surgical technique
Each NanoKnife therapy is preceded by the most accurate localization of the tumor. MRI images are taken with an endorectal coil or a 3D biopsy for smaller tumors. This rather expensive 3D biopsy is not required if the entire prostate is affected and should be completely derived. The procedure is performed under general anesthesia because the patient is not allowed to move during treatment. The anesthesia is performed as TIVA (total intravenous anesthesia) with propofol and other drugs. The patient does not suffer from nausea after nausea and wakes up relatively quickly.
The surgery involves first planning the placement of the electrodes based on the patient's ultrasound and MRI images.
The manufacturer of the NanoKnife device recommends to insert the electrodes with a grid or template, as it is also used in brachytherapy. However, the electrodes are placed without a grid, because then you can set them individually and the ultrasound recording a constant control of the placement allowed. The electrodes are then connected to the NanoKnife device to generate the surges. The preparation usually takes more time than treatment with the power surges. The surges are used only a few minutes. The entire procedure takes about two hours.
The day after surgery, the patient can usually leave the clinic. He then has to wear a catheter for another 10 to 14 days, as the prostate swells through the procedure and compresses the urethra. This depends on how large the volume of the prostate was and how extensive cells were destroyed with NanoKnife.
After surgery with NanoKnife remains after a focal treatment, as well after a complete ablation usually something healthy prostate tissue. z. From the prostate capsule. This results in the PSA value not reaching 0.01 ng / ml as after a prostatectomy, the result is a higher PSA value than the lowest measurement (nadir), similar to an irradiation. After the NanoKnife therapy a sporadic immune reaction of the body to still untreated cancer foci is observed. Scientific evidence for this reaction has so far only been shown in preclinical studies, ie not in patients. It is believed that both cell membrane fragments and the body-degraded, electroporated tissue, similar to a vaccine, enable the immune system of the body to attack the remaining tumor cells.
Safety and side effects of NanoKnife therapy
An evaluation of the treatments performed so far revealed very small side effects. The patient usually has no wound pain after the operation, as this surgery does not trigger inflammation.
In all cases the patients remained continent. However, after the surgery often occurs a strong urge to urinate, which only passes after a few months. Especially after total ablation there is a larger amount of cells that have to be broken down by the body. This degradation can take six to twelve months. If the urethra is partially closed, the urinary stream is correspondingly weak. This can also lead to the urinary bladder can not be completely emptied, which leads to the urinary urgency mentioned.
Another possible cause is irritation of the nerves of the sphincter muscle as a result of surgery, as may occur after irradiation. These nerves then signal prematurely a strong urge to urinate. Retention of erectile function after surgery depends on whether a focal operation or a complete ablation has been performed. In both surgical procedures, only 7.1% of patients had erectile dysfunction. In a complete ablation of the prostate occur in about 45% of men temporary, lasting up to twelve months erectile dysfunction. These are reflected in more than 80% of those affected. If a hormone therapy to reduce the size of the tumor was performed before the operation, this will additionally impair the ability to have an erection even after the end of the hormone therapy for some time. At about 10% of complete ablations were found to have permanent impotence.
In a complete ablation is often dependent on the location of the tumor damage to the unavoidable nerves responsible for the erection Also the degradation of the dead Tissue after surgery can cause stretching and thus injury to lead these nerves.
A common side effect is urinary retention, which requires the use of a catheter for more than 14 days. The operation injures the urethra leading through the prostate gland and there must be a sufficiently large gap in the electroporated tissue for the urine. If the urinary retention is not yet after four weeks. This complaint can be remedied with a TUR-P. In a TUR-P, the undegraded cells are removed through the urethra (transurethral) under visualization (endoscopically) with an electric sling under anesthesia. A TUR-P laser treatment is not suitable after an IRE because the cells have already been destroyed by the IRE. The TUR-P requires a hospital stay of several days.
After a TUR-P you have a wound surface, which heals after some time. In general, you have to spare about four weeks. There may be pain when urinating and prolonged sitting can be uncomfortable. In addition, a NanoKnife operation uses water containing 5% glucose to maintain a safe distance to the gut and other organs. This water accumulates with blood due to gravity in the penis and scrotum (scrotum) and leads to swelling and a blue coloration of these organs. Medically, this side effect is harmless.
