TürkçeNo, not every prostate cancer requires surgery, and not every detected tumor necessarily has a fatal character. Prostate cancer surgery is performed without delay only at stages when the tumor has a high growth rate, displays an aggressive cellular structure, and poses a direct life-threatening risk to the patient’s health. In silent and very slowly progressing forms of the disease, unnecessary surgical interventions that would burden the body are carefully avoided. In individuals diagnosed with this condition, the timing of surgical intervention is determined entirely on a personalized basis, with a focus on preserving quality of life at the highest possible level, together with the anatomical extent of the tumor, its biological potential, and the patient’s general health profile.
Is Prostate Cancer Really Always Fatal?
When prostate cancer is mentioned, it is quite common for people to imagine a condition that spreads very rapidly and is irreversible. According to statistics, the fact that it is the second most common organ cancer among men is one of the factors that fuels this fear. As age advances, the likelihood of cancerous cells developing in the prostate gland increases considerably. The disease is most commonly detected in individuals aged sixty-five and older. However, there is a very important medical fact that should not be overlooked here. Many studies show that a significant proportion of elderly men have cancer cells within the prostate tissue, yet these individuals lose their lives not because of prostate cancer but due to very different and ordinary causes such as heart disease or the natural aging process.
This clearly reveals that prostate cancer can often be extremely slow-growing, almost dormant, and structured in a way that may cause no harm to the person throughout life. Sometimes a tumor remains only a few millimeters in size for years and shows no tendency to spread to other organs. Of course, this does not mean that the disease will always follow an innocent course. If the cancer cells have an aggressive character and are not detected in time, they may spread to the lymph nodes, bones, or other organs. When the disease is diagnosed while it is confined only to the prostate gland, the chance of disease-free survival remains very high, whereas these success rates may decline when it has spread throughout the body. Therefore, the main issue is not merely the presence of cancer, but being able to determine precisely whether that cancer poses a real risk to the person’s life.
What Is Replacing Traditional Methods in Prostate Cancer Diagnosis?
In the past, suspicion of prostate cancer was based mainly on measuring the PSA level in the patient’s blood and performing a digital physical examination. When a suspicious condition was detected, tissue samples were taken from various regions of the prostate using standard ultrasound in what could be described as a blind manner. Conventional ultrasound devices do not have the ability to clearly distinguish cancerous tissue from healthy tissue. Therefore, detecting cancerous cells through ten or twelve samples taken from random areas of the prostate was somewhat dependent on chance.
The greatest disadvantage of this old method was that truly dangerous and aggressive tumors could remain hidden in hard-to-reach areas of the prostate and be missed. Another important problem was that when the needle happened to reach very small and slow-growing cancer foci that would never harm the patient, the person could unnecessarily be labeled as a cancer patient. Moreover, because these biopsies were mostly performed through the bowel, there was a risk that bacteria from the intestinal flora could enter the bloodstream and cause serious infections. To protect patients from these infections, intensive antibiotic treatments were started days in advance. Today, however, long-term antibiotic use solely to lower PSA levels or prevent infection is not preferred because it leads to resistant bacteria. Medical approaches have shifted significantly toward more rational and targeted diagnostic tools without exposing the patient to the risk of infection.
Why Are Multiparametric MRI and Fusion Biopsy Important for Prostate Cancer?
Today, when a suspicious condition is seen in blood tests, instead of taking patients directly for biopsy, an advanced technology called multiparametric prostate MRI is used. This special MRI does not merely examine the shape of the prostate tissue; it analyzes in great detail the movement of water molecules within the tissue, cell density, and the blood supply structure in the region. Based on the data obtained from radiological examinations, the likelihood of a dangerous tumor being present in the prostate is graded using a special scoring system. If this score is low, there is most likely no aggressive tumor in the patient’s prostate, and the patient is largely spared the stress of a biopsy. However, if the score is high, it becomes clear that a tissue sample must be taken from that area.
