TürkçeProstate cancer radiation therapy is a highly effective and curative oncological treatment that directly targets and destroys tumor cells using high-energy radiation beams. Achieving the highest level of success in this process depends on critical urological preparations performed before treatment to ensure that the radiation is precisely focused on the target while protecting healthy organs. Mapping the prostate with special markers, applying protective hydrogel spacers that separate adjacent tissues from the radiation field, and managing potential urinary tract or bladder sensitivity after treatment with modern techniques form the foundation of this comprehensive therapeutic approach. Properly planned interventional steps effectively control the disease while safely preserving quality of life.
How Does Prostate Cancer Develop and How Is the Decision for Radiotherapy Made?
The prostate is an important part of the male reproductive system. It is a walnut-sized gland located just below the urinary bladder, through which the urethra passes. Prostate cancer may develop when the cells within this gland begin to multiply uncontrollably due to aging or genetic predisposition. One of the most remarkable characteristics of the disease is that it usually causes no noticeable symptoms in its early stages. Symptoms such as difficulty urinating, a weak urinary stream, or frequent nighttime urination are generally associated with benign prostate enlargement rather than cancer. Because of this silent progression, regular screening tests are extremely important for early detection.
After the disease has been diagnosed, different treatment options such as surgery and radiotherapy are evaluated during treatment planning. The decision regarding which treatment is more appropriate depends on many factors, including the size of the tumor, the patient’s age, overall health status, and personal preferences. Radiotherapy offers a powerful alternative for patients who do not wish to undergo surgery or for whom anesthesia presents significant risks. It is also frequently used as an additional treatment following surgery in certain high-risk cases.
What Does the Blood PSA Test Mean in Prostate Cancer Screening?
The most commonly used method for the early detection of prostate cancer is the Prostate-Specific Antigen (PSA) test, which is performed using a simple blood sample taken from the arm. PSA is actually a protein produced by the prostate gland that helps liquefy semen. Under normal conditions, only very small amounts are found in the bloodstream. However, when there is damage, inflammation, benign enlargement, or cancerous growth within the prostate, the amount of PSA entering the bloodstream begins to increase.
During evaluation, different reference values are considered according to the patient’s age. The main reference age groups are:
- 40–49 years
- 50–59 years
- 60 years and older
The main reason for this age classification is that the prostate gland naturally enlarges with age, leading to a gradual increase in PSA levels. Since the prostate is smaller in younger men, lower PSA values are expected. If a patient’s PSA level exceeds the safe reference range for their age group, or if a suspicious area of hardness is detected during a digital rectal examination, obtaining a tissue sample becomes necessary.
How Is Prostate Cancer Diagnosed with MR Fusion Biopsy?
In the past, prostate biopsies were performed only under ultrasound guidance, and tissue samples were taken randomly from different areas of the gland. However, this traditional approach could miss small tumors hidden in the anterior regions of the prostate or deep within the tissue. To overcome this limitation, modern medicine has introduced the much more precise MR fusion biopsy technique.
Before the procedure, the patient undergoes a detailed prostate MRI, and suspicious areas are marked with millimetric precision using computer software. This map is then transferred to the ultrasound system used during the biopsy, allowing both images to be superimposed. As a result, the biopsy needle is directed not to random areas but directly toward suspicious targets.
In current practice, the procedure is performed through the skin between the scrotum and the anus (transperineal approach). The greatest advantage of this approach is its extremely low infection risk, since there is no contact with the bowel. Because the procedure is performed under local anesthesia or mild sedation, patients generally experience very little discomfort.
Into Which Risk Groups Are Patients with Prostate Cancer Classified?
The tissue samples obtained during the biopsy are examined in detail under a microscope in pathology laboratories. This examination determines the degree of structural abnormality in the cells and how aggressive the cancer cells appear. This degree of cellular abnormality is known as the Gleason Score. The Gleason Score serves as a guide in determining the treatment strategy.
The internationally accepted risk groups used to classify the disease are:
- Low risk
- Intermediate risk
- High risk
In patients within the low-risk group, the tumor is still very small, the PSA level remains below a certain threshold, and the cellular structure is relatively close to normal. For these patients, “active surveillance,” which involves closely monitoring the disease through regular tests and imaging rather than initiating immediate treatment, may sometimes be considered. In the intermediate-risk group, the tumor has grown somewhat larger and cellular abnormalities have become more pronounced. In the high-risk group, the disease has a strong potential for rapid progression, the cellular architecture is severely disrupted, and powerful treatment methods should be initiated without delay.
How Does Radiotherapy Affect Prostate Cancer?
