- Up to a quarter of prostate cancer patients suffer incontinence after surgery
- Steve Gregory, 60, from Hampshire, underwent Retizius-sparing prostatectomy – a procedure which approaches the prostate from beneath the bladder
- The procedure has a far lower risk of causing incontinence
Up to a quarter of prostate cancer patients suffer temporary or permanent incontinence after surgery. Steve Gregory, 60, a retired IT director from Hampshire, underwent a procedure said to reduce this risk. ANGELA EPSTEIN reports.
As someone who has always been fit, I never thought that I’d develop prostate cancer. But for about a year before my diagnosis, I was waking up twice a night to go to the loo.
In February 2016 I finally saw my GP, mainly because my close friend, Nick, had been diagnosed with the disease, so it was on my mind.
Steve has had pioneering prostate surgery
I underwent a prostate specific antigen (PSA) blood test, to check for a protein linked to prostate cancer. My levels were slightly raised, so my doctor did a rectal examination to check the prostate gland. He told me that he thought he could feel something bulky, so I was referred to a specialist for a biopsy. The results showed I had cancer. Luckily, an MRI scan confirmed the cancer hadn’t spread. However, my only option was surgery — I was advised against radiotherapy as I have a strong family history of abdominal cancer and there is a chance that radiation could increase the risk of cancer in the bowel area in ten to 15 years. So, in September 2016, I was sent for keyhole surgery to remove my prostate. But on the day of the operation, when I came round I was horrified to learn that it hadn’t happened. Ten years before, I’d had surgery for a hernia where a piece of mesh was used to repair a weakness in my abdominal wall. Now I was told that, had my surgeon tried to reach the prostate via the mesh, it could have damaged the area: he felt there was no other way to access the prostate, so abandoned the operation.
Up to a quarter of prostate cancer patients suffer temporary or permanent incontinence after surgery. I resigned myself to radiotherapy — despite the risks. Then my friend Nick mentioned my situation to his surgeon.
Professor Christopher Eden at The Royal Surrey County Hospital. Professor Eden was pioneering a new way of doing prostatectomy, which would not only overcome the mesh issue by approaching the prostate a different way, but he said it had a far lower risk of causing incontinence. A few weeks later I saw Professor Eden privately. He said he would approach the prostate removal from underneath the bladder rather than above, avoiding the mesh as well as the structures in the area of the groin that control continence, reducing the risk of incontinence from 5 per cent with regular keyhole surgery to less than 1 per cent. Remarkably, I could have the operation on the NHS, though it was relatively new.
I had it in November 2016 and was in for two days. I had some pain — not in my prostate, but in my stomach: that was because they expand it with carbon dioxide during surgery to make the area more accessible. It hurt for a day afterwards as the gas slowly released itself.
When I woke up, I discovered I had a catheter in my stomach — not in my penis — which wasn’t what I expected at all. Professor Eden explained this was also a new method, to avoid the pain that often occurs when you have a tube inside your penis after the operation. I went home a few days later with a catheter, which was removed a week later, and painkillers.
A few weeks on and test results showed all the cancer had gone. I no longer had to rush to the loo and didn’t suffer incontinence. I have check-ups every three months and my PSA reading is non-detectable — I’m fighting fit. I even did a 1,000 km bike ride over several days raising £2,000 for charity. If Nick hadn’t told his surgeon about me I would have had potentially risky radiotherapy — I see it as a minor miracle.
Professor Christopher Eden is a consultant urologist at The Royal Surrey County Hospital, Guildford, and a co-director of private prostate surgery specialist Santis. Many men diagnosed with prostate cancer fear incontinence — Steve was no different. There is now a technique that avoids the ligaments and tissues around the prostate that control continence in an area known as the cave of Retzius. Retzius-sparing prostatectomy involves approaching the prostate from beneath the bladder rather than above — we do this using robotic technology. In a conventional prostatectomy the structures supporting the continence mechanism are dismantled in order to get access to the prostate, but they are preserved in this new technique.
Surgeons only recently started doing prostatectomy this way because of the technical difficulty in this approach as it involves operating in a smaller space. Yet my initial research with my patients has found that with this procedure, 90 per cent of men are fully continent immediately afterwards. The remaining 10 per cent of men who had this new type of surgery were continent by three to six months — three times better than the best results using the standard approach. The surgery, a two-hour keyhole procedure, is performed by the da Vinci robot. The robot arms are controlled from a console next to the operating table. Carefully watching the 3D video display in the robot’s console, I used my index and middle fingers to move the instruments around. The robot has a far greater range of movement than the human hand — it can rotate instruments to a full 180 degrees, eliminating the risk of surgical error through hand tremors. The video displayed in the console is highly magnified, meaning less chance of damaging nearby nerves.
To start with, six small incisions are made around the abdomen and a camera is then inserted through a tube placed in one to magnify everything. The abdomen is filled with carbon dioxide to expand the area, creating a larger space to operate in. Going under the bladder, I then use the console to guide instruments towards the prostate and dissect it away from both the bladder and urethra (the tube that takes urine out of the body). Once the prostate is successfully removed, the bladder and urethra are reconnected.
Traditionally, after a prostatectomy, the patient has to have a catheter or tube to drain urine from the body while the area heals. However, rather than placing this through the penis, I use what’s known as a suprapubic catheter, which runs through the lower part of the tummy. This increases patient comfort and allows earlier, easier catheter removal. In the conventional operation, the bladder is separated from the abdominal wall to get at the prostate — you couldn’t, therefore, use a suprapubic catheter as it would allow urine to leak out of the bladder and into the abdominal cavity once the catheter had been removed.
Suprapubic catheters can only be safely used after a Retzius-sparing prostatectomy.
WHAT’S THE DOWNSIDE?
Operating from underneath the bladder using a robot requires an experienced surgeon, says Paul Cathcart, a consultant urological surgeon at Guy’s and St Thomas’ Hospital in London. This angle of approach can affect the view of the area so ‘there may be a greater risk of leaving cancer behind — that’s why it is critical that patients only go to a surgeon experienced in this procedure’.
‘Risk of incontinence is a concern for patients facing a prostatectomy, but equally, the most important thing is that the cancer is successfully removed,’ he says.
‘This best suits those with a small prostate,’ adds Mr Cathcart. ‘If a large prostate is removed, this leaves a big space between the bladder and urethra, which is harder to reconnect. However, if this can preserve surrounding structures and lead to an early return to continence, then it will benefit patients.’
By Angela Epstein for the Daily Mail