At this point, MR-TRUS fusion biopsy technology comes into play. This system works by superimposing the patient’s previously obtained MRI images with the images from the ultrasound device used during the procedure in a computer environment. Like a smart navigation system, it marks the suspicious cancer focus on the screen. The urologist directs the needle not to random areas of the prostate but directly into the exact center of this marked target. Today, this procedure is generally performed through the skin rather than through the bowel. The main advantages these smart transperineal biopsy procedures offer patients are as follows:
- Near-zero risk of infection
- Easy access to the anterior regions of the prostate
- Obtaining tissue samples from the targeted area with millimetric accuracy
- A significant reduction in the likelihood of bleeding after the procedure
- Less pain
Is Immediate Surgery Necessary in Every Prostate Cancer Diagnosis?
Many people who see the word cancer in the pathology report after a biopsy think they must undergo surgery the very next day to prevent the disease from spreading throughout the body. However, prostate cancer does not always require urgent surgical intervention. When the tissues obtained from the patient are examined under a microscope, a special scoring system is used to show how rapidly the cancer cells divide and how aggressive they are. If the detected cancer is confined to only a small area of the prostate, the cells tend to grow slowly, and the person’s general health is suitable, the decision for surgery may be postponed.
The aim here is to protect the patient from conditions that may reduce quality of life, such as urinary incontinence or impairment of sexual functions, which may arise due to the nature of the surgery. There are two different waiting strategies applied to patients at this stage. One is the active surveillance approach, which involves monitoring the patient very closely with regular tests. The other is watchful waiting, which is applied mainly to elderly patients and those with other serious illnesses and involves moving to palliative treatments if the disease begins to cause symptoms. In short, depending on the patient’s age and the character of the cancer, careful monitoring instead of undergoing surgery may sometimes be a much safer and more reasonable option.
How Does the Active Surveillance Process Proceed for Prostate Cancer?
A decision for active surveillance does not mean leaving the patient untreated and abandoning them to their condition. On the contrary, this process requires a very meticulous and disciplined follow-up program. Planned check-ups are carried out to keep the patient within the safest possible range without losing the opportunity for treatment. Throughout this surveillance process, the patient’s condition is continuously monitored to determine whether the disease shows signs of progression. If any adverse development occurs, a plan to move to definitive treatment methods is kept ready without delay.
The main methods used in monitoring a patient included in an active surveillance program are as follows:
- PSA blood tests performed at specified intervals
- Regular physical prostate examinations
- Multiparametric prostate MRI scans performed during follow-up
- Confirmatory biopsies performed at the end of the first or second year
In addition to this intensive follow-up program, changes the patient makes in daily life also form a very important part of the process. The person is expected to establish a healthy dietary routine and avoid animal and saturated fats as much as possible. Eating a diet rich in vegetables and fiber, exercising regularly, avoiding smoking, and keeping stress under control contribute positively to the process by strengthening the body’s general defense system. If an increase beyond expected limits is observed in blood values during follow-up, an enlargement in tumor volume is detected on MRI images, or the cells are found to have become more aggressive in the confirmatory biopsy, the surveillance process is ended and surgical interventions offering a more definitive solution are pursued.
When Is the Decision Made to Perform Surgery for Prostate Cancer?
Although waiting and surveillance options are very valuable for certain patient groups, sometimes the clinical picture of the disease makes it necessary to decide directly on surgery. If tumor cells display an aggressive structure under microscopic examination and have a high growth rate, the surgical procedure known as radical prostatectomy becomes an option to prevent the disease from extending beyond the prostate capsule and spreading to the lymph nodes or bones.