Radiotherapy is a treatment modality that uses high-energy radiation beams to stop the growth of cancer cells and gradually destroy them. These radiation beams directed at the prostate damage the genetic material of cancer cells, eliminating their ability to multiply. Since the cells can no longer regenerate, they eventually die and are removed by the body.
The primary objective during treatment planning is to deliver a radiation dose high enough to eradicate the cancer while minimizing radiation exposure to nearby healthy organs such as the bladder and rectum. Due to their biological characteristics, prostate cancer cells are particularly sensitive to receiving high doses of radiation in fewer treatment sessions. This scientific principle has enabled the development of modern radiotherapy technologies that shorten treatment duration while improving patient comfort.
Which Methods Are Included in External Beam Radiotherapy?
External beam radiotherapy is a treatment method in which the patient lies on the treatment table while radiation beams generated by an external source are directed into the body toward the targeted area. In the past, this treatment covered much larger areas and was associated with more side effects. Today, thanks to advances in computer technology, it has become significantly safer.
The main modern external radiotherapy techniques include:
- Intensity-modulated technique
- Image-guided technique
- Stereotactic treatment
In intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT), the radiation beams are shaped to precisely match the three-dimensional contour of the prostate. The intensity of the beams is adjusted from different angles so that the highest radiation dose is concentrated only within the cancerous tissue. Stereotactic body radiotherapy, also known as pinpoint treatment, delivers extremely high radiation doses to the tumor with millimetric precision in far fewer treatment sessions. Unlike older treatment schedules that lasted for many weeks, this approach can often be completed within just a few weeks.
How Is Brachytherapy (Internal Radiotherapy) Applied in Prostate Cancer?
Brachytherapy involves placing small radioactive sources directly into the center of the prostate using specialized instruments rather than delivering radiation from outside the body. As a result, the radiation source is positioned directly within the tumor, allowing radiation energy to remain confined to the prostate without significantly affecting surrounding healthy tissues.
Brachytherapy is generally divided into two categories according to the rate at which radiation is delivered:
- Low-dose-rate treatment
- High-dose-rate treatment
In low-dose-rate treatment, tiny radioactive seeds approximately the size of rice grains are permanently implanted into the prostate. These seeds slowly and continuously emit radiation over several months, gradually destroying the tumor from within, and are primarily preferred for low-risk patients. In high-dose-rate treatment, however, the radioactive sources are not left permanently inside the tissue. Instead, they are temporarily inserted into the prostate through specialized needles, deliver a very high radiation dose within minutes, and are then removed. In patients with more aggressive disease, this method is often combined with external beam radiotherapy to enhance treatment effectiveness.
Why Are Gold Markers Placed Inside the Prostate Before Radiotherapy?
The prostate is not a completely fixed organ within the body. Daily physiological events such as breathing, bowel movement, or the fullness of the bladder can cause millimetric shifts in its position. During external radiotherapy, the treatment machine focuses on predetermined coordinates. If the prostate has shifted from its planned position, radiation may miss the target and instead affect the bowel or bladder.
To prevent these millimetric positional changes from compromising treatment accuracy, gold fiducial markers are inserted into the prostate before radiotherapy through a minor urological procedure. Performed under local anesthesia in an outpatient setting, this short procedure involves placing several tiny pieces of pure gold into designated areas of the prostate under ultrasound guidance.
The main advantages of this procedure include:
- Precise targeting
- Protection of surrounding organs
- Millimetric tracking
Because gold appears very clearly on the X-ray imaging systems used by radiotherapy machines, the system first identifies these markers before each treatment session. It then calculates the prostate’s exact position for that day and delivers radiation only to the locked target area. This minimizes the possibility of missing the target.
How Does the Hydrogel Spacer Used to Protect the Rectum Prevent Radiation Damage?
From an anatomical perspective, the back surface of the prostate lies almost directly adjacent to the rectum, the final part of the large intestine. While radiotherapy targets the prostate, this close anatomical relationship means that some high-dose radiation may unintentionally reach the rectal wall. Over time, this may lead to tissue damage, thinning of the bowel wall, and serious rectal bleeding.
Hydrogel spacer application has been developed to address this problem and has produced highly successful outcomes. During this procedure, which is performed in the operating room under general or spinal anesthesia, a special liquid gel that gradually dissolves within the body is injected into the narrow space between the prostate and the rectum. Within seconds after injection, the gel solidifies into a soft cushion-like structure.
