Prostate cancer is the most common cancer in men in the UK. It usually develops slowly and symptoms do not necessarily appear for a long time. For many men with prostate cancer, treatment is not needed immediately and in some cases not at all.
For those who do require treatment, options include the surgical removal of the prostate, radiotherapy or brachytherapy.
The nerves for erections are in close proximity to the prostate. If the results of an MRI scan or biopsy indicate that the cancer is next to the prostate, the nerves are likely to be cut out during the procedure. However, following the operation it is frequently found that the cancer was not actually near the nerves and therefore the nerves could have been saved.
To overcome this problem, Mr Senthil Nathan, Consultant Urological and Robotic Surgeon, explains ClinicSafe – a pioneering new technique developed by The London Clinic urologists, radiologists and pathologists. This allows the nerves to be preserved during robotic radical prostatectomy, resulting in better continence and erections post-surgery.
What is robot-assisted radical prostatectomy?
Robot-assisted radical prostatectomy is one of the most successful treatment options for patients with intermediate, or aggressive cancer of the prostate. It’s a complex and major operation which has been simplified by using keyhole techniques to remove the cancerous prostate. With the assistance of a robot there is increased precision and control and good outcomes have been achieved worldwide.
How is the exact area of the cancer detected?
MRI imaging and biopsies, or a combination of both methods, are effective ways of determining where the cancerous areas are located. Large studies have shown the positive predictive value (ability of the MRI to indicate cancer), is around 48%. Based on the MRI scans alone if we sacrifice the nerves on these patients nearly 50% of them may have had an unnecessary removal of the nerves.
At The London Clinic, we have devised a modified NeuroSAFE TM technique called ClinicSafe which is MRI guided to improve the accuracy of detecting exactly where the cancer is, in proximity to the nerves.
What does the ClinicSafe technique involve?
The prostate and the seminal vesicles are subjected to a frozen section immediately following the operation. Depending on the frozen section report, if cancer is found on the margins then the nerves are removed but if not, the nerves can be saved to help maintain the erectile function of the patients.
To date we have completed 31 procedures with this method. In all these men, the standard procedure would have involved removing the nerves along with the prostate. With this new technology only 3 out of 31 men required partial excision of the nerves on one side, as opposed to sacrificing the nerves on both sides. Therefore, nearly 90% of men in whom there was an indication to carry out a wider excision and sacrifice the nerves, benefited by saving the nerves with the use of this technique
A patient's perspective
Danny Schogger is a patient of Mr Senthil Nathan. He underwent a radical robotic prostatectomy using the ClinicSafe technique. This is his story:
How did you find out you had prostate cancer?
I didn’t have any symptoms but my wife’s father had prostate cancer and unfortunately in his case, they had left it too late and it had gone into his bones. My wife encouraged me to have a PSA test and when I eventually did it was little bit raised. I realised, it could just be an enlarged prostate, amongst other things, but I knew I should look into it further, so I went for an MRI scan which revealed an indication of cancerous cells. This was followed a week later by a biopsy which confirmed the cancer was there on one side of my prostate. I then had a full-body scan, to see whether the cancer had spread to my bones, which thankfully it hadn’t. That was the first piece of good news I’d had in a while, but the fact remained it needed to be removed. There were two ways of doing this; surgery or radiotherapy.
How did you make your decision?
I had been erring on the side of radiotherapy as I didn’t fancy the operation, but my wife and kids and the consultant urged me to have it removed. It’s 50/50 from the results that we have in terms of success rate, but radiotherapy for me would have been a three year course.
However, it was then explained to me that with the surgery there would be a risk to the nerves surrounding my prostate, which if damaged would mean I might suffer from incontinence and erectile dysfunction. I was alarmed by that, as it’s a big deal – life changing, but then the surgery is live-saving. I knew the cancer had to come out and surgery was the most effective treatment option for this, even if I had to have radiotherapy after that as well.
How did you find out about the nerve-sparing technique (ClinicSafe)?
It took me a while and quite a few conversations with various consultants at different hospitals as it is such a new procedure. One recommended I speak to Mr Nathan at the London Clinic, as he was pioneering this new nerve-sparing technique.
Initially, I spoke to a specialist nurse at the Clinic who was terrific and then to Mr Nathan directly to discuss my options. He pointed out that if we were to leave the cancer it would go into my bones and it would spread but if it was removed, I would have a normal life expectancy. With the new ClinicSafe technique, he assured me that he and the team would be able to do everything possible to protect the nerve. He was so confident it completely transformed my way of thinking, so surgery it was.
He wanted a particular pathologist, the reason being when they do the robotic operation, (which is in itself mind boggling), they take a frozen section and then they can judge if there is cancer in it and if they’ve taken enough away.
The consultant came back into the room after the operation and said he was very pleased with how it had gone and to come back in 10 days’ time. When I did, I found out I was completely cancer free. Of course it can come, back and I still have to have my blood tested every 3 months but if it does come back, I can have radiotherapy.
How did you feel, physically and emotionally, after the operation?
Emotionally, both before and after the operation I was quite calm. I knew I was in good hands and the care was amazing. They were all so personable, explaining the technical terms, making me feel comfortable and encouraging me to ask questions. Not only that, but they were also jovial as well as serious – at all the right points. The only time I became emotional was the 10 days after the operation when I was told I was cancer free – and then the relief hit me.
How long did it take you to recover in terms of urinary continence and sexual activity?
I had been concerned about this but my recovery was far quicker than I expected. The leakage stopped in 6-7 weeks. The specialist nurse told me to do pelvic floor exercises’ and that it was one of the most important things to do. I didn’t want to hear about it at first but she said I had to know and I had to do them – so I did. Not once a day but 5-6 times a day minimum, as recommended. This builds up your muscle where your urethra has gone into your bladder instead of your prostate, so you’re just teaching the muscle what to do and that to me was really important. My leakage stopped quickly because I was proactive in doing that.
My sex life also came back sooner than I expected. Within 6-8 weeks it was proven to me the nerves had been spared. You have a dry orgasm but the sensation is exactly the same and I found that enlightening. I thought, if that’s the only difference then it’s really not an issue. I think all these things are quite important for people to know. It’s the same reaction, the same feeling, exactly the same except you don’t come out with anything. If that’s the worst result of surviving cancer, then that’s fantastic.
Now it’s been 20 weeks and of course I can have occasional niggles but nothing too bad. I’m really happy with the way it’s healed. It’s incredible how the body can recover but obviously having a strong team behind you helps – everyone from Mr Nathan, the Anaesthetists, the Specialist Nurses, to the Medical Secretaries – they’re at the top of their trade and passionate about achieving the very best outcome for the patient.
So surgery was the right decision for you?
After my initial reluctance to have the cancer surgically removed, I am now relieved to have gone down this route and very grateful to Mr Nathan and his team for the work they have put into the amazing robotic surgery, alongside this new nerve-saving technique. Right now I am pretty much back to normal, where as I could have been at the beginning of my 3 years of radiotherapy treatment. If you are a man with normal erections and you are lucky and vigilant enough to catch the cancer before it has spread, then this surgical procedure combined with the nerve-sparing technique is a great option.
Also, what I didn’t know before is that if you have radiotherapy, you can’t then remove the prostate afterwards because of scar tissue. But if you remove it first and the cancer comes back then you can still have radiotherapy, so if it were to come back now I would have that treatment.
Any views expressed in this article are those of the featured specialist(s) and should not be considered to be the views or official policy of The London Clinic.