Prostate Cancer Surgery in Turkey

Prostate cancer surgery is an effective treatment method planned according to the stage of the disease and the patient’s general condition, aiming for the surgical removal of the malignant tumor developing in the prostate gland. Radical prostatectomy is the most commonly applied technique and aims to completely remove the cancerous tissue.

Radical prostatectomy methods include open surgery, laparoscopic, and robotic techniques, each offering different advantages. Minimally invasive approaches are preferred by providing clinical benefits such as less blood loss, shorter hospital stay, and rapid recovery.

The recovery process after prostate cancer surgery varies depending on the patient’s age, accompanying diseases, and the surgical technique applied. Urinary control and sexual functions may improve over time; regular follow-up and rehabilitation are important during this process.

The risks of prostate cancer surgery include infection, bleeding, urinary incontinence, and erectile dysfunction; however, with appropriate patient selection and an experienced surgical team, the incidence of these complications can be reduced. Early diagnosis and correct treatment planning increase the success rate.

What Is Prostate Cancer and How Does It Develop in the Body?

The prostate, which has an extremely important place in the design of the male body, is a walnut-sized gland located just below the urinary bladder called the bladder and surrounding the urinary tract like a ring. Its most basic duty is to produce that special fluid that nourishes the sperm enabling reproduction, protects them against external factors, and ensures their survival. All tissues in our body, such as the lungs, liver, or skin, have a flawless renewal cycle; cells are born in a certain order, do their job, divide, and disappear when their time comes. However, sometimes, due to genetic errors or the accumulation of external factors, the control mechanism inside these cells is disrupted.

When the cells inside the prostate lose this control mechanism and begin to multiply continuously and without limits, like the stop button of a factory breaking down, the masses we call tumors are formed. These tumors may be completely benign, meaning they only grow where they are and remain there, or they may also have a malignant character.

The main features that distinguish these cells called malignant from healthy tissue cells are as follows:

• Uncontrolled proliferation
• Breaking through the capsule
• Spreading to surrounding tissues
• Jumping to distant organs

Malignant cells gain the ability over time to pierce the shell they are in and move outside. In more advanced stages, they can infiltrate the blood and lymph vessels and travel to other parts of the body, especially the bones, establishing new colonies there. However, wherever they go, they continue to carry the characteristics of the prostate from which they originated and continue to feed on the male hormone in the body. This information forms the basic philosophy of the treatments to be applied in the later stages.

Which Risk Factors Are Important in the Development of Prostate Cancer?

There is no single and simple answer to the question of why prostate cells suddenly enter this process of uncontrolled proliferation. The process takes shape through the combination of many factors accumulated over the years. However, we have extremely strong clues showing who is more prone to this condition. Knowing these clues is of vital importance for catching the disease at the earliest stage, before it causes any symptoms.

The age factor is the most obvious influence in this picture. As human life gets longer and cells divide and multiply over the years, the probability of small errors accumulating in the DNA replication process increases. For this reason, while this condition is encountered quite rarely in men under the age of fifty, as age advances, especially in the sixties and seventies, the accumulation of these genetic errors becomes much more evident. In addition, a person’s genetic heritage is also one of the strongest guides determining the speed and direction of the process. If this disease is present in close blood relatives in the family tree, especially in a father, uncle, or brother, the risk naturally increases.

The main risk factors that directly increase the probability of this disease occurring and that should be carefully monitored are as follows:

• Advanced age
• Family history
• Genetic mutations
• Ethnic origin

Scientific studies conducted in recent years have shown that some special changes in our genetic code (especially changes in the BRCA genes, which are also known in women for breast cancer) also make it easier for cells to get out of control in men. In individuals carrying this genetic heritage, the disease may knock on the door at a much earlier age, contrary to the general rules. Therefore, knowing the risk factors is the first and strongest step to be taken to increase awareness.

What Symptoms Does Prostate Cancer Show?

One of the most confusing points in the nature of this disease is that it usually grows in deep silence in its early stages. When the anatomical structure of the prostate gland is examined, cells showing a tendency to become cancerous mostly begin in the outer parts of the gland farthest from the urinary tract. Therefore, even if the mass starts to grow, it does not place any pressure on the urinary tract or create an obstruction for a long time. During this silent period, the person can continue their life in an extremely healthy way, completely unaware of what is happening in their body.

However, over time, when the mass expands and begins to compress the urinary canal passing through it, or when this condition progresses simultaneously with age-related normal prostate enlargement, some signals affecting daily life begin to appear. These signals generally make themselves known through changes in urination habits. Since the bladder cannot empty completely, the person feels the need to go to the toilet much more often.

