Prostate Cancer

What is transurethral resection of the prostate (TURP)?

- ADVANCED DISEASE STATE to prevent urinary symptoms - Surgical removal of inner portion of prostate: Get to the prostate through the urethra -Most commonly used surgical procedure for BPH -May be used in advanced prostate cancer to relieve symptoms -No external skin incision

What is involved in the observation or active surveillance for prostate cancer in low risk tumors?

- Confined to the prostate, small, expected to grow slowly - No symptoms o Watchful waiting o Monitor the cancer closely

What are the post-op complications for TURP?

- Hematuria · Bladder spasms · Urinary incontinence · Urethral stricture: Narrowing · Impotence · Changes in orgasm · Infertility

How is low risk prostate cancer monitored closely?

- PSA level every 6 months - DRE yearly - Prostate biopsies and imaging every 1-3 years

What is prostate cancer?

-A slow growing tumor that arises from androgen dependent epithelial cells of the prostate -Hormones like testosterone stimulate the growth of cancer cells

What are the different kinds of hormone therapies?

-Can be used in addition to radiation -Androgen deprivation therapy -Surgical castration (orchiectomy) -Luteinizing hormone-releasing hormone (LHRH) agonists -Antiandrogen receptor antagonists

What are the different kinds of immunotherapy and targeted therapy?

-Cancer vaccine -Immune checkpoint inhibitors -PARP inhibitors

What is robot-assisted laparoscopic radical prostatectomy?

-Complete removal surgically of the prostate gland, seminal vesicles, vas deferns, and surrounding tissue -Potential for nerve damage in the area of the prostate · Can cause impotence · Nerve sparing procedures to prevent

What is catheter traction?

-Decrease bleeding in the area of the prostate and bladder -Three way system that pulls back to provide traction on the catheter -Reason: pull down on the neck of the bladder to provide hemostasis to the area of the prostate by putting pressure onto the bladder -Inflate the balloon and pull to provide short term hemostasis

What are the urinary symptoms present in prostate cancer?

-Difficulty voiding -Frequency -Urinary retention or difficultly emptying the bladder with each void -Decreased size and force of urinary stream: Especially with a urethra obstruction

What are the different kinds of radiation?

-External beam -Stereotactic radiosurgery (CyberKnife): Focused radiation treatment on tumor - Brachytherapy

What is a TRUS guided biopsy?

-Guide the needle biopsy -Ultrasound probe in the rectum -Needle goes into the tumor through the perineal area

What is a prostate specific antigen (PSA)?

-Normal: < 4 ng/ml -> 4.0 ng/ml suggests need for further testing -Likelihood of cancer increases as PSA increases

What is involved in patient education and support of prostate cancer in the early stages?

-Person needs to be comfortable living with cancer with no anxiety -Encourage to engage in risk reduction therapies · Low fat diet with lots of fruits and veggies · Decreased red meat · Mediterranean diet · Healthy lifestyle · Weight reduction · Exercise · Supplements are mixed research: Saw Palmeto and Lycopean

How is hematuria managed?

-Significant problem -Continuous bladder irrigation -Catheter traction

When is chemo used?

-Used in advanced disease when hormone therapy is no longer effective -Resistance to hormone therapy despite increasing the drug levels -The tumor still grows -Often a adjunct to androgen deprivation therapy

What is involved in surgical castration?

-orchiectomy -Removal of the testes which is where testosterone is made

Where does prostate cancer often spread to first?

Bones

What is androgen deprivation therapy?

Decrease testosterone levels

T/F: Chemotherapy is a standard treatment for early stage prostate cancer

False, is not

What is Laparoscopic radical prostatectomy?

For prostate cancer that is confined to the prostate gland if you opt for treatment in addition to surveillance

What are normal PSA levels?

Less than 4.0

What is stage III?

Local spread to bladder or rectum but not to lymph nodes or distant sites

What does a transrectal ultrasound (TRUS) detect?

