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THE LATEST IN PROSTATE CANCER DIAGNOSIS AND TREATMENT
1 The main reception at King Edward VII's Hospital (PHOTO: KING EDWARD VII'S HOSPITAL)
King Edward VII’s Hospital is one of the UK’s leading centres for urology, bringing together an exceptional multidisciplinary team of consultant urologists who are all leaders in their fi eld. Having recently welcomed world-renowned prostate cancer specialists to an already impressive consultant group, the hospital invested heavily in technology to ensure their patients can access the latest, minimally invasive prostate cancer treatments.
The hospital was the fi rst in the Harley Street area to acquire the latest da Vinci xi © robot, allowing its surgeons to perform precise, minimally invasive robotically-assisted laparoscopic prostatectomies. Patients can also benefi t from focal therapy treatment using high-intensity focused ultrasound (HIFU) or Nanoknife, the minimally invasive qualities greatly reducing the side e ects of prostate cancer treatment.
Professors Mark Emberton and Caroline Moore explain more about the latest diagnosis and treatment techniques at King Edward VII’s Hospital:
Transperineal MRI-guided prostate biopsy
The most important way to get an accurate assessment of your prostate cancer risk is to have a high-quality MRI (magnetic resonance imaging) scan, followed by a biopsy if needed. Suspicious areas on the MRI, and sometimes the areas where cancers are commonly seen, will need to be sampled using a biopsy needle. Traditionally the biopsy needle was passed through the back passage into the prostate. Not surprisingly, this could be associated with infections after the procedure, as it is di cult to clean the rectum. A transperineal biopsy – passing the needle through the perineum (the
2 The elegant waiting area | 3 The hospital's London urology specialists (PHOTOS: KING EDWARD VII'S HOSPITAL)
Professor Mark Emberton Professor Caroline Moore
area between the back passage and the scrotum) is much cleaner and the risk of infection is greatly reduced. An ultrasound probe in the rectum is used to view the prostate in real time during the procedure.
The accuracy of targeting the MRI lesion depends upon the skill of the person doing the procedure. It can be
helped by using computer software to fuse the MRI image showing a suspicious area onto the ultrasound image used during the procedure.
Such MR-US fusion techniques are now regularly in use at King Edward VII’s Hospital.
High-intensity focused ultrasound
The aim of focal HIFU treatment is to preserve quality of life, including erectile function, without sacrificing control over the cancer. The minimally invasive qualities of this procedure help to reduce the impact of the side eects that commonly occur after major prostate surgery.
HIFU uses sound waves, produced from high-frequency vibrations originating from a transducer, to create localised cell kill. Temperatures of up to 80-100˚C are reached in the tissue at the focus point, resulting in cell death through necrosis and cavitation. Since its development in the 1940s, it has been used to treat benign and malignant lesions within a number of solid organs, including the uterus, brain, kidney and liver, with the addition of prostate from the 1990s.
The procedure involves delivery of treatment using a transrectal probe, usually under general anaesthetic, with real-time monitoring of treatment eect on an ultrasound platform. The area to be
treated is chosen by the surgeon, based on the prostate MRI and biopsy results.
HIFU is a means of delivering ‘focal therapy’, with treatment targeted to cancer lesion(s) rather than to the whole prostate. Preservation of some ‘normal’ prostatic tissue and surrounding neurovascular structures potentially reduces the sideeect burden associated with standard radical therapies. The outcomes of longer-term studies are now awaited.
HIFU is considered an alternative primary treatment option to traditional radical therapy (radical prostatectomy, external beam radiotherapy, seed brachytherapy). The advantages of HIFU as a prostate cancer treatment is that it is minimally invasive, delivered in the day-case setting, only requires one hospital visit for treatment, and is repeatable if needed.
Furthermore, additional prostate treatment – such as cryotherapy, radiotherapy or surgery – is not precluded if cancer recurrence occurs following HIFU, albeit with a higher risk profile than in the treatment-naïve gland. HIFU treatment is limited to prostates of a moderate size that can be covered by the focal length for treatment, as the anterior aspect of the gland cannot be reached in large glands.
Medium-term outcomes for HIFU have been published, reporting both cancer control and the eect on sexual and urinary function. Biochemical diseasefree survival rates of 75-84%, 63-72%, and 45-68% in low, intermediate and high-risk groups, respectively, were demonstrated over five to eight years of follow-up in recent publications involving a large UK cohort. Around one in four men will have a second HIFU treatment by five years, and one in 15 men will have radical treatment with surgery or radiotherapy.
In terms of functional outcomes, 1% of men have some urine leakage after HIFU, which compares very favourably with radical treatment. Of men who have good erections without the need for tablets before HIFU, two in three will continue to have these after treatment, and one in three men will need to have tablets to
4 A prostate lead nurse guides patients every step of their journey (PHOTO: KING EDWARD VII'S HOSPITAL)
support the erections. The majority of men will notice a reduction in the volume of ejaculate, and fertility can be reduced.
HIFU also has a place as a salvage treatment in cases of recurrent disease following both external beam radiotherapy and seed brachytherapy.
Nanoknife
Nanoknife, also referred to as irreversible electroporation therapy for prostate cancer, is a focal technique used in the treatment of prostate cancer. It is used particularly for small cancers in the anterior prostate.
In irreversible electroporation, quick electrical pulses are administered, with the use of electrodes, around and into the tumour to kill cancerous cells. The name ‘Nanoknife’ is derived from the fact that these electrical pulses eectively cut open the cells’ membrane. The advantages of Nanoknife treatment for prostate cancer include a short hospital stay and recuperation period, a painless procedure that has minimal side-eects, and that the procedure can be repeated.
Disadvantages include a catheter being required for a few days, some men may be infertile due to decreased/ absent ejaculatory fluid, and, currently, there is no long-term data available on side-eects and outcomes.
Robotically assisted laparoscopic prostatectomy
Radical prostatectomy is a well-established treatment for prostate cancer. It has evolved over the years from open surgery into laparoscopic (key-hole) and, currently, robotic-assisted laparoscopic (RALP). In terms of cancer control, it has been shown to have excellent outcomes.
Prostate cancer treatment using the da Vinci xi © robot
The operation is performed using a keyhole technique utilising the latest da Vinci © robot to aid the surgeon. Through small incisions, a special 3D camera and robotic arms are placed into the pelvis, which are then controlled by the surgeon from a separate console within the theatre. This set-up oers a very high-definition view of the prostate (magnified, very well-illuminated 3D, double HD) and surrounding structures, along with highly accurate and versatile movements within the body, allowing the prostate, seminal vesicle (tubes which help produce semen), and occasionally lymph nodes to be removed.
The robotic method has revolutionised radical prostatectomy, as it has led to a significant reduction in blood loss and reduced the length of hospital stay for the
patient over open surgery, whilst giving the surgeon a precision of movement not previously possible by either the open or laparoscopic techniques.
The procedure used today is called an ‘anatomical approach’, which is designed to reduce blood loss and tissue trauma, and can also reduce damage to the nerves necessary for erections.
With thanks to Prostate Matters – prostatematters.co.uk
If you are concerned about your prostate health, or you have received a diagnosis for prostate cancer and are considering private treatment, call a member of the dedicated patient services team at King Edward VII’s Hospital to discuss your options: +44 (0)20 7467 4344, Mon-Fri 9am-5pm
5 Professor Mark Emberton performs the Nanoknife technique | 6 The da Vinci xi © surgical system (PHOTOS: KING EDWARD VII'S HOSPITAL)
