Prostate Cancer Q&A

Greg Shaw, Consultant Urological Surgeon at The Prostate Centre has been with HCA Healthcare UK since 2016 and here he takes us through his routine, robotic surgery and the latest ways of diagnosing prostate cancer.

I would say 90% of the work I do is regarding prostate cancer.  

I specialise in developing new ways to diagnose prostate cancer. One of these is MRI-Ultrasound Fusion Biopsy. This works by combining an MRI scan image with real-time ultrasound imaging of the prostate. Now, the clever bit is, you take the MRI image which shows you where the suspicious growth is and you superimpose it on your live ultrasound image. Using this technique, you can see a real-time image of any suspicious areas within the prostate, so you can then insert your biopsy needles very precisely into the area of suspicion. It's proving to be a very informative and highly accurate technology.

It's less about surgeon preference and more about using the surgery that is best for each individual patient. Fortunately, most prostate patients can now benefit from robotic surgery, this means many patients have a faster recovery time and spend less time in hospital. There is also a very low rate of complications associated with robotic surgery. 
 
Years ago, robotic surgery was only used in very specific cases, but now, as we've learnt more about how effective this surgery is and the recovery benefits to patients, this has flipped to opting for robotic surgery, unless there is a reason why an alternative type of surgery would be more effective. My team does around 800 cases a year and I think we probably only needed to do around 10 open surgery cases last year. 

For some patients, robotic surgery isn't the best surgical option. 
 
This may be because they've had previous abdominal surgery and the scarring from this can make the use of the robot less effective. Other patients may have existing health conditions that prevent us from using the robot, such as a heart or lung condition. This is because when we operate robotically, patients are laid in a position where their head is down at a 30-degree angle, to allow access to the pelvis. Existing heart and lung conditions make this difficult, as does a high BMI. For these patients, we'd recommend alternative treatments.

Me personally, I do about 150 robotic prostatectomies in a year, across my NHS and private practice, so about three a week. 
 
After the operation, I have many thankful patients who are very pleased with the recovery benefits of robotic surgery. Usually, their cancers are cured with surgery alone and this is what makes my job so rewarding. 

Every patient is different and recovery times can vary, but I remember I once operated on a patient who had his operation in the morning and at about 4.00pm that same day, I found him to have finished The Times crossword and made a start catching up on his emails! So people can go back to working from home on their computer within a day if they feel up to it. 
 
The mobility takes a little bit longer, but most patients are back to full activity, such as jogging or playing tennis, within a month. Comparatively, that's quite quick. With open surgery, for example, it can take two to three months for the surgical wound to heal and the patient’s mobility to return to this extent.

I was first introduced to robotics when I worked at Cambridge University Hospitals, back in 2010. I was a lecturer on prostate cancer for five years and Cambridge had a robot, so that was the first time I got to use it.
 
That was over a decade ago, so it was one of the original models. It only had three arms, whereas nowadays they have four arms so you can do more with them. It has improved greatly since then in terms of what you can do, but the concept was there and I was impressed the moment I saw how precise it was, as well as the view. When you look down the robotic console you get a view that's 3D - stereoscopic vision with 10 times magnification and perfect illumination, as if your nose were an inch from the prostate, which could not be achieved with open surgery. It's only with this very special equipment that you could get that kind of view, and because you can get that kind of view, you can be even more precise with how the tissues are dissected. 

After my first experience with the robot in Cambridge, I spent a year on a specialised training course. As part of a Royal College of Surgeons Fellowship, I was in theatre with a robot every day for the best part of that year. You learn pretty quickly when it's that intensive, it was a fantastic experience. I have now personally performed over 800 robotic radical prostatectomies. The learning process is ongoing and my results seem to improve with time.

