Localised prostate prostate cancer refers to prostate cancer that has spread to areas outside the prostate gland, but remains in the prostate region, that is in the prostate gland and the seminal vesicles.
As with all treatments choosing a treatment for localised prostate cancer, or cancer that is described as T1 or T2, depends on the individual's circumstances – such as his age, stage and grade of cancer. In general patients have the choice of surgery, a radical prostatectomy, radiotherapy or watchful waiting.
A radical prostatectomy can be done in a number of different ways including open surgery and robotic surgery and is the removal of the prostate and the seminal vesicle. The aim is to remove the cancer and not damage the adjacent tissue whilst achieving the trifecta – cure, continence and potency as well as minimal complications.
The aim of the surgery is to cure the cancer and reduce the risk of incontinency and impotence. Having performed over 4,000 open surgery cases to date, the most in the Southern Hemisphere, I have been able to refine this technique to ensure exceptional outcomes in terms of cure, continency and minimal complications.
Robot assisted laparoscopic prostatectomy is performed in less than two hours, there is minimal blood loss and the procedure is done through tiny incisions leading to a quicker recovery. Many patients are up and walking the same day and home within two days.
The aim with this surgery is to achieve complete removal of the cancer whilst preserving urinary control and erection function - the trifecta. As one of Australia's most experienced robotic surgeons, I perform more than 200 cases each year.
The DaVinci robot is controlled using two joystick-like arms and several foot pedals. These controls move robotic arms that can be fitted with a variety of different tools. Typically an incision of one to two centimeters allows three or four arms to enter into the patient's body.
The controls then convert every five inches of my movement to one inch of movement inside the patient – this allows for improved fine motor actions. In the theatre I sit at a station and use the built in 3-D monitor for vision to complete the surgery.
Advantages of robotic prostatectomy
The DaVinci robot has revolutionised surgery and thousands of patients have benefited from the use of this technology. With miniature incisions and a laparoscopic approach robotic surgery offers:
Quicker return to normal activity
Reduced risk of incontinence and impotence
Less blood loss
Reduced pain, most patients do not require pain medication after discharge.
This state-of-the-art surgical procedure can offer the best chance for complete recovery. Wristed instrumentation, tremor filtration and 3D magnification aid in performing one of the most demanding aspects of the procedure — nerve-sparing for preservation of sexual function and continence.
Who can have robotic surgery?
Some patients are better suited for robotic surgery, however the prostate cancer must be confined to the prostate gland.
Patients who have had a stroke or cerebral aneurysm are not candidates for robotic prostate surgery, as the surgical table is titled head-first at a 45° angle for the one to three hour procedure. And some cardiac and pulmonary disorders exclude patients from robotic prostate surgery such as angina, congestive heart failure, severe restrictive lung disease, asthma or cardio-obstructive pulmonary disease and any condition requiring supplemental oxygen.
Other factors include severe glaucoma, hip disease or a disorder that's not compatible with the surgical position and obesity.
When can I have sex?
It is recommended to wait four weeks before having sex. Please remember that most patients will be able to climax but there will be no ejaculate.
When can I return to work?
Most patients are able to return to work within one to two weeks and nearly all activity can be resumed by four weeks. Men with occupations that require heavy lifting will need to be on light duties for four to six weeks.
When will I know if all the cancer has been removed?
I will assess recovery, remove the catheter and review the final pathology report with the patient at the first follow-up appointment, which are usually four to seven days after surgery.
When will I be able to have an erection again?
Everyone is different. Some patients start having erections very soon after surgery while others take up to two years. However, my team has consistently demonstrated superior outcomes with the maintenance of sexual function. Each patient is encouraged to see the nurse at my practice who will answer questions.
Why a Robotic Radical Prostatectomy?
Traditional radical prostatectomies require either a large incision with unpleasant side effects or feature limited vision and dexterity. At St Vincent's, I can provide the best opportunity for full recovery from prostate cancer. Experience demonstrates that a robotic radical prostatectomy successfully overcomes these shortcomings and offers patients improved benefits, including minimal risk of incontinence and impotence.
Why should I choose St Vincent's Private Hospital?
St Vincent's Private Hospital was the first hospital in NSW to perform a DaVinci robotic radical prostatectomy in 2005 and today we have the latest model of the machine. The early adoption of this highly advanced laparoscopic prostate cancer treatment demonstrates its commitment to providing world-class healthcare.
Radiotherapy is an important management option for patients with localised prostate cancer. Radiotherapy uses targeted x-rays to destroy cancer cells with radiation and can cure cancer in many sites of the body.
Low dose rate brachytherapy, commonly known as SEEDS, involves the implantation of radioactive pellets or seeds into the prostate. Depending on the size of the prostate between 75 and 100 seeds are used.
High dose rate (HDR) brachytherapy involves the placement of wires into the prostate to deliver high doses of radiation directly into the prostate. Three treatments are given over a 36-hour period and are intended for patients with advanced prostate cancer.
Active surveillance involves the careful monitoring of prostate cancer progression in patients with less aggressive tumours. An increasing proportion of patients with Gleason 6 cancers, particularly in the older age group, are having their tumours monitored.
