URO-ONCOLOGY CONDITIONS AND PROCEDURES
Further information for patients and families
Prostate cancer is common, with at least 17000 diagnoses each year in Australia, and 3000 deaths. Not all men develop the same kind of prostate cancer, and prostate cancer does not behave in the same way in every man. Some men develop prostate cancers that move very slowly, and may not require any treatment, and others may have aggressive tumours that grow locally, may spread to other parts of the body (metastasise) and cause severe problems like pain, spinal cord compression and organ failure.
Men with raised PSA (prostate specific antigen) blood test levels, a strong family history, a suspicious finger test (digital rectal exam) or other tests may present for further evaluation.
If prostate cancer is suspected, Dr Handmer may recommend further investigations to make the diagnosis, and to determine the best approaches to your treatment. These investigations can involve scans such as the multiparametric MRI of the prostate (aka mpMRI), CT, bone scan or PMSA PET scans, special blood tests and biopsies of the prostate.
Biopsies can be obtained by the ‘transperineal’ route, which means through the skin just below the base of the scrotum, or by the ‘transrectal’ route, which means through the back passage. Each approach has different advantages and disadvantages.
Dr Handmer recommends multidisciplinary care of prostate cancer, involving formal MDT discussions, and involvement of other professionals including Oncologists (Medical and Radiation), Nuclear Medicine Physicians, Radiologists, Pathologists, Care Co-ordinators and expert Nursing teams.
Men with a new diagnosis of prostate cancer may have different treatment strategies offered, such as:
Watchful waiting – where an expectant approach is taken, usually for less aggressive tumours or where patients prefer not (or are too unwell) to have treatments
Active surveillance – where a regimen involving blood tests, finger tests and MRI scans may be recommended to identify whether the tumour is showing concerning signs of progression and to avoid treatments in the interim
Robot assisted radical prostatectomy (aka RARP / RALP / RALRP) using the da Vinci ™ Xi robotic system (available at Lake Macquarie Private Hospital and Lingard Hospital in Newcastle), with procedural steps to help preserve the nerves that cause erections (where appropriate)
Open radical prostatectomy
Radiation therapy – such as EBRT or in some instances, brachytherapy
Hormone therapy or chemotherapy
What happens after radical prostatectomy?
Most patients will have a catheter in place for around one week, and you will then return to hospital to have the catheter removed (this does not require any anaesthetic).
Dr Handmer may recommend a medication such as sildenafil (Viagra) each day after the catheter is removed as this may help with blood supply to the penis and to help recover erections.
Pelvic floor exercises taught by an experienced pelvic floor physiotherapist may help you recover control of urination and Dr Handmer may recommend you learn and practice these exercises preoperatively, and then resume them once the catheter is removed and the immediate postoperative recovery period is passed (around two weeks postop)
PSA checks are performed to assess cancer control, and the first check is usually due around 6 weeks postoperatively, and checks are initially every three months. Your formal histopathology (result of the specimen removed) in conjunction with your PSA helps Dr Handmer monitor your cancer, and some patients may need more treatments.
What adverse effects can follow radical prostatectomy?
Radical prostatectomy, whether performed robotically, laparoscopically or open is major surgery. The prostate is traversed by the urethra, acts as a conduit for the passage of urine and semen, is close to very important structures including the valve that helps control urination, the rectum, the tubes that carry urine from the kidney, and many of the nerves that affect erections. Though the cuts to your abdomen may be small, this is still a big deal!
In addition to the general risks of surgery, such as the risk of anaesthesia, bleeding, blood clots, damage to adjacent organs and infections, there are three additional major considerations when undergoing prostate surgery:
Control of urination (continence)
Temporary or permanent incontinence are potential side effects of radical prostatectomy.
Some of the factors that make leakage more likely include prior history leakage or urinary problems, prior prostate surgery including TURP, a short membranous urethra, radiotherapy, aggressive cancer, age, and whether (and how well) you perform pelvic floor exercises.
Initially, you will have a catheter (tube) in the penis after surgery, usually for around one week. When that tube is removed, it is very common to have urinary leakage - though many patients are immediately dry. Leakage becomes progressively less common as time goes by.
Dr Handmer may recommend pelvic floor exercises, both before and after surgery, (once your catheter is removed and you are healing well) supervised by an experienced pelvic floor physiotherapist to help speed up your recovery. By three months, patients who experience leakage typically have a substantial reduction, and ongoing significant leakage by one year is unusual. Some people experience ongoing significant leakage.