There are also international studies that confirm the great safety of NanoKnife therapy, which concludes:
NanoKnife can safely be used in patients with prostate cancer, and the majority of the side effects are transient."
At the SIR (Society of Interventional Radiology Annual Scientific) 2015 meeting, the experts present said, "NanoKnife is a new, effective treatment for prostate cancer therapy at various stages. It offers improved safety over other conventional therapies.
Innovative prostate cancer therapy: TULSA-PRO treatment
Focal treatment for prostate cancer with MRI-guided TULSA-PRO
The world's first focal treatment of the prostate with TULSA-PRO was carried out in a specialized clinic in the west of the country. Our goal in this treatment is to destroy prostate cancer and to preserve the prostate as an organ with all its functions. Male potency should also be preserved and incontinence avoided. With the optimized form of HIFU therapy, the so-called TULSA-PRO, these goals can usually be achieved.
TULSA-PRO stands for Transurethral ULtraSoundAblation of the Prostate. Transurethral means "through the urethra". Ablation stands for "removal of body tissue", here by heating. Focal treatment means that only a selected area is treated in order to preserve the organ. MRT stands for Magnetic Resonance Tomography and is a device that uses cross-sectional imaging techniques based on magnetic fields and not X-rays.
During this treatment, diseased tissue in the prostate is cooked and removed. The cooking is done using ultrasonic waves that generate heat (up to 86 degrees). The area to be treated is precisely delimited beforehand so that healthy tissue, the nerves for potency and the sphincter muscle for continence are to be avoided. The treatment takes place within the prostate, i.e. through the urethra and not through another organ such as the large intestine. With therapies through the large intestine, the disadvantage is that the nerves for potency lie between the large intestine wall and the prostate and are inevitably always treated as well. Once damaged, nerves cannot regenerate.
We always carry out the organ-preserving treatment with TULSA-PRO focally. This means that the area with the prostate cancer is specifically treated while the healthy part of the prostate can be preserved. Depending on the extent, a quarter (quadrant ablation) or half (hemi-ablation) of the prostate is treated.
MRI-guided HIFU therapy, the TULSA-PRO, can offer men a number of benefits that can usually be achieved with focal treatment for prostate cancer:
- With a focal TULSA-PRO treatment, prostate cancer can be destroyed through targeted heat while preserving the organs and function. For this, an exact delimitation of the area to be treated is necessary, which is already carried out during the 3D planning using current MRI images. When narrowing down, a check is made to see whether too little or too much of the prostate tissue is overcooked.
- With the TULSA-PRO treatment, the path to the prostate goes through the urethra. To do this, a treatment stick is placed in the urethra. This has the advantage that the treatment takes place within the prostate, because the urethra runs centrally through the prostate and therefore no other organs, such as the large intestine, can be damaged by it.
- Active cooling is integrated in the treatment rod and means that the urethra is constantly cooled during the heat treatment. This allows the urethral wall to be spared the heat. This is also intended to ensure that the nerves and vessels (neurovascular bundles) can remain protected from long-term side effects.
- In addition to delimiting the area, precise heat distribution is necessary. With the TULSA-PRO treatment, therapy can be planned and implemented in such a way that the required heat is only distributed to the edge of the prostate (prostate capsule). Such a control is possible with TULSA because the temperature development in the selected area can be observed and controlled live (in real time) on the monitor during the entire treatment.
- With this treatment, a selected area in the prostate can be treated uniformly (homogeneously).
- The rest of the prostate remains untreated during therapy. Thus, incontinence and impotence can be prevented.
Course of a TULSA-PRO treatment
The TULSA-PRO is an MRI-guided treatment of the prostate that passes through the urethra (transurethral) and can destroy a prostate cancer using ultrasound energy that produces heat. This ultrasound energy comes from a treatment rod, which is an ultrasound-controlled applicator, and is inserted into the urethra. There are 10 treatment elements in the treatment rod, from each of which ultrasonic energy comes.
Treatment rod with activated elements
Each element can be activated individually. This individual activation of the elements is ideal for a locally limited treatment of prostate cancer. For example, elements 2, 3, 4, 5 can be used for treatment because the tumor has this extent. Elements 1, 6, 7, 8, 9, 10 are not activated in such a case.