The main symptoms that may occur when the disease progresses and begins to create physical pressure on the urinary tract are as follows:

• Frequent urination
• Waking up at night to urinate
• Difficulty starting urination
• Weakening of urine flow
• Intermittent urination
• Feeling of incomplete bladder emptying
• Blood in the urine
• Blood in the semen
• Persistent bone pain
• Unexplained weight loss

The appearance of these symptoms definitely does not require that a bad scenario be written immediately. This is because in a very large proportion of men in the middle and advanced age groups, completely benign normal prostate enlargement, which is considered a natural part of aging, may also cause exactly the same complaints. The important thing is to seek the opinion of a specialist without delay when these signals are noticed and to ensure that the correct distinction is made.

Which Screening Methods Are Used for Early Diagnosis of Prostate Cancer?

In the past, it was thought that all men in society should regularly undergo the same tests. However, modern medicine realized that putting everyone in the same basket was not right, and that it could lead to unnecessary concerns and unnecessary interventions by finding silent conditions that would never harm the person. For this reason, today an intelligent screening approach that is “specific to the person and the situation” is adopted.

In this approach, the person’s age, family health history, and any complaints are evaluated as a whole. If the person has no complaints, a joint decision is made by discussing the benefits that screening will provide and the unnecessary stress burden it may bring. However, there are some situations in which making these evaluations is of critical importance for the person’s future quality of life. The oldest yet most reliable physical assessment tool used in this process is the prostate examination performed by expert hands. Even this simple examination can open the door to early diagnosis by detecting even a millimetric hardness on the surface of the prostate.

The main groups of people recommended to undergo health screening according to their individual risk profile are as follows:

• Men over the age of fifty
• Those with urinary complaints
• At-risk individuals over the age of forty
• Those with a family history of cancer

While the age limit is lowered in the high-risk group, individuals with a long life expectancy and good general health status constitute the group that benefits the most from these follow-ups.

What Does the PSA Test Mean in the Diagnosis of Prostate Cancer?

In the medical world, Prostate Specific Antigen (PSA), a protein produced by the prostate and regulating the consistency of semen, is an extremely valuable messenger molecule that can be measured with a blood test and gives us clues about the situation inside. The discovery of the PSA test truly created a revolution in the diagnosis of prostate cancer. However, the most misunderstood aspect of this test is that it is not only specific to cancer but directly “specific to the prostate.”

In other words, a high PSA value measured in the blood shows that there is activity in the prostate, but it does not definitively prove that the cause of this activity is cancer. It is just like a smoke detector; when the detector goes off, you cannot say that there is definitely a devastating fire in the house, sometimes the smoke from food forgotten in the kitchen may also trigger that alarm. The PSA value also tends to increase naturally with age as the prostate enlarges in a benign way.

The very common benign conditions that can cause an increase in the PSA level measured in the blood other than cancer are as follows:

• Benign prostate enlargement
• Prostate inflammation
• Urinary tract infections
• Insertion of a urinary catheter
• Recent sexual activity

For this reason, specialists evaluate the figures in the blood test by considering the person’s age, the actual size of the prostate, and the current general health condition as a whole. Sometimes, even if the values are completely within normal limits, a small tissue hardness felt during examination may be a much more meaningful warning sign. The blood test and physical evaluation are two inseparable companions that make up for each other’s deficiencies.

How Are MR and PET Devices Used in Prostate Cancer Imaging?

It is not always possible to clarify the internal situation with only blood tests or physical examination. Unfortunately, the standard ultrasound devices used in the old days to examine the prostate did not have sharp enough eyes to distinguish healthy tissue from diseased tissue. Today, however, a tremendous leap has been made in this field thanks to the technology called Multiparametric Magnetic Resonance (mp-MRI).

These advanced MR devices do not just measure the outer contours or size of the prostate; they examine with a magnifying glass the cellular mobility in the deepest parts of the tissue, how water molecules circulate, and how densely the cells are arranged. Since cancerous cells stand together much more tightly and densely than normal cells, they reveal themselves on the MR screen by shining like a flashlight in a dark room. These images are evaluated by specialists through a certain scoring system, and the degree of suspicion in that area is clearly determined. In this way, unnecessary procedures on a completely clean prostate carrying no risk are prevented.