If that leakage persists towards a year after surgery, Dr Handmer may recommend further investigations and additional treatments for incontinence including sling procedures (such as the AdVance sling) or the implantation of an artificial urethral sphincter (AUS).
The primary objective of radical prostatectomy is to control prostate cancer
Preoperative investigations such as biopsies, blood tests and scans can only form an estimate of the situation. Your prostate and (if applicable) other tissue will be sent for formal examination by a histopathologist (Specialist Pathologist) and gives a much more accurate picture of the cancer
A positive surgical margin is where the Pathologist thinks that cancer is present at the edge of the tissue that was removed, and that some may still be present in your body. Positive surgical margin rates are significantly affected by the grade (aggressiveness) and stage (where it is) of the tumour, particularly by the location and volume of the tumour in the prostate and whether the tumour is spreading outside of the gland into surrounding tissue. Other factors that affect margin rates include the way in which the procedure is performed (e.g. nerve sparing).
A positive surgical margin does not necessarily mean that your cancer will return - approximately 50% of people with positive margins go on to develop 'biochemical recurrence' which is where the PSA level increases beyond 0.2 postoperatively. Some men without positive surgical margins may also develop 'biochemical recurrence'.
In some cases of 'biochemical recurrence', Dr Handmer may recommend additional radiotherapy to reduce your risk of recurrence.
The nerves that help to control erections travel very close to the surface of the prostate, surrounded by layers of fascia (connective tissue).
Temporary or permanent impairment of these nerves is a common side effect of radical prostatectomy.
You can imagine the prostate and its surrounding layers of fascia and nerves as being like and onion with many layers of skin. The nerves travel between layers of the onion skin.
A 'nerve sparing' operation aims to preserve as many layers of the onion skin as possible but necessarily involves peeling closer to the onion, which runs the risk of getting close to the tumour and even leaving cancer behind. Conversely, a 'non nerve sparing' operation involves removing the prostate without peeling as close to the tumour.
Sometimes, a nerve spare will be safe on one side of the prostate (where the tumour is not close) but not on the other.
Nerve sparing does not guarantee that erections will return after radical prostatectomy. Factors that predict return of erections include: younger age, strong erections preoperatively, nerve sparing. Dr Handmer may also recommend using sildenafil (Viagra) or similar drugs postoperatively to assist in recovering erections.
Some people are able to achieve erections normally after radical prostatectomy, others need medications, or injections to the penis, or a penis pump. Some patients elect to have a prosthetic device implanted into the penis to give erections.
KIDNEY AND ADRENAL CANCER
Kidney cancer affects over 4000 Australians each year. In the past, kidney cancers came to medical attention when they were very advanced, causing pain in the abdomen, bleeding in the urine and a mass that could be palpated (felt). In modern times, lesions (lumps and bumps) are commonly found in kidneys and adrenals on scans, and some of these may be cancers.
Early detection of kidney cancer is important, as although there are many treatments, there is - unfortunately – currently no cure for kidney cancer that has spread throughout the body.
Dr Handmer may recommend further scans of the kidney, including CT, MRI or ultrasounds, and in some instances may advise that a biopsy (sample) of the concerning lesion is obtained with a needle.
Dr Handmer may recommend treatment for kidney cancers, including:
Surveillance – watching a lump carefully to see if or how it changes over time
Robot assisted partial nephrectomy (aka RPN) – where the tumour and (sometimes) a small piece of normal kidney is removed via keyhole surgery with the da Vinci Xi robot, leaving the rest of the kidney in place
Laparoscopic partial nephrectomy – similar to robotic partial nephrectomy, but without the assistance of the da Vinci Xi robot
Open partial nephrectomy – where part of the kidney is removed through an incision allowing Dr Handmer to access the kidney directly
Where the entire kidney is removed with keyhole surgery or via an open incision (where appropriate)
In some cases a patient who has kidney cancer that has spread to other organs may still benefit from removal of the affected kidney
Cryotherapy, radiofrequency ablation, stereotactic radiotherapy, other treatments
Immunotherapy, targeted therapy or chemotherapy
For adrenal cancer that has not spread, Dr Handmer may recommend removal of the adrenal gland with keyhole surgery.
Urothelial cancer (bladder cancer) can affect the bladder, ureters (tubes between the bladder and kidneys), kidneys and urethra (tube you pass urine through).
Bleeding in the urine, known as haematuria, is a concerning situation. In most cases, a diligent search for the cause needs to occur, and importantly, Dr Handmer will want to exclude bladder cancer.