Treatment in the MRI machine only begins when the treatment rod has reached its optimal position. This means that the activated elements in the treatment rod are targeted to the tumor volume. By rotating the rod, the area with the prostate cancer is treated in a targeted manner.
The ultrasound energy that comes from the activated treatment elements cooks off the tissue in the area and ablates it. While the rod is actively treating, the system in the rod simultaneously protects the urethral wall through an integrated cooling system so as not to cause damage from the heat. To be on the safe side, the colon is also equipped with an additional cooling system.
The treatment can be observed and controlled live on the monitor during the entire time.
With this clinic you rely on a partner with experience, quality and safety:
- Over 400 patients have already been treated with TULSA-PRO
- The first focal TULSA-PRO treatment worldwide was successfully carried out in this clinic
- Highly specialized medical team consisting of radiologists and urologists with decades of experience
- Appointments within 7 days and short waiting times thanks to structured processes
- State-of-the-art equipment, beautiful rooms and a friendly team
Evaluation by a patient: "TURP, carried out by the clinic's chief physician"
There are specialists, good specialists and specialists in a medical field. The chief physician belongs to the latter. The operation he performed was a complete success. I am very grateful to Professor M. My quality of life has improved in unexpected ways since then. I can unreservedly recommend advice and treatment from this expert in his field to every troubled man.
Assessment by Jameda verified patient: "Excellent medical treatment and diagnostics"
The doctors are excellent specialists. You got me with theirs innovative diagnostic options made a super fast and absolutely reliable diagnosis of the cause of my increased PSA value. The carcinomas were precisely defined and this data could be used during the operation... the nerve retention was the result. I recommend this clinic 100%.
Rating by Jameda verified patient: "excellent"
Highest professional quality under the direction of Dr. L. and Prof. M. Pleasantly friendly and competent staff at all levels. Unusually aesthetically furnished rooms and hospital rooms for a clinic, real flowers even in the bathroom. Compared to my experience with the conventional HIFU, my stay in the clinic was a successful walk, my PSA is down to 0.02 after almost six weeks. After almost 7 years of prostate cancer, I have never had the result. THANKS! I can really only give top marks.
Assessment by Jameda verified patient: "Tulsa Pro Treatment in February 2019"
I can only report very good things about the reception, about the MRI examination and the subsequent extensive clarification about the further measures and risks and after the consultation I went home with a calm feeling. After a lot of thought and further discussions with my family doctor, I then decided on the Tulsa Pro OP. An appointment for the operation was quickly found. The recording went smoothly in a very calming friendly atmosphere. After the operation, I was accompanied by the nurse again when I went to the very friendly room. In the hours that followed, I was always looked after in a friendly and competent, calm and attentive manner by the nurses and doctors. Here you could really relax and feel good. I was released back home the following day. Now after over a year and a full recovery, I am super happy to have chosen this treatment. I am Dr. L. and his team of doctors are very grateful and, from my point of view, I can highly recommend this treatment method to all affected prostate patients.
Rating by Jameda verified patient: "the best of the best"
Very friendly reception and competent clarification regarding the investigation. The evaluation of the MRI examination has shown that a biopsy is necessary for further clarification. I had the MRT-guided prostate biopsy performed the following day without any pain under local anesthesia. After examining the biopsy and communicating the findings, I was shown the various treatment options in an understandable way, with both advantages and disadvantages. I then opted for the MRI-controlled TULSA treatment, in which the cancer cells were destroyed under general anesthesia. The next day I was able to leave the clinic without any complaints, have been symptom-free for 3 years and never had to take any medication or have any follow-up treatment after the operation. The PSA value was 7.5 before the operation and since the procedure (check every 3 months) it is between 2-3. Even if Bielefeld was not necessarily on the way for me (750 km away), I would immediately consider the Alta Klinik again. I can only recommend the Alta Klinik from A-Z and felt that I was in good hands. Many thanks to the entire clinic team.
Assessment by Jameda verified patient: "Strange but true!"