Whilst most prostate cancers occupy large areas of the prostate, there are some that occupy less than half and often less than a quarter of the prostate gland. These more focal prostate cancers probably constitute about 20% of all prostate cancers. With high quality3T multiparametric MRI combined with template 3D transperineal biopsies and sometimes combined with PSMA PET scanning, it is now much more possible to identify this select group of patients. The advantage of focal treatments of the prostate with energy sources such as the NanoKnife allow eradication of the cancer with minimal side effects.
Whole-gland therapies such as surgery, radiotherapy and brachytherapy have a long and established track record in the treatment of multifocal and high grade prostate cancer. However, their use in more focal cancers may be regarded as overtreatment based on recent data from a large randomised trial (PROTECT trial ). Furthermore, radical prostatectomy, radiotherapy and brachytherapy have a significant side effect profile including urinary incontinence, impotence and rectal damage which are largely avoided by focal NanoKnife therapy.
Why Focal Nanoknife (IRE)
Of the different energy sources used to treat focal prostate cancer, these can largely be separated into thermal energies using freezing and heating and non-thermal energies. Thermal energies such as cryotherapy, high intensity focused ultrasound and laser therapy destroy all tissue including cellular and non-cellular elements as well as nerves and blood vessels and major structures such as rectum, bladder and sphincter. Furthermore, it is difficult to reliably get heat and cold into some tissues with high blood flow and calcification. NanoKnife (IRE) is a non-thermal ablative energy which selectively destroys cells whilst preserving non-cellular tissue elements.. Needles are placed into the prostate via the skin behind the scrotum and a high power electrical current is passed between the electrodes to destroy the cancer and approximately 1 cm of surrounding tissue . IRE has low toxicity on critical anatomical structures such as vessels, nerves (neurovascular bundle) and organs such as the rectum, bladder and urinary sphincter. This makes this technology particularly attractive in the prostate wherestructures such as the neurovascular bundle which supplies erections, the rectum and the sphincter are very close by. Furthermore, this energy source isextremely reliable in destroying the tissue irrespective of the nature of the tissue. Finally, this is arepeatable treatment whereas other therapies such as brachytherapy andradiotherapyare not.
How Is Focal IRE Done?
After a full workup to ensure that our patients are suitable for the program they then undergo a day surgery procedure which takes between 40 and 60 minutes. Depending on the extent of the cancer this may simply ablate the lesion, a quarter of the prostate or a half of the prostate. No prostate cancer cells are resistant to this treatment. Large areas can be treated with minimal side effects.
After the treatment patients stay in the day surgery unit for two to four hours and they are discharged home with a Foley catheter in place. Postoperatively pain is minimal and patients are discharged with tablets for mild pain, moderate pain, bladder spasms and relaxation of the prostate and antibiotics as required.
On day 2 a limited multiparametric MRI is performed. The Foley catheter is left in for two to five days depending on the extent of the treatment.
Focal gleason large-volume Gleason 6 prostate cancer, Gleason 3+4=7 focal prostate cancer and Gleason 4+3=7 focal prostate cancer and select low-volume Gleason 4+4 prostate cancer.
PSA < 15
MRI identifiable tumour which correlates perfectly with targeted biopsies.
Template biopsies confirmed nosignificant prostate cancer outside of this region or outside of that side of the prostate.
Patient refuses standard therapies such as surgery, radiotherapy and brachytherapy.
Patientover 55 and preferablyover 60.
Patient fit for general anaesthesia.
Patient accepts the need for ongoing monitoring.
We believe that this treatment is ideal for patients with limited cancer of intermediate grade (Gleason 3+4 or 4+3 or small Gleason 4+4 tumours). We do not believe that multifocal cancer or very high grade cancer should be treated with this focal therapy as the results of surgery, radiotherapy and brachytherapy in these more extensive cancers is much more established.
We have now treated 200 patients since February 2013.
All patients have been meticulously followed up ( 100% followup )with validated quality of life questionnaires and high quality MRIs and biopsies
Our current outcomes for focal irreversible electroporation in the primary setting (not after radiotherapy) is:
97% clearance of the primary tumour.
0% ongoing incontinence.
Less than5% erectile dysfunction.
No major (Clavien 3 or 4) complications.
Less than10% recurrence in other parts of the prostate ( up to 5 year Follow up ), one third of which had successful redo treatments.
Thirty patients had focal IRE after radiation with no major complications, < 5% mild incontinence and < 20% erectile dysfunction with 90% clearance of the primary tumour.
Currently we are conducting an international multicentre trial to evaluate the role of focal NanoKnife therapy in patients who failed radiotherapy (FIRE trial).
Quality of life questionnaires from our research team.
Multiparametric MRI at six months.
Transperineal biopsy at 12 months.
Possible PSMA PET scanning if these studies are indeterminate.