Tests including urine cytology (looking for cancer cells in your urine), scans such as the CT IVP, and a cystoscopy (camera in the bladder) may be recommended.
Treatments for bladder cancer are affected by whether the tumour is invading into the muscle of the bladder (MIBC) or not (NMIBC), and whether the cancer cells themselves are particularly high grade or aggressive.
In general, Dr Handmer may recommend the following treatments for non-muscle invasive bladder cancer:
Surveillance cystoscopy (camera tests on a schedule to ensure it has not come back)
Cystoscopy and transurethral resection of bladder tumour (putting a camera into the bladder and using special instruments to remove the tumour), or ablation (destruction of the tumour) with a diathermy (electrical energy) or laser (light energy)
Intravesical therapies such as BCG (putting in special solutions with catheters on a schedule to treat the cancer)
Muscle invasive bladder cancer is treated with much larger surgeries in most cases, as it can be a life threatening diagnosis. Dr Handmer recommends multi-discliplinary care for muscle invasive bladder cancer and may recommend one or more of the following procedures:
Radical cystectomy (removing the bladder completely) with lymph node dissection (taking lymph nodes that may be affected by cancer) and urinary diversion (changing the plumbing so that urine can drain a different way to how it used to). This is the gold standard procedure for muscle invasive bladder cancer. This can be performed as open surgery or with assistance from the robot, and Dr Handmer may recommend that you receive chemotherapy before or after the procedure to reduce your risk of getting cancer back in the future. In many cases the urinary diversion will be via an ileal or colonic conduit (using a segment of your bowel to bring urine up to a bag), and in some circumstances may involve a neobladder (newly constructed bladder from a segment of your bowel)
Multimodal therapy, which involves resecting as much of the tumour as possible with a camera, and using chemotherapy and radiotherapy in combination to treat the remainder of the tumour
Chemotherapy or radiotherapy alone, often most appropriate for patients who have evidence of bladder cancer elsewhere in the body at the time of their diagnosis
Radical Cystectomy - Further Considerations
Radical cystectomy is major surgery usually performed with the objective of preventing death from bladder cancer
Recovery will require the involvement of a dedicated team including stomal therapy, physiotherapy, occupational therapy, nurses and doctors
Major surgery has major risks, and Dr Handmer works to prevent complications wherever possible (often with 'prehabilitation'), and detect and manage them pro-actively when they do occur
KIDNEY STONES AND BLADDER STONES
Further information for patients and families
KIDNEY STONES / NEPHROLITHIASIS
Stones in the kidney are frequently incidentally discovered on CT and ultrasound scans that are performed for another reason, or patients may experience pain, infections or other problems with their kidneys leading to the diagnosis.
In general, Dr Handmer may recommend intervention for stones in the kidney that are unlikely to pass in the future, or where there is a complicating factor (e.g. poor kidney function, a single kidney, infections) or where patients prefer to have them treated for personal or occupational reasons, for example, pilots.
Options to treat kidney stones depend on the size of the stone(s), location in the kidney, and various other factors. In Newcastle, we have all current technologies for the minimally invasive treatment of kidney stones in both public and private settings. Generally, the treatments Dr Handmer may recommend include:
Laser destruction of the stone with tiny cameras that are introduced through your urethra (urine tube) into your bladder then up the ureter to the kidney
Shockwave treatment using ultrasound energy through your skin
Operating through a small puncture into the kidney (PCNL), particularly for larger stones
In some rare cases, robotic, laparoscopic (keyhole) or open stone procedures
URETERIC STONES / URETEROLITHIASIS
Most patients with ureteric calculi (stones in the tube from the kidney to the bladder) find out about their condition because they experience severe pain known as renal colic, often necessitating hospitalisation. This pain is often described as the worst pain a person has ever felt, and until the stone has passed completely or been treated, may come and go at random unpredictable times of a duration of hours, days, or even weeks.
Ureteric calculi can be life threatening, particularly if infection is present, or of kidney function has deteriorated significantly.
Many patients with renal colic will require emergency placement of a ureteric stent (slippery plastic tube between the kidney and bladder) to relieve the obstruction, prior to treatment of their stones. This is especially the case if the patient is unwell, has an infection, poor kidney function, or the stone is in certain locations.
Some patients with renal colic will spontaneously pass their stones, especially with medications to help them manage pain and other problems that can occur.