This creates a physical separation between the prostate and the rectum, moving the rectal wall away from the high-dose radiation field. As a result, the risk of bowel bleeding or bowel movement problems after radiotherapy is significantly reduced. The injected gel completes its function over several months before gradually being absorbed and eliminated from the body through the urinary system.
When Is Radiotherapy Recommended After Prostate Cancer Surgery?
In some cases, patients may choose complete surgical removal of the prostate as their primary treatment. However, after surgery, the removed tissue is carefully examined by pathologists to determine whether the tumor has extended beyond the prostate capsule and whether cancer cells remain at the surgical margins. If there is a high risk that microscopic cancer cells remain, surgery alone may not be sufficient.
In this situation, radiotherapy is introduced as an additional treatment. Postoperative radiotherapy is generally divided into two main categories:
- Adjuvant radiotherapy
- Salvage radiotherapy
Adjuvant radiotherapy is administered soon after surgery, before the patient’s PSA level begins to rise, based on high-risk findings identified in the pathology report to prevent recurrence from occurring. However, because this approach may expose some patients who have already been cured by surgery alone to unnecessary radiation, it is now evaluated more carefully.
How Is Salvage Radiotherapy Applied in Recurrent Prostate Cancer?
The preferred modern urological approach is to closely monitor the patient after surgery. If serial PSA measurements begin to rise above a certain level during follow-up, this indicates that residual cancer cells may have become active again. Radiotherapy administered promptly at this stage is known as salvage radiotherapy.
Timing is critical in salvage radiotherapy. Starting radiation treatment before PSA levels rise substantially, while the disease is still at a molecular stage, significantly increases the likelihood of treatment success. This approach protects patients from unnecessary side effects associated with routine adjuvant treatment while ensuring that they receive the appropriate intervention when it becomes necessary. Depending on the extent of the disease, hormone-suppressing medications may sometimes be added to further enhance treatment effectiveness.
What Are the Early Bladder-Related Side Effects of Radiotherapy?
While radiotherapy directed to the pelvic region destroys cancer cells, it may also temporarily cause inflammation in nearby healthy tissues. During radiation treatment or within the first few months after its completion, some patients may develop urinary symptoms. This is a natural tissue response to radiation.
The most common early complaints include:
- Frequent urination
- Burning during urination
- Sudden urinary urgency
- Difficulty urinating
In particular, irritation of the bladder lining may cause patients to feel the need to urinate much more frequently than usual. Radiation may also produce temporary swelling and edema within the prostate gland, leading to mild narrowing of the urethra and a slower urinary stream. These symptoms are generally temporary and tend to improve within a few weeks with adequate fluid intake, pain relievers, or simple medications that relax the muscles of the prostate.
How Is Urethral Stricture Treated If It Develops After Radiotherapy?
Months or even years after radiotherapy, scar tissue may develop within the urethra as a long-term effect of radiation. Since this scar tissue loses its elasticity, it gradually narrows the urinary passage and makes urination increasingly difficult. Conditions such as diabetes or exposure to very high radiation doses may increase the risk of developing urethral strictures.
When urethral narrowing occurs, treatment is generally planned in a stepwise manner. The first step is usually an endoscopic incision procedure. Under anesthesia, special optical instruments are inserted through the urethra, and the narrowed segment is widened by making an internal incision using either a laser or a cold knife. This procedure is often highly effective for short strictures, although recurrence may occur if the scar tissue is particularly dense.
If endoscopic treatment is insufficient or the narrowing is extensive, open reconstructive surgery may be necessary. During this operation, the narrowed segment of the urethra is completely removed, and the healthy ends are reconnected. Alternatively, tissue taken from the inner cheek may be used as a graft to widen the urinary passage. When performed by experienced surgeons, open reconstructive procedures can provide lasting relief.
How Are Late Bladder Bleeding Complications After Radiotherapy Controlled?
One of the rare but troublesome late side effects of radiotherapy is damage to the small blood vessels lining the inside of the bladder. These fragile vessels lose their normal structure and become prone to bleeding even after minimal irritation. Persistent blood in the urine and the accumulation of blood clots within the bladder can significantly reduce the patient’s quality of life.
The methods used to manage these persistent bleeding episodes include:
- Clot evacuation
- Intravesical medication
- Endoscopic coagulation of bleeding vessels
- Hyperbaric oxygen therapy
Initially, the bladder is irrigated to remove accumulated blood clots, and special solutions that promote hemostasis are administered. If bleeding persists, endoscopic treatment may be performed to seal the bleeding blood vessels using electrical energy. When these local treatments remain ineffective, hyperbaric oxygen therapy is considered. Breathing pure oxygen under high pressure inside a specialized chamber stimulates the formation of healthy new blood vessels within the bladder wall and significantly promotes tissue healing.