In more advanced stages of the disease or when it is wondered whether it has spread throughout the body, a much smarter system, Gallium-68 PSMA PET scans, comes into play. There is a special antenna (PSMA) on the surface of cancerous cells, thousands of times more than on normal cells. Smart molecules administered to the patient through the vein and programmed only to find these antennas go and attach themselves wherever there is a suspicious cell in the body and make it light up on the scanner. Thus, even formations of millimetric size do not go unnoticed.

How Is a Biopsy Performed for the Definitive Diagnosis of Prostate Cancer?

No matter how wonderfully imaging methods work, the only world-accepted way to definitively understand the character of a tissue is to take tiny samples from that tissue and look at the face of the cells under a microscope. In the past, biopsy procedures were performed by taking random pieces from the prostate under the blurry guidance of ultrasound. This was sometimes like looking for a needle in a dark room, and there was a risk of missing important areas.

Today, however, this darkness has been completely illuminated with the technology called targeted Fusion Biopsy. The system works just like the advanced navigation devices in our cars. The patient’s previously obtained high-resolution detailed MR images are uploaded to the computer. During the procedure, this MR map is superimposed (fused) on the images of the ultrasound device used. Thus, that suspicious area seen and marked by the MR but unnoticed by the ultrasound appears on the screen as a bright three-dimensional target. Uncertainty is eliminated by taking samples with millimetric precision right from the very heart of that target.

With the development of medical technology, the main prostate biopsy methods applied today are as follows:

• Standard ultrasound-guided biopsy
• Cognitive fusion biopsy
• Software-assisted fusion biopsy
• Direct magnetic resonance-guided biopsy

Where this sampling procedure is performed has also evolved in terms of patient comfort and safety. Since the traditional method, in which the needle passes through the intestine, carries a risk of infection, transperineal procedures performed completely through the outer skin and by a cleaner route are now coming to the forefront. Thus, the risk of febrile infections requiring hospitalization after the procedure has been reduced almost to zero.

What Does the Gleason Score Mean in the Grading of Prostate Cancer?

When the small tissue samples taken reach the pathology laboratory, they are washed with special dyes and placed under the microscope. The main purpose here is to understand how much the cells have lost their normal and well-behaved structure and gone out of control. A very special scoring system called Gleason Scoring has been used in the medical world for years to measure this cellular deterioration.

The farther the cells are from their completely healthy state, the higher the score they receive. The pathology specialist examines the two most common different arrangement patterns of the cells in the tissue and gives them scores between 1 and 5. These two scores are added together to create the identity card of the disease. However, because these mathematical totals can sometimes confuse patients, a new five-step grouping system (ISUP) that expresses the situation more clearly has also been developed.

If the cells are quite similar to their normal structures, this represents a low-risk, dormant, very slowly moving situation that perhaps may never move at all throughout a lifetime. However, if the cells have completely changed shape and become unrecognizable, this indicates a high-risk and rapid process that must be intervened in without delay. This detailed identity card is the most important compass that determines which colors the treatment spectrum to be offered to the person will consist of.

What Is Active Surveillance in Low-Risk Prostate Cancer?

When the word cancer is heard, an urgent surgery or a process full of heavy medications usually immediately comes to mind. However, some of these cellular changes in prostate tissue have such a slow and such a lazy character that it has been scientifically proven that they will never harm the person in any way until the end of their life. In such cases, the strategy applied to protect the patient from the stress or side effects that an unnecessary surgery may bring is called Active Surveillance.

Active surveillance definitely does not mean ignoring the disease and leaving the patient to their fate. On the contrary, it means keeping the situation under very close and high-attention observation. Individuals who choose this path give blood tests at certain intervals, undergo examinations, and when necessary, it is checked with advanced imaging devices such as MR whether the tissue remains in a dormant state. If, during this close follow-up lasting for years, even the slightest stirring, growth, or sign of change in character is observed in the dormant cells, the patient is removed from the surveillance program and the most appropriate treatment step for that time is started immediately. Thanks to this wonderful approach, thousands of people can continue their lives within a completely safe circle without losing anything from their quality of life.

How Is Robotic Surgery Applied in the Treatment of Localized Prostate Cancer?

If the disease has not extended beyond the prostate capsule and has remained completely limited to that area, complete removal of that diseased tissue from the body is one of the most definite and effective ways to regain health. Although this surgical intervention used to require major operations performed with wide abdominal incisions, thanks to the meeting of technology and engineering with medicine, it can now be performed with unique elegance through Robot-Assisted Surgery systems.