There are three factors in general that help predict the passage of stones in the ureter:
Size – smaller stones are more likely to pass – but just because a stone is small (<5mm) does not mean that it will definitely pass, or pass within a reasonable time frame
Location – a stone that is closer to the bottom of the tube, and has navigated some of the anatomic tight points in the ureter is statistically more likely to pass
Duration – a patient presenting with a half hour of pain is much more likely to pass their stone than a patient with a two week history
Those that do not, or cannot, or should not attempt to pass their stones may require intervention. As mentioned above, this may initially be a ureteric stent, but definitive management necessitates destruction or removal of the stone.
Similar to management of stones in the kidney, Dr Handmer may recommend one of the following treatment for ureteric stones:
Laser destruction using small cameras and your existing anatomy (plumbing) to access the stone without surgical cuts – most patients will be suitable for this treatment
Shockwave lithotripsy (ESWL) – often not suitable for ureteral calculi
Basket retrieval using small cameras and a tiny three dimensional wire snare to grasp and remove stones
Rarely – robotic, laparoscopic or open procedures
Many patients who present with stones are suitable for treatment of the stone without a stent being placed ahead of time – this is called primary treatment.
The objective of primary treatment is to avoid stenting as much as possible, because stents are often uncomfortable and may cause irritation, bleeding and pain. In most cases, patients with a primary procedure can have a day surgery to remove the stone, and a short duration of a stent (a few days or a week) which can then be retrieved with a flexible camera, or with a string through the urethra (urine tube) depending on your preference.
Just as stones can form in the kidney and ureter, stones may also form in the bladder.
Stones in the bladder often indicate a problem with bladder emptying, and it is very common for patients with bladder stones to also need surgery to their prostate gland to help them pass water more freely, and to reduce the risk of forming another bladder stone in the future.
In addition to the techniques used to treat stones in the kidney and ureter, bladder stones are often treated with special instruments that can crush the stone directly, or with a small incision to remove larger stones. Dr Handmer may recommend prostate outlet surgery be performed in some cases at the same time, or at another time soon after the treatment of the stone.
Further information for patients and families
Problems passing urine can happen at any time, but are increasingly common with advancing age. Voiding symptoms that were classically described as ‘prostatism’ are now often called Lower Urinary Tract Symptoms or ‘LUTS’ due to obstruction of the bladder (because the outflow from the bladder travels through the prostate in men). This is a different – though related - thing to benign prostatic hyperplasia (BPH), which is the physical change at the cellular level that occurs within the prostate gland. There are – of course - many other problems that can occur with urination that are unrelated to the prostate.
Dr Handmer may ask you to describe your symptoms, with particular reference to
· Whether your stream is weak
· If the urine flow starts and stops
· Whether pushing and straining is required to empty
· If you have incomplete emptying of your bladder
· Whether you frequently pass urine
· Whether you have urgency to go (a hurry)
If the underlying problem is related to an overgrown prostate, Dr Handmer may recommend procedures such as:
· TURP – transurethral resection of the prostate aka ‘prostate re-bore’
· Laser TURP
· ‘Simple prostatectomy’ using open or robotic surgery
· Other procedures as circumstances may dictate
FUNCTIONAL VOIDING DISORDERS
Many problems passing urine are not due to overgrown prostate glands. Some of these problems relate to overactivity of the bladder (OAB) also known as detrusor overactivity (DO), dysfunction of the normal reflexes involving in urination, or weakness of normal supporting structures that normally help you stay dry.
Diagnosis of these conditions is sometimes possible based on symptoms and some imaging tests such as ultrasound, however, they may also require specialised tests such as video urodynamics, in which the bladder is filled, asked to store urine, and asked to pass urine while very detailed pressure and volume measurements are made.
Treatments might involve multiple different components, however, they generally involve addressing either lifestyle, medical or surgical aspects.
Surgeries that Dr Handmer may arrange include:
· Cystoscopy – camera in the bladder
· Dilation or hydrodistension – filling the bladder to capacity and ensuring the emptying valves are appropriately sized
· Injection of botox into the wall of the bladder
· Other procedures to repair weaknesses or problems that have been identified
Some patients may require catheters temporarily or permanently. Catheters, their placement and their management are all in the expert domain of Urologists.
Dr Handmer may need to place a catheter as part of your treatment. This may be through the urethra (normal urine tube), or suprapubically (through the skin in the abdomen directly into the bladder). Each has different advantages and disadvantages that will be discussed with you.
Some patients who need longer term catheterisation may choose to insert and remove catheters themselves to help drain the bladder. Where this is indicated, Dr Handmer may help arrange training for you to achieve this.