How Does an Artificial Urinary Sphincter Help Treat Permanent Urinary Incontinence After Radiotherapy?
Particularly in patients who have previously undergone prostate surgery followed by radiotherapy, the urinary sphincter muscles responsible for maintaining continence may be subjected to a double injury. Radiation can reduce the elasticity and strength of these muscles, causing permanent urinary leakage during coughing, sneezing, or standing up. Although pelvic floor muscle exercises are recommended during the first months, surgery may become necessary when tissue damage is severe.
Simple sling procedures placed beneath the urethra are generally not preferred in patients who have received radiation therapy because their tissue healing capacity is reduced. Instead, implantation of an artificial urinary sphincter is considered the most reliable and successful solution.
The artificial sphincter is a completely internal three-component system that is not visible from the outside. It consists of a cuff surrounding the urethra, a small pump implanted within the scrotum, and a fluid-filled reservoir placed inside the abdomen. The system normally remains closed, preventing urinary leakage. When the patient wishes to urinate, they squeeze the small pump in the scrotum several times, causing the cuff around the urethra to deflate so urine can pass freely. After a short period, the fluid automatically returns to the cuff, securely closing the urinary passage once again. This system allows patients to return to daily and social life with confidence and continence.
How Does the TUR-Forage Procedure Provide Relief If Obstruction Develops in Advanced Prostate Cancer?
Sometimes, independently of prostate cancer treatment, the tumor tissue may grow to such an extent that it completely compresses the urethra passing through its center. The patient becomes unable to urinate, excessive urine accumulates within the bladder, pressure may be transmitted to the kidneys, and an emergency situation develops.
In such unavoidable circumstances, a minimally invasive procedure called TUR-Forage is performed. This operation is not intended to completely remove the cancer but rather to relieve the obstruction and restore the patient’s ability to urinate comfortably. Under anesthesia, instruments are inserted through the urethra, and the obstructing tissue is shaved away from the inside, effectively creating a tunnel.
The potential risks associated with this palliative procedure include:
- Bleeding during the procedure
- Postoperative swelling
- Retrograde ejaculation
- Difficulty controlling urination
Since shaving the tissue widens the bladder neck, semen frequently flows backward into the bladder rather than exiting through the penis during orgasm. In addition, depending on the extent of the tumor, there is a possibility of injury to the urinary sphincter muscles. Therefore, this procedure should only be performed when absolutely necessary by highly experienced surgeons.
How Is HIFU Applied If Prostate Cancer Recurs After Radiotherapy?
In some patients, many years after radiotherapy, the tumor may recur only within the prostate without spreading elsewhere in the body. In the past, surgically removing a previously irradiated prostate that had become adherent to surrounding tissues was extremely risky and was associated with a high incidence of complications such as urinary incontinence. Today, High-Intensity Focused Ultrasound (HIFU) has become an important treatment option in such situations.
HIFU works by directing high-intensity sound waves through a specialized instrument inserted via the rectum and focusing them directly on the cancerous area within the prostate. Just as a magnifying glass concentrates sunlight onto a piece of paper to generate heat, these sound waves create extremely high temperatures only within the cancerous tissue, causing thermal destruction of the malignant cells. The greatest advantage of this procedure is that while targeting the cancer, it largely preserves the nerves responsible for erections and the muscles responsible for urinary continence. As a result, patients have the opportunity to receive an alternative treatment with fewer serious side effects.
How Should Follow-Up Be Managed for a Healthy Life After Prostate Cancer Treatment?
For every patient who successfully completes cancer treatment, recovery is not considered finished. The most important goal is preserving this state of health and maintaining it for many years. Regular urological follow-up is indispensable for detecting recurrence at an early stage and managing any late side effects caused by treatment. During follow-up, the most important indicator remains the blood PSA level, which should be measured at regular intervals according to the patient’s risk profile.
Hormonal medications used during treatment may have tiring effects on the bones and muscles. The following measures are recommended to make this period easier:
- Healthy nutrition
- Regular physical exercise
- Calcium supplementation
- Vitamin D supplementation
Establishing weekly exercise routines is particularly important for preserving muscle mass and preventing osteoporosis. Maintaining a healthy body weight through proper nutrition also helps prevent metabolic problems such as insulin resistance. These supportive measures, planned under medical supervision, not only help patients remain oncologically healthy but also enable them to maintain a high quality of life with lasting comfort. Although the journey through prostate cancer is long and requires patience, current medical approaches and regular follow-up allow patients to return safely to their daily lives.
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