Pair Matched Patient Reported QOL following Focal IRE versus Robot Assisted RP : An alternative approach to study outcomes of a new PC Treatment. 2018 Submitted with minor revision World Journal of Urology Scheltema M …. Stricker PD
Genito-Urinary Function & QOL after Focal IRE of different Prostate Segments Submitted to Diagnostic & Interventional Radiology 2018 Scheltema M …. Stricker PD
Stricker PD. Nanoknife focal therapy. Invited speaker. 3rd Friends of Israel Urological Symposium 5-7th July 2016. Tel-Aviv, Israel.
Tran M, Jackson B, Boehm M, Haynes A-M, Stricker P, Irreversible Electroporation for Focal Prostate Cancer: Safety, Short-term Functional and Oncological Outcomes. Poster Presentation. 68th Urological Society of Australia and New Zealand Annual Scientific Meeting 11th – 19th April 2015, Adelaide, South Australia
Van den Bos W, Stricker PD et al. Focal Therapy Using IRE in prostate cancer. Synergy Miami, November 2016. Miami Beach, Florida USA.
Siriwardana A, van den Bos W, Kalsbeek A, Thompson J, Ting F, Boehm M, Haynes A, Shnier R, Delprado W and Stricker PD. Focal Irreversible Electroporation (IRE) as a primary and salvage treatment for localised prostate cancer. USANZ 2017 Annual Scientific Meeting 24-27th February 2017, Canberra, Australia
Scheltema, MJ, van den Bos W, Siriwardana AR, Kalsbeek AMF. Thompson JE, Ting F, Bohm M, Haynes AM, Shnier R, Delprado W, Stricker PD. Focal Irreversible Electroporation as primary and salvage treatment for prostate cancer. 5th Global Congress on Prostate Cancer. 28 – 30 June 2017, Lisbon Portugal
Scheltema MJ, Chang JI, van den Bos, Bohm M, Delprado W, Gielchinsky I, de Reijke TM, de la Rosette J, Sirawardana AR, Shnier R, Stricker PD. Diagnostic Accuracy of Mulitparametric Resonance Imaging Following Prostate Cancer Focal Therapy with Irreversible Electroporation. 93rd Annual Meeting Western Section of the American Urological Association, 6 -10 August 2017, Vancouver British Columbia Canada
Scheltema MJ, Chang JI, van den Bos, Gielchinsky I, de Reijke TM, Sirawardana AR, Bohm M, de la Rosette J, Stricker PD. Genito-Urinary Function and Quality of Life after Focal Irreversible Electroporation of Different Prostate Segments. 93rd Annual Meeting Western Section of the American Urological Association, 6 -10 August 2017, Vancouver British Columbia Canada
Scheltema MJ, Chang JI, Bohm B, van den Bos W, Gielchinsky I, Kalsbeek AF, van Leeuwen PJ, de Reijke TM, Siriwardana AR, de la Rosette JJ. Stricker PD. Pair-matched Patient-reported Quality of Life following Focal Irreversible Electroporation versus Robot-assisted Radical Prostatectomy. 37th Congress of the Societe Internationale d’Urologie. 19-22 October 2017, Lisbon Portugal.
Stricker PD Focal Nanoknife Therapy Invited speaker Tolmar National Symposium
NERVE-SPARING ROBOT-ASSISTED SURGERY
Day surgery procedure.
One to two days in hospital
Two to five day Foley catheter.
Six day Foley catheter
Three to six week recovery
Mild to moderate pain.
<1% Major Complications
< 1% major complications.
1-2% ongoing incontinence.
< 10% impotence rate
10-30% impotence (recovery period required).
Suitable for unifocal tumours
Suitable for multifocal tumours.
15% recurrence rate.
PSA recurrence between 10 and 30% depending on extent of tumour.
Can be repeated.
Cannot be repeated
Needs active ongoing surveillance
Focal IRE treatment for the treatment of localised prostate cancer is safe.
IRE is 97% effective in the eradication of the index lesion of the prostate.
There is a < 15% recurrence rate in the rest of the prostate at five years of followup.
IRE has low toxicity and lower common side effects compared to established treatments.
IRE is suitable for recurrences after radiation therapy.
Major complications have not occurred in our series of 200 patients with up to five year followup.
MRI is useful in the followup of patients however it misses between 10 and 20% of recurrences which can only be picked up by transperineal biopsy.
IRE ideally is used selectively in focal intermediate grade prostate cancer to avoid over treatment by more conventional treatments
Multifocal intermediate and high grade prostate cancer generally are much more serious conditions than focal intermediate grade prostate cancer and until IRE can be shown to have
Professor Phillip Stricker, St Vincent's Clinic, St Vincent's Prostate Cancer Centre, Garvan Institute, Kinghorn Cancer Centre. Team: Alexander Blazevski MD, Brian Yuen MD, John Chang MD, Jayne Matthews, Angela Papazoglou, Quoc Nguyen, Anne-Marie Haynes, Maret Boehm, Matthijs Scheltema MD, Willemien Van Den Bos MD, Ilan Gelchinsky MD
From diagnosis and treatment to rehabilitation and research, I believe my highly experienced team and I bring a multifaceted approach to understanding and helping our patients. A summary of these key aspects of that approach is available here in PDF format. If you are suffering from prostate cancer or have reason to believe you might be, you are welcome to contact us or, intially, complete our comprehensive second opinion form.