The decision for surgery is not made solely by looking at the condition of the cancer cells. Physicians evaluate the patient’s general health profile as a whole when making this critical decision. The main factors considered when planning the surgical procedure are as follows:
- The patient’s biological age
- Current and past health problems
- The current stage and extent of the cancer
- The determined aggressiveness score of the cells
- The patient’s estimated life expectancy
Patients in the intermediate- and high-risk groups are the ones who benefit most from surgical treatment while the tumor is still confined within the organ. During surgery, not only is the prostate gland removed, but the seminal vesicles that carry semen are also removed. In cases where the disease is advanced and the risk is considered high, the lymph nodes in the pelvic region and around the blood vessels are also thoroughly removed. In this way, pathways that could act as bridges for the spread of cancer throughout the body are attempted to be closed. These removed tissues are examined in detail after surgery. If the margins are clear, patients can breathe a sigh of relief and return to routine follow-up. However, if the disease is found to have a tendency to extend beyond the tissue boundaries, additional methods such as radiotherapy may also be used in the following period to support recovery and prevent recurrence of the disease.
Why Is Robotic Surgery Preferred in Prostate Cancer Treatment?
The prostate gland is located in the deepest part of the pelvis in human anatomy, just below the bladder, within a narrow area surrounded by a dense network of blood vessels and nerves. Reaching this dark and confined area with open surgical methods, meaning by making a large incision in the abdominal region, is quite challenging. Open surgeries both prolong recovery time and increase the likelihood of damage to surrounding tissues. Today, robotic surgery systems, one of the most advanced opportunities provided by medical technology, are used to overcome these difficulties.
In robotic surgery, large incisions are not made as in open surgery. Only a few very small openings, each a few centimeters in size, are created in the patient’s abdominal area. High-resolution three-dimensional cameras capable of magnifying tissues many times and very thin robotic arms are inserted through these openings. The urologist performing the surgery controls these arms with precision from a unit called the console located immediately beside the patient. The arms of the robotic system can rotate around their own axis with a flexibility beyond that of the human wrist and completely filter out the natural tremor of the human hand so that it is not transmitted to the surgical field.
This technological superiority allows much more delicate work to be performed between tissues. Blood vessels prone to bleeding can be brought under control rapidly during the procedure, so blood loss is extremely low compared with open surgery. In addition, with techniques used in recent years, the prostate can be removed by approaching from behind the bladder without touching the muscle structures and ligaments around the prostate that help maintain urinary continence. Avoiding intervention in the natural support points of the anatomy increases the speed at which patients return to life after surgery to an extraordinary degree. Thanks to the small incisions, patients experience much less pain, and hospital stays generally decrease to only a few days.
What Is Recovery Like After Prostate Cancer Surgery with Robotic Surgery?
The two main concerns occupying the minds of patients who are going to undergo prostate cancer surgery are experiencing urinary incontinence after the operation and permanently losing sexual function. Thanks to the superior features of robotic surgery that show anatomical structures up close, the aim is to preserve these functions to a great extent. After the operation is completed, the bladder and urinary channel are sutured back together. To allow this new connection to heal safely, a thin urinary catheter is generally kept in place for a period of one week to ten days.
After the catheter is removed, the patients’ functional recovery process begins. The main steps patients should pay attention to in order to improve their quality of life during the recovery period are as follows:
- Exercises that strengthen the pelvic floor muscles
- A balanced diet that does not irritate the urinary tract
- Short and non-strenuous walks in daily life
- Routine check-ups performed at intervals determined by the doctor
In the early period, when the catheter has just been removed, it is quite normal to experience minor urine leakage because the muscles have not yet fully adapted. However, with the help of pelvic exercises, the vast majority of patients regain normal urinary control that does not affect their social lives within a few months. The recovery of sexual function requires somewhat more time and patience than urinary control. The nerve networks responsible for erection pass directly over the prostate like a spider web. If the cancer has not spread to these nerves, the precision of the robotic arms allows them to be carefully separated and preserved. However, as a natural result of the surgery, the nerves are temporarily affected and enter a dormant state. With monthly follow-ups, these nerves are expected to gradually wake up. A noticeable improvement generally begins from the sixth month onward, and by the end of the first year, recovery in sexual life is usually achieved together with appropriate supportive treatments.
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