In this system, the surgeon sits at a special console right next to the patient and controls advanced-technology robotic arms. High-resolution cameras sent inside through a few very small millimetric holes opened in the abdominal region project details that the human eye cannot see onto giant screens. Since the robotic arms can rotate around their own axis much more agilely than the human wrist, they allow millimetric stitches to be placed even at the deepest, narrowest, and hardest-to-reach points of the body.

The main advantages that robotic surgery offers to the patient and the surgical team compared to traditional open surgeries are as follows:

• High-resolution imaging
• Precise movement capability
• Less bleeding
• Rapid recovery process
• Short hospital stay
• Preservation of urinary continence muscles
• Preservation of sexual function nerves

Thanks to this extraordinary precision, those delicate nerve networks passing right around the organ and the muscular structures that provide urinary continence can be preserved. With very little pain, patients can usually walk out of the hospital and return home within one or two days.

Which Medications Are Used in the Presence of Advanced-Stage Prostate Cancer?

In some cases, the cells may have gone خارج the prostate and may have traveled through the bloodstream to other points in the body and settled there. At this point, intervening only where the prostate is would be insufficient, like extinguishing only one tree in a forest fire. Systemic, that is, intelligent and powerful drug treatments covering the whole body are needed to find and neutralize the cells circulating throughout the body and hiding here and there.

These prostate-origin cells need the male hormone in the body (testosterone) intensely in order to survive, find energy, and multiply. Testosterone is like a fuel for them. Our strongest weapon in advanced-stage treatments is to cut off this fuel source and starve the cells. With this method, known as hormone therapy, the testosterone level in the blood is reduced to very low levels. Cells whose fuel is cut off begin to shrink, go to sleep, and disappear.

This fuel-cutting process, which in the past was performed only with simple injections, is now supported by much more advanced next-generation smart agents in pill form. These next-generation drugs completely block, at the cellular level, the cells’ production of fuel by alternative routes or their use of that fuel. In necessary cases, stronger agents that stop cell division are also added simultaneously to the treatment, transforming the disease into a chronic health condition kept under control successfully for years.

What Is the Smart Lutetium Method in the Treatment of Resistant Prostate Cancer?

Sometimes, as a result of treatments lasting for years, cancer cells may learn ways to survive even in a fuel-free environment and develop a shield of resistance against existing drugs. To break this resistance, the medical world has developed a tremendous technology that truly seems to have come out of science fiction movies. In this field called theranostics, molecules are used simultaneously for both diagnosis and treatment.

As you may remember, we talked about the smart diagnostic molecules that attach to the PSMA antennas on the cells to find the cells in the body. This time, scientists attached not a diagnostic camera but a powerful yet very short-range treatment bomb called Lutetium-177 to the back of the molecule that finds that antenna. This smart system, which mixes into the blood through the vein, goes wherever it is in the body and finds only the cancerous cell, attaches to its antenna, and shatters it by injecting the radiation directly into that cell. It causes no harm to the healthy tissues around it.

Some side effects that patients may experience after the application of this innovative and targeted treatment are as follows:

• Dry mouth
• Temporary nausea
• Feeling of fatigue
• Decrease in blood values

These side effects are generally short-lived and conditions that can be easily managed with supportive measures. Applied in sessions at certain intervals, this method opens a new window to life by producing incredibly successful results even in cases that have developed resistance to all other drugs.

How Is Quality of Life Preserved After Prostate Cancer Treatment?

In the management of this process, the main goal has never been only to eliminate the cancer; the real issue is to ensure that after the disease the person can continue their life in complete physical and mental integrity without breaking away from social life and without losing self-confidence. The drugs used or the surgical interventions applied may cause some temporary changes in the body that need to be adapted to again. Managing these changes requires a professional approach just like the surgery itself.

For example, after surgery, special physiotherapy exercises are introduced so that the muscles in the pelvic region can regain their former strength and the urinary continence function can recover quickly. Regularly exercising these muscles, just like an athlete training, accelerates the recovery process incredibly. Metabolic changes such as hot flashes, muscle loss, or a decrease in bone density that hormone medications may create in the body can be successfully balanced with correctly planned light daily walks, bone-supporting vitamins, and regular nutrition.

In addition, this process requires not only the body but also the mind to heal. Psychosocial support to be received for emotional fluctuations, anxieties, and the process of adapting to life is one of the most illuminating parts of the treatment journey. When the patient and the healthcare team join hands, no matter how rough the roads passed through are, the end of the process can be completed safely and healthily.