The diagnosis and treatment of prostate problems is still largely based on traditional principles and methods and leads to life-changing side effects! I did not want to endure this, although my urologist urgently advised me to do so and had already prepared everything without consultation! I searched and found the solution to my problem in Dr. med. L.! With a lot of confidence and still soft knees, I underwent this therapy in November 2018. At no point during or after the treatment did I have any pain. After 2 weeks I was able to remove the urinary catheter. After 6 weeks all symptoms of the treatment (blood in the urine and urine stream) were back to normal!! After 3 months, in February 2019, the follow-up examination was made. Result: Everything is fine again! My libido has not suffered, I am consistent, potent and orgasm and ejaculation work as before! PSA before: 7.28 after: 1.59! My prostate carcinoma with a Gleason score 7b (4 + 3) with 4 parts up to 95% has been resolved! My heartfelt thanks go to Dr. med. L. for his great Tulsa Pro Therapy and his passionate work with his patients! I am just as grateful to his employees who looked after me extremely well! I'm so happy!
Prostate Cancer Prognosis
The prognosis for prostate cancer depends on the stage in which the treatment was performed. Specialists have the notion of “five-year survival rate”, which helps estimate the success of treatment. So, for patients who consulted the doctor in Stage I, the five-year survival rate is more than 90% ‒ that is, more than 90% of people live 5 years and longer after treatment. For Stage II cancer this figure is 80%, for Stage III and Stage IV ‒ 40 and 15%, respectively.
If the patient appeals for medical aid in Stage I of the disease, as a result of the therapy he manages to completely regain control of the bladder function, sexual function, get rid of the tumour and return to work. After successful treatment, the negative manifestations of prostate cancer are eliminated; the disease does not decrease life expectancy.
In Stage II and Stage III, the success of treatment depends largely on the doctor’s professionalism and the patient’s health, age and the way he feels in general. Therapy takes more time, the treatment is more complicated, but the chances of success are quite large ‒ after treatment the life expectancy of most patients is 15 years or more.
In Stage IV prostate cancer, the prognosis is poor ‒ few patients can live for more than seven years after long-term combination therapy.
The Advantages of Treatment in Germany
- Minimal side effects
- Precise dose concentration in the tumor (in beam and chemotherapy)
- Quick treatment courses
- High chances for recovery
- High quality of life during and after treatment
- Qualified and experienced specialists
- Safety and reliability
- Trust-based relationship with the patient
Urologic centers in Germany provide reliable help in preserving or restoring male health. You can trust our specialists in full and rely on their competency and professionalism.
Prostate Cancer: Leading German Hospitals
Though cancer of prostate is the most common kind of malignant diseases in men, it is also has one of the highest rate of successful curing. The result of treatment depends of timely diagnosis and immediate measures taken. Treating prostate cancer is also very delicate task and it is very important to find a doctor who could feel all the nuances of your disease. The modern methods of treatment often allow not only get rid of death but to keep male sexual function. For details you can ask a qualified specialist in field of urology and prostate cancer. Please have an advice of expert and apply via GMG.
Urologic clinic of Mainz University Medical Center
University professor J.V. Turoff, the Doctor of Medical Science, Head of the urological department has more than 20 years of practical experience in the area of prostate diseases research and treatment.
The clinic is focused on robot-assisted laparoscopic surgery (da Vinci) with radical prostatectomy, organ-reserving resections, laser enucleation of the prostate, etc. Robot-assisted surgeries by da Vinci method have been actively practiced since 2007. Since 2012 the clinic holds symposiums on the robotized surgery in Germany.
Stuttgart University Hospital
The urologic oncology department is headed by professor Ulrich Humke who became one of the “2013 Best German doctors in the area of prostate cancer treatment”.
Specialization: oncologic surgery, uro oncology, urologic surgery, reconstructive urology, benign and malignant prostate diseases.
Urology and urologic oncology clinic in Friedrichshafen, Da Vinci surgery center
Urology and urologic oncology center of Friedrichshafen is headed by the expert in urology area, Dr. Wilhelm Esser-Bartels. Urology and oncologic urology clinic of Friedrichshafen together with Da Vinci Center provide the best modern technologies in the area of prostate cancer treatment. The clinic’s specialists have huge practical experience in minimally invasive urologic laparoscopy, laser prostate surgery and robot-assisted surgeries with the use of da Vinci® SI HD robot.
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