The most important thing is that men are aware of their prostate and know what's normal for them. That way, as men age, they are more aware of any changes to the norm. Partners can also help with this and often it’s my patient’s partners who start to notice symptoms, such as being woken up at night by their partner needing to use the toilet more often, or waiting longer for them to pass urine, those kinds of symptoms. Blood in the urine should always prompt a visit to a doctor.
 
As men age, it's extremely common to develop prostate problems. Symptoms are not always due to cancer, but can be. Catching cancer early can make a big difference. The earlier it's caught - the better the treatment outcome. That's why it’s so important not to ignore symptoms and speak to your GP if you notice any changes.
 
I would advise that men over the age of 50 get regular Prostate Specific Antigen (PSA) testing to stay on top of their health. PSA is a protein, made by the prostate and found in the blood which can be detected with a blood test. While an elevated PSA level doesn’t always mean cancer, the higher the level, the more likely it is that a man has prostate cancer, so it is advisable for men over 50 to have regular PSA tests. If the result is high this can be investigated further to diagnose the underlying cause.

Men who have a family history of prostate cancer, as well as men of Afro-Caribbean origin are at an increased risk of developing prostate cancer. For these patients, I would recommend discussing any concerns with their GP. For those with an increased risk, starting PSA monitoring at a younger age, such as in their 40's, may be beneficial.
 
For men who do have a higher than average PSA level detected, provided this is not due to urine infection, further investigations like MRI scanning can be used to identify the cause.

The prostate is right in front of the rectum, which is part of the bowel. Thus, the prostate is examined medically with a finger in the back passage. Cancer can spread into the rectum but that's pretty unusual and there isn't a strong link between colorectal cancer and the prostate other than rare genetic conditions which can predispose to both prostate and bowel cancer.

When I see younger patients with prostate cancer who need to have their prostate removed, it's really important for me to support them by giving them the best chance of preserving their continence and sexual function. NeuroSAFE is a relatively new technique that can help to spare the nerves around the prostate which generate penile erections and help with urinary continence. The main aim is to preserve nerves, and therefore sexual function, without compromising on the removal of the cancer. 
 
During my time as a surgeon, I have had patients who have decided not to go ahead with surgery because of the potential loss of sexual function (losing their erections), only to come back and see me when the cancer had spread, and was thus too late to cure. For me, this really motivates me to work on these new pioneering techniques that can improve the quality of life for men after prostate cancer treatment. 

It's a technique developed in Germany. During the prostatectomy, we spare the nerves, which is what we want to do for all men, but with NeuroSAFE we check the safety of having done so, by looking at the prostate under a microscope, in real-time during the operation, with a pathologist to see that the nerves have been spared without exposing the cancer in that area. The aim is to preserve as much nerve as possible without compromising on removing all of the cancer. This adds another step to the operation but may allow the surgeon more certainty about the safety of nerve-sparing and can have significant benefits for the patient’s future sexual function.

Every patient is different, but if their erections were strong before surgery, then they have better chances of regaining useful erections after surgery. The more nerve tissue is spared, the higher their chances of recovering their erections. Younger men tend to recover their erections better than older men.
 
For some patients, after surgery they may require daily tablets to regain erectile function, others require more involved treatment with injections or vacuum pump devices. It really does all depend on the individual and the degree of nerve-sparing achieved. This is something we plan with individual patients on a case by case basis by analysing the results of their MRI scan and prostate biopsies.

So, the thing that makes it really special is that we're a team. We've got a whole range of people who have a wealth of experience in treating prostate cancer and prostate disease. We come from a range of different backgrounds, so we've got oncologists, surgeons, radiologists, pathologists, all with their own specialised knowledge. And we meet regularly - we take part in what's called a multidisciplinary team meeting. 
 
We get together to review and discuss the cases of any patients who come through The Prostate Centre with a cancer diagnosis. We believe that a consensus of expert opinion is stronger than a single specialists view, this means our patients benefit from the experience and expertise of the whole team. We guide each other and provide a forum to discuss all the options available to each patient, and focus particularly on more difficult or unusual cases.