Presence and location of tumor

What is the most common cancer in US men?

Prostate

Who is at a higher risk of prostate cancer?

Risk increases with age ("if a man lives long enough he will get this"), in men with a first-degree male relative with prostate cancer (especially with men who had it at an early age), and in African Americans

What is stage I?

Small tumor confined to prostate, low Gleason grade, and low PSA level

What is stage IV?

Spread to regional lymph nodes and/or distant organs (bones, lungs, liver, brain)

How is urine output determined with CBI?

Subtract volume of irrigate infused from the total volume in catheter drainage bag

T/F: Most men have at least temporary ED from prostate cancer surgery

True

What is stage II?

Tumor remains confined to prostate but larger, higher Gleason grade, and PSA levels

What is a urethral stricture due to?

bladder neck constrictor or narrowing of the urethra

Likelihood of cure is high in ___ disease; often diagnosed in ___ stages

early; advanced

What is the basic anatomy of the male reproductive tract?

o Below the bladder o Urethra goes through the prostate gland o Seminal vesicles are near the urethra o Urinary symptoms are common in advanced prostate cancer

What is involved in a prostate cancer diagnosis?

o Digital rectal exam o Prostate specific antigen (PSA) o Transrectal ultrasound (TRUS) o TRUS guided biopsy

What are the clinical manifestations of prostate cancer?

o Early stage cancer may be asymptomatic o Urinary symptoms are common o Hematuria o Blood in semen o Painful ejaculation

How is prostate cancer graded?

o Gleason grade based on features of prostate cancer cells o Graded on a scale of 1 to 5 - Grade 1: resembles normal prostate tissue - Grade 5: "high grade", undifferentiated, barely resembles normal cells - Higher the grade the more aggressive, grow quickly, and spread to other areas

What is a digital rectal exam?

o Insertion of a finger into the rectum o Palpate the prostate through the anterior rectal wall o Divided into two lobes with the median sulcus in the middle -You can feel the median sulcus and the lobes and if there is tumor present you will be able to feel it · Otherwise it will feel smooth · Tumor will be hard with irregular borders

What are the different surgery options for prostate cancer?

o Laparoscopic radical prostatectomy -Robot-assisted laparoscopic radical prostatectomy o Suprapubic prostatectomy o Perineal prostatectomy o Retropubic prostatectomy o Transurethral resection of the prostate (TURP)

What are the prostate cancer screening guidelines?

o Men with a 10+ year life expectancy should have an opportunity to make an informed decision in consultation with their health care provider about prostate cancer screening o Screening discussions should begin at age 50 in men with average risk and earlier in men at high risk o Screening involves: Prostate specific antigen (PSA) test with or without digital rectal exam

What are the different avenues of prostate cancer treatment?

o Observation or Active Surveillance: If the tumor is very small and only in the prostate o Surgery: Most common and may be combined with radiation in advanced diseases o Radiation o Hormone therapy o Chemotherapy o Immunotherapy and Targeted Therapy

What might bone metastasis cause?

significant pain, fractures, spinal cord compression, or hypercalcemia

What are treatment strategies in addition to opioids for bone metastasis?

· Bisphosphonates: Decrease the breakdown of bone · Denosumab (Xgeva): Promote bone growth · Corticosteroids: Relieving edema and inflammation · External beam RT · Radiopharmaceuticals (Strontium-89,Samarium-153): · Relieve pain and positively impact the disease process · Kyphoplasty to stabilize vertebral fractures

What are PARP inhibitors?

· DNA repair · Good for those with Braca gene mutation · Rucaparib (Rubraca) · Olaparib (Lynparza)

What are the symptoms of a urethral stricture?

· Decrease urinary stream · Urinary retention · Overflow incontinence

What are common chemo drugs?

· Docetaxel (Taxotere) · Cabazitaxel (Jevtana) · Mitoxantrone (Novantrone) · Estramustine (Emcyt)

What is a perineal prostatectomy?

· Enters through the perineum · Not common

What are the SE of radiation?

· External beam has more skin SE, dermatitis, and bowel irritations · Bowel problems (radiation proctitis (inflammation of the rectum), diarrhea, rectal bleeding, bowel incontinence) · Urinary problems (radiation cystitis, increase frequency, burning with urination, hematuria, urinary incontinence, urethral stricture) · Impotence · Fatigue: Energy conservation strategies · Lymphedema: Radiation can affect lymph nodes; Occurs in the lower extremities and genital regions

What are examples of antiandrogen receptor antagonists?

· Flutamide (Eulexin) · Bicalutamide (Casodex)

What is a suprapubic prostatectomy?

· Go in above the bladder · Remove the prostate here

What is brachytherapy?

· Implant radioactive seeds into the prostate · Localized with some spread to the other tissues

How is a urethral stricture treated?

· Intermittent self-catheterization to treat · Bladder neck or urethral dilation · Goal: Decrease narrowing of stricture

What are examples of Luteinizing hormone-releasing hormone (LHRH) agonists?

· Leuprolide (Lupron) · Gosereline (Zoladex)

How are bladder spasms managed?

· Maintain CBI to prevent blood clot formation · Oxybutinin (Ditropan) · Belladonna opium suppositories

How is impotence treated?

· Oral phosphodiesterase 5 (PDE) inhibitors (sildenafil, tadalifil, vardenafil): Viagra, Cialis -Penile injection -Intraurethral alprostadil -Vacuum-assisted erection devices -Penile implants

What are immune checkpoint inhibitors?

· Pembrolizumab (Keytruda): PD-1 inhibitor · Boosts immune response against the cancer

How can you teach a pt abut pelvic floor muscle exercises?

· Post op · ID pelvic floor muscles · Stop urination mid stream · Tighten the muscles that pass gas · You can do them in any position but might be better laying down · Hold the contraction for 3 secs and release for 3 secs and repeat! · 3x a day with 10 sets of repetitions · Do not flex the muscles in the abdomen of buttocks and breath easily

What are penile injections?

· Prostaglandin E1, papaverine, phentolamine · Self injection · Vasodilators

What is a dry orgasm?

· Retrograde ejaculation into the bladder · Pleasurable but no ejaculation

What is a penile implant?

· Semi rigid rod in the penis that can be bent up and down · Inflatable has a fluid filled reservoir and a pump to achieve a erection · Release valve to have it go back to normal

What are the SE of androgen deprivation therapy?

· Similar to menopause symptoms · Hypogonadism with more estrogen · Vasomotor flushing (hot flashes) · Loss of libido · Decreased bone mineral density (osteoporosis) · Anemia · Fatigue · Increased fat mass, lipid alterations, and decreased muscle mass · Gynecomastia (breast tissue growth) and mastodynia (pain in breast tissue) · Increased risk of diabetes: Insulin resistance and metabolic syndrome

What are cancer vaccines?

· Sipuleucel-T (Provenge) · Boosts the immune system to attack the cancer cells · Used in advanced cancers · Made specifically for each patient · Altered blood cells are given to the patient and attack the prostate cancer

What is kyphoplasty good for?

· Stabilize vertebral fractures · Men with vertebral compression fractures · Balloon between the vertebrae with cement to stabilize and support

How is urinary incontinence managed?

· Stress incontinence is common · Older men have higher rates of permanent cases · Improves with time after surgery · Continence products: To collect the leakage of urine -Pelvic floor muscle (Kegel) exercises can help accelerate time to heal

What is a intraurethral alprostadil?

· Suppository into the urethra to stimulate erection

What is a retropubic prostatectomy?

· Surgical incision lower going around the bladder to remove the prostate

What is continuous bladder irrigation?

· Three-Way System for Bladder Irrigation · Regulate flow of irrigation to keep urine pink without blood clots · Speed up the flow if